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Providing postoperative pain management without over-prescribing opioid medications is an important consideration for orthopaedic surgeons, who have traditionally been one of the top-prescribing medical specialties. [1]

This has driven multiple proposals for limiting the number of opioids prescribed, as well as preventing the possible diversion of unused prescriptions, including: [2-9]

• Greater reliance on non-opioid medications
• Combinations of nerve blocks
• Use of medical cannabis
• Easier ways to dispose of unused opioids
• Preoperative education/counseling

In a study presented at the at the American Orthopaedic Society of Sports Medicine’s (AOSSM) Annual Meeting 2022, researchers from Rothman Orthopaedics in Philadelphia, Pennsylvania, explored another strategy: prescribing fewer opioid tablets at discharge.

“During the 21st century, opioid medication prescription and consumption has increased, which has led to an increase in opioid abuse, dependence, and fatal overdoses,” said study co-author Emma E. Johnson, from Rothman Orthopaedics.

“Health care providers, particularly surgeons, have recently focused on decreasing the number of opioids prescribed, as overprescribing is a known cause contributing to the opioid epidemic.”

Study Methodology

For this study, Ms. Johnson and her colleagues designed a prospective, randomized trial to evaluate the effects of prescribing different quantities of opioids following anterior cruciate ligament (ACL) reconstruction. They focused on patients’ postoperative opioid consumption, pain levels, and satisfaction with pain management.

Preoperatively, the researchers from Rothman Orthopaedics enrolled 135 patients with an ACL tear who were scheduled for surgery. These patients were randomly assigned to 1 of 3 postoperative prescription groups:

• 15 tablets of oxycodone, 5 mg (n=41 patients)
• 25 tablets of oxycodone, 5 mg (n=40)
• 35 tablets of oxycodone, 5 mg (n=49)

All patients received a nerve block and general anesthesia during the surgical procedure. At discharge, they were instructed to take acetaminophen and non-steroidal anti-inflammatory drugs, with the opioid medication to be used only for breakthrough pain.

Patients were asked to complete pain and medication logs twice daily for the first 14 days postoperatively. In addition, they were asked to fill out an opioid medication satisfaction survey at 2 weeks postoperatively, and they completed International Knee Documentation Committee (IKDC) questionnaires before surgery and periodically up to 6 months postoperatively.

There were no significant differences among the groups in mean age at surgery, BMI, ratio of males to females, or subjective pain and function preoperatively.

Study Findings

The mean total morphine milligram equivalents (MME) consumed was similar among the 3 groups (P>0.05):

• 3 MME in the 15-tablet group
• 9 MME in the 25-tablet group
• 1 MME in the 35-tablet group

Patients in the 15-tablet group were significantly more likely than those in the 25- and 35-tablet groups to report that they felt they had received too few tablets (20.6%; P=0.05). However, these patients did not report significantly different pain levels, opioid consumption, or satisfaction metrics compared with patients who had received more opioid tablets. The researchers found no significant difference among the 3 groups for:

• Subjective morning or afternoon pain for the first 14 days after surgery
• Total opioid pills consumed
• Patient satisfaction with the ability of the opioid to treat their condition
• Patient satisfaction with the amount of pain relief they experienced since surgery
• Patient satisfaction regarding the number of narcotics initially prescribed after surgery.
• Postoperative function at 2 weeks, 6 weeks, 3 months, and 6 months, as measured by IKDC scores

Ms. Johnson presented these findings at the AOSSM meeting, concluding that “giving lower quantities of opioid medication appears to be as effective in appropriately controlling postoperative pain as higher quantities, and may help to limit the number of opioids prescribed and possible diversion of unused prescription opioid medication.”

Source

Johnson EE, et al. The Effect of Prescribing Patterns on Utilization of Opioid Medication in ACL Reconstruction: A Randomized, Prospective Trial (Paper 04). Presented at the American Orthopaedic Society of Sports Medicine’s Annual Meeting 2022, July 13-17, 2022, Colorado Springs, Colorado

References

1. Morris BJ, Mir HR. The opioid epidemic: impact on orthopaedic surgery. J Am Acad Orthop Surg. 2015 May;23(5):267-71. doi: 10.5435/JAAOS-D-14-00163.
2. Moutzouros V, Jildeh TR, Tramer JS, et al. Can we eliminate opioids after anterior cruciate ligament reconstruction? A prospective, randomized controlled trial. Am J Sports Med. 2021 Oct 20:3635465211045394. doi: 10.1177/03635465211045394. Online ahead of print.
3. Jildeh TR, Khalil LS, Abbas MJ, Jildeh TR, Khalil LS, Abbas MJ, Moutzouros V, Okoroha KR., Okoroha KR. Multimodal nonopioid pain protocol provides equivalent pain control versus opioids following arthroscopic shoulder labral surgery: a prospective randomized controlled trial. J Shoulder Elbow Surg. 2021 Nov;30(11):2445-2454. doi: 10.1016/j.jse.2021.07.008. Epub 2021 Aug 12.
4. Greis A, Renslo B, Wilson-Poe AR, Liu C, Radakrishnan A, Ilyas AM. Medical cannabis use reduces opioid prescriptions in patients with chronic back pain. 2022 Jan 20;14(1):e21452. doi: 10.7759/cureus.21452. eCollection 2022 Jan.
5. Greis A, Larsen E, Liu C, Renslo B, Radakrishnan A, Wilson-Poe AR. Perceived efficacy, reduced prescription drug use, and minimal side effects of cannabis in patients with chronic orthopedic pain. Cannabis Cannabinoid Res. 2021 Nov 12. doi: 10.1089/can.2021.0088. Online ahead of print.
6. Renslo B, Greis A, Liu CS, Radakrishnan A, Ilyas AM. Medical cannabis use reduces opioid prescriptions in patients with osteoarthritis. 2022 Jan 24;14(1):e21564. doi: 10.7759/cureus.21564. eCollection 2022 Jan.
7. Kim DH, Hong G, Lin E, Kim SJ, Beathe J, Wetmore D, Memtsoudis S, Liu J. Pericapsular nerve group block combined with a lateral femoral cutaneous nerve block decreases opioid consumption after hip arthroscopy: a retrospective cohort study (Poster 3250). Presented at the 47th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine, March 31-April 2, 2021, in Las Vegas, Nevada.
8. Agarwal AK, Lee D, Ali Z, Wu Y, Cognilio M, Uritsky T, Delgado MK. Effect of mailing an at-home disposal kit on unused opioid disposal after surgery: a randomized clinical trial. JAMA Netw Open. 2022 May 2;5(5):e2210724. doi: 10.1001/jamanetworkopen.2022.10724.
9. Carender CN, Anthony CA, Rojas EO, Noiseux NO, Bedard NA, Brown TS. Perioperative opioid counseling reduces opioid use following primary total joint arthroplasty. Iowa Orthop J. 2022 Jun;42(1):169-177.