It’s been nearly two years since I prescribed opioid medication to any patient under 25 years of age after doing their anterior cruciate ligament (ACL) reconstruction. Each patient had the opportunity to get a rescue opioid prescription. Somewhat surprisingly, no patient has needed one. There have been other surprises and lessons learned along the way. I’m sharing them here because I think they have a wider application outside of orthopaedics, or even medicine in general.
Identifying the stakeholders
Lesson 1: Invite expertise.
Complex problems are solved by teams. Inviting expertise from other disciplines results in greater idea generation. I routinely consult with our team of physical therapists and our sports navigator to ask them what is working well and what could be improved in providing pain control for our patients. They do not prescribe the medication or consume it. Nonetheless, they are a huge part of the patient’s postoperative journey. As a frequent point of contact, they see the patients more often than I do after surgery. They have been an invaluable source of feedback on the patient experience. We are also fortunate enough to have a primary care sports medicine physician in our practice, who brings another discipline of expertise to our monthly meetings. Our advanced practice providers (physician assistants and nurse practitioners) provide yet another perspective on how to best treat our patients.
Lesson 2: Industry can be a positive or negative influence.
The role of industry in the propagation of the opioid epidemic is well documented. The pharmaceutical companies manufacturing opioid painkillers pushed their products with wild abandon during the years leading up to the highest opioid utilization (circa 2017). But industry can help minimize opioid use too. On the positive side, I have partnered with Corganics to provide high quality, organic, THC-free CBD as a non-opioid medication option. The team at EMSI has helped coordinate the delivery and use of transcutaneous electrical nerve stimulation devices as a non-medication pain control option. Profit motive is itself neither good nor bad – it is neutral. If the mission aligns with patients’ desired outcomes, the result is win-win.
Lesson 3: You don’t know someone’s values unless you give them the opportunity to express them.
Many parents prioritize opioid avoidance above absolute pain control. This somewhat surprised me. I thought that parents’ desire to avoid having their kids experience pain would lead them to want the most potent pain control options. Not so. Although they wanted optimal pain control for their kids, parents have been uniformly enthusiastic about opioid-free surgery. Many are well aware of the potential side effects and dangers, and are wary about having them prescribed to their minor children. As a result, I didn’t have to sell this idea to parents at all.
Feedback
Lesson 4: Measure something.
Just measuring something will result in improvement, with seemingly no additional effort.
“Count something. Regardless of what one ultimately does in medicine—or outside of medicine, for that matter—one should be a scientist in this world. In the simplest terms, this means one should count something. … It doesn’t really matter what you count. You don’t need a research grant. The only requirement is that what you count should be interesting to you.” —Atul Gawande, Better: A Surgeon’s Notes on Performance
We collect a bunch of different metrics for our ACL reconstruction patients from surgical data to pain scores to functional outcomes. When we dialed down to just two measures, clarity and direction emerged. We decided to focus on a pain scale (visual analog score) and the number of opioid pills consumed (before going opioid free – now the number of opioid pills consumed is consistently zero). Finding out how many pills were used helped us to question prescribing practices and ultimately whether those drugs were prescribed at all. Measuring pain scores helped keep the focus on an outcome that mattered to the patients and provided simple feedback to ensure we weren’t veering off track. At the outset, I had hoped to achieve equivalent pain scores without opioids. I would have even taken the trade-off of slightly worse pain scores without the side-effects of opioids. I was pleased to see that not only did we not compromise pain scores, they actually improved!
“The things we measure are the things we improve.” - James Clear
Non-attachment
Lesson 5: Be willing to change the status quo.
Doing something because ‘that’s how you were trained’ is not a good enough reason. Patients used to stay for days in the hospital after a joint replacement. Turns out, your chances of getting that joint infected are lower if you leave sooner. We used to prescribe dozens of Percocet after orthopaedic surgeries. But until you look and see that some patients take 3, or 1, or zero pills, you won’t start to question what’s actually needed for most patients.
Lesson 6: Be willing to change your own protocol.
Once you’ve invited the expertise of other stakeholders to form a multidisciplinary team, listen to their advice and feedback. It’s great to have a well-researched, literature-supported, well thought out protocol. But never marry yourself to the way you’re doing something. Having the humility to admit that someone else might have a better idea will stand you in good stead. The protocol is not written in stone. Letting patients know that you will make every effort to control their pain goes a long way to making them comfortable going forward with an opioid free protocol. After all, the focus is on service. This flexibility mitigates the fear of uncertainty. We’ve all survived every second of pain we’ve ever suffered, but future pain represents an unknown. No one wants to be home, alone, in pain, and without options. Just knowing that they have the option of stronger pain medication is enough to allay these fears. I say just the knowledge is enough because zero patients in our cohort of ACL reconstructions in patients under 25 years of age have needed a rescue opioid prescription. Zero. And their pain scores have actually been lower. No opioids. Less pain.