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1.5 ANCC Contact Hours Perioperative Management for the Patient With Long-Term Use

Carina Jackman

In the nearly one in four patients present- patterns of preoperative opioid use. Approximately one ing for reports current opioid use. Many of these in four patients undergoing surgery in the study re- patients suffer from chronic pain disorders and opioid ported preoperative opioid use (23.1% of the 34,186-pa- tolerance or dependence. Opioid tolerance and preexisting tient study population). Opioid use was most common chronic pain disorders present unique challenges in regard in patients undergoing orthopaedic spinal surgery to postoperative . These patients benefi t (65%). This was followed by neurosurgical spinal sur- geries (55.1%). bitartrate was the most from providers who are not only familiar with multimodal prevalent medication. and hydro- pain management and skilled in the assessment of pain, chloride were also common ( Hilliard et al., 2018). but also empathetic to their specifi c struggles. Chronic pain Given this signifi cant population of surgical patients patients often face stigmas surrounding their opioid use, with established opioid use, it is imperative for both and this may lead to underestimation and undertreatment nurses and all other providers to gain an understanding of their pain. This article aims to review the challenges of the complex challenges chronic pain patients intro- presented by these complex patients and provide strate- duce to the postoperative setting. gies for treating acute postoperative pain in opioid-tolerant patients. Defi nitions Common pain terminology as defined by the Chronic Pain and Long-Term International Association for the Study of Pain, a joint Opioid Use consensus statement by the American Society of Addiction , the American Academy of Pain The burden of chronic pain in the United States is stag- Medicine and the American Pain Society (2001 ), and the gering. A National Health and Nutrition Examination CDC is as follows: Survey found that, in 2002, 14.6% of adults described Pain . An unpleasant sensory and emotional experi- localized or widespread chronic pain lasting greater ence associated with actual or potential tissue damage than 3 months. Another survey in 2003 determined that or described in terms of such damage. 43% of adults in the United States suffer from musculo- Chronic pain. Pain lasting greater than 3 months and skeletal pain conditions of various durations. Perhaps past the time of normal tissue healing. this prevalence of chronic pain led to the current rising Multimodal treatment. The concurrent use of sepa- trend of prescription opioid medications. The Centers rate therapeutic interventions with different mecha- for Control and Prevention (CDC) estimates that nisms of action within one discipline aimed at different 9.6 million to 11.5 million adults (equivalent to 3%–4% pain mechanisms (e.g., the use of pregabalin and opi- of the adult U.S. population) received a prescription for oids for pain control by a ; the use of non- long-term opioid in 2005. The trend continued steroidal anti-infl ammatory drugs [NSAIDs] and ortho- from 2007 to 2012, as opioid prescriptions per capita sis for pain control by a physician). increased 7.3% (Dowell, Haegerich, & Chou, 2016) Long-term opioid use. Use of on most days for Opioids continue to be prescribed routinely for manag- more than 3 months. ing chronic pain. The CDC now estimates that one in fi ve Addiction. A primary, chronic, neurobiological dis- patients in the United States with noncancer pain is pre- ease, with genetic, psychosocial, and environmental scribed opioids in offi ce-based settings for pain complaints. Adults 40 years and older, women, and non-Hispanic whites are most likely to be prescribed opioids (CDC, 2017 ). Carina Jackman, MD, Department of , Division of Pain This widespread use of opioids has implications in Medicine, University of Utah, Salt Lake City. the perioperative setting. Recently, a cross-sectional, The author has disclosed no confl icts of interest. observational study evaluated the prevalence and DOI: 10.1097/NOR.0000000000000526

© 2019 by National Association of Orthopaedic Nurses Orthopaedic • March/April 2019 • Volume 38 • Number 2 159 Copyright © 2019 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. factors infl uencing its development and manifesta- expectations regarding pain. The patient is placed on tions. It is characterized by behaviors that include one continuous pulse oximetry and the nurse performs fre- or more of the following: impaired control over drug quent assessments of pain, level of sedation, and res- use, compulsive use, continued use despite harm, and piratory status. He continues to use the craving. PCA overnight with adequate pain control. . A state of adaptation that is The acute pain service is consulted to help transi- manifested by a drug class-specifi c withdrawal syn- tion the patient back to oral medications on postopera- drome that can be produced by abrupt cessation, rapid tive day 1. Based on his total IV PCA use in the preced- dose reduction, decreasing blood level of the drug, and/ ing 24 hours, they recommend continuing his TD or administration of an antagonist. at his home level of 25 mcg/hour and transi- Tolerance. A state of adaptation in which exposure to tioning to oral oxycodone 15 mg as needed four times a drug induces changes that result in a diminution of a day. This oxycodone dose is three times his usual one or more of the drug’s effects over time. home dose. Acetaminophen is scheduled every 6 hours. On postoperative day 3, he is stable on his oral opioid dosing and ready for discharge. The RN and the physi- Case Study cian team both review a clear plan for weaning his oxy- codone down to preoperative levels over the next 2 HISTORY weeks. He is counseled to take his opioid medications A 56-year-old man presents for L4-S1 transforaminal only as directed. A follow-up appointment is planned lumbar interbody fusion for degenerative spondylolis- for a week after discharge to ensure he is successfully thesis. His medical history includes chronic low back tapering. pain, daily opioid use, and that is well con- trolled with sertraline. He works in a shipping ware- house for a furniture retailer. He reports approximately Current Trends in Postoperative 15 years of chronic low . He began taking opi- oid medications 10 years ago. Pain Management On the day of surgery, his home regimen includes a Review of the literature reveals that fewer than half of 25 mcg/hour of transdermal (TD) fentanyl patch in ad- patients undergoing surgery report adequate postopera- dition to taking oral oxycodone 5-mg tablets, four times tive pain relief. Approximately 80% of patients report a day. He does not have any history of opioid addiction. acute postoperative pain and 75% of those patients rate He did experience acute withdrawal symptoms when he their pain as being moderate, severe, or extreme ( Chou forgot to replace his fentanyl patch a few weeks ago. et al., 2016). Surgical patients with preexisting chronic pain and long-term opioid use are likely more at risk for PLAN poorly managed postoperative pain, longer length of hospitalization, and need for specialized pain manage- First, the surgical and teams identify that the ment services. An observational study compared 30 patient is at risk for poorly controlled pain postopera- chronic pain patients using opioids with 25 patients tively, given his chronic, high-dose opioid use. A pain managed without opioids. The opioid group had a much plan is established preoperatively and shared with the higher level of initial pain after surgery. Both chronic patient. This includes a discussion of his baseline toler- pain groups exhibited a much slower resolution of pain ance to opioid medications and the accompanying chal- following surgery when compared with patients with- lenges. This plan involves multimodal analgesia, intra- out chronic pain ( Chapman, Davis, Donaldson, Naylor, venous (IV) opioid patient-controlled analgesia (PCA), & Winchester, 2011). and consultation of the acute pain service postopera- These trends are signifi cant given that inadequate tively if necessary. postoperative pain control has many adverse effects. In the preoperative holding unit, the patient receives Normal respiratory and gastrointestinal functions are oral acetaminophen and pregabalin. The anesthesiolo- slower to return to normal. A heightened physiologic gist engages him in a detailed discussion about realistic stress response results from poorly controlled pain. This expectations for pain control after the surgery and pro- delays healing and increases risk for the development of vides reassurance that treatment of his pain will be a additional chronic pain ( Rajpal et al., 2010). Therefore, priority for the care team. The anesthesiologist confi rms there should be strategies in place to better care for the site of the TD fentanyl patch and routine dosing of these multifaceted patients. sertraline for depression. Intraoperatively, pain treat- ment includes and sufentanil infusions. Small dexmedetomidine boluses are titrated as the surgeon is closing and on arrival to the post-anesthesia care unit Challenges of the Chronic Pain (PACU). is infi ltrated around the inci- Population sion at time of closure. In the PACU the RN administers There are several central challenges to acknowledge in several doses of IV hydromorphone; however, his pain surgical patients with chronic pain on long-term opioid remains poorly controlled. A hydromorphone IV PCA is therapy. These challenges contribute to the burden of initiated. postoperative pain as well as the slower trajectory of On arrival to the orthopaedic fl oor, the inpatient pain resolution. Recognizing the following complica- nurse quickly establishes rapport, reviews the plan for tions may help providers to fully implement a compre- postoperative pain care, and confi rms reasonable hensive plan when treating these patients.

160 Orthopaedic Nursing • March/April 2019 • Volume 38 • Number 2 © 2019 by National Association of Orthopaedic Nurses Copyright © 2019 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. PHYSICAL DEPENDENCE OR TOLERANCE TO OPIOIDS Application for Practice and Most patients with prolonged opioid use have developed Treatment Strategies physical dependence and sometimes tolerance as defi ned These challenges of opioid tolerance or dependence, co- previously. Complex changes at the cellular and synaptic morbid affective disorders, and higher postoperative level are implicated. Tolerance involves many alterations pain burden and complications may be addressed with involving the opioid receptors including desensitization, specifi c strategies when managing these patients. In internalization, and downregulation. Dependence and 2016, the American Pain Society and the American withdrawal symptoms are related to opioid receptor Society of Anesthesiologists published Guidelines on the counteradaptation. Counteradaptation is defi ned as Management of Postoperative Pain . changes in receptor signaling pathways, specifi cally neu- Implementing many of these recommendations is es- rotransmitter release, that occur in response to frequent pecially critical in patients with chronic pain and long- exposure to opioid medications. For example, alterations term opioid use. There are multiple meaningful tools for in neurotransmitter release are known to impact de- orthopaedic nurses and advance practice nurses to im- scending pain modulation in the midbrain. plement in their practice.

COMORBID AFFECTIVE DISORDERS REVIEW HISTORY AND ESTABLISH RELATIONSHIP Depression and are prevalent among chronic First, based on a review of the and the pain patients. One study found that depression and anx- patient’s home medications, providers can identify at- iety symptoms predicted both level of pain and pain- risk patients. Second, a thorough preoperative evalua- related . Over half of chronic pain patients in tion including a history of chronic pain, medical and that study reported a burden of both depression and psychiatric comorbidities, substance abuse, and previ- anxiety symptoms ( Lerman, Rudich, Brill, Shalev, & ous pain treatment regimens and responses should be Shahar, 2015). Patients prescribed opioids for chronic performed ( Chou et al., 2016 ). There should be both a pain have more affective disorders and substance abuse pre- and a postoperative discussion with the patient when compared with patients not using opioids for about goals for pain control as well as realistic expecta- chronic pain ( Hilliard et al., 2018 ). Affective disorders, tions. Providing preparatory information about ex- most specifi cally anxiety, present unique obstacles for pected level of discomfort may be helpful (Gorcyzca, controlling postoperative pain and should be assessed. 2013). Both the physician and the nurse should contrib- ute to this discussion. ELEVATED RISK OF COMPLICATIONS AND PAIN Postoperatively, the orthopaedic nurse may play a pri- A review of the literature demonstrates higher compli- mary role in pain care by establishing a trusting relation- cation rates and postoperative pain in patients taking ship with the patient (e.g., by reassuring patients of their chronic opioids prior to surgery. Generally, preexisting confi dentiality and nonbias pertaining to their chronic chronic pain predisposes a patient to a slower rate of opioid use). Patients should be assured that controlling pain resolution after surgery. This trajectory of pain their pain will be a priority. However, the nurse should resolution is much slower in patients who chronically also reinforce the realistic expectations that were estab- use opioids ( Chapman et al., 2011). lished preoperatively. In addition, safety, specifi cally One study compared outcomes in 49 total knee ar- avoiding oversedation or respiratory depression, will throplasty (TKA) patients with either preoperative hold the same level of priority as achieving optimal pain chronic opioid use or nonuse. Those with chronic opi- management. Opioid tolerance may be an obstacle in oid use had a signifi cantly higher rate of complications. treating their pain; however, reassurance that the care Complications included revision or repeat arthroscopic team will implement all available multimodal strategies evaluation, prolonged pain, and recovery and referral should be emphasized (Taylor & Stanbury, 2009). for specialized pain management services (Zywiel, Overall, there should be education tailored to the in- Stroh, Lee, Bonutti, & Mont, 2011). Another prospective dividual patients regarding the plan and goals for their cohort study of TKA patients examined pain 6 months pain management as they arrive in the PACU or ortho- after surgery. Preoperative opioid users achieved signifi - paedic fl oor. This plan remains fl uid during their stay cantly less pain relief from the knee surgery ( Smith and the pain treatment plan may be adjusted based on et al., 2017 ). Furthermore, an extensive database review how adequate their pain relief is or any adverse effects including 324,154 patients 1 year after TKA or total hip that arise ( Chou et al., 2016; Mehta & Langford, 2006). arthroplasty found a similar trend. Opioid-naïve patients in the review demonstrated lower 30-day read- ASSESS, TREAT, AND REASSESS mission rates and were less likely to need an early surgi- Next, a validated tool should be uti- cal revision ( Weick, Bawa, Dirschl, & Luu, 2018). lized to track responses to treatment and to adjust treat- Overall, total postoperative opioid burden is also im- ment. The 2016 Guidelines on the Management of pactful. Another examination of population-based data Postoperative Pain includes a complete list of the vali- investigated how outcomes in orthopaedic surgery spe- dated pain intensity assessment scales. In general, they cifi cally are affected by levels of postoperative opioid use. include specifi c Numeric Rating Scales and verbal Higher opioid prescription levels postoperatively were rating scales as well as visual analog scales, Pain correlated to higher length of stay, cost, and complica- Thermometer and Faces Rating Scales (Chou et al., tion rates, specifi cally , thromboembolic, and 2016 ). In most patients two or more scales may be used gastrointestinal complications (Cozowicz et al., 2017). to more accurately characterize and track their pain.

© 2019 by National Association of Orthopaedic Nurses Orthopaedic Nursing • March/April 2019 • Volume 38 • Number 2 161 Copyright © 2019 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. Opioid Dosing if the established pain plan fails to provide adequate pain relief and the primary team is unsure of how to To avoid symptoms of withdrawal and adequately man- best proceed, consider a pain consult. Or, if the primary age acute-on-chronic pain, dosing of provider is uncomfortable escalating to higher doses of baseline opioids should be continued. Specifi cally, long- opioid medications, a consult is also warranted. acting opioids should be maintained at the same dose Depending on institution-specifi c guidelines, an acute and scheduling. This includes oral extended-release opi- pain service may need to be involved in continuous dos- oids, transdermal fentanyl, and implanted intrathecal ing of medications such as ketamine or dexmedetomi- pump infusions. The short-acting or immediate-release dine in the postoperative period. opioid dose should be increased or maintained based on postoperative pain assessment and after considering other multimodal adjuncts being administered. Alternative If the patient is unable to tolerate oral medications In addition, nonpharmacologic interventions should due to aspiration risk or ileus, the IV equivalent to the also be considered. Use of transcutaneous electrical oral opioid dose should be provided. An IV PCA method nerve stimulation has been validated in the postopera- may be employed if IV dosing is necessary for more tive period. Its success is dependent on the location and than a few hours and the patient has the cognitive ca- etiology of the pain. The American Pain Society guide- pacity to understand the delivery device. PCA dosing is lines found insuffi cient evidence to recommend acu- preferred over nurse-initiated intermittent bolus of opi- puncture, , or cold therapy as adjunct pain treat- oids ( Chou et al., 2016 ). Hydromorphone is most com- ments; however, their use is also not discouraged (Chou monly used for postoperative PCA dosing; however, et al., 2016). Certainly, thermal modalities as well as there is currently a nationwide shortage of hydromor- manual therapies to help with pain relief may be success- phone. may be considered as a substitution. ful in some patients ( Mehta & Langford, 2006). If hospi- Continuous pulse oximetry should be employed while tal resources provide massage or , this may on the orthopaedic fl oor, as opioid dosing is escalated allow for simple distraction and therefore pain relief. above baseline home doses. Care providers should also monitor sedation and signs of hypoventilation or hy- SUPPORT AND TREAT AFFECTIVE SYMPTOMS poxia. Pulse oximetry alone has a low sensitivity for de- Psychological interventions also play a central role in tecting hypoventilation, especially when supplemental pain control for long-term opioid patients. Patients oxygen is being administered. Nurse observation of men- with preexisting anxiety and depression should con- tal status changes and respiratory rate may be just as im- tinue their established pharmacotherapy. portant in preventing adverse outcomes from opioids. If Pharmacological adjuncts should be considered, espe- a patient is overly sedated or shows signs of hypoventila- cially for treating symptoms of anxiety that may nega- tion, the opioid dosing should be decreased. Opioid an- tively impact pain control (Wu & Raja, 2001). Nurses tagonists should be readily available (Chou et al., 2016). may be most likely to note escalating symptoms of anxiety and recommend additional treatment. Multimodal Cognitive-behavioral therapies may be implemented Evidence supports that multimodal analgesia, or use of to supplement pharmacotherapy. These modalities have analgesics with various mechanisms of action, provides been shown to have positive effects on pain, anxiety, and not only better pain control but also improved recovery, use ( Chou et al., 2016). Nurses may be central reduction in morbidity, and lower costs ( Rajpal et al., in ensuring these therapies are performed. Strategies 2010; Wu & Raja, 2001 ). For example, a review of 22 include guided imagery and other guided relaxation randomized controlled trials involving a preoperative techniques. Music may be used as a part of guided re- dose of oral revealed a reduction of postop- laxation or as a specifi c intervention. is an- erative pain, opioid consumption, and related adverse other technique that requires specific training. effects (Rajpal et al., 2010). A quality improvement study Intraoperative suggestions or positive affi rmations comparing 100 postoperative patients using an IV opi- while the patient is under general anesthesia have also oid PCA versus 100 patients receiving oral multimodal been used with positive outcomes (Chou et al., 2016). therapy reached similar conclusions. They found that Even providing basic reassurance to the patient and the oral multimodal group required signifi cantly less consistent empathy may ease some of the anxiety bur- opioid to control their pain. In addition, they reported den. Nurses may help patients with distraction or atten- fewer , less functional issues, and heightened tion diversion; however, these methods are less sup- patient satisfaction in comparison to the PCA group ported in the literature (Gorczyca, Filip & Walczak, ( Rajpal et al., 2010 ). Applying multimodal therapies to 2013 ). An inpatient or outpatient referral for psychiatric augment existing opioid use is especially critical. assessment should be considered if symptoms are not Scheduled NSAIDs, acetaminophen, gabapentin, or pre- well controlled. gabalin and ketamine infusions may all help depending on the nature of the pain (Buvanendran & Kroin, 2009). EDUCATE AT DISCHARGE Finally, patients should be educated about the pain Pain Consult treatment plan to follow after discharge from the hospi- There are several postoperative situations that warrant tal, specifi cally tapering of pain medications to an ap- a consult to a pain medicine physician or acute pain ser- propriate maintenance dose (Box 1). Counseling at the vice. This may not be available at all institutions. First, time of discharge offers important tools for the patient.

162 Orthopaedic Nursing • March/April 2019 • Volume 38 • Number 2 © 2019 by National Association of Orthopaedic Nurses Copyright © 2019 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. Buvanendran , A. , & Kroin , J. ( 2009 ). Multimodal analgesia BOX 1. GOALS IN POSTOPERATIVE MANAGEMENT OF CHRONIC for controlling acute postoperative pain. Current PAIN PATIENTS Opinion in Anesthesiology , 22 ( 5 ), 588 . 1. Identifying at-risk patients Centers for Disease Control and Prevention . (2017 ). 2. Establish trust and confi dence; discuss pain treatment plan Prescribing data . Retrieved from https://www.cdc.gov/ drugoverdose/data/prescribing.html 3. Comprehensive postoperative assessment of pain and Chapman , R. , Davis , J. , Donaldson , G. , Naylor , J. , & ongoing reassessment Winchester , D. ( 2011 ). Postoperative pain trajectories 4. Maintain equi-analgesic dosing of baseline opioids to prevent in chronic pain patients undergoing surgery: The ef- withdrawal and best manage pain fects of chronic opioid pharmacotherapy on acute a. Continue long-acting opioid prescription, pain. The Journal of Pain , 12 ( 12 ), 1240 – 1246 . infusion, or transdermal fentanyl Chou , R. , Gordon , D. , de Leon-Casasola , O. , Rosenberg , J. , b. Consider increasing short-acting opioid dose appropriately Bickler , S. , Brennan , T. , … Wu , C. (2016 ). Guidelines on the Management of Postoperative Pain: Management of 5. Apply additional analgesic treatments for acute pain a. Multimodal therapy to augment opioids: NSAIDs, Postoperative Pain: A Clinical Practice Guideline from acetaminophen, ketamine, gabapentin/pregabalin, the American Pain Society, the American Society of regional anesthesia Regional Anesthesia and Pain Medicine, and the American b. Alternative therapies: massage, acupuncture, heat/cold Society of Anesthesiologists’ Committee on Regional applications, TENS unit Anesthesia, Executive Committee, and Administrative c. Consult acute pain service team as needed and if available Council. The Journal of Pain , 17 ( 2 ), 131 – 157 . Cozowicz , C. , Olson , A. , Poeran , J. , Morwald , E. , Zubizarreta , 6. Treat comorbid symptoms of psychological affective disorders N. , Giraridi , F. , … Memtsoudis , S. ( 2017 ). Opioid a. Anxiolysis with medication prescription levels and postoperative outcomes in b. Cognitive strategies . Pain , 158 ( 12 ), 2422 – 2430 . c. Recommend psychiatric referral or consult Dowell , D. , Haegerich , T. M. , & Chou , R. (2016 ). CDC 7. Defi ne and implement appropriate maintenance opioid guideline for prescribing opioids for chronic pain . therapy for discharge MMWR Recommendations and Reports, 65 (1), 1 – 49 . Note. NSAIDs = nonsteroidal anti-infl ammatory drugs; TENS = doi: http://dx.doi.org/10.15585/mmwr.rr6501e1 transcutaneous electrical nerve stimulation. Gorczyca , R. , Filip , R. , & Walczak , E. (2013 ). Psychological aspects of pain. Annals of Agricultural and Environmental Medicine , Special Issue 1 , 23 – 27. Hilliard , P. , Waljee , J., Moser , S. , Metz , L. , Mathis , M. , Nurses can review the plan for tapering medications, Goesling , J. , & Brummett , C. ( 2018 ). Prevalence of pre- how to take medications safely, and how to manage pos- operative opioid use and characteristics associated with opioid use among patients presenting for surgery . sible side effects. They may also review signs and symp- JAMA Surgery , 153 ( 10 ), 929 – 937 . toms of overdose with family members and the patient Lerman , S. , Rudich , Z. , Brill , S. , Shalev , H. , & Shahar , G. ( Chou et al., 2016). ( 2015 ). Longitudinal associations between depression, anxiety, pain and pain-related disability in chronic pain patients. Psychosomatic Medicine , 77 (3 ), 333 – 341 . Conclusion Mehta , V. , & Langford , R. (2006 ). Acute pain management for In summary, many patients presenting for surgery, espe- opioid dependent patients. Anaesthesia , 61 (3 ), 269 – 276 . cially orthopaedic surgery, carry a preexisting diagnosis Rajpal , S. , Gordon , D. , Pellino , T. , Strayer , A. , Brost , D. , of chronic pain and many also use long-term opioid Trost , G. , … Resnick , D. (2010 ). Comparison of perio- perative oral multimodal analgesia versus IV PCA for therapy. Chronic pain patients present unique chal- spine surgery . Journal of Spinal Disorders & Techniques , lenges for achieving postoperative pain control. 23 ( 2 ), 139 – 145 . Tolerance to opioid medications, coexisting depression, Smith , S. , Bido , J. , Collins , J. , Yang , H. , Katz , J. , & Losina , and anxiety and higher levels of postoperative pain all E. ( 2017 ). Impact of preoperative opioid use on total add to the diffi culty of adequately treating pain in this knee arthroplasty outcomes . The Journal of Bone and population. Understanding these specifi c complexities Joint Surgery , 99 ( 10 ), 803 – 808 . should allow for more comprehensive care. Applying a Taylor , A. , & Stanbury , L. ( 2009 ). A review of postoperative care plan that addresses patient trust and expectations, pain management and the challenges . Current maintenance and escalation of opioid therapy, adjunct Anaesthesia & Critical Care , 20 ( 4 ), 188 –194 . analgesics, alternative pain treatments, anxiolysis strat- Weick , J. , Bawa , H. , Dirschl , D. , & Luu , H. (2018 ). Preoperative opioid use is associated with higher read- egies, and education at time of discharge may help bet- mission and revision rates in total knee and total hip ter care for these multifaceted patients. arthroplasty . The Journal of Bone and Joint Surgery , 100 ( 14 ), 1171 – 1176 . REFERENCES Wu , C. , & Raja , S. ( 2001 ). Treatment of acute postoperative American Academy of Pain Medicine, the American Pain pain . The Lancet , 377 ( 9784 ), 2215 – 2225 . Society, and the American Society of Addiction Zywiel , M. G. , Stroh , D. A. , Lee , S. Y. , Bonutti , P. M. , & Medicine . (2001 ). Consensus statement: Defi nitions re- Mont , M. A. (2011 ). Chronic opioid use prior to total lated to the use of opioids for the treatment of pain . knee arthroplasty. The Journal of Bone and Joint Surgery , Glenview, IL: American Pain Society. 93 ( 21 ), 1988 – 1993 .

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© 2019 by National Association of Orthopaedic Nurses Orthopaedic Nursing • March/April 2019 • Volume 38 • Number 2 163 Copyright © 2019 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.