Pain Management The Orthopaedic Surgeon s Perspective

November 2007 Highlights Report: Pain Management The Orthopaedic Surgeon s Perspective This Highlights Report offers an overview of Pain Management The Orthopaedic Surgeon s Perspective by Harry N. Herkowitz, MD, Douglas R. Dirschl, MD, Terry R. Light, MD, Louis U. Bigliani, MD, S. Terry Canale, MD, with the assistance of Thomas S. Thornhill, MD, David H. Sohn, MD, and Santhanam Suresh, MD, FAAP, members of the Oversight Committee, OREF-AOA Pain Management Initiative. www.oref.org www.aoassn.org

INTRODUCTION Postoperative pain management is of great importance to orthopaedic surgeons. However, pain control can be complex owing to the array of pain management choices and their side effects as well as pain control needs that differ with the individual patient and orthopaedic procedure. To better understand the pain management practices in orthopaedic surgery, the American Orthopaedic Association (AOA) and the Orthopaedic Research and Education Foundation (OREF) surveyed members of the orthopaedic community regarding their use of and satisfaction with postoperative pain management modalities. The survey divided respondents by their primary area of expertise: total joint replacement, sports medicine, or spine surgery. Other aims of the survey were to determine where gaps in knowledge exist and where future research and education should be directed. Methods The sponsoring organizations invited an estimated 20,000 orthopaedic surgeons to complete an online survey that was posted from February 2006 through June 2006. The survey was developed through a joint effort between the AOA and the OREF, with assistance from a group of surgeon advisors and a survey consultant. The survey inquired about the surgeon s experience with a variety of pain management therapies. These modalities included aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), non-narcotic analgesics, narcotic analgesics, patient-controlled analgesia (PCA) with narcotics, continuous infusions of analgesics directly into the wound or via catheter, epidural infusions with local anesthetic or with anesthetic and additives, nerve blocks, transdermal systems, and muscle relaxants. For each modality, respondents were asked if they were very, somewhat, or not at all satisfied. When dissatisfied, they were prompted to give the reasons for dissatisfaction. Additionally, the survey questioned orthopaedic surgeons about which resources they rely on for advice and education about pain management and which medical professionals they consult for guidance. Last, surgeons answered how they select pain management modalities, which emerging technologies they believe are promising, and what future guidelines need to be established for pain management. RESULTS Profile of Respondents The pain management survey generated 660 responses. The largest percentage of surgeons (37.0%) performed primarily total joint replacement, followed by spine procedures (32.4%) and sports medicine procedures (30.6%). Most responding surgeons were experienced, with an average of 17 years in practice. Most respondents (52%) reported performing 16 to 30 procedures each month, and an additional 28% performed more than 30 procedures monthly. More than half (54%) of respondents perform their surgical procedures at a teaching institution. Orthopaedic surgeons gave narcotic analgesics the highest satisfaction rates. 2 www.oref.org

Table 1 SURGEON SATISFACTION WITH PAIN MANAGEMENT MODALITIES* Modality Sports % Total Joint % Spine % Aspirin Not at all 47 Not at all 50 Not at all 61 NSAIDs Somewhat 58 Somewhat 62 Somewhat 62 Non-narcotic Analgesics Somewhat 60 Somewhat 54 Somewhat 62 Narcotics Very 66 Very 54 Very 61 PCA Very 42 Very 46 Very 64 Continuous Infusion (into wound) Very 48 Not at all 44 Not at all 63 Continuous Infusion (proximal to wound) Very 37 Not at all 37 Not at all 71 Epidural Infusion (no narcotics) Very 44 Somewhat 53 Somewhat 41 Epidural Infusion (with narcotics) Somewhat 36 Somewhat 45 Somewhat 41 Nerve Blocks Very 78 Very 57 Somewhat 39 Transdermal Systems Somewhat 49 Not at all 50 Somewhat 56 Muscle Relaxants Not at all 50 Not at all 51 Somewhat 55 *Choices for satisfaction level were very satisfied, somewhat satisfied, and not at all satisfied. The satisfaction level that received the highest percentage of responses from each group is shown. Survey participants were located across the United States in a geographic distribution similar to that of the American Academy of Orthopaedic Surgeons (AAOS) membership. Two-thirds of respondents came from 23 states and the District of Columbia comprising the Atlantic and North Central regions. Satisfaction by Modality In response to questions about satisfaction with postoperative pain therapies, orthopaedic surgeons in all subspecialties gave narcotic analgesics and patient-controlled analgesia (PCA) the highest satisfaction ratings (Table 1). There were some specialty-specific differences. Nerve blocks got high satisfaction rates from sports surgeons but not from spine surgeons. Spine surgeons also disliked treatments with a risk of causing urinary retention, such as epidural infusions, or of increasing bleeding, such as aspirin. Most total joint and spine surgeons did not use modalities with a potential for infection, such as continuous infusion directly into the wound. The main causes of dissatisfaction with pain therapies were ineffectiveness and potential adverse events. www.aoassn.org 3

Aspirin and NSAIDs Of the 660 responding surgeons, 334 reported they advised their patients to use aspirin for pain relief after surgery. More than half (53%) of these surgeons, however, stated they were not at all satisfied with aspirin for management of postoperative pain. Among 488 surgeons who recommended NSAIDs (e.g., ibuprofen, indomethacin, naproxen, piroxicam) after surgery, nearly 33% said they were very satisfied, and 58% said they were somewhat satisfied. Sports medicine surgeons were almost twice as likely to state they were very satisfied with NSAIDs than either total joint or spine surgeons (Table 1). Spine surgeons (45%) sometimes would use NSAIDs after lumbar decompressions but not fusions. REASONS FOR DISSATISFACTION: ASPIRIN & NSAIDS Not effective at reducing pain Concerns with bleeding May hinder healing or fusion GI problems Narcotic Analgesics and PCA More than 540 surgeons said they prescribed narcotic analgesics (e.g., codeine, hydrocodone, meperidine, morphine, oxycodone, propoxyphene, tramadol) postoperatively. Most surgeons (60%) said they were very satisfied with narcotics. Only 1% stated they were not at all satisfied. Of the 413 surgeons who used PCA with narcotics (e.g., morphine, hydromorphone [Dilaudid]), 51% said they were very satisfied. Only 13% said they were not satisfied with PCA. The orthopaedic specialists who most often reported being very satisfied with PCA were spine surgeons (64%; Table 1). In contrast, 46% of total joint surgeons and 42% of spine surgeons posted very satisfied ratings. REASONS FOR DISSATISFACTION: NARCOTICS & PCA Ineffective Nausea and constipation Disorientation Addiction potential (narcotics) Continuous Infusion with Anesthetic Fewer than 15% of all respondents said that they used continuous infusion devices, but 30% of sports medicine physicians reported using them after rotator cuff (RC) repair. About two-thirds of sports medicine surgeons were satisfied with the use of this modality, whereas spine surgeons and to a lesser extent total joint surgeons tended to be unhappy with continuous infusion as a postoperative pain management technique. REASONS FOR DISSATISFACTION: CONTINUOUS INFUSION Potential for infection and soft-tissue or nerve damage Hassle to use Ineffective or unpredictable results 4 www.oref.org

Epidural Infusion with Anesthetic Fewer than 10% of responding surgeons ever recommend an epidural anesthetic for postoperative pain management. The highest reported use was by joint replacement surgeons; 27% used epidurals early in the postoperative period. On the whole, surgeons were somewhat satisfied with epidural infusion, with lower satisfaction rates among spine surgeons than for total joint surgeons (Table 1). Sixty-five percent of sports medicine surgeons reported that patients undergoing meniscal procedures needed just 1 to 2 weeks of pain medication. For the remaining procedures, there was no agreement on the length of time that pain medications needed to be used. Similarly, there was no consensus among total joint or spinal surgeons on the length of time patients require pain medication after discharge for typical procedures in these subspecialties. REASONS FOR DISSATISFACTION: EPIDURAL INFUSION Nerve Blocks Lack of efficiency Potential for urinary retention Among the 356 surgeons who recommended nerve blocks, 60% said they were very satisfied and 29% rated being somewhat satisfied. Satisfaction rates varied by surgical specialty (Table 1), with sports medicine surgeons being much more satisfied than spine surgeons or total joint surgeons. REASONS FOR DISSATISFACTION: NERVE BLOCKS Lack of efficiency Potential for nerve injury or muscle weakening DURATION OF THERAPIES Surgeons were surveyed on how long they usually prescribe pain medications after discharge for certain procedures they perform. The duration of postoperative pain medication differed widely by procedure and surgical specialty area. The duration of postoperative pain medication differed widely by procedure and surgical specialty area. TRUSTED RESOURCES AND INFLUENCES FOR CHANGE Information Ninety-five percent of surgeons stated that journal articles serve as their primary source of information for guidance regarding pain management therapies. More than 60% of surgeons get information from their peers, textbooks, and specialty society courses. Spine surgeons relied on courses for information less often than did sports and total joint surgeons. If unsure what type of pain medication to prescribe after surgery, 58% of all surgeons would consult a pain management specialist, and 56% would seek guidance from an anesthesiologist. Nearly all respondents (91%) said they would switch to a different pain management product if it had better safety and www.aoassn.org 5

effectiveness. Other important deciding factors for switching products included reproducible or better published clinical results, fewer side effects, shorter duration of therapy, and lower cost. Familiarity with the product also reportedly helped sway surgeons. Most surgeons are not strongly influenced by peer recommendation, convenience, change in hospital pain management protocols, or a formulary change. Less than 10% of surgeons commented that research opportunities influenced their decisions to switch therapies. EMERGING THERAPIES Regardless of specialty, surgeons surveyed hoped for the development of non-addictive, non-narcotic, long-acting pain therapies. All respondents to this question mentioned injectable medications, especially COX-2 inhibitors. Other non-narcotic treatments that surgeons consider most promising for pain control included: Adjunctive pharmaceutical therapies such as neurotropic agents and calcium channel blockers Acupuncture Electrical stimulation Cryotherapy Self-hypnosis or yoga Aromatherapy Intrathecal drug administration (e.g., ziconotide) Surgeons hope for the development of non-addictive, non-narcotic, long-acting pain therapies. Future Protocols The survey asked respondents to specify guidelines they believe are needed for the management of their patients postoperative pain. Surgeons offered a range of recommendations, with six major themes emerging: 1. Use of pre-emptive measures for the management of pain to reduce a patient s reliance on pain medications (i.e., narcotics) postoperatively, with pre-operative patient education to expect some pain postoperatively. 2. Use of multi-modality approaches. 3. Individualized care to allow for the uniqueness of each patient s pain threshold and emotional needs. 4. Better sharing/publication of effectiveness information using evidence-based research. Surgeons believe a need exists for additional peer-reviewed articles that demonstrate efficacy and safety, and for prospective randomized studies that compare pain management therapies. 5. Minimize reliance on narcotics. 6. Study NSAIDs and their effects on bone and soft-tissue healing. Conclusions The 2006 OREF-AOA Pain Management Initiative aimed to understand the perspective of orthopaedic surgeons on pain management. According to the survey results, orthopaedic surgeons find narcotics to be the best way of managing postoperative pain in their patients, although they dislike the side effects. Specialty-specific preferences in pain management exist. Sports medicine surgeons preferred nerve blocks and continuous infusion, whereas total joint surgeons favored 6 www.oref.org

PLEASE SHARE YOUR FEEDBACK on this article at www.oref.org/painhighlights or photocopy this page, then record your responses and fax to 847.698.7806. THANK YOU. 1. How useful is the content of this article for you? Not at all Somewhat Very 2. Did you or will you share this article with a colleague? Yes No 3. Did this highlights report encourage you to seek out the full report? Yes No 4. Are you interested in learning more about this topic? Yes No 5. If yes to #4, in what format? (please check all that apply) Journal supplement Web cast hosted by OREF-AOA On-site educational program Online discussion forum Audio conference hosted by OREF-AOA E-mail 6. On what other topics would you like information? Related to postoperative patient care Related to clinical research or treatment issues 7. What is/are your major area(s) of practice? 8. What is your practice environment (please check all that apply) academics clinical/private practice other 1-24 physicians 25-49 physicians 50+ physicians 9. Any suggestions or questions? OPTIONAL Name E-mail nerve blocks over infusion directly into the prosthetic joint. And spine surgeons preferred PCA as well as narcotics, while expressing dissatisfaction with aspirin and epidural anesthesia. This survey made an important contribution by identifying areas that orthopaedic surgeons believe need improvement. Respondents want safe, effective alternatives to narcotics. They also desire guidelines in the use of pre-emptive anesthesia and multi-modal approaches to pain management. Most respondents are willing to change pain management modalities if they are demonstrated to be safe and effective. Orthopaedic surgeons most trusted resources are publications as well as anesthesiologists and pain specialists on pain management teams. Therefore, future guidelines should be developed with other members of the pain management team and should be published in peer-reviewed journals. Authors Harry N. Herkowitz, MD William Beaumont Hospital, Royal Oak, MI Douglas R. Dirschl, MD University of North Carolina School of Medicine, Chapel Hill, NC Terry R. Light, MD Loyola University Medical Center, Maywood, IL Louis U. Bigliani, MD Columbia University, New York, NY S. Terry Canale, MD Campbell Clinic, Germantown, TN Thomas S. Thornhill, MD Brigham and Women s Hospital, Boston, MA David H. Sohn, MD William Beaumont Hospital, Royal Oak, MI Santhanam Suresh, MD, FAAP Children s Memorial Hospital, Chicago, IL Interested in more information? A complete report of findings is being reviewed for publication. Please visit www.oref.org or www.aoassn.org for updates. www.aoassn.org 7

Interested in more information? A complete report of findings is being reviewed for publication. Please visit www.oref.org or www.aoassn.org for updates. ABOUT OREF The Orthopaedic Research and Education Foundation (OREF) is the one foundation serving the entire orthopaedic community. Since its founding in 1955, with support from orthopaedic surgeons, industry and patients, OREF has funded more than $73 million in research and educational initiatives. From pioneering the first treatments for osteoporosis to searching for biofactors capable of improving tendon-to-bone healing, OREF-funded investigators remain on the leading edge of orthopaedic advancements and meaningful improvements in patient care. OREF is a not-for-profit 501(c)(3) organization. All contributions are tax-deductible to the extent allowed by law. ABOUT AOA Founded in 1887, The American Orthopaedic Association (AOA) is the oldest and most distinguished orthopaedic association in the world. Membership in the AOA is achieved by those who have made a significant contribution to education, research, and the practice of orthopaedic surgery. The AOA s dedication to the specialty and its members continues by equipping orthopaedic surgeons with knowledge and skills necessary to lead effectively in the ever-changing landscape of the healthcare environment. In pursuit of its mission to identify, develop, engage, and recognize leadership to further the art and science of orthopaedics the AOA focuses on leadership issues associated with the specialty via its diverse constituency of orthopaedic leaders. This single themed focus materializes in the form of leadership and educational programs, confrontation of critical issues, awards, and fellowships. 6300 North River Road, Suite 700 Rosemont, Illinois 60018 (847) 698-9980 This article is one component of the OREF-AOA Pain Management Initiative, made possible through an educational grant from Pfizer, Inc. Currently, the AOA has over 1,450 members. www.oref.org www.aoassn.org 2007 Orthopaedic Research and Education Foundation and the American Orthopaedic Association Printed in USA 0710-PMI