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comparable pain relief to AEDs for postherpetic neuralgia and diabetic neuropathy.117,122,160-161 Amitriptyline has the best-documented analgesic effects but also the most side effects.19 Intolerance of side effects, particularly among elderly patients, often limits TCA use.118-119 Whereas newer antidepressants (e.g., serotoninnorepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors [SSRIs]) are generally better tolerated,123-124 randomized controlled trials have yet to demonstrate analgesic efficacy.d,123,149,162 There is preliminary evidence that venlafaxine, a new serotonin-norepinephrine reuptake inhibitor that lacks TCA side effects, may be efficacious in the treatment of neuropathic pain.123,124 However, these results await formal evaluation in a randomized placebo-controlled trial. iii. Side effects TCA selection is largely based on patient characteristics and the drug side effect profile, because analgesic efficacy among individual Information Statement Opioid Use, Misuse, and Abuse in Orthopaedic Practice This Information Statement was developed as an educational tool based on the opinion of the authors. It is not a product of a systematic review. Readers are encouraged to consider the information presented and reach their own conclusions. The United States is in the midst of an epidemic of opioid drug (narcotic drug) use, misuse, and abuse. 1 To address this critical public health issue, all physicians and orthopaedic surgeons must be accountable for their direct or indirect contributions to the epidemic and should responsibly develop solutions to effectively treat this epidemic. It is estimated that the United States consumes 80 percent of the global opioid supply. 2 According to the U.S. Food and Drug Administration (FDA), more than 50 million Americans were prescribed some type of narcotic pain medication in 2011, which represents a nearly 100 percent increase in narcotic pain medication prescriptions since 2008. 2 This increase in opioid prescription medication corresponds to an increase in opioid diversion to nonmedical users as well as a resurgence in heroin use. 3-5 Opioid overdose is now the leading cause of accidental death in young adults. 6 Opioids are associated with a higher risk of postoperative death. 7 Opioids also increase the risk of fall and fracture in the elderly. 8, 9 The AAOS believes that a comprehensive opioid program is necessary to decrease opioid use, misuse, and abuse in the United States. New, effective education programs for physicians, caregivers, and patients; improvements in physician monitoring of opioid prescription use; increased research funding for effective alternative pain management and coping strategies; and support for more effective opioid abuse treatment programs are needed. The American Academy of Orthopaedic Surgeons supports the following strategies for safer and more effective pain management and treatment: Standardized Opioid Prescription Protocols/Policies: Orthopaedic surgeons and their team members can more effectively depersonalize discussions about opioids by using standardized opioid protocols in all settings (inpatient, outpatient, office) to control opioid use. Orthopaedic practices should establish protocols/policies to better control and limit opioid prescription dosages as well as appropriate/inappropriate opioid uses for acute musculoskeletal injuries, postsurgical pain, and chronic pain. Surgeons and team members should explain to patients that opioid protocols/policies benefit patients and extended families and cannot be violated. Such opioid protocols/policies should include: • Practice-based Opioid Use Consensus: Each practice should set ranges for acceptable amounts and durations of opioids for various musculoskeletal conditions treated, both surgically and nonsurgically. • Strict Limit on Opioid Prescription Size: A prescription should only include the amount of pain medication that is expected to be used/appropriate, based on the protocol established. For patients who live longer distances from their surgeons, two prescriptions for smaller amounts of opioids with specific refill dates should be considered rather than a single large prescription. Most patients do not fill the second prescription, so this strategy limits potential opioid misuse. • Limit Extended-Release Opioids: Orthopaedic surgeons most often treat acute pain following injury or surgery. Such acute pain typically improves over hours to days, rather than days to weeks. With one exception, extended-release opioids are not FDA-approved for the treatment of acute pain. • Extended release opioid medications have the following characteristics: o They are intended for severe, long-lasting pain from cancer. 10 The effectiveness, risks, and role of long-term opioids for nonmalignant pain are unclear. Orthopaedic surgeons should consider using alternative non-opioid treatments or referring patients to multidisciplinary pain centers for treatment of chronic nonmalignant pain. o They do not allow for the titration and decrease of opioids, which makes it more difficult to limit opioid intake. o They are a popular class of opioid medications among opioid misusers and abusers. o They should be restricted to approved research protocols until the risks and benefits for the treatment of acute orthopaedic pain are better understood. •
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