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Lower opioid use linked with postop education, fewer prescribed opioids
Fewer opioid tablets prescribed after ACL reconstruction correlated with lower postoperative opioid consumption, according to recently published study results. Further, education correlated with lower duration and quantity of opioid use.
"[The] more medication you give people the more they seem to take,” John W. Xerogeanes, MD, told Healio.com/Orthopedics. “Number two if you educate patients and family members preoperatively (explain that they will have pain after surgery, but that they should only take narcotic pain medicine if their pain is intolerable, and instead start with Tylenol), you’ll find that most people do well with a minimal amount of narcotic pain medicine. Thus, we think there is a large psychological component here and have shown that with education and challenging people to take less narcotics, they will.”
Researchers identified 264 adolescent and adult patients who underwent ACL reconstruction at a single academic ambulatory surgery center for a quality improvement initiative. Patients completed a survey at 3 weeks postoperatively that assessed opioid tablets consumed, days of postoperative opioid use and opioid-related adverse effects.
Investigators randomly assigned patients into three cohorts based on the date of surgery. First, those who underwent surgery between December 2016 and July 2017 (n = 109) received 50 tablets of Percocet (oxycodone hydrochloride and acetaminophen, Endo Pharmaceuticals). The second group (n = 77) underwent surgery between August 2017 and February 2018 and received 30 tablets. Lastly, 78 patients who underwent surgery between March 2018 and September 2018 received 30 tablets plus education on opioid use.
Then researchers compared the number of tablets taken and the days of opioid use between the 50-tablet and 30-tablet with no education groups and between both 30-tablet groups (no education vs. education).
Results showed that patients who received 50 tablets used a mean of 25.4 tablets for 5.8 days whereas patients who received 30 tablets and no education used a mean of 15.6 tablets for 4.5 days. Patients who received 30 tablets and postoperative education used a mean of 12.4 tablets for 3.5 days, a 3.2 tablet difference compared with patients given 30 tablets and no education. Compared with the 50-tablet cohort, both 30-tablet cohorts had lower rates of self-reported constipation and fatigue. No difference was seen in medication refills among the groups.
"This has dramatically changed our opiate prescribing patterns for ACl reconstruction,” Xerogeanes said. “Where we used to give 50 opiate tablets after surgery, we currently now only give 20! In my practice alone, that’s almost 1,000 [less] opioid tablets prescribed per year." – by Monica Jaramillo
Disclosures: Farley reports no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.
Perspective
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Orthopedic surgeons contribute significantly to the overall opioid prescription burden in the United States. In light of the current opioid epidemic, finding a balance between providing adequate postoperative analgesia while minimizing the number of opioid prescriptions has been a challenge. The authors should be commended for their study on the effect of reducing tablet quantity on postoperative opioid consumption, as well as the effect of preoperative opioid education on ACL reconstruction.
This study confirms the long-held suspicion that preoperative educational protocols are paramount to decreasing opioid consumption. Moreover, it is encouraging to see that fewer prescribed pills caused patients to ration their pain medications over the same duration. It should be noted that the authors did not attempt to collect patient outcome scores — it is possible that patients prescribed fewer pills had subjectively worse satisfaction or generated more patient phone calls to physicians. Overall, this study illustrates that patient counseling and decreasing prescribed tablets serve as important tools for orthopedic surgeons in a multimodal pain protocol during ACL reconstruction.
Henry Ford Health System