Nerve Blockade and Chronic Opiate Use After Orthopedic Surgery

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We read with great interest the article about Sun et al’s1 retrospective review from 2002 to 2012. Anesthesiologists are invited to provide certain services for patients, but are rarely given complete control over postoperative pain management, particularly after discharge.
Spinals wear off in the immediate postoperative period as do epidurals, unless continued postoperatively. Neither method controls pain that continues days afterward.
Early ambulation decreased venous thrombosis and length of stay so single-shot femoral nerve block (FNB) studies increased by 2000. However, translation of the literature into practice lags considerably. Hirst et al2 described continuous FNB in 1996, yet more than a decade passed before multiple publications compared it with single-shot blocks. Many orthopedic surgeons eschew continuous catheters, fearing increased risk of falls or infections. Single-shot FNB for postoperative pain management in total knee arthroplasty remains common due to decreased costs compared with continuous catheters/elastomeric pumps, but limits pain control to 24–48 hours.
Peripheral nerve blocks may fail and do abate. Therefore other medications must be available. Multimodal analgesia includes nonsteroidals, gabapentin and pregabalin (GABAergic) medications, acetaminophen, topicals, liposomal bupivacaine, clonidine, ketamine, and opiates. However, some orthopedic surgeons object to cyclooxygenase-2 inhibitors due to potential cardiac risk, cyclooxygenase 1-2 inhibitors due to increased bleeding, GABAergics because of dizziness/falls, clonidine because of hypotension, topicals because of skin reactions, etc. Liposomal bupivacaine is not typically combined with FNB due to fears of local anesthetic toxicity.
In 1997, the publication “Pain is the Fifth Vital Sign”3 adopted by The Joint Commission in its 2001 Pain Management Standards4 changed both prescription practices and patient education regarding postoperative pain. Before that, patients were told to expect pain postoperatively and prescribed roughly 5 days of pain pills after discharge. Publicized physician reprimands by state medical boards for inadequate pain management resulted in opiate prescriptions rising to more than 100 million per year in 1998. Adoption of Press-Ganey scoring in 2008 pushed opiate prescription rates even higher in the United States, topping at 219,000,000 in 2011. Thus, surgeons prescribe opiates regardless of anesthetic interventions or adequacy of pain control. Furthermore, prescriptions filled does not equate to patient use. A 2013 study examined ads on Craigslist for prescription opiates being sold,5 and law enforcement investigations in West Virginia have uncovered families making thousands of dollars a month selling prescriptions.
Ultimately, until anesthesiologists are given complete charge of postoperative pain management using multimodal analgesia and patients expect to have some pain after discharge, regional anesthesia is unlikely to diminish chronic opiate prescriptions postoperatively.

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