Before COVID-19 drastically altered day-to-day life in the U.S., a different crisis was center stage. It was one of the country’s most significant public health issues of the last decade, linked to an estimated 72,000 deaths in 2017 alone.
That year, with the U.S. accounting for about 99.2 percent of total global hydrocodone consumption, HHS officially declared a public health emergency: the opioid epidemic.
A contributor to escalating unemployment, homelessness and opioid-related crime rates, the opioid crisis quietly continues as COVID-19 dominates headlines. With 3 million people still suffering from opioid-use disorder in the U.S., as Forbes reported in early April, it’s safe to say the epidemic will exist throughout the COVID-19 pandemic and beyond.
As the opioid crisis continues, so do orthopedic injuries. Providers cannot rest on their laurels when it comes to orthopedic pain management for two reasons: one, because people with opioid use disorder may be more vulnerable to COVID-19, and two, because elective orthopedic cases are delayed in 30-plus states, meaning patients will wait months — many in severe pain — for nonurgent surgeries to resume.
For providers also waiting for normal operations to resume, now may be the time to reevaluate pain management protocols before cases ramp up.
Orthopedic pain management strategies
A 2018 study published in Anesthesiology found a link between multimodal pain management and decreases in opioid use, prescriptions and complications for patients undergoing total joint replacement. Opinions vary on exactly which multimodal combinations are most effective, and providers must make decisions on a case-by-case basis.
Many hospitals and practices include cold therapy in their postoperative protocol for joint surgeries. In several studies, including one published by Orthopaedics & Traumatology: Surgery & Research in 2014 and one published in 2017 in the Journal of Arthroplasty, cold therapy has been shown to lower pain, decrease swelling and inflammation, and limit narcotic usage among patients.
However, cost-cutting measures have led hospitals to switch out motorized cold units for less expensive gel packs. But there’s a reason gel packs are less expensive.
The products can quickly warm up, creating additional work for nurses who must then replace them. For the same reason, traditional ice therapy may not deliver the same comfort that continuous cryotherapy does, according to a 2001 study by researchers at Durham, N.C.-based Duke University Medical Center.
In contrast, investing in motorized cold therapy lessens pain intensity for patients, the researchers found. Motorized therapy also “makes life easier” for both hospital staff and patient caregivers at home, according to Dayne Mickelson, MD, an orthopedic surgeon and sports medicine specialist with Proliance Orthopaedics and Sports Medicine in Bellevue, Wash.
“There is definitely an ease-of-use to the [motorized] unit, which stays cool for much longer and can be set up and then left alone while [providers are] still checking the skin every few hours,” Dr. Mickelson said. Additionally, motorized units provide consistent temperature control, which in turn improves outcomes compared to no treatment, according to a randomized study of 100 patients undergoing anterior cruciate ligament reconstruction. Notably, units such as Breg’s Polar Care Wave can provide a combination of cold therapy and active compression without demanding more involvement from care teams.
This combination gives physicians an even greater advantage when it comes to managing patients’ pain.
A match made in research
In 2016, Chinese researchers discovered that knee surgery patients who underwent compressive cryotherapy tended to have less pain than patients given cryotherapy alone, and their study concluded that compressive cryotherapy benefits those patients in early rehabilitation. The following year, researchers published findings that cryotherapy and intermittent compression resulted in “significantly” lower total blood loss and much less pain three days after total knee arthroplasty.
An even earlier study, which was published in 2012 in the Journal of Knee Surgery, concluded that the “use of combined cryotherapy and compression in the postoperative period after ACL reconstruction results in improved, short-term pain relief and a greater likelihood of independence from narcotic use compared with cryotherapy alone.”
The combined modalities can decrease the likelihood of narcotic use even more drastically than with cold therapy alone because they successfully alleviate pain and swelling, Dr. Mickelson explained.
“There are studies that demonstrate decreased pain [and therefore decreased opioid] requirements with cryotherapy,” he said. “Compression has been also shown to decrease swelling and inflammation, which we know improves early motion and rehab.”
Compelled by these and other findings, Dr. Mickelson uses cold therapy as part of his own multimodal pain management strategy. The compressive cryotherapy comes after prescriptions of Tylenol and nonsteroidal anti-inflammatory drugs, with limited narcotics prescribed for breakthrough pain. Both Dr. Mickelson and his patients are impressed by the results.
“We have found that the majority of patients undergoing sports medicine cases involving the shoulder and knee benefit from cryotherapy by decreasing inflammation and pain,” he said. “Athletes and trainers find it helps them rehab faster. For patients who are sensitive or tolerant to narcotic pain medications, this provides another means to decrease their dependence on them.”
Dr. Mickelson said he has had a number of patients “swear by their cold therapy systems” used to manage their pain after ACL or total knee replacement surgeries.
As part of a multimodal pain management strategy, the cold therapy systems enable patients to reduce — if not eliminate — their reliance on narcotics.
“They now recommend it to friends who have to undergo surgery as well,” he said. “Many come in now for their preoperative visit and already have one setup.”
Opportunities on the horizon
Patients will be seeking this kind of effective pain relief for orthopedic conditions after the COVID-19 crisis is contained and elective case restrictions are lifted — and practices will need to be prepared to help them despite pandemic-related financial hardship.
Outpatient facilities in particular can expect cases to surge. Joint replacement volumes are expected to grow by 77 percent over the next decade, according to Sg2, and Bain & Co. projected in September 2019 that nearly 30 percent of knee replacements will be performed in ASCs by the mid-2020s.
CMS has already taken steps to accelerate the migration of procedures to the outpatient setting, and specifically to ASCs. The agency added total knee arthroplasty to the ASC-payable list for 2020, indicating total hip arthroplasty could make the list in the near future.
Outmigration will continue even after surgery centers are converted into COVID-19 relief centers and tapped to serve in new capacities, some industry leaders say. By stepping into these unfamiliar roles, ASCs are making their value known, which may help further the transition of surgical care to the outpatient setting after the pandemic.
If analyst projections are correct, the rapid migration of total joints to outpatient settings is a given. Today, more than 300 ASCs offer total joint replacement in the U.S. Going forward, new outpatient total joint programs will be established, and physician experts will be put in charge of them.
One of the most important assignments for these physician leaders will be developing appropriate pain management protocols. These clinical decisions can have a tremendous effect on the continuing opioid crisis — and motorized cold therapy, which has been shown to reduce the need for narcotics, will be a valuable tool to have on hand.
“Our goal is to limit the amount of narcotics a patient needs while keeping their pain at a tolerable level,” Dr. Mickelson said. “Since cold compression therapy has been shown to lower pain scores, reduce swelling, decrease the need for opioids, and improve early objective motion measurements, it would be a natural part of the program to get them recovered and rehabbed as fast as possible.”
This article is sponsored by Breg.