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“Orthopaedic Surgeons Responding to the US Opioid Crisis.” Commentary on

“Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury.”

Mir, Hassan R., MD, MBA; Sanders, Roy W., MD

Journal of Orthopaedic Trauma: May 2019 - Volume 33 - Issue 5 - p 215
doi: 10.1097/BOT.0000000000001479

Florida Orthopaedic Institute, University of South Florida, Tampa, FL

The authors report no conflict of interest.

Accepted February 19, 2019

The United States finds itself in the current opioid crisis because of the rise in opioid prescriptions and the number of pills being diverted for nonmedical use over the past few decades. The number of opiate-related deaths has more than quadrupled since the 1990s and is now more than deaths from motor vehicle collisions. In addition to the rising death toll, opioids have impacted public health as a result of related issues such as emergency department visits for nonmedical use and adverse events, substance use disorder and dependence, substance abuse treatment admissions, and overall nonmedical drug use and societal effects.

Although the opioid crisis has been largely fueled by the oversupply of prescription opiates in circulation, there has been a concomitant resurgence in the number of deaths related to heroin and an even greater rise in the number of deaths related to illicit fentanyl. Therefore, the opioid crisis in the United States may be even worse than reported when considering the additional effects from related illicit drugs on death rates and the aforementioned other health and societal issues.

There are approximately 1 million physicians in the United States, with nearly 2% of them practicing orthopaedic surgeons (∼20,000). Although small in number, orthopaedic surgeons are the fourth highest prescribers of opioids behind primary care physicians, internists, and dentists for the percentage of prescriptions dispensed by US retail pharmacies. However, many patients who are treated by primary care physicians, internists, and emergency department physicians have acute and/or chronic musculoskeletal pain.

Over the past few decades, the use of opioids for musculoskeletal pain diagnoses in ambulatory settings including primary care clinics and emergency departments has doubled. Over 20% of the patients who receive a first opioid prescription of any duration progress to receiving more prescriptions episodically and 6% progress to long-term use. Up to 50% of patients who take opioids for 3 months remain on opioids 5 years later and are likely to become life-long users. Therefore, changing prescribing habits should be a high priority.

Numerous guidelines and toolkits have been released by professional societies, health care systems, pharmacies, insurance companies, and governmental organizations in response to the opioid crisis. Although some of these guidelines address certain aspects of pain from musculoskeletal conditions, many are focused on the management of chronic pain, and few give concrete examples of practical methods and prescribing practices that can be easily implemented when caring for acute musculoskeletal injuries. Therefore, the Orthopaedic Trauma Association convened an expert panel with the aim of producing comprehensive guidelines and recommendations that can be used by orthopaedic practices as well as other specialties to improve the management of acute pain after musculoskeletal injury.1

The impact of orthopaedic surgeons on the management of musculoskeletal pain can have an effect both within the specialty and an even greater potential impact outside of the specialty by decreasing the utilization of opioids as first-line treatment and monotherapy for acute and chronic musculoskeletal conditions. We applaud the Orthopaedic Trauma Association Musculoskeletal Pain Task Force for their efforts and believe that the readers will find this open access publication valuable.

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1. Hsu JR, Mir H, Wally MK, et al; the Orthopaedic Trauma Association Musculoskeletal Pain Task Force. Clinical practice guidelines for pain management in acute musculoskeletal injury. J Orthop Trauma 2019;33:e158–e182.
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