Sports Medicine Can Do Without Opioids

Beating Back an Epidemic

The problem of opioid addiction now affects us all. For me, the biggest shock came when one of my patients, former National Football League quarterback Erik Kramer, tried to commit suicide after his 18-year-old son, a high school quarterback, died of a heroin overdose.^[1]

It's a vivid illustration of the way the ripples from drug abuse are becoming a tsunami that destroys not only the addicted but everyone around them. As sports physicians, we must do our part to beat back the waves, beginning with our approach to controlling patients' pain.

The magnitude and complexity of the problem makes it truly daunting. In the year ending July 2017, a total of 66,972 people died of drug overdoses in the United States, a 14.4% increase over the previous year. That includes more than 115 deaths from opioids per day.^[2]

These overdoses are killing Americans at a faster rate than the AIDS epidemic at its height. They are killing more than the number that die from traffic accidents or suicides. More have died from opioids than were killed in the entire Vietnam War.^[3]

Paving the Road to Devastation

To understand how we can stop this epidemic, it helps to know how we got here. In the 1990s, drug makers convinced doctors' associations and government policy makers that new formulations of opioids such as OxyContin would not addict patients, and that they were essential to control pain. Prescriptions soared.

But patients did become addicted. One study found that 8.2% of patients who took opioids for the first time after total knee arthroplasty were still using them 6 months later,^[4] despite weak evidence that the drugs are effective for chronic pain management.^[5] Not only does abuse of these prescriptions kill thousands, but for many people, these medications serve as a bridge to illegal drugs.^[6]

The amount of opioids prescribed in the United States peaked in 2010, but doctors still wrote 70 opioid prescriptions for every 100 people in 2015, three times more than in 1995 and four times more than in Europe.^[7]

Protecting, Then Empowering, Patients

For the clinician, the phenomenon poses a complicated challenge. We cannot ignore our patients' pain. But we usually can't tell which patients are at risk for addiction. We also usually don't know when they are suffering from other mental health problems.

To play our part in addressing this national problem, sports physicians must start by recognizing the magnitude of it. I'd like to see addiction come out of the closet. It should be a medical diagnosis like any other, so that patients can freely discuss whether they have struggled with it in the past, gone through rehabilitation, or are still misusing drugs.

As it stands, most people can't get coverage for addiction treatment, and rehabilitation programs are relegated to the margins of medicine. As physicians, we must attend to the psychological, emotional, and addictive aspects of our patients' lives, even when the healthcare system does not.

Sometimes we can make a difference in surprising ways. When I was in medical school at Washington University in St. Louis, Missouri, I trained to run a marathon. Every day I ran to the hospital. One day I passed my patient who was at the hospital for mental illness, and he asked me why I was running. I told him it made me feel good.

"Would it make me feel good?" he asked.

"I bet it would," I answered. And after getting permission from his head physician, I took him for a run. He could barely run a quarter mile, but he came back saying how good it made him feel. So the next day we ran again, and the next day after that.

I believe that exercise empowers people to discover that solutions are within them. It would be naive to think that running is all that the average patient needs to recover from addiction. But in combination with behavioral modification and addiction medications such as methadone, it can provide powerful benefits.

Identifying High-Risk Patients

I've found it essential in my practice to develop relationships with rehabilitation programs to which I can refer my patients. I've referred some to in-patient 30-day detoxification followed by outpatient rehabilitation. Other patients come to me already enrolled in rehabilitation programs.

In Malibu, there are several programs that attract patients from around the world. They come to me with sports medicine problems while they're in town. It's very important to be aware of the complexity of these patients and work closely with their other physicians to coordinate the medical management with the addiction therapy, especially to know which drugs to prescribe and which ones to avoid.

I've also treated patients who injured their knees because a drug abuse problem led to a car crash. These patients may be enmeshed in legal problems and enrolled in rehabilitation but are continuing to abuse drugs and are unable to comply with my advice for recovering from surgery.

These very complex patients require careful management. I spend a lot of time on communication when treating them, trying to preempt problems. To provide such patients with the best possible care, I have worked closely with rehabilitation programs, such as Beit T'Shuvah in Culver City, California. With runners enrolled there, I've talked about the principles of my book, The Win Within, which shows readers how to modify their own behavior.

Non-opioid Pain Management

The second step we can take to prevent opioid abuse is to address our patients' pain carefully and systematically so that they can manage without opioids. My goal is always to create for my surgery patients an experience that is devoid of pain. I follow the motto "No pain is your gain," because it's not just the best approach for my patients' health; it's the best possible way to promote my practice.

A lot of surgeons routinely send patients home with prescriptions for 30 hydrocodone/acetaminophen or oxycodone tablets. I've moved away from prescribing those drugs, along with codeine and most of the other opioids, because of my concern about addiction.

Instead, I rely on preemptive blocks and long-acting liposomal local anesthetics. Typically, I inject ketorolac into the area around the joint before, during, and after the surgery. After surgery, I prescribe a variety of acetaminophen and nonsteroidal anti-inflammatories. I recommend ice, compression, and sometimes electrical stimulation. Only when these measures fail do I prescribe tramadol, a synthetic opioid. It does have some addiction potential, but much less than hydrocodone, codeine, or oxycodone.^[8]

I also have a discussion upfront with the patient about my strategy to create a pain-free experience for them. When patients ask for opioids, I tell them I'm very effective at pain management and that my surgical technique aims to avoid causing pain in the first place.

That works about 98% of the time. Over the years, a handful of patients have tried to manipulate me for opioid prescriptions. For this reason, I pay close attention to the reports I get from central databases that track patients' prescriptions from one pharmacy to another.

The most dramatic report I ever received concerned not a patient but another physician, who got the license and Drug Enforcement Agency numbers of several of his colleagues. I got a report saying that I'd written about 30 prescriptions for him in 1 year. Several of us spoke to him, and he entered a rehabilitation program.

Success in managing patients' pain requires careful monitoring. I ask patients to score their pain on a 1-10 visual analogue scale. Not only does this help me analyze the situation of an individual patient, but it allows me to evaluate my success across my practice by averaging the scores of dozens of patients. And by participating in the Arthrex Surgical Outcomes System, I can compare my results with those of other physicians. I challenge all physicians to take on this level of pain management.

No Easy Fixes

Although I feel confident in my approach, I also think surgeons' options are limited until our healthcare system finds a better approach to mental illness. Many people become addicted to opioids not because they got prescriptions after surgery, but because it's the only way they know to douse the flames burning inside their heads.

So the problem is going to require attention from politicians as well as doctors. The purple ribbons that some members of Congress wore at the State of the Union Address in January provided a reminder of the problem, but we need much more than that. As I write this, we don't even have an administrator for the Drug Enforcement Agency.

All of us must work together to develop comprehensive solutions of prevention and caring to bring an end to this crisis.

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