OPINION - By Dr. Andrew Wickline
New York Daily News May 16, 2022 at 5:00 am
Did you know that your grandma could become addicted to opioids because of a knee replacement? It’s more likely than you might think.
Knee replacements — with more than 1 million performed every year — nearly always require opioids for pain control. It’s no surprise that the proportion of older adults seeking treatment for opioid abuse nearly doubled in recent years, particularly as the number of joint replacements increased drastically.
The Centers for Disease Control and Prevention will soon issue its 200-page 2022 best practices for prescribing opioids. Its size and complexity means few of us will actually read it. With a record number of people dying from overdose deaths in 2021, the opioid epidemic in this country demands real solutions.
Orthopedic surgeons like me hold the dubious distinction of belonging to the third-highest opioid-prescribing specialty. Our goal remains to someday eliminate opioids after surgery through protocol innovation, colleague collaboration and industry partnership.
Every pill surgeons order can cause substance abuse. A 10-day opioid supply carries up to a 20% risk of addiction. A 24-hour supply runs a 6% chance of addiction. By getting their wisdom teeth pulled, your teenager — consuming opioids for one day — could develop an addiction. Approximately 80% of heroin addicts first misused prescription narcotics.
Yes, I realize that many people who get opioid prescriptions to counter chronic pain use them safely. I sympathize with these patients. Clamping down on their ability to get pills can seem cruel. But unfortunately, this is an ecosystem. One person’s necessary prescription can quickly become another person’s path to a debilitating addiction.
Across all specialties, pharmacies fill more than 200 million opioid prescriptions annually. A recent article shows that Florida reduced postoperative total knee narcotics by 38%, from 174 oxycodone down to 108 oxycodone per patient.
My published research found that 86% of total knee replacement patients needed no more than 10 pills total from the operation through 90 days. My colleague Vinod Dasa, MD, vice chairman for academic affairs at Louisiana State University’s Department of Orthopedics', performs knee replacements with zero narcotics in two-thirds of his patients.
Yet despite being offered two of the lowest opioid protocols in the nation, many surgeons have not implemented similar narcotic-sparing practices.
There’s a legitimate reason for their resistance. Switching from conventional protocols to a low- or no-opioid protocol takes time and effort with no financial reward. Surgeons recently faced another 9% decrease in reimbursement from Medicare on top of the inflation-adjusted 68% cut since 1992. In addition, private insurance and Medicare provide little to no additional reimbursement for non-opioid alternatives.
I propose a radical solution.
First, we should incentivize prescribers to achieve lower national rates and tie prescriptions to specific surgical procedures or medical diagnosis codes. Physicians will establish a national maximum number of pills per procedure or code similar to Michigan’s guidelines. Every prescription that meets the new lower threshold receives a credit of $100.
Patient pain and satisfaction scores can be tracked with the medical codes and adjusted to achieve optimal pain management while markedly reducing the number of opioids on the street. Even if all 200 million prescriptions per year reached the lower target and received the $100 incentive ($20 billion), it would still leave $22.5 billion in the White House’s historic opioid epidemic budget for other priorities.
This solution would also identify the reasons for narcotic consumption.
In further published research, my team found that the common belief that total knee replacement leads to a high rate of addiction may not be true. Additional factors may be at play such as back pain or other recent surgeries. We need to get in the weeds to figure out who is using opioids, how they get them and why they need them.
Second, after one year, we should identify and talk to outliers about why they continue overprescribing. Some providers will still find it easier to prescribe narcotics than change their protocols. They may require additional education or potentially lose their prescribing privileges. The program will also need to account for the chronically addicted and other special cases to ensure that no one is unnecessarily harmed.
Third, we should require that insurance carriers and Medicare reimburse surgeons for non-opioid alternatives. Insurance companies frequently label new, promising treatments as “experimental” and refuse to cover them. Such products should qualify for pilot program status with the costs absorbed by insurance and Medicare. Multiple clinics can then conduct trials and publish results in real-world settings to verify true reduction while properly managing patient comfort.
Whether it’s your Gigi, Noni or Mimi, surgeons can now fix their knee or hip with limited exposure to addictive drugs with the least discomfort possible. We can avoid the extra pills that their grandkids may pilfer and become addicted to.
Surgeons don’t need 200 pages of guidelines. We need funded incentives to cover the costs of revamping surgical protocols. An ounce of prevention costs less than a pound of cure.
Wickline is a fellow of the American Academy of Orthopedic Surgeons.
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