Given the severity of the opioid crisis, specialty practices must innovate. Time, resources, expertise and commitment to the mission of pain management encourage new practice methods. As just one example of innovation that we see occurring in the specialty setting, we describe a new pre-operative program at Hospital for Special Surgery (HSS) in New York City, the oldest orthopedic hospital in the United States. Patients undergoing orthopedic surgery usually have a higher short-term requirement for pain management, often including opioids.

The increased availability of medication for surgery has been a substantial contributor to the opioid epidemic.^{Reference Morris and Mir1} This additional excess volume of opioid pain medication creates not only a larger reservoir for diversion, but through the development of opioid tolerance and hyperalgesia — increased sensitivity to pain — it can also increase the frequency of pain complaints, leading to a cycle of additional unnecessary (and therefore ineffective) treatment associated with further increased need for opioids.

This is a particular problem in orthopedic surgery, which is often planned to treat a painful condition for which opioids may already have been prescribed; in the context of spinal surgery, for example, a recent study has found that more than 50% of patients report using opioids pre-operation.^{Reference Armaghani2} By inducing hyperalgesia, pre-operative use of opioids may cause an idiosyncratic increase in the intensity of pain complaints.^{Reference Angst and Clark3} This could potentially lead to surgical treatment of problems which, while perhaps radiographically evident, may not have otherwise prompted to the patient to seek care.

Orthopedic surgeons have been significant prescribers of opioid pain medication,⁴ and attempts have been made to address the epidemic by managing the volume of opioids given pre and postoperatively.^{Reference Dowel, Haegerich and Chou5} Given the various factors which influence the peri-operative use of opioids, HSS (including the author) developed an institutional response that focuses on changing prescribing habits through aggressive education (for prescribers and patients) and pre-surgical patient evaluation. The core of this program, which has now been in place for two years and for which data collection is still ongoing, is developing a clear understanding of the risk of opioid use, not simply in terms of side-effects such as overdose and addiction, but the risk of increased and persistent pain, and therefore poor surgical outcomes. Combining pre-operative assessment, the availability of non-opioid treatments, and the standardization (and enforcement) of surgery-specific guidelines has led to a significant decrease in opioid volume, and improved outcomes.^{Reference Soffin6}

Pre-operative assessment begins in the surgeon's office before elective surgery has been scheduled, with a secondary check by the internal medicine physician performing the pre-operative clearance evaluation to ensure that all patients are screened. All staff are educated to ask every patient a series of five questions (1. Do you take pain medications? If yes, how much and how often? 2. How long have you been taking pain medications, and why? 3. Do you use illegal drugs? If yes, what? If no, have you ever? 4. Do you drink alcohol? If yes, how much and how often? 5. Have you ever been in detox for drugs and/or alcohol?). The goal is to identify all patients who are taking prescribed opioids, or who might have a substance use disorder, so that a plan can be developed for how to best manage them after admission for surgery. Patients who are receiving more than a certain amount of opioid pain medication, for instance, those who are using a long-acting opioid, who have been on an opioid for more than six months, or who have a substance abuse history, will be referred for a more thorough evaluation by a pain clinician which includes a toxicology screen, a discussion with their prescriber, and when indicated, consultation with an addiction counselor. This evaluation will be used to develop an in-hospital treatment plan, in some cases including a pre-operative tapering schedule to reduce the patient's exposure to opioids. When possible, a reduction of 50% in the pre-operative dose of pain medication has been demonstrated to reduce the risk of abuse and improve functional outcomes after orthopedic surgery.⁷

During hospitalization and surgery, patients are managed with a multi-modal analgesic approach. This concept (the details of which are beyond the scope of this sidebar) employs regional anesthetics, anti-inflammatory medications, and early rehabilitation in an effort to minimize exposure to opioids. In addition, the hospital is developing a pilot program to foster opioid-free surgery. Such efforts are already underway internationally and are likely to become prevalent in the United States.

Post-operatively, it is critical to ensure a balance between adequate pain relief for rehabilitation and tapering off opioid pain medications as soon as possible. Patients exposed to opioids prior to surgery are often on much higher doses post-operatively and have little guidance with respect to dose reduction.^{Reference Clarke8} Unless there is careful coordination, weaning either does not occur or falls to the patient and their primary care physician who may not be equipped to manage this situation. While being made aware of this issue is part of the pre-operative education program, a plan is essential.

Ideally, all patients, surgeons, and primary care physicians would have access to a pain management (or when necessary addiction) specialist to provide supervision and weaning off opioids.

While programs like this are more easily developed and implemented in an academic tertiary care setting, the pathways are generally applicable. It is our hope that educational programs will be developed to continue studying and raising awareness about the efficacy of such strategies in improving patient safety and mitigating the need for opioids — all while drawing attention to the need for a rapid increase in the number, geographic diversity, and reimbursement for medical pain and addiction specialists.