Orthopaedic surgeries hurt. According to the Journal of the American Academy of Orthopaedic Surgeons, orthopaedic surgeons dispensed the third highest number of opioid prescriptions among physicians in 2009. While no physician wants to see a patient in pain, providing alternatives to traditional pain reduction methods is crucial to curbing opioid addiction. 

The University of Minnesota Department of Orthopaedic Surgery’s team of physicians has developed innovative pain reduction techniques, including the use of liposomal bupivacaine (a local anesthetic that prevents pain by blocking signals at nerve endings) for interscalene blocks and intraoperative lidocaine. These have greatly reduced patient reliance on opioids for pain management during recovery. Some sites have also begun developing and testing protocols that guide when opioids are prescribed, and in what quantity, with the goal of mitigating risks associated with opioid addiction. 

Deborah Bohn, MD, is an assistant professor who specializes in hand surgery and primarily works at TRIA Orthopaedic Center. Within her practice, Bohn realized that patients were not always using the number of pills they were prescribed. 

“It used to be that doctors would give however many pain pills they thought patients needed, or however many they were taught to dispense, without really having a good knowledge of what patients actually use after certain procedures,” Bohn explained. “What we’ve done is limit or change the amount of prescribing we’re doing and align the number of pills we prescribe to what the patient will actually use.” 

Bohn acquired research regarding typical opioid use after hand surgery and developed an order set to serve as a guide for physicians performing these surgeries. Bohn and her team conducted a three-month chart review before enacting their order set, and then did another review three months after implementation. 

“We asked all six surgeons to use the order set, which guided them to prescribe a certain number of pills based on what the average person actually uses. We were basically doing evidence-based prescribing,” Bohn explained. “We found that almost across the board we decreased the number of pills prescribed by 50 percent. Each doctor, in each category, decreased pills between 35 and 60 percent. If you estimate conservatively, that’s 24,000 fewer pills being prescribed per year by the six hand surgeons at TRIA.” 

“...I think the key is to help patients understand that the goal is manageable pain, not zero pain.” -Alicia Harrison, MD 

Bohn found that there was no significant change in patient satisfaction after implementing the order set, and only seven percent of patients called back requesting a refill. Other subspecialties at TRIA are now looking to create their own order sets using Bohn’s model. 

“As a result of our work in hand surgery, we are doing the same thing for ACL. It’s not as clear there how many pills people are using, so we are collecting that data. We are also collecting patient satisfaction questionnaires, and are going to implement an order set. Because of this work, we will improve prescribing practices for ACL, and will then move on to total joint replacement,” Bohn said. 

Bohn is not the only physician thinking outside the box to develop pain control techniques that reduce the number of pills prescribed to patients. Alicia Harrison, MD, has begun treating her shoulder patients with and without the use of liposomal bupivacaine for interscalene blocks. The nerve block is administered as a single injection and can ease pain for up to 72 hours. 

“We found that our shoulder arthroplasty patient population had a shorter length of stay and decreased use of opioids using this technique,” said Harrison, an orthopaedic surgeon and assistant professor in the Department of Orthopaedic Surgery. 

“We want to address our patients’ pain,” said Harrison. “We don’t want them to hurt; however, the reality is that fractures and surgery are painful and we need to find the lowest risk pain mitigation strategy to make that pain manageable. I think the key is to help patients understand that the goal is manageable pain, not zero pain.” 

Marcy Bents, a nurse practitioner for the Department of Orthopaedic Surgery, noted that pain management expectations must be communicated with patients before undergoing surgery. Bents, together with nurse manager Andi Olson and Madeline Youngberg, a medical student, have worked closely with orthopaedic surgeon and professor David Polly Jr., MD, to examine the use of intraoperative lidocaine in his spine patient population. 

“Dr. Polly started using short-term intraoperative lidocaine infusions for these patients,” Bents said. “Literature shows that lidocaine has multiple benefits; the biggest one is reducing inflammation and thus reducing pain at the basic nerve and cell level.” 

Other institutions have begun using lidocaine infusions successfully. To test this theory, the team compared 30 of his patients who had lidocaine administered, and 30 who did not. 

“Bents found the length of stay in the hospital decreased by half a day, and patients presumably used fewer narcotics,” explained Polly. 

Unfortunately, lidocaine is known for having potentially high toxicity rates and patients receiving an infusion must be closely monitored. Monitoring patients isn’t an issue when the lidocaine is introduced intraoperatively but will require additional resources to be administered postoperatively. Currently, the team is waiting on partners within M Health to administer and monitor the infusion for patients postoperatively. 

“We will ask the pharmacy and therapeutics committee to look at our protocol and approve it for use in the general population postoperatively and then we will test the expected change,” Bents noted. 

Overall, the Department of Orthopaedic Surgery is working at all sites to re-evaluate conventional pain relief techniques and develop innovations that can abate opioid prescriptions. 

“I hope our research leads to a better understanding of safe, effective pain management strategies,” Harrison said. “I also hope it shows patients that we want to address their discomfort and provide for their long-term wellbeing. We are all partners in guiding patients to the best pain management strategies and curbing opioid use is an important part of that.”