No Opioids After Total Knee Replacement is Possible
The opioid crisis became real for our family a few weeks ago. Yes, there is talk about the opioid crisis among health professionals, but the talk is more related to the statistics - versus what it means on a personal level.
A few weeks ago a funeral was held for a young man who died of a heroin overdose. He was my niece's fiance. He had attended many family functions over the last 5-6 years. He died at the age of 27. The family worry now revolves around our niece - her feelings, how she is emotionally handling the loss, her "friends" and how they will "support" her, and our ability to be helpful while not enabling. We also have thoughts of the unknowns: we hope she isn't using, yet we know she is in an environment in which heroin is available. From this one experience, I have met quite a few people who have lost a loved one to heroin. I never realized that once a person tries or uses heroin, the urge for more and the addiction are so strong.
With all my patients who have had total hip or knee replacements, I always take time to discuss pain control. In all honesty, generally speaking, I am not against opioids. I do believe this medication does have a role in pain control as a short term solution. I can only hope that every physician who prescribes an opioid does a thorough screening to ensure that the use of the opioid will be helpful rather than harmful. Even then, patients can choose to lie about an addiction history, so there may not truly be a safe screening process.
I recently read an article in the Frederick, Maryland newspaper. It caught my eye because it focused on the option of no opioids post-operatively. I know from treating many individuals after knee replacements that the pain seems to be the greatest the first week after surgery. Every patient may not be a candidate for no narcotics - it seems this would be based on a case by case situation.
The protocol that the surgeons included the injection of Exparel around the joint. The medication provides post surgical analgesia that seems to last about 72 hours. The surgeon also implanted a pain pump into the thigh. This was used for the first few days after surgery.
The other intriguing aspect within the article was the reference to "physical therapist as navigator” model.
Physical therapists seem to be the conduit bringing everything together. About a month prior to surgery, a physical therapist meets with the patient to perform a home safety assessment and to ensure the patient is good surgical candidate. Physical therapy services begin in the home the first week after surgery. Physical therapists are coordinating with the surgeon, the anesthesiologist and the patient on the best plan for treatment.
You may begin seeing more and more patients not prescribed a narcotic after having a joint replacement. In the mean time, do you have processes in place to educate your patients about how to decrease the use of a narcotic when it has been prescribed? Are you able to set realistic expectations so patients are able to slowly eliminate the narcotic from their daily lives? And most importantly, do you follow up to ensure your patients are no longer taking narcotics when the medication is no longer truly necessary?