Becker's ASC Review

49 Executive Briefing Sponsored by: B efore 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 Elective surgeries may be on pause, but the opioid crisis isn't — The case for new pain management protocols

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