I'm the co-director of sports medicine at MetroHealth in Cleveland, which is one of the other hospitals that's not the Cleveland Clinic. And just to let you guys know that even though we've been dealing with this COVID-19 crisis, we did have this opioid crisis beforehand and it did not go away. I'm gonna let you know what's been going on. Here's the MetroHealth sports team. We've got myself as a surgeon. I've got three payment art physicians that work with me. We are an all-female physician group. I'm kind of proud of that. Wasn't on purpose, but it's cool. My disclosures are boring. So we're gonna talk about what happened on the opioid crisis during the pandemic. We're gonna talk about future usage trends that we might be seeing coming out of this. And let's talk about how to preserve appropriate prescribing habits for your own practices. Orthopedic surgeons are some of the highest opioid prescribers and it's just a necessity of our field. We take care of fractures. We take care of injuries. We sometimes see chronic pain. So we do need to prescribe opioids. We can't get away from that. And everyone should be familiar with how we got here. In the 80s and 90s, there was a disproportionately high amount of opioid prescriptions going out. And then the Agency for Healthcare Quality and Research Study in 92 demonstrated that there was supposed to be a larger need for opioids in the country. This turned into the fifth vital sign and undocumented chronic pain protocols were now being used for acute pain and became a requirement for accreditation. And then in 2008, for the first time, drug overdoses overtook motor vehicle accidents as the leading cause of death in our country for the first time in history. It has not stopped. In about 2012, there was a big push for states to ramp up their prescription drug monitoring programs and now every state has one of those to control and to tabulate the controlled substance uses in that state. In 2016, the CDC did issue an advisory about how to manage chronic opioids, but it seems like the train had already left the station. In 2017, a national public health emergency was declared that we were in an opioid crisis. There was a White House special summit the next year and the economic report that year revealed that 2.8% of our gross medic product was going towards the opioid epidemic. And a law was passed that year to establish a lot more funds to fight this. And after the initial battle to get all the pill mills closed, next the states started to turn towards enforcing laws for their own constituents. So this is just some samples of what was going on in Ohio. Every single month, the monthly reports were finding doctors who were not paying attention to the laws and getting caught. Sometimes they were prescribing for relatives. A lot of times it was just a few patients following the law that got them caught. They were having license suspended, license sanctioned, and sometimes licenses pertinently revoked. And then on a national level, the Controlled Substances Act is the law that regulates controlled substances and controlled prescriptions across the country. And the attorney general decided to use this to file civil injections against physicians, which is the first time this has happened. He started in Ohio and doctors started going to jail sometimes for life. So we saw the educational opportunities increase dramatically from this. At the Academy meeting in 2019, there were about 151 educational opportunities that reflected the opioids. So this worked. We started to see the opioid prescription rate decrease between 2006, 2019. Doctors across the country took control of this and reduced the amount of substances we're getting in the community. Unfortunately, this did not change the deaths that we were seeing. It just changed the origin of the drug, where they were coming from. You can see here that the overdose deaths from natural and semi-synthetic opioids, which is what we usually prescribe, oxycodone, Vicodin, whatnot, those kind of start to flatten out. But the amount of synthetic opioid deaths really started to skyrocket. Then in late December 2019, a novel coronavirus showed up in Wuhan, China and circled the globe. We all remember what happened after that. Nationwide shutdown here in 2020. Major increases in stress, isolation, a lot of mental health issues, even in people who haven't had problems before. Those who did have mental health issues had their therapy appointments canceled, had difficulty accessing drugs. And this was right around the same time that there was an easier access to the synthetic opioids. So the pandemic plus the opioid epidemic created the perfect storm for substance abuse disorders. In 2020, drug overdose deaths in this country went up 30%. In 2021, they went over 100,000 deaths for the first time in history. Is this because of the prescriptions? No, we're still lowering the number of prescription drugs that are out there. So it's no longer the pharmaceutical source that we're seeing these deaths come from. Meantime, during the pandemic, there were some judicial actions going on to help address one of the sources of the large amount of opioid deaths in the country. The largest generic opioid manufacturer settled a $1.6 billion settlement for their role in things. The McKinsey firm, who was the drug consultant for Purdue Pharma and a lot of other manufacturers settled for $573 million. And then Purdue Pharma settled a number of lawsuits across several states and eventually just dissolved the company. That was the company that came out with OxyContin in the 1990s. Bringing this down to our level, what was going on with sports and with sports medicine? We all know our team athletes became isolated. They had their loss of social and peer groups. They didn't have their normal exercise routines, which in a regular athlete could make you depressed. If they had depression, it was already gonna be exacerbated. And a lot of my football players, I take care of a women's professional football team in Cleveland, a lot of them said that they used football as one of their techniques to manage their mental health. And they would exercise and train all year just to get on the football field and just to smash people. And that's what helped their anxiety and helped their depression. And the loss of that caused a ton of stress for these ladies. After COVID-19, we've all seen this in the office. People ramped up, sports returned, and a lot of athletes came back too fast, too soon. They weren't used to training. There were some pretty high injury rates. There was a presentation at the academy just earlier this year that was documenting how much higher the injury rates were. And that unfortunately leads to a higher risk of loss participation again, because while you are out trying to get your injury better, you're not gonna be able to participate in sports again. This, if you think about this, creates a theoretical higher risk of being exposed to a surgery and again, to having an opioid exposure. So where do we go from here? How are we going to address this problem going forward? You've gotta know the tenets of basic prescription rules around opioids. You have to know your state laws and make sure you abide by them. You have to protect your passwords to your EMR. Don't share them. That way no one else is gonna be prescribing under your name. I don't think anyone has paper prescriptions anymore, but if you do, don't sign them blank. You have to document the reason for opioids. You have to give an appropriate reason that patients require the medication. You need to educate patients as to why we don't prescribe opioids much anymore, the risks behind them, and let them know that a state agency is monitoring their prescriptions. Sometimes that gives them a little pause as do I actually want this prescription now? And be aware that we have to treat patients' pain appropriately, but there are always gonna be drug seekers. They are out there. The leader of our special investigation unit said that you may not be seeing them, but they are seeing you. Know that people who have mental health issues are at higher risk for abuse. If they have depression, alcohol or substance abuse, personality disorders, a history of sex abuse or chronic pain, they're gonna have a higher risk of developing an addiction and developing a problem with opioids and controlled substances. If you don't have a multimodal pain protocol in your practice, now is the time to do that. There's been a lot of research proving this really reduces the amount of opioids that are gonna be used in your office practice. This slide is not in my handout, so if someone wants to take a snapshot of this to get kind of a high-level overview of what a multimodal protocol looks like. If you're doing a major surgery, you consider doing preoperative NSAIDs or COX-2 inhibitors. They will dampen the response of the nociceptors and they give an opioid sparing effect afterwards. Regional blocks, spinal blocks, local anesthetics are very useful. Numb nerves equal dumb nerves. If a nerve is numb before it's been cut, sometimes it wakes back up and it never knows that it's been cut, so that's very useful. Some surgeries will benefit from antineuropathic agents. If you're working inside a joint at the end of the surgery, consider putting an anesthetic and a morphine inside there. Get your pain medicine at the source where it's necessary. Afterwards, put patients on scheduled anti-inflammatories and acetaminophen for a certain number of days. Round-the-clock medicine. Don't wait for the pain to catch up to them. If they stay ahead of it, they're gonna be less likely to need the opioid. Let patients know the opioids are for breakthrough. Right now, the AOS suggested guidelines for pain management is for moderate surgeries, things that are like an ACL or a shoulder scope, to do no more than 20 to 30 of the five milligram oxycodone pills for the total recovery. Also remind patients that there's alternative for pain management. Sometimes they're so used to hear us say, you have to ice this, you have to ice that. They don't realize there's actually science behind cryotherapy. They don't realize that the inflammatory response slows down in colder environments, and that's why we use it. Educate them, and that'll help. So in conclusion, initially, national and state interventions reduced the overprescription that we had been doing of controlled substances. Unfortunately, COVID-19 increased the illicit drug overdose deaths dramatically. We have to continue to educate patients and ourselves to avoid lending ourselves to this problem. We have to be mindful of the impacts of our prescribing decisions, and we need to use multimodal pain control strategies. This is a quote. Anyone who's seen me talk before knows I love this quote. In science, it often happens that scientists say, you know, that's a really good argument. My position is mistaken. And they would actually change their minds, and you never hear that old view from them again. They really do it. It doesn't happen as often as it should because scientists are human, and change is sometimes painful, but it happens every day. I cannot recall the last time something like that happened in politics or religion. That's Carl Sagan. That's a preeminent scientist from Cornell. So I had some people who helped me put this together. There's my MetroHealth crew. Thank you.

opioid crisis

COVID-19 pandemic

orthopedic surgeons

prescribing habits

prescription drug monitoring programs