A new approach to orthopedic post-operative pain [PODCAST]

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“My brain is still struggling to comprehend the battle for the status quo a physician faces each day; one who must, by default, be cognizant of the lurking dangers of an opioid prescription, while also helping the patient on their swiftest way to recovery, led by the very same guidelines. But what happens when the patient slips on the road to recovery and out from underneath the physician’s caring cloak towards substance abuse? Whether the patient’s role changes at that very threshold is a different story. While it certainly is a part of this somewhat self-perpetuated epidemic, the struggle to keep a status quo has ancient roots and every physician has — if not knowingly so — sworn to abide by them when uttering the anecdotal resemblance of the Hippocratic Oath: ‘I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.’

But what if we dare to question the application of this ancient commitment on this particular matter? Should we have already done so, or can we afford to wait until the death toll reaches an unspeakable capita? Should opioids for postoperative pain even be permitted to dance on this slippery spectrum between adequate analgesia and addiction?

I wish the answer were that simple.”

Jesse Seilern und Aspang and Mara Schenker are orthopedic surgeons.

They share their stories and discuss the KevinMD article, “America’s prescription epidemic: Breaking an ancient promise.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Mara Schenker and Jesse Seilern. Mara is an orthopedic surgeon, Jesse is a postgraduate research fellow, and together they co-wrote the KevinMD article “America’s prescription epidemic: Breaking an ancient promise.” Mara and Jesse, welcome to the show.

Mara Schenker: Thank you.

Jesse Seilern und Aspang: Thank you very much for having us.

Kevin Pho: So I’m going to ask each of you to share your stories and journey to where you are today. Jesse, why did you go first?

Jesse Seilern und Aspang: Absolutely. So thank you for having us, first of all. I’m a postgraduate research assistant, and I am here at Grady Memorial Hospital on one of many journeys, I guess, for young aspiring surgeons. My story starts in Austria. This is where I was born, in Vienna, actually, the capital city of Austria. And so I spent a lot of my childhood and youth education in Europe, including Germany and the U.K. However, my undergraduate degree I earned in the U.S., with a sports scholarship, so my previous career was in athletics.

After that, I started to pursue a medical scholarship to become an orthopedic surgeon, which led me to be, you know, an apprentice of some sort and also a research fellow of Dr. Mara Schenker here in the U.S. And so this is how I ended up on this research team, roughly a year ago, and we’ve been doing great, great things in the research world ever since.

Kevin Pho: So Jesse is an aspiring orthopedic surgeon. In traveling down that path, what are some of the biggest challenges that you face thus far?

Jesse Seilern und Aspang: The challenges basically are just staying diligent, I think, keeping in mind the goal that you want to reach. As we all know, the road is pretty long. For me, it’s been especially long, since in Europe most medical schools are six-year programs, and knowing that going into medical school definitely helped: I will be in school for six years and then practice and train in orthopedics for five more years before becoming somewhat independent. But that road is the most fun part to me, you know, pursuing something that takes time, takes practice, and takes diligence. So to circumvent your question, nothing is really that hard. It’s more a question of whether you’re willing to do it or not.

Kevin Pho: Mara, can you please share your story and journey to where you are today?

Mara Schenker: So I grew up in Pittsburgh, Pennsylvania, and I also had a previous career in athletics. I used to do competitive martial arts, taekwondo; I did that for 20 years. I went to college at the University of Pittsburgh and medical school at the University of Chicago. I did my year of research out in Vail, Colorado, in orthopedics, which is very similar to Jesse and a lot of the people who I’ve mentored: I had a very similar research experience to what he has. And then I did my residency in orthopedic surgery at the University of Pennsylvania, did my fellowship at Harborview Medical Center in orthopedic trauma in Seattle, Washington, and I’ve been at Grady now since 2015. I recently took over as the chief of orthopedics for Grady and the director of orthopedic trauma, and I decided I liked school so much that I’m starting my MBA in January of this year at Kellogg.

Kevin Pho: And for those medical students who are interested in perhaps a career in orthopedics, what’s your biggest piece of advice?

Mara Schenker: I get asked this question a lot, and I always bring it back to my taekwondo story. When I was in college, I was doing taekwondo competitively, and I can remember somebody who was in a career advisory position saying, “Why are you wasting your time with this? You should be doing X, Y, and Z.” And at the time, that was what I was passionate about, what I absolutely loved, and I remember thinking, “Well, that’s not great advice, because this is what I enjoy.” And then, the day that I won the world championships, no one has asked me that question ever since.

I was asked to walk a predictable line, and I said, “You know, this is not where my passion actually is.” And then, when I demonstrated that I had what it took to be very successful in that world, all of a sudden all of those doubts and fears went away. And so my advice to students is: Do what you’re passionate about, do what you love, and do what you love well, and the rest will just fall into place.

Kevin Pho: And you also mentioned in your story that you’re pursuing an MBA degree. Why is that?

Mara Schenker: Yes, I also get asked that question a lot. My interest right now is in the intersection between health informatics, so the medical record and data, and efficiency and cost containment, and trauma care in particular. And I think there is a huge gap. I think a lot of other industries have figured out how to navigate the data better than health care has. And so my interest is in potentially working with, partnering with, industry to bring some of the other technologies that have been developed for other industries into health care, specifically on the informatics side of things.

Kevin Pho: Wonderful. So let’s transition into the article that both of you are among the co-authors of. It’s titled “America’s prescription epidemic: Breaking an ancient promise.” Jesse, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you guys decided to co-write it?

Jesse Seilern und Aspang: So I guess I’ll start with the inception of this article and when this idea was created to actually put it to paper. It was during one of our research meetings that we have weekly with this academic community partnership with the Christopher Wolf Crusade, which is an NGO committed to patient education and a behavioral approach to pain management, especially in light of the opioid epidemic and those staggering. Dr. Schenker has established a great partnership with them to do some research projects, seeing how the implementation of this strategy actually works in the orthopedic trauma setting.

So in one of these meetings, we were discussing the situation of a patient coming out of the CVS pharmacy with a full bottle of prescription medication, and that full bottle of prescription medication is opioid medication. And it’s actually well intended by the physician and whoever was involved in the clinical care of this patient. However, at some point there was just a loop, maybe, I guess, just a hole in the treatment or in the timeline, where the patient did not receive education on these opioids.

And most of us know someone, or even know someone who knows someone, who has had problems with addiction in the past. Walking with a full bottle of these pills to the car or out of the pharmacy, unknowingly having a really high potential for side effects, or that risk that’s associated with these medications, was a little bit, you know, staggering. It can also give you some goosebumps thinking about it, if it’s your wife, if it’s, you know, a person who’s dear to you, and all the things that could happen if the patient is not educated on these medications. So that was basically the inception of the article.

And this idea perpetuated to where everybody knows one, so to say, and in this case, it was a dear family member of mine who received one of these medications. And there is just that conflict that a physician has, by actually treating the patient and giving the patient adequate pain control but, on the other hand, knowing the effect that it can have if something goes wrong. There are numerous scenarios: The patient forgets how many to take, takes one too many, or maybe two too many, or the patient even leaves the prescription medication unattended in a children’s room or somewhere else, or somebody who has access to the medication stash can actually reap those, you know, negative side effects that this full prescription bottle could bring, if the patient is not educated properly on it.

So to bring this conflict to light, this article was created to basically illuminate that we physicians swear an oath to protect the patient, but also, you know, not to overtreat a certain injury or overtreat a certain condition to where it actually could harm the patient. And this is the fine line that we’re trying to find, or at that time were trying to find, on how to best navigate that situation if it ever arises. And I think we have a couple of answers to this, and one of them is based in our many research avenues with this community academic partnership with the Christopher Wolf Crusade here, which we can talk about in a little bit.

Kevin Pho: Jesse, when you say that patients are not adequately educated about the dangers of opioid medications post-op, what exactly do you mean by that?

Jesse Seilern und Aspang: So I guess there could be a generalization that I was stating. However, it is a generalization that I’m willing to make, just to raise awareness of this point. You will see some patients who, for one profile, are prescription-abiding patients who take the medication as prescribed, thinking that that has a protective effect against, you know, the risk of addiction or anything else of that sort. And then you have patients who unknowingly take medication just because of the fact that they have a lot of pain, and do not know of the risk of addiction.

So we find that, especially in the orthopedic trauma setting, patients who get hit by pain and are opioid naive, in a better sense of words, who have never had opioid medications before, do not necessarily know what the medication is, or how to deal with the medication, or if there are even other ways of treating their pain. So for them, this opioid is something new. And as we all know, it’s a stressful time. If you come into the orthopedic trauma population with a severe injury, you most likely will remember only half of what your health care team has discussed with you. And it may be that at one point medication abidance was discussed with you and you forget, or it may even be that this completely fell through the loops, and you did not discuss with your physician or with your discharging nurse the schedule, the risk factors, and the side effects that you should be aware of when taking these narcotics after you get discharged from the hospital.

Kevin Pho: Mara, can you take us through a sample post-op course, especially when it comes to post-operative pain? What normally happens after an orthopedic procedure in terms of managing post-op pain? Take us maybe through a journey from the post-op course in the hospital through discharge from the hospital.

Mara Schenker: Sure. So what I do is a little bit different from a lot of orthopedic surgery, in that our surgery is unplanned. And so the patients are coming to us with a significantly painful injury, and we haven’t had an opportunity to discuss pain control afterwards with them. And so that is challenge number one. We have done everything we can, prior to this partnership with the Christopher Wolf Crusade, to standardize our prescribing practices, so making sure that, you know, you have X, Y, and Z, that here’s your taper that you’re going to be on for a period of time after your trauma, with the goal of getting everybody off of opioids within six weeks.

And one of the challenges that we came up against was that there are not a lot of great alternatives. And so I was trained, I mean, we were all trained, that, you know, a patient has a score: You’re asked your pain score, 0 to 10. Somebody has a pain score of 5, and the answer to that pain score of 5 is a medication. And so that’s a problem.

And one of the solutions that we’ve come up with is that we actually have a new member of the health care team. It’s called a life care specialist, who is there both to educate on the opioid side and also to provide patients with alternative, behavior-based strategies for pain management after trauma. And so that’s now become a part of our course in the post-operative process, and that alone has made a huge difference, because it does give them an alternative. They feel like people are paying attention. They have a human being who’s there to be able to give them personalized, like, “Here is an opioid. Here are the risks of opiates. We understand that you have pain, and there are other options for managing your pain outside of a pill.”

So that has worked extremely well for us. We’re still in the research phase there. We have four life care specialists at Grady right now in our orthopedic trauma department, with the hopes and plans to expand to more. I think it’s made a huge difference. When you look at how we’ve approached the opioid epidemic in the past, it’s all been very prescriber-focused, so reducing the number of pills that I prescribe. This is very patient-centric, so it’s prevention, but it’s also acknowledging that pain is very real and that we have other options outside of the pills.

Kevin Pho: Mara, when you talk about behavioral approaches to pain management, what exactly do you mean by that?

Mara Schenker: Sure. So they teach them mindfulness strategies. We use the Community Resiliency Model, which is something that’s been well described in other industries but hasn’t necessarily been used in the orthopedic trauma population for pain. And we use deep breathing, reflective listening, motivational interviewing, and things along those lines. But we also very much get into the patient’s background, so we ask a lot of social determinants of health questions and prior substance use questions, and really acknowledge the pain and the patients, where they’re coming from.

Kevin Pho: And what exactly would that look like in terms of follow-up for this behavioral approach to pain management? Would they be in contact with some type of clinician or coach several times a week? What would that look like?

Mara Schenker: Sure. So right now, we’re still in the process of trying to figure out what that is and who the best patient is to work with a life care specialist. They see our patients whenever they’re in the inpatient setting, and right now we’re following them up to three months postoperatively, ideally to get them to the point where they’re no longer needing medications. And we’ll see. I mean, some patients may need shorter-term follow-up. Like, if I were a patient, I might just need somebody to come in and check in with me and say, “Hey, here are some alternative strategies for pain medication,” but you don’t necessarily need the opioid education side of things. But some people need the full opioid education and also need the continuous check-in.

And so that’s one of the perks of having a real human in this process: They’re able to, and they’re trained to, recognize how often somebody needs to be checked in with. And so we’re about halfway through our randomized control trial that we’ve been doing. We have a pilot series of about 120. In our current study, we’re about halfway through, or a little over halfway through. We should have findings by, hopefully, next summer to help us define what this looks like.

Kevin Pho: And Jesse, have you run into any obstacles or roadblocks when it comes to implementing your program?

Jesse Seilern und Aspang: Not necessarily. The only point I would want to make is that with orthopedic trauma, we are basically exposed to patients who are at a higher risk for any type of substance abuse, really. So I think we’re definitely hitting the nail on the head by implementing these strategies in this population. As we all know, it’s really feasible to do it in the elective surgery population: We have all the time we want and all the time we need to educate somebody before the surgery. But with an orthopedic trauma patient, we don’t. And on top of that, we have the high risk of the orthopedic trauma patient already having a propensity for these associated factors, you know, with addiction and substance abuse. So I think the challenge of getting to that patient is really just, like Dr. Schenker pointed out, knowing that patient, knowing the profile of that patient, in order to tailor some of these behavioral strategies.

Kevin Pho: We’re talking with Mara Schenker and Jesse Seilern. Mara is an orthopedic surgeon, Jesse is a postgraduate research fellow, and together they are among the co-authors of the KevinMD article “America’s prescription epidemic: Breaking an ancient promise.” Now I’m going to ask each of you for your take-home messages to the KevinMD audience. Jesse, I’m going to have you go first.

Jesse Seilern und Aspang: My take-home message is that, you know, given the current pandemic, we shall still not forget that the opiate epidemic is, you know, still not a problem of yesterday. It’s quite recent in everyday lives, and, you know, even though it’s not making the same headlines as COVID-19 at the moment, it’s still a serious issue in the United States, and it’s not really close to being resolved. So I think focus, on the research side and also on the clinician side, should still be put on this. And what we’ve learned so far is that patient-specific and patient-centric education is definitely a feasible way to pursue some of these problems that the opioid epidemic has brought.

Kevin Pho: And Mara, what’s your take-home message that you want to leave with the KevinMD audience?

Mara Schenker: Sure. My take-home message is that we need to really think about the patient when we’re looking at strategies for pain management and reducing the risk of the opioid epidemic. Prior focuses have mostly been on the prescriber side, and I think we have a lot of work to do on the patient’s side.

Kevin Pho: Mara and Jesse, thank you so much for sharing your time and insights, and thanks again for being on the show.

Mara Schenker: Thank you.

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