Key points

Background

Over the past 20 years, there has been a dramatic increase in the attention that professional societies and regulatory agencies (American Academy of Orthopaedic Surgeons [AAOS], Eastern Association for the Surgery of Trauma ([EAST], Trauma Anesthesia Society [TAS], World Health Organization [WHO], Agency for Health Care Policy and Research, American Pain Society [APS], American Society of Anesthesiologists [ASA], US Department of Veterans Affairs, Joint Commission on Accreditation of Healthcare Organizations [JCAHCO], International Association for the Study of Pain [IASP], European Pain Federation [EFIC], Australian and New Zealand College of Anesthetists) have given to the importance of the evaluation and treatment of acute pain. These groups have affirmed the substantial negative impact of inadequately treated acute pain, and some have specifically acknowledged the “rights” of patients to appropriate pain control (WHO, APS, JCAHCO, IASP). During this same time, the number of reliable acute pain management strategies, techniques, and applications has also grown significantly. Despite our greater capacity to improve the treatment of acute pain and the increased awareness of the negative financial and physiologic consequences of inadequately treated acute pain, many patients continue to suffer from moderate, severe, or excruciating acute pain following trauma and surgery.

In addition, the overreliance on opioids as the primary analgesic agent has become the “status quo” and presents several important barriers to a rapid recovery, as well as other important negative long-term consequences. Although opioids may relieve pain in multiple areas of the body simultaneously, often a helpful feature in trauma-related injury, they are not effective analgesics for sources of “dynamic” pain (cough, ambulation) compared with other modalities. Further, they do not mitigate central sensitization, a key determinant in the development of chronic pain, and their role in mitigating the negative consequences of the neuroendocrine response is lacking as well. The overreliance on opioids over the past few decades to minimize pain and suffering has led to a prescription opioid epidemic with substantial overdose death and addiction rates, which demonstrate that this strategy is not sustainable ( Figs. 1 and 2 ). Despite this apparent conundrum, there is a growing body of literature that demonstrates significant improvements in patient outcome and health care resource utilization when acute pain management strategies are improved or optimized by incorporating multimodal analgesia (MMA) strategies. Given the growing awareness of significant downstream implications, acute pain management demands greater attention and emphasis in health care.

US trends in opioid-related deaths between 2000 and 2015. Note: commonly prescribed opioids caused a significantly higher rate of deaths over the 15-year period than an illegal substance such as heroin.

( From Centers for Disease Control and Prevention. National Center for Health Statistics (CDC/NCHS). National Vital Statistics System, Mortality. CDC WONDER, Atlanta, GA: US Department of Health and Human Services, CDC; 2016. Available at: https://wonder.cdc.gov/ . Accessed June 15, 2016.)

US trends in the distributions of opioid sales and concomitant deaths/abuse treatment admissions. The need for substance abuse treatment has increased similarly with the increase in sales of prescription opioids.

( Data from National Vital Statistics System, 1999–2008, Automation of reports and consolidated orders system (ARCOS) of the drug enforcement administration (DEA), 1999–2010; Treatment Episode Data Set, 1999–2009.)

Patients with orthopedic trauma comprise the full range and extremes of injury severity, age, and health status. It is well known that orthopedic injuries are among the most painful. Beyond the common barriers to adequate acute pain treatment previously described in published articles, there are additional barriers that may interfere with the provision of optimized acute pain management for patients with orthopedic trauma and deserve special consideration.

Due to the nature of acute traumatic injury itself, the patient demographics of traumatic injury, and the overall management of patients with acute traumatic injury, many patients with orthopedic trauma have a particularly high risk of experiencing short-term and long-term negative consequences related to suboptimally managed acute pain. These consequences are both clinically and financially relevant and result from the undertreatment of acute pain, opioid-related adverse drug events (ORADEs), and prolonged exposure to opioids.

Although there exists a humanitarian interest in relieving the immediate suffering of patients with orthopedic trauma, it has become even more evident that simply increasing pain level monitoring and treating high pain scores with more opioids is not an adequate solution, as this increases the likelihood of numerous harmful effects. This article discusses the scope of the financial and physiologic consequences of inadequately managed acute pain in the patient with orthopedic trauma, reviews examples in the literature of significant outcome differences, and summarizes current guidelines for the management of acute pain. In addition, fundamental institutional elements necessary for replicating positive physiologic and financial outcomes related to optimized acute pain management are highlighted and discussed.

Background

Over the past 20 years, there has been a dramatic increase in the attention that professional societies and regulatory agencies (American Academy of Orthopaedic Surgeons [AAOS], Eastern Association for the Surgery of Trauma ([EAST], Trauma Anesthesia Society [TAS], World Health Organization [WHO], Agency for Health Care Policy and Research, American Pain Society [APS], American Society of Anesthesiologists [ASA], US Department of Veterans Affairs, Joint Commission on Accreditation of Healthcare Organizations [JCAHCO], International Association for the Study of Pain [IASP], European Pain Federation [EFIC], Australian and New Zealand College of Anesthetists) have given to the importance of the evaluation and treatment of acute pain. These groups have affirmed the substantial negative impact of inadequately treated acute pain, and some have specifically acknowledged the “rights” of patients to appropriate pain control (WHO, APS, JCAHCO, IASP). During this same time, the number of reliable acute pain management strategies, techniques, and applications has also grown significantly. Despite our greater capacity to improve the treatment of acute pain and the increased awareness of the negative financial and physiologic consequences of inadequately treated acute pain, many patients continue to suffer from moderate, severe, or excruciating acute pain following trauma and surgery.

In addition, the overreliance on opioids as the primary analgesic agent has become the “status quo” and presents several important barriers to a rapid recovery, as well as other important negative long-term consequences. Although opioids may relieve pain in multiple areas of the body simultaneously, often a helpful feature in trauma-related injury, they are not effective analgesics for sources of “dynamic” pain (cough, ambulation) compared with other modalities. Further, they do not mitigate central sensitization, a key determinant in the development of chronic pain, and their role in mitigating the negative consequences of the neuroendocrine response is lacking as well. The overreliance on opioids over the past few decades to minimize pain and suffering has led to a prescription opioid epidemic with substantial overdose death and addiction rates, which demonstrate that this strategy is not sustainable ( Figs. 1 and 2 ). Despite this apparent conundrum, there is a growing body of literature that demonstrates significant improvements in patient outcome and health care resource utilization when acute pain management strategies are improved or optimized by incorporating multimodal analgesia (MMA) strategies. Given the growing awareness of significant downstream implications, acute pain management demands greater attention and emphasis in health care.

US trends in opioid-related deaths between 2000 and 2015. Note: commonly prescribed opioids caused a significantly higher rate of deaths over the 15-year period than an illegal substance such as heroin.

( From Centers for Disease Control and Prevention. National Center for Health Statistics (CDC/NCHS). National Vital Statistics System, Mortality. CDC WONDER, Atlanta, GA: US Department of Health and Human Services, CDC; 2016. Available at: https://wonder.cdc.gov/ . Accessed June 15, 2016.)

US trends in the distributions of opioid sales and concomitant deaths/abuse treatment admissions. The need for substance abuse treatment has increased similarly with the increase in sales of prescription opioids.

( Data from National Vital Statistics System, 1999–2008, Automation of reports and consolidated orders system (ARCOS) of the drug enforcement administration (DEA), 1999–2010; Treatment Episode Data Set, 1999–2009.)

Patients with orthopedic trauma comprise the full range and extremes of injury severity, age, and health status. It is well known that orthopedic injuries are among the most painful. Beyond the common barriers to adequate acute pain treatment previously described in published articles, there are additional barriers that may interfere with the provision of optimized acute pain management for patients with orthopedic trauma and deserve special consideration.

Due to the nature of acute traumatic injury itself, the patient demographics of traumatic injury, and the overall management of patients with acute traumatic injury, many patients with orthopedic trauma have a particularly high risk of experiencing short-term and long-term negative consequences related to suboptimally managed acute pain. These consequences are both clinically and financially relevant and result from the undertreatment of acute pain, opioid-related adverse drug events (ORADEs), and prolonged exposure to opioids.

Although there exists a humanitarian interest in relieving the immediate suffering of patients with orthopedic trauma, it has become even more evident that simply increasing pain level monitoring and treating high pain scores with more opioids is not an adequate solution, as this increases the likelihood of numerous harmful effects. This article discusses the scope of the financial and physiologic consequences of inadequately managed acute pain in the patient with orthopedic trauma, reviews examples in the literature of significant outcome differences, and summarizes current guidelines for the management of acute pain. In addition, fundamental institutional elements necessary for replicating positive physiologic and financial outcomes related to optimized acute pain management are highlighted and discussed.

Impact of acute pain

Inadequate postoperative pain relief may delay recovery, lead to a prolonged hospital stay, and increase medical costs. The IASP defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Thus, pain is influenced by not only the discrete nociceptive input that is transmitted centrally but also by cultural expectations and emotional interpretations of the subject. The latter aspect should not be underestimated, as the implications are wide-reaching. Patient surveys consistently indicate that patients fear pain more than they do the possibility that surgery will not alleviate their problems. Some patients delay surgery because of the fear of the associated pain. In fact, the fear of pain may inhibit participation in physical therapy, delay discharge, and affect surgical outcome. Unrelieved acute pain can lead to confusion, especially in patients at risk, resulting in additional testing, monitoring, and increased health care resources.

In the teleologic sense, the recognition of injury through nociceptive input is critically important to the organism. However, the experience of severe pain in humans sets into motion physiologic responses that carry the risk of severe negative acute consequences, as well as long-standing problems, such as the development of chronic pain. The neuroendocrine “stress response” is particularly problematic when the source of severe pain is the scalpel of the surgeon, which is intended to heal and repair a patient. An exaggerated and prolonged neuroendocrine response to acute pain leads to several undesirable consequences, including tachycardia, hypertension, increased work of breathing, intestinal stasis, hypercoagulability, decreased immune surveillance, and a negative nitrogen balance. These conditions may increase the likelihood of acute myocardial infarction, cerebrovascular accident, respiratory failure, ileus, deep venous thrombosis, pulmonary embolism, and confusion. These complications are more likely to occur in patients with certain risk factors or comorbidities, such as advanced age, coronary artery disease, chronic obstructive pulmonary disease, and preexisting dementia. Morrison and colleagues have shown that cognitively intact elderly patients with hip fracture who experienced severe pain were 9 times more likely to suffer from delirium than did patients whose pain was adequately treated. They found that using less than 10 mg of morphine per day resulted in an increased risk (RR = 5.4) of developing delirium. Although opioid-related adverse events and their consequences were not reported in this study, an increased incidence of delirium as well as any of the downstream consequences of delirium (treatment, more tests, increased monitoring, greater length of stay [LOS], delayed recovery, increased incidence of transfer to skilled facilities) will confer a greater financial burden.

Severe pain interferes with pulmonary toilet, ambulation, physical therapy, and occupational therapy. In addition to delaying overall recovery, severe pain leads to immobilization and leaves patients at risk for common postsurgical complications, such as pneumonia, deep vein thrombosis, and catheter-associated urinary tract infection. Severe pain, fear of severe pain, and other circumstances may lead to inhibited joint mobility for extended periods of time. Early mobilization has led to improved outcomes in some patient populations. The clinical significance or importance of facilitating early joint mobility and increasing early range of motion through optimized acute pain management and more assertive therapy regimens might be debated because some long-term outcomes produce similar results. Dismissing the importance of analgesia-facilitated early joint mobility, however, may predispose some patients to experiencing increased development of adhesive capsulitis, delayed functional rehabilitation, or chronic pain conditions. These undesirable outcomes may lengthen hospital stay, necessitate additional procedures and office visits, contribute to long-term morbidity, decrease quality of life, and delay the return to activities of daily living. Severe pain may necessitate significant opioid doses or intubation and mechanical ventilation, both of which can interfere with or preclude serial physical examinations. This is of critical importance in some patients with orthopedic trauma who may be at risk for acute compartment syndrome. Severe pain in mechanically ventilated patients may also delay weaning from mechanical ventilation, which additionally interferes with recovery and extends LOS.

In addition to these immediate physiologic consequences, inadequately managed acute pain may continue pathologically as chronic pain, defined as ongoing acute pain for at least 3 to 6 months’ duration. In fact, up to one-third of patients in chronic pain clinics indicate that their chronic pain was the result of trauma or acute pain of surgery. The incidence and intensity of chronic pain due to surgery has been well-characterized. There are risk factors specific to individual patients (genetic, psychological, less education, lower socioeconomic status) and types of surgery (amputation, thoracotomy, repeat procedures), which increase the likelihood of pain chronification. One of the most recognized modifiable risk factors for the chronification of acute pain is poorly controlled acute pain.

Additionally, severe pain is a significant source of patient dissatisfaction. It has been shown that increasing opioid use improves patient satisfaction to a small degree when compared with less use. However, prescribing more opioids to this end can sacrifice patient safety and lead to increased opioid dependence and diversion. Further, beyond increasing physiologic and financial consequences of ORADEs, the patient dissatisfaction related to the ORADEs, which are likely to increase from a more liberal use of opioids, may mitigate some of this potential positive effect of increased opioid use. It has been demonstrated, for example, that if given a choice, patients are willing to sacrifice the quality of analgesia that they receive if this will eliminate the risk of ORADEs. The increasing willingness of patients to trade effective analgesia depends on the ORADE in question. Patients are most willing to sacrifice analgesia to avoid experiencing vomiting, mental cloudiness, itching, and constipation.

The psychological stress and strain brought on by acute pain on the patient and family members involved with a major orthopedic trauma is not insignificant and can result in negative consequences as well. Inadequately controlled acute pain is associated with a high incidence of posttraumatic stress disorder, adjustment disorder, depression, acute stress disorder, and substance abuse. Risk factors for continued opioid use were assessed postoperatively through a questionnaire in adult patients who had orthopedic surgery after suffering a musculoskeletal trauma. Patients with a known history of psychiatric illness, evidence of maladaptive behavior, or history of chronic pain were excluded. Patients with greater signs of posttraumatic psychological stress (those who scored higher for catastrophic thinking, anxiety, posttraumatic stress disorder, and depression) were significantly more likely ( P <.001) to report taking opioid pain medications 1 to 2 months after surgery, regardless of injury severity, fracture site, or treating surgeon. Their postsurgical disability severity magnitude was significantly higher ( P <.001) than patients not using opioids. Depression and postsurgical pain also can manifest in further complications and increased utilization of health care resources after orthopedic surgery in the long term.

Opioid utilization in acute pain and its complications

The use of opioids for postoperative pain control has been the “status quo” in acute pain management. Patient-controlled analgesia (PCA) use has proven to improve patient satisfaction and decrease pain scores compared with “as needed” opioid administration with an increase in opioid consumption. However, using opioids as a primary analgesic agent often leads to negative physiologic and financial outcomes. The organized efforts to diminish pain and suffering and improve pain scores in one hospital led to a 49% increase in ORADEs and twice the rate of oversedation. The in-hospital odds ratio of cardiopulmonary arrest per 1000 bed-days doubles (odds ratio [OR] 0.92 vs 1.81) when patients are using opioids. The OR nearly doubles again (OR 3.47) when patients also use other sedatives.

The broad effect of opioids is due to their centrally acting mechanism of action. This central effect helps the patient with pain located anywhere in the body but leads to unintended systemic side effects in numerous organ systems. The most critical side effects of opioids are hypotension, oversedation, respiratory depression, and ileus; however, even seemingly minor complications, such as postoperative nausea and vomiting, confusion, constipation, and itching carry with them demonstrable negative consequences. The Joint Commission issued a Sentinel Event Alert in 2012 to warn providers about several identified characteristics that put patients at risk of the respiratory depressant effects of opioids ( Box 1 ). Opioids with these groups of patients should be used with even greater caution.

Gastrointestinal complications from opioids are some of the cost common of the ORADEs, and postoperative gastrointestinal dysfunction (PGID) is the most common cause of delayed hospital discharge after surgery of all types. Effective regional anesthetic techniques and other multimodal strategies along with the avoidance of general anesthesia (particularly opioid analgesia) are associated with a reduced incidence of PGID. In a prospective study of patients having bowel surgery, the impact of pain intensity and opioid utilization on incidence of ileus found that total morphine dose (not incision length) was correlated strongly with return of bowel sounds ( P = .01), flatus ( P = .03), and bowel movement ( P = .02). Thus, although minimally invasive surgery has numerous advantages to patients, decreasing opioids may have a more profound effect on PGID. This assertion is corroborated by the findings of Barletta and colleagues that opioid dose is more influential on incidence of ileus than whether surgery is open or laparoscopic. Although the detrimental effect of ileus is twice as common in bowel surgery, many patients with orthopedic trauma are patients with polytrauma who could still be impacted by concomitant injury and therefore to the same significant implications of opioid utilization.

The ORADEs far more likely to impact isolated patients with orthopedic trauma are nausea, vomiting, and constipation. The economic consequences of these side effects are discussed elsewhere, but nausea and vomiting are a significant source of patient dissatisfaction and increased LOS. Patients with constipation have statistically significant higher hospital admissions, emergency room visits, home health services, nursing home care, physician office visits, other outpatient/ancillary care, and laboratory tests. They also have significantly higher mean all-cause costs for emergency, physician visits, nursing facility, home health, and prescription drug services compared with patients without constipation.

The impact of opioid addiction due to exposure to opioids during episodes of acute pain cannot be overemphasized. In a recent study, 47% (51 of 109) of persons presenting for treatment of oxycodone addiction had their first exposure to opioids through a prescription for pain, and 31% of this subgroup had prior histories of problems with alcohol or another substance.

Although it may be self-evident that exposing patients to high doses of opioids over a long period might increase the likelihood of the development of addiction, even brief exposure to opioids may be enough to lead to addiction. In a retrospective cohort study of opioid-naïve patients having minor surgical procedures, the 27,636 patients (7.1%) who received opioids for less than 7 days (vs no opioid prescription) were 44% more likely to become long-term opioid users within 1 year (OR 1.44; 95% confidence interval [CI] 1.39–1.50). Complicating matters further, substance use disorders are significantly more common in patients with orthopedic trauma. Between 40% and 60% of patients sustaining major trauma are affected by substance abuse disorder. Because the same populations are at high risk for experiencing acute and chronic pain, the prevalence of substance use disorders among persons treated for pain is high, and acute pain management is therefore even more complex and is associated with further risk of addiction.

Beyond the short-term risks and long-term complications of opioid use, opioids are less effective than other available analgesic modalities. In fact, they can increase pain through a paradoxic and poorly understood mechanism referred to as opioid-induced hyperalgesia, which has been associated with very high doses of opioids. Numerous studies have demonstrated that MMA using continuous peripheral nerve blocks (CPNBs) are superior to opioids with regard to effectiveness of analgesia. More important than the effectiveness of various analgesic modalities on resting pain scores is the effectiveness with dynamic pain (coughing, deep breathing, getting out of bed, transferring, ambulating, physical therapy, dressing changes) scores. This metric demonstrates the willingness and ability of the patient to actively participate in recovery, which could mitigate multiple hospital complications related to immobility (pneumonia, deep vein thrombosus), prevent functional decline (muscle strength, nutritional status), and remove barriers to discharge criteria (ambulation distance). Tolerating these activities without the need for intravenous (IV) opioids would remove another common barrier to discharge. In a large, prospective single-center analysis of 18,925 consecutive postsurgical patients, D. M. Pöpping and colleagues demonstrated that patient-controlled epidural anesthesia for thoracic and abdominal surgery and CPNB for extremity surgery resulted in significantly lower mean dynamic and resting pain scores (visual analog scale 0–100) compared with PCA ( P <.05). Even when studies demonstrate that opioids alone are equivalent to MMA protocols in terms of dynamic pain score, the increased opioid doses necessary to produce this level of analgesia come at the expense of unwanted consequences. In a prospective study comparing PCA to an MMA protocol that did not involve nerve blocks for upper extremity surgery demonstrated equivocal rest and dynamic pain scores during the first 48 hours but found that the patients using PCA experienced more ORADEs on the day of surgery and postoperative day 1 and required significantly more rescue opioids once the PCA was removed. Further, the MMA group reported significantly higher patient satisfaction than the PCA group.

Economic consequences of inadequate acute pain management

Calculating the financial impact of various changes to patient care can pose many problems. One is being able to recognize and track all the hard and soft costs that are affected by the change. For example, excessive work duties and deficient nurse staffing leads not only to higher rates of medical errors, it leads to nursing dissatisfaction and turnover. Attending to analgesic needs and complications of opioids is a cumbersome and time-consuming task for nursing staff even with accepted modalities such as an IV PCA and reducing nursing interventions because of optimized analgesia practices may permit nursing staff to focus attention on other duties in a timelier fashion and improve job satisfaction. The effect of these changes may not be easily recognized as causal and would be even more difficult to financially quantify. Studies have demonstrated, however, that opioid-sparing techniques reduce nursing time due to reduced need for monitoring and fewer adverse events. The same may occur when the actual cost savings from reducing IV PCAs or IV opioids are not calculated with the cost implications of unrecognized IV PCA costs or from reducing the incidence of ORADEs. Quantifying the marketing and public relations benefits of improved analgesia within a community or recognizing that patients may have chosen the facility primarily due to the lure of optimized analgesia may also go unnoticed.

This issue is complicated further when it is not considered from a global perspective, as financial implications often span numerous departments. That is, some financial implications may appear to be negative when viewed in isolation. For example, the costs due to the increased use of local anesthetic might increase within the pharmacy budget. However, shortening LOS by 2 days or sending patients routinely to a floor bed instead of to an intensive care unit (ICU) or stepdown bed should nullify the concerns. Shortening LOS and facilitating ICU discharge can be achieved simply through MMA techniques by reducing opioid utilization and their costly negative consequences. Further, by preventing serious complications related to severe pain, for example atelectasis and pneumonia after multiple rib fractures using a continuous paravertebral nerve block or thoracic epidural, patients avoid an extended LOS related to these complications and may decrease the need for additional expenses such as an increased level of monitoring or intubation and ventilation due to severe pulmonary compromise. One study using continuous intercostal nerve blocks in 102 patients with rib fractures reduced LOS from 5.9 days in historical controls to 2.9 days. In patients with hip fracture, another study found decreased LOS and other cost-saving results by implementing an early aggressive pain management protocol using continuous fascia iliaca nerve blocks and facilitating a quicker time to operative repair in patients with hip fracture, which saved approximately $2350 per patient.

Another problem in quantifying economic implications is agreeing on the finite value or even on the validity of individual cost changes to the system. This is particularly true of soft costs. For example, some would debate the financial value of being able to discharge surgery center patients from the post anesthesia care unit (PACU) 1 hour earlier at the end of the day, but not in time to allow for an additional case to be added, as the nurses are still paid until the end of their shift.

Despite the complexities of quantifying some aspects of financial value, any aspect of patient care that can reliably reduce LOS, diminish the need for additional resources, improve patient satisfaction, allow for additional reimbursed charges, or reduce the number and severity of complications to patients will have an enormous positive financial impact for the health care facility. Each of these elements has been shown to be positively affected through the utilization of CPNBs and other multimodal analgesic strategies within organized health care facility programs.

The financial impact of ORADEs is often overlooked, particularly those that are considered “minor” side effects; however, Oderda and colleagues demonstrated that even minor ORADEs remain a significant financial burden to hospitals. In a retrospective review of all surgical patients receiving at least 1 dose of opioids, those patients who experienced an opioid-related adverse drug event (ADE) had median total hospital costs significantly increased by 7.4% (95% CI 3.83–10.96; P <.001) and median LOS increased by 10.3% (95% CI 6.5–14.2; P <.001) compared with matched non-ADE controls. Oderda and colleagues concluded that ORADEs occurred more frequently in patients receiving higher doses of opioids (determined to be only 10 mg of morphine per day) and were associated with an increased risk of experiencing ADEs (OR 1.3; 95% CI 1.07–1.60; P = .01). The top 5 symptoms experienced by patients were nausea/vomiting (49.9%), itching/rash (34.1%), mental status change (16.9%), bradypnea (16.7%), and hypoxia (5.8%). The average cost and LOS increase for orthopedic patients experiencing an ORADE was $861.50 and 0.52 days, respectively.

In a subsequent study selecting for patients experiencing more painful surgical procedures (open and laparoscopic colectomy, laparoscopic cholecystectomy, total abdominal hysterectomy, total hip arthroplasty), Oderda and colleagues discovered even more concerning financial implications when patients experienced ORADEs. In this 2-year, retrospective study of a 450-hospital database of 319,898 patients, 12% of these surgical patients experienced an ORADE and had a higher adjusted mean cost ($22,077 vs $17,370) of $4707 increase ( P <.0001) and a greater LOS (7.6 days vs 4.2 days) of 3.4 days ( P <.0001). Further, the adjusted OR of being a total cost and LOS outlier were 2.8 and 3.2 times greater in the ORADE group. These patients were also more likely to be readmitted (OR 1.06, 95% CI 1.02–1.09).

Although minor ORADEs carry an unexpected increase in financial burden, patients who suffer from severe complications from ORADEs, such as respiratory distress or oversedation, may require escalation of care, transfer to an ICU, or possibly mechanical ventilation. A meta-analysis of 30,000 patients estimated the incidence of opioid-induced ventilatory impairment for PCA to be 1.2% and for an opioid-containing epidural to be 1.1%. Although this is a relatively low complication rate, the number of patients in the United States using a PCA who are harmed by PCA errors is estimated at 6.5%, and the mortality rate resulting from a PCA is estimated to be between 1 in 33,000 and 1 in 338,000.

When patients experience severe pain, and require an IV PCA or when patients experience opioid-induced ventilatory distress, respiratory monitoring needs are often escalated, transfer to stepdown or ICU beds may be required, and LOS may be increased. LOS also will be extended related to ORADEs when increased doses of opioids are used to treat severe pain. The financial costs involved may be substantial. The average hospital cost in the United States for inpatient stay in a floor bed at a nonprofit hospital is $2025. Transferring to an ICU bed because of concerns of respiratory insufficiency increases costs to $6,667, and the need for mechanical ventilation due to an occurrence of respiratory insufficiency raises the cost to $10,794 for the first day. Subsets of patients who are at increased risk of respiratory depression due to opioid use, such as those identified by the 2012 Joint Commission Sentinel Alert, will require a costlier escalated level of monitoring or will succumb more frequently to costly opioid-induced respiratory complications whenever opioid use is not minimized. Recognizing the costs related to minor and more serious ORADEs, the perception that continuing to use opioids as the primary or sole analgesic is an inexpensive option should be reconsidered ( Box 2 ).

Negative outcomes because of delays in orthopedic procedures or the need for ICU admissions where infection risks are elevated due to nonorthopedic trauma-related injuries are not unexpected with major traumatic injuries. Acute pain management strategies that minimize the need for opioids may have unexpected positive influences on patient care by hastening recovery milestones related to other injuries, obviating the need for a higher level of monitoring, and mitigating delays in subsequent surgical procedures. Consider a patient recovering from an exploratory laparotomy before going on to major orthopedic surgery. Relatively small amounts of opioids after the exploratory laparotomy can lead to complications and delays that could influence the overall hospitalization, LOS, and potentially the outcome of their orthopedic injury. For example, in a retrospective study by Barletta and colleagues, the incidence of ileus and extended LOS was examined in patients after elective colectomy. The odds of developing an ileus were significantly higher when patients received as little as 2 mg or more hydromorphone per day (OR 9.9). This was more relevant than if the surgeon performed the surgery as a laparoscopic procedure (OR 3.1), and the likelihood of ileus increased further with increasing number of days of IV opioids (OR 1.5). They found that the incidence of an increased LOS was associated with development of an ileus ( P <.001), 2 mg or more hydromorphone per day ( P <.01), and age ( P <.005). Asqeirsson and colleagues found that the financial burden of patients who developed an ileus after colectomy surgery increased costs by $8296 and extended LOS by 4.9 days. These findings show that opioid use, even in small doses, can be directly responsible for significant complications and financial cost. Alternatives to opioid use in the postoperative setting may decrease complications and costs.

Inadequate pain management leads to increased likelihood of emergency room visits and readmission. As payments for care from the Centers for Medicare and Medicaid Services (CMS) are now distributed as a single payment for defined episodes of care (despite additional hospital costs incurred from an unexpected readmission for postoperative pain or from a prolonged LOS due to ORADEs) instead of fee-for-service, hospital savings increase when fewer health care resources are used. Examples of cost reductions through decreased readmission rates was demonstrated by Williams and colleagues with 948 ACL repairs performed over 4 years by using 5 different types of anesthesia with and without the use of single-injection and continuous nerve blocks. When nerve blocks were incorporated into the anesthetic, PACU bypass occurred in 82% of patients (only 2% with general anesthesia alone), and readmission rates dropped enough to cut costs by 12% and save the hospital $98,000 per year. Only 3 patients with nerve blocks were readmitted, and all 3 occurred when the single-shot nerve blocks resolved. Reliably decreased LOS with positive financial consequences was demonstrated through aggressive postoperative pain management and hastening operative fixation in patients with hip fracture. With a focus on opioid reduction and continuous fascia iliaca nerve block infusion initiated early in the emergency department, this coordinated effort saved an average of $2350 per patient after the first year of implementation.

The priority of acute pain management greatly increased for health care facilities since the CMS introduction of the Value-Based Purchasing (VBP) Program in 2010. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a patient questionnaire designed to compare patient perspectives and experience of hospital care, is one of several domains within VBP used to measure hospital performance and reimbursement. Patient satisfaction scores from the random HCAHPS survey now play an enormous part in yearly hospital reimbursement as well as future earnings, and “Satisfaction with Pain Management” is 1 of the 9 rated sections of the HCAHPS survey. In general, hospitals are now graded yearly by CMS based on shifting categories of global quality metrics within the VBP Program. Quality metrics in 2017 include HCAHPS survey (25% of global score in 2017), safety, efficiency and cost reduction, clinical care outcomes, and clinical care processes. Each year, a percentage of CMS payments for services are withheld until the end of the year (3% in 2017) and either paid out or lost depending on VBP model scores. In addition, the amount that hospitals will be paid in the future for individual procedures or admissions are adjusted based on past HCAHPS scores and VBP model results. HCAHPS scores, therefore, have enormous implications, especially for hospitals with a high percentage of Medicare patients.

Although “Satisfaction with Pain Management” is expected to be removed from the overall score calculation by 2018 because of the concern that it could influence the increased prescription of opioids during a national opioid crisis, it will remain publicly reported. This may not diminish the impact of acute pain management on CMS reimbursements as much as one might think at first glance. Patient satisfaction (or experience of care) with several other items that remain on the survey (communication with doctors, communication with nurses, responsiveness of hospital staff, communication about medicines, and communication about discharge information) may still be significantly linked with the effectiveness of acute pain management. For example, when patients experience excellent acute pain management through the utilization of opioid-sparing strategies, CPNBs and MMA, they require fewer nursing interventions to maintain their level of analgesia. Because of this, they experience fewer ORADEs and are more likely to be awake and alert. These 2 circumstances allow nursing staff to attend to other critical responsibilities or to provide more “non–pain-related” interactions with patients, potentially improving the patient-provider relationship. Alert patients are more likely to recall instructions about medications and discharge instructions as well as the time spent with them by surgeons. One large, cross-sectional observational study found that patients rated “Nurse Communication” as the most important of the 9 patient experience measures that correlated most with overall satisfaction.

Alert, comfortable patients are more likely to accelerate their level of activity and to be able to optimize time during physical therapy. This hastens recovery, minimizing the risk of exposure to hospital-acquired infections or common postoperative complications. These aspects of care are elements within other parts of the HCAHPS scores. This scenario may lead to better HCAHPS survey scores related to these additional categories. In fact, one study at a trauma center retrospectively examined HCAHPS responses of 2933 surgical patients and found that postsurgical pain scores were highly correlated with overall patient satisfaction. Studies are needed to verify and quantify these associations.

Further, hospitals may be able report better scores in the “Efficiency and Cost Reduction” category through diminished health care costs per beneficiary by minimizing LOS, decreasing readmissions due to pain, and avoiding costs related to ORADEs. These are all expected outcomes from optimized acute pain management that have been reliably demonstrated in the literature.