For the past year and a half, orthopaedic trauma surgeon Babar Shafiq has implemented a pain alleviation protocol for trauma patients that has reduced opioid prescriptions by approximately two-thirds, and he plans to further reduce that number by half in an upcoming prospective study. “It has been very successful,” says Shafiq, who is also an assistant professor of orthopaedic surgery. “Before this protocol, many people were prescribed up to 120 pills on discharge, and now we are prescribing them 42. Patients are not dissatisfied, as some would expect. We have also noticed that patients are not requesting refills as much as they used to, despite being given far less of these medications, because we have incorporated multimodal treatment.”

During the height of the opioid epidemic, Shafiq recognized the need for a standardized way to treat orthopaedic trauma patients, so he partnered with anesthesiologist Marie Hanna, director of Johns Hopkins’ Acute Pain Service and the Perioperative Pain Clinic, to create a new pain-alleviation protocol. Together, they developed what Shafiq describes as “a full complement of effective pain alleviation strategies” that can be implemented easily by providers.

The pain alleviation protocol involves two pathways, one for opioid-naïve patients (patients without significant prior opioid history) and another for opioid-tolerant patients (patients with chronic opioid use and those with dependence on illicit opioids). These protocols involve preoperative multimodal treatment with acetaminophen, gabapentin, cryotherapy and elevation, as well as patient education. Intraoperatively, patients receive non-steroidal anti-inflammatory drugs, ketorolac (which is very effective for pain relief) and regional anesthesia. The treatment pathway for opioid-tolerant patients uses this multimodal approach but also incorporates acute pain services, ketamine and longer-acting nerve blocks. Postoperatively, patients receive the same multimodal regimen as preoperatively, with limited narcotics and an aggressive 10-day weaning schedule. “We give them prescriptions that will last two weeks, but I meet with each patient and explain that I really want them to stop these medications in three to seven days,” says Shafiq.

For opioid-tolerant patients, the Perioperative Pain Program led by the anesthesia department assists with long-term medication weaning, with the goal of returning patients to their baseline narcotic use or no narcotic use at all. “Patients are very happy with this program,” says Shafiq. “It helps provide opioid-tolerant patients with individualized pain alleviation strategies postoperatively when their pain was often under-alleviated before. Before the protocol, opioid-tolerant patients would be prescribed the same prescription as opioid-naïve patients, but they would use it all very rapidly. This was problematic, but we have a program for them now. We have a solution.”

Shafiq’s future research will focus on multi-center studies to help understand the ethical issues regarding pain alleviation in orthopaedics and to develop best practices that include medication-related and psychosocial treatment. Shafiq admits, “There is a psychological component to pain that we do not manage well. Self-efficacy and pain catastrophizing are important concepts that can affect a patient’s recovery. These are phenomena we are starting to understand better, and I am trying to incorporate these concepts in my treatment of patients.” Most importantly, he says, “We listen to the patient. We strive to treat the person, not just the fracture.”