What is the risk associated with taking opioids after orthopaedic surgery?

This month my group has a paper coming out in the Journal of Pediatric Orthopaedics(first author Eli Cahan) investigating how the risk of development of opioid use disorders may relate to pain medication prescribed after orthopedic procedures. This specific project used a large database to track children and adolescents who had ACL reconstructions, which is a common orthopaedic procedure. We’re also working on a similar project in patients with scoliosis.

This is a topic that is high up on the list of concerns parents have for me when considering surgery for their child. Awareness of the risks of opioid use is high right now and has dramatically changed since I began my training.  Physicians' understanding of their role in the opioid crisis has evolved rapidly over my time as a doctor. Since I was caring for patients as a resident 12 years ago, I have steadily prescribed less opioid medication for the same procedures. Unfortunately, rates of opioid overdose continue to rise in the US.

The idea for this project came after I read an article by a colleague of mine, Alan Schroeder. Dr. Schroeder has research interest in quantifying risk associated with standard medical practice.  The idea is that even though we mean well we may be exposing patients to a lot of unquantified risk for unintended consequences. His group wrote an interesting paper, looking at the risk of opioid use disorder after wisdom tooth removal. They demonstrated that patients who had opioid prescriptions after wisdom tooth removal had a higher risk of developing opioid use disorders in the year after surgery than age-matched controls who did not have surgery. It was a high impact paper that may change the way surgeons counsel patients before elective procedures. We set out to see if opioid prescribing patterns after orthopedic surgery may also put patients at risk.

There are clearly some differences in these two patient populations and our methods and results were not exactly the same. ACL reconstruction, though it is not an emergent procedure, is in a different category of elective procedures than wisdom tooth removal. Our patients are already starting with an injury that causes pain.  We first demonstrated that the incidence new diagnosis of opioid use disorder in the year after ACL surgery was fairly low at about 0.7% Since people did not choose whether or not to have an ACL injury, we decided to forgo the control group and instead to look at how differences in opioid prescribing patterns after surgery might relate to subsequent risk of developing opioid use disorder.  We looked for, but did not find, a relationship between the volume of the initial prescription and development of opioid use disorder.  We did, however, find that patients who developed an opioid use disorder within a year postop were much more likely to have received a repeat prescription of opioids after their initial prescription.  

It's worth noting that our methods probably only picked up the most severe cases of opioid use disorder so there might be a larger population of patients with milder problems with opioid use that go undiagnosed.  Furthermore, there are probably other benefits to decreasing the amount of opioid initially prescribed.  We work with our anesthesia and pain medicine team to prescribe multimodal regimens that include a lot of non opioid pain control techniques to try to minimize the amount of opioids that patients take.

This should make providers think twice about re-prescribing opioids after ACL reconstruction and may help identify a patient population at risk for opioid use disorders.  We hope that by identifying this patient population early we can decrease the risk!

John Vorhies MD

Using temporary flexible rods for single-stage correction of severe scoliosis and kyphosis

In February our group published a paper in the Journal Orthopedics describing a technique for single-stage correction of severe scoliosis using temporary flexible rods.  Jeffrey Kwong was the first author and did the majority of the work for this when he was a medical student at Stanford.  He is now a resident at UCSF.  Research can sometimes take a long time to come to fruition. A version of this project was initiated several years ago by one of my partners, Kali Tileston, during her fellowship and then we continued to gather data and work together to bring it to its current state

This paper describes a technique that my senior partner, Larry Rinsky, developed for treating severe scoliosis and kyphosis. When we do a spinal fusion for scoliosis or kyphosis, our number one goal is to safely halt the progression of the problem so it does not further affect a child's health. We are also trying to correct the deformity so that the child can have a balanced spine and the highest level of function possible. With larger and stiffer scoliosis curves achieving correction safely and effectively is more likely to require advanced techniques. With these curves we typically use a higher implant density (more screws, bands or wires) but even then as we leverage those implants, they can fail.  One way to deal with this is to try to correct the deformity in 2 stages, first doing an anterior surgery or perhaps placing the patient in halo gravity traction before a definitive posterior spinal fusion. These approaches are effective but they take time and expose the patient to multiple surgical episodes.  For some patients it is better to get it all done at once.  

Dr. Rinsky started using flexible rods to slowly achieve correction without putting too much stress on the screws.  In pediatric orthopedics we often use small diameter flexible titanium rods to treat long bone fractures.  These are readily available in most large children's hospitals and common sizes are smaller than the rods that we typically use for spinal fusion.  The technique is described in full in the paper; after exposing the spine and placing anchors, Dr. Rinsky would place 1 or 2 flexible rods in the anchors to gradually correct the curve and then sequentially replace them with the larger stiffer final rods, allowing him to get the correction in an iterative process.  He taught this technique to me and his practice partners and we all use it from time to time with larger curves.

In the paper we describe a cohort of 34 patients with spinal deformity that had treatment using this method.  We found it to be safe and effective in this group.  Hopefully this paper will equip surgeons with one more tool that they can use to safely take care of patients with spinal deformity.

John Vorhies MD