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Revised: March 22, 2017[Type here]Prescribing Guidelines for PennsylvaniaThe Safe Prescribing of Opioids inOrthopedics and Sports MedicineIndividuals may seek care with an Orthopedicand Sports Medicine specialist due to a sportsinjury or other acute or chronic condition.Patients seeking care with Orthopedics and/orSports Medicine specialists can experience pain thatleads to orthopedic consultation and surgery.Assessment and effective treatment of painwhenever possible is important to improving patientoutcomes.The included guidelines address the use of opioidpain medication in orthopedics and sports medicine.They are intended to help healthcare providers 2017 Brought to you by the Commonwealth of Pennsylvaniaimprove patient outcomes and to supplement, butnot replace, the individual provider’s clinicaljudgment.It is recommended that providers review associatedPennsylvania State Guidelines related to the use ofopioids in chronic non-cancer pain, various medicalsubspecialties and patient populations, pharmacyguidelines, and dental guidelines, which mayprovide insight into treatment options for thesepopulations.

Safe Prescribing of Opioids in Orthopedics and Sports MedicineProviders should remember that exercise (includingrehabilitative exercise), Osteopathic ManipulativeTreatment (OMT), physical therapy, acupuncture, orpsychotherapy (e.g. cognitive behavioral therapy)will often ameliorate pain and improve function. Inmany situations, these approaches should be triedfirst and only then should pharmacological agents beconsidered.BackgroundPrescription drug overdose deaths have beenincreasing at an exponential rate. The United StatesCenters for Disease Control and Prevention (CDC)reported that in 2014 over 47,000 overdose deathsoccurred in the United States, with more than 60percent (28,647) of these deaths involving opioids.In 2014, 1.5-times more people died from drugoverdoses than died in automobile accidents. InPennsylvania, the number of opioid related deaths isalso staggering. In 2015, it was reported that at least10 individuals died each day in Pennsylvania of adrug overdose.While the United States makes up only 4.4% of theworld’s population, Americans utilize 80% of theworld’s supply of opioids. Prescribing decisionsaffect not only the patient, but their family andsociety-at-large. New or occasional abusers of painmedications obtain a significant portion of theirprescription drugs for non-medical purposes throughfriends and family, rather than through legal means.As a result, even appropriately prescribed opioids fora specific patient can lead to significant harm toanother, if that person takes the pain medicationsnot prescribed to him or her.Moreover, the amount of opioids prescribed byphysicians following surgery appears to be trendingupwards. Between 2004 and 2012, opioidprescriptions increased by 18%. Further, in 2012,70% of opioid-naïve patients who had a low-risk,minor surgical procedure, filled an opioidprescription within seven days of the surgery. 2017 Brought to you by the Commonwealth of Pennsylvania 2More recent data indicates that opioid prescribingcompleted at the time of surgery may have animportant impact on the risk for both chronic opioiduse, and the risk for development of substance usedisorder.In order to address the opioid epidemic, many havecalled for more judicious prescribing on the part ofphysicians and other healthcare providers.Orthopedic surgeons are the third highestprescribers of opioid prescriptions behind familypractitioners and internists. Therefore, orthopedicsurgeons have a unique opportunity to improvepatient outcomes through best practices related toproper assessment and treatment of pain thatincludes mindful opioid prescribing.1. General Opioid Guidelines:A. Patient assessment should include propermethods for pain assessment.i.Providers should understand thatwhile patient-reported pain intensity,most commonly obtained via thenumerical rating scale (NRS), canprovide important information, it mustbe incorporated into a morecomprehensive patient assessment.ii.Opioid prescribing decisions shouldnot be based solely on the NRS painintensity report.iii.Opioid prescribing decisions shouldalso be based on functionalassessment of patients, weighingpotential benefits opioid analgesicsmay have on function againstpotential harms.B. Patients benefit most from multi-modalityanalgesia and functional improvement.i.Opioids should rarely be used as theonly analgesic. Pain care can includenon-opioid medications, regionalanesthesia, and various modalities oftherapeutic and supportive care.

Safe Prescribing of Opioids in Orthopedics and Sports Medicineii.Providers should remember thatexercise,OMT(OsteopathicManipulative Treatment) , or psychotherapy (e.g.cognitive behavioral therapy) willoften ameliorate pain and improvefunction. In many situations, theseapproaches should be tried first andonly then should pharmacologicalagents be consideredC. Patients utilizing opioids previously who presentwith a new painful condition should be advisedthat they may not experience effective paincontrol.i.The administration of higher doses ofsystemic opioids may not lead toimproved pain control.ii.Opioid-tolerant patients are atincreased risk for opioid-inducedserious adverse events when opioiddoses are aggressively increased inan effort to obtain improved paincontrol.D. Discuss pain medicine strategy with the patientat the initial encounter. As it pertains to opioids,this should include the type of opioid, time periodto weaning, and time to cessation of therapy.i.We recommend documentation ofthis discussion in the medical record.E. For inpatient care, including surgical admission,complete and document a history and physicalexamination, including thorough medicationreconciliation, and document a diagnosis andtreatment plan. Pain care starts with a diagnosisand a treatment plan that includes goals of careand clear expectations for treatment.i.Discontinuation of opioid(s), orreferral for consideration of chronicpaintreatmentshouldbeincorporated in the treatment plan. 2017 Brought to you by the Commonwealth of Pennsylvania 3F. Act 124 of 2016 dictates that when initiatingopioid pain medication treatment, practitionersmust access and document review of dataavailable through the Prescription DrugMonitoring Program (PA PDMP AWARxE)databasei.The law also mandates query of thePDMP prior to every opioid andbenzodiazepineprescription,whether a new prescription orcontinuing therapy. Every query ofthe database should be documentedin the patient’s medical record.G. There are new Pennsylvania laws as of 2016which limit the prescription of opioids in specificpopulations, which may apply to orthopedic andsports medicine prescribers:i.No practitioner may prescribe a minor( 18 years old), more than a sevenday supply of opioids, unless in thedocumented medical opinion of thepractitioner longer therapy is needed,or the opioid is for cancer, palliative,hospice, or chronic pain care. If thereis only an authorized adult in chargeof the minor (no parent or guardian)no more than a 72-hr supply may beprescribed.(Act 126 of 2016)ii.No practitioner may prescribe morethan a seven day supply of opioids toa patient seeking care in anemergency department, urgent care,or receiving care at a hospital inobservation status (greater than 23consecutive hours of onsite services,not in the emergency department,while not admitted inpatient), unlessin the documented medical opinion ofthe practitioner longer therapy isneeded, or the opioid is for cancer,palliative, or hospice care. (Act 122 of2016)

Safe Prescribing of Opioids in Orthopedics and Sports Medicineiii.No practitioner in an emergencydepartment,urgentcare,orobservation status may prescribe arefill (continuation of previous orchronic therapy) of an opioid drugproduct. (Act 122 of 2016)H. Orthopedic patients and patients with sportsinjury are at risk for opioid misuse anddependence. Opioid abuse risk factors includea personal history of addiction, history ofaddiction in the first degree relative, or history ofconcurrent psychiatric illness.i.Prior or current history of substanceuse disorder should be assessed andopioids should be used with cautionin this situation. The prescribingprovider should be knowledgeableabout resources for treatment ofopioid use disorder in theircommunity and refer patients forcollaborativemanagementasnecessary.I.In general, opioids should not be prescribed incombination with a benzodiazepine, as the useof both medications significantly increases therisk of respiratory arrest and death.i.When opioids must be used incombination with benzodiazepines,the lowest dose of opioid while stillproviding effective analgesia shouldbe used, and consideration should begiven to careful monitoring ofadequacy of ventilation.ii.Consideration should be given to theprescribing of naloxone in patientsreceiving high doses of opioids (50100mg morphine equivalents) or inthose patients receiving opioids incombination with benzodiazepines. 2017 Brought to you by the Commonwealth of PennsylvaniaJ. 4Patients should be informed that all medications,especially opioids, should be stored in a secureplace, out of the reach of children.K. When opioids are no longer necessary for theindication for which they were prescribed, theyshould be disposed of in a safe manner andshould not be stored for future use. Pennsylvaniamaintains drug take back centers. Locations fordrug take back centers can be found px2. Orthopedic Opioid Guidelines: TraumaTrauma care can represent a particular challenge topatient-partnered approach to analgesia, dependingupon the extent of the trauma. Patient stabilityremains the initial and top priority, and the approachto trauma care should remain consistent with theAdvanced Trauma Life Support (ATLS) protocol.In studies, up to 20% of adult orthopedic traumapatients seek prescription analgesia after dischargefrom multiple providers. This can speak to bothlingering disability and significant pain of trauma, aswell as the increased propensity toward opioidaddiction with heightened dosing and duration ofopioid analgesia. It is for these reasons that theorthopedic trauma provider should, after stabilizationof the patient, consider the following:A. If opioids are administered with, or in temporalproximity to, a benzodiazepine or other sedativemedication, extreme caution should be observedwith regard to respiratory and neurologiccomplication, given the risk of morbidity andmortality.B. Depending on the type and extent of trauma,consideration must be given to the sedatingeffect of opioids with regard to preserving thevalidity of neurologic assessments. To this end,we refer you to the general guidelinesrecommending the lowest dose of opioid whilestill providing effective analgesia, adopting a