Surgeons’ Estimates of Opioid Needs Highly Variable

Orthopedic Surgeons’ Estimates of Opioid Consumption Following Total Knee Arthroplasty Found Highly Variable – Pain Medicine News – Dec 2019

A survey has uncovered wide variability in how orthopedic surgeons interpret their patients’ postoperative opioid consumption after total knee arthroplasty (TKA).

I find it odd that the leading sentence of this article talks about the “interpretation” (not estimate) of their patients’ postoperative opioid “consumption” (not need).

the researchers surveyed 36 orthopedic surgery residents, fellows and attendings at the institution. Respondents were asked to estimate the percentage of patients using opioids in the month before undergoing their TKA, as well as one to three months postoperatively.

It seems nonsensical to ask a doctor what percentage of patients were using opioids before a surgery they performed when they may not have been that patient’s doctor previously.

Patients who were on opioid maintenance therapy were excluded from the analysis.

I don’t see how they differentiated “opioid maintenance therapy” from “the percentage of patients using opioids in the month before”.

This kind of convoluted “reasoning” is typical of opioid studies because the straight data too often points to the effectiveness of opioids and lack of harm. Therefore, researchers find strangely staged scenarios and establish all kinds of obscure criteria to find a way to collect data that will make opioids look like a bad option.

Estimates Accurate on Average, But Disparate

These answers were then compared with data from 189 adult patients (mean age, 69.9±10.1 years) who underwent primary TKA at the institution over an eight-month period, from 2017 to 2018. Demographic data were extracted from electronic health records, whereas opioid prescription data came from the CURES database.

Patients’ mean ASA physical status was 2.6±0.5; they consumed a mean of 165.0±180.8 morphine milligram equivalents during their inpatient stay.

This is statistical nonsense. The standard deviation/amount of variation (180mg) is greater than the average dose (165mg). This means there was so much variation in the data that “averages” are meaningless.

As the Table illustrates, surgeons’ mean estimates of patient opioid consumption tracked closely with actual postoperative opioid prescription fills, which the researchers used as a surrogate for opioid consumption.

Table: Patient Opioid Consumption Over Time
Surgeons’ Estimates Actual Use
Within 30 days of surgery, % 23.5±18.9 14.8
One month after surgery, % 53.6±23.9 51.3
Two months after surgery, % 23.7±12.4 22.75
Three months after surgery, % 12.5±7.7 16.4

Yet as accurate as the surgeons may have been on average, the investigators were surprised by the wide variation in their responses.

It seems these researchers know nothing about individualized medicine, which is now actively promoted and pursued by the National Institute of Health, most cancer centers, and the most expensive pharmaceuticals.

“If you look at the data point scatterplot, they’re all over the place,” Dr. Lii told Pain Medicine News (Figure).

Yes, and that’s as it should be due or the amount of individual variation in our current health status, past history with opioids, age, occupation, and the rest of the zillions of differences between us.

“You have some surgeons who believe that none of their patients need opioids and subsequently estimate very low numbers of patients who use opioids. And then, some surgeons think their patients are in pain all the time and all of them need opioids.”

More Education Needed

No amount of book learning can trump personal experience. The best possible, and perhaps the only way for anyone to understand pain is to have it themselves.

2 thoughts on “Surgeons’ Estimates of Opioid Needs Highly Variable

  1. Kathy C

    These kinds of “studies” are an attacks on science and credibility. It is all cherry picking and paltering! The most striking fact is that not al of these surgeries turn out well. Some people postpone these surgeries, for years, relying on pain medications or they become de-conditioned, from years of inactivity due to the knee pain. There were numerous cases of failing implants, post surgical infections, and other adverse events. Of course none of these studies, ever include the full range of factors involved in these surgeries. Depending on the outcome they are seeking, they always choose the patients who will provide the outcome they want.

    To prove that opioids are bad they would choose patients who were already on opioids, perhaps due to one or more previously botched surgeries. The FDA hid millions of device reports, and the surgeons had to replace these knee implants, often multiple times. These adverse evens were also accompanied by. sepsis and infections. Patients who had multiple knee joint replacements after these failures, would have spent years unable to walk so they became de-conditioned. These industry funded, medical researchers would have either selected out the patients who experienced, multiple surgeries, post op infections, and years of chronic pain, or included them selectively, without mentioning the history.

    What is the most obvious and stunning, is that these surgeons report no adverse events ever. These have been left out of the conversation entirely. They have even come up with false narratives about how it was the patients fault, there were complications. When these surgeons chose to misreport adverse events, mislead the public about complications and cover up for the device industry they drank the Kool Aid too. Since the complications are not tracked in any of the data, many of these surgeons would not even know the rates of infection, failed implants and other adverse events. If a patient reported post op pain, the goal would be to ignore it, and pass them along to another practitioner. The records could be be redacted too.

    We are living in the age of alternate facts. Surgeons hid the device failures, and covered up for the industry. Since the FDA had hidden the facts, it was relatively easy. They also found psychologists willing to characterize patients with device failures, as deserving of blame. There was no real incentive in the medical industry, to protect patients, it was a lot more profitable to do these surgeries multiple times. CMS never flagged any of this, they just continued to pay, even when the same patients had multiples of the same surgery. Many of the patients who suffered “complications” were older and easy to explain away, as lifestyle choice or that they had the wrong mindset. They paid psychologists to speak at their pharma and industry meetings, to tell them just that.

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