Reducing Opioid Use, Improving Outcomes Among Opioid-Tolerant Orthopaedic Surgery Patients
The Preoperative Pain Screening Services, a pain screening and pain management program developed by clinicians at Hospital for Special Surgery (HSS), has demonstrated success in identifying and treating opioid-tolerant patients before elective orthopaedic surgery, leading to better clinical outcomes and eventual opioid independence.
There are many reasons why optimizing patients with chronic pain for surgery can be challenging.
“What ‘optimization’ means is different for every individual,” said Faye Rim, MD, FAAPMR, assistant attending physician and Director of Pre-Surgical Chronic Pain Management at HSS. “Part of the optimization process is setting realistic expectations and then working from there. This may take more time than we have with a scheduled surgery.”
Patients with chronic pain often have higher preoperative opioid use. Long-term opioid use can cause physical dependence as well as opioid-induced hyperalgesia. As a result, these patients often request increased amounts of opioids after surgery and have decreased opioid independence.
In addition, these patients often have a higher prevalence of psychiatric disorders such as depression and anxiety that contribute to poor pain management. Alcohol and recreational drug use can also cause perioperative complications.
“While standardization of processes and procedures helps minimize medical errors and improve overall standard of care, it does not account for individual preferences and needs,” Dr. Rim said. “Preoperative pain screening and an integrated perioperative pain service allows a patient-centered model to exist within ‘checklist medicine.’ For those patients who don’t fit a standard mold, we can tailor a pain program to best meet their needs.”
HSS has developed a method of identifying opioid-tolerant patients before surgery, as well as interventions to reduce their risk profile and increase optimal outcomes.
During preoperative evaluation, patients are asked 5 questions as part of screening questionnaires administered at the surgical office. If patients answer “yes” to any of the questions, they are reviewed for a possible substance use disorder and opioid tolerance and are referred for a pain management consultation before surgery.
In the pain management consultation, there are 3 main goals:
- Identifying patients who are at risk for opioid misuse or poor pain control
- Setting expectations regarding the planned procedure and the expected intensity and duration of pain
- Developing a plan for postoperative pain management
During the consultation, a pain history is taken regarding the patient’s past and current treatments for pain and comorbid disorders. A urine toxicology screening is conducted, and prescription monitoring databases are reviewed. Patients with inconsistent findings or evidence of aberrant behavior are referred to a pain management social worker or to addiction medicine services. Patients who are on high opioid doses (defined as greater than 100 mg oral morphine equivalents) are tapered to lower doses before surgery, with coordinated care from their outside pain medicine prescribers.
A series of case studies from HSS, published by A&A Practice Journal, demonstrates examples of the program’s success.  Patients in the case studies range in age from 38 to 72 years, and all were using high doses of opioids before surgery. These patients were:
- Using high doses of prescribed medications
- “Doctor shopping” to acquire prescription opioids from multiple sources
- Using concurrent prescription medications and illicit drugs
In most cases, surgery was delayed for approximately 3 months to taper patients off high doses of medication and to treat dependence or addiction. All patients were able to taper off high doses of medication prior to surgery and had positive outcomes. In 1 case, stopping opioid and benzodiazepine use reduced pain levels and improved mental health so thoroughly that surgery was no longer necessary. 
These success stories demonstrate that a structured program to identify and optimize patients before elective orthopedic surgery can lead to better clinical outcomes and eventual opioid independence.
The Preoperative Pain Screening Service at HSS has been in place since 2015 and has formally screened about 800 patients per year.
“It is specifically the cooperation within the hospital that makes this program so successful,” said Dr. Rim. “We have had the support of administration, surgical services, nursing and anesthesia. We coordinate from outpatient and inpatient and cooperate with physicians outside the HSS system as needed.”
Surgeons raised initial concerns that referral to pain management might deter patients from getting surgery that was important to their care. However, this coordinated, patient-centered care model does not appear to affect overall patient satisfaction.
It will be important for future work to identify which preoperative interventions are beneficial; the best methods for opioid tapering, and to what levels; and how various interventions for substance use may affect overall morbidity, mortality, or length of stay.
HSS is currently in the process of collecting data on adherence to tapering plans, drop-out rates, missed patients and outcome data such as opioid use, patient satisfaction and lengths of stay.
Although starting a program similar to this one may require additional resources, it may be cost-efficient over time, and it is likely that larger systems will be able to implement and support similar programs.
- Donofrio J, Peterson C, Liu S, Rim F. Impact of structured patient centered pre-operative pain consult and interventions from a dedicated Perioperative Pain Service: A case series of four patients. A&A Practice. Published online July 17, 2020. doi: 10.1213/XAA.0000000000001279