Impact of a Standardized Multimodal Analgesia Protocol on Opioid Prescriptions After Common Arthroscopic Procedures

Access to an Educational Video Preoperatively Has No Effect on Postoperative Opioid Use After Arthroscopic Partial Meniscectomy of the Knee: A Prospective Cohort Study

Purpose

To determine whether access to a website with an educational video would decrease postoperative opioid use in patients undergoing arthroscopic partial meniscectomy.

Methods

Enrolled patients who underwent arthroscopic partial meniscectomy at a single center were randomized to either the intervention or control group prior to surgery. The intervention group received a card with access to an online educational video regarding opioids with their postoperative instructions; the control group did not. The online video was just over 5 minutes long and contained general information about the dangers of opioid use, how to safely dispose of unused opioids, and local support contact information. Data were collected by telephone 10 to 14 days postoperatively and analyzed with GraphPad Prism version 9.5.0. Patient characteristics including age, sex, body mass index, allergies, smoking, depression, alcohol abuse, American Society of Anesthesiologists level, diagnosis of chronic obstructive pulmonary disease, hypertension, diabetes, substance abuse, employment status, workers' compensation, and sports participation were analyzed and correlated with postoperative opioid use.

Results

A total of 166 patients were included in this study, with 78 in the control group and 88 in the intervention group. Mean number of pills consumed was 3 in the control group and 2.2 in the intervention group. This difference did not reach statistical significance. Patients who were obese, smokers, or diagnosed with depression both consumed more opioids and were less likely to take no narcotics postoperatively. Patients who participated in sports consumed fewer total opioids on average than those who did not. Subgroup analysis of patients with higher risk factors did not show a difference between the control and intervention groups in the average amount of opioid used or the likelihood of using no narcotics. Among all patients, 82 (49%) used no narcotics postoperatively and 90% used 8 or fewer tablets.

Conclusions

Directing patients to an educational website and video is not an effective tool in decreasing opioid consumption. Patients undergoing arthroscopic meniscectomy who are obese, active smokers, and clinically depressed or do not participate in sports are likely to use more postoperative narcotics. Regardless of access to the online educational video, half of patients used no narcotics.

Level of Evidence

Level II, prospective cohort.

Trends in Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction: A Systematic Review

Background

Despite the prevalence of patient-reported outcomes (PROs) to evaluate results after anterior cruciate ligament (ACL) reconstruction, there exists little standardization in how these metrics are reported, which can make wider comparisons difficult.

Purpose

To systematically review the literature on ACL reconstruction and report on the variability and temporal trends in PRO utilization.

Study Design

Systematic review.

Methods

We queried the PubMed Central and MEDLINE databases from inception through August 2022 to identify clinical studies reporting ≥1 PRO after ACL reconstruction. Only studies with ≥50 patients and a mean 24-month follow-up were considered for inclusion. Year of publication, study design, PROs, and reporting of return to sport (RTS) were documented.

Results

Across 510 studies, 72 unique PROs were identified, the most common of which were the International Knee Documentation Committee score (63.3%), Tegner Activity Scale (52.4%), Lysholm score (51.0%), and Knee injury and Osteoarthritis Outcome Score (35.7%). Of the identified PROs, 89% were utilized in <10% of studies. The most common study designs were retrospective (40.6%), prospective cohort (27.1%), and prospective randomized controlled trials (19.4%). Some consistency in PROs was observed among randomized controlled trials, with the most common PROs being the International Knee Documentation Committee score (71/99, 71.7%), Tegner Activity Scale (60/99, 60.6%), and Lysholm score (54/99, 54.5%). The mean number of PROs reported per study across all years was 2.89 (range, 1-8), with an increase from 2.1 (range, 1-4) in studies published before 2000 to 3.1 (range, 1-8) in those published after 2020. Only 105 studies (20.6%) discretely reported RTS rates, with more studies utilizing this metric after 2020 (55.1%) than before 2000 (15.0%).

Conclusion

There exists marked heterogeneity and inconsistency regarding which validated PROs are used in studies related to ACL reconstruction. Significant variability was observed, with 89% of measures being reported in <10% of studies. RTS was discretely reported in only 20.6% of studies. Greater standardization of outcomes reporting is required to better promote objective comparisons, understand technique-specific outcomes, and facilitate value determination.

Opioid Requirement After Anterior Cruciate Ligament Surgery: Opioid Use After Anterior Cruciate Ligament Surgery Is Low With a Multimodal Approach, and Fifteen Oxycodone 5-mg Tablets Are Sufficient

Purpose

To prospectively determine opioid consumption in patients undergoing anterior cruciate ligament (ACL) repair and reconstruction and to develop evidence-based prescription guidelines following ACL surgery.

Methods

This multicenter prospective study enrolled patients undergoing ACL reconstruction and repair. Subject demographics and opioid prescriptions were recorded at enrollment. All patients were given education on opiate use and followed the same perioperative, multimodal analgesic regimen. Following surgery, patients were given postoperative "pain journals" to document visual analog scale pain scores and daily opioid consumption for the first 7 postoperative days and on postoperative visit at 14 days.

Results

In total, 50 patients were included in this analysis between the ages of 14 and 65 years. Patients were prescribed a median of 15 oxycodone 5-mg pills and consumed a median of 2 pill postoperatively (range 0-19 pills). 38% of patients consumed 0 opioid pills, 74% of patients consumed ≤5 opioid pills, and 96% of patients consumed ≤15 opioid pills. Patients reported a mean daily visual analog scale value of 2.8 of 10; mean satisfaction with pain management was high at 4.1/5 on a Likert satisfaction score. Overall, patients consumed a mean 34% of their opioid prescriptions, leaving 436 opioid pills not consumed.

Conclusions

This study suggests that current expert panels may be recommending an excessive volume of opioids. Based on our findings, we recommend that patients be prescribed no more than 15 Oxycodone 5-mg tablets following ACL surgery. Despite this lower volume prescription, mean pain scores remained below 3 of 10, patient satisfaction with pain control remained high, and 66% of opiate medication prescribed was not used.

Level of Evidence

II, prospective prognostic cohort investigation.

Perioperative Opioid Use in Anterior Cruciate Ligament Reconstruction Patients

Anterior cruciate ligament reconstruction (ACLR) is one of the most commonly performed outpatient orthopaedic procedures, yet there is little data about perioperative opioid prescribing practices. The purposes of this study were to quantify the perioperative opioid prescriptions filled by patients who underwent ACLR and to identify factors associated with greater postoperative opioid use. Patients who underwent ACLR at a single institution between June 2015 and May 2017 were studied using a regional prescription monitoring database to identify all preoperative and postoperative outpatient opioid prescriptions up to 2 years postoperatively. The number of morphine milligram equivalents of each opioid was calculated to determine total morphine milligram equivalents (TMEs) filled preoperatively, at discharge, and refilled postoperatively. Patients who refilled an opioid prescription postoperatively were compared with those who did not. Ninety-nine of 269 (36.8%) total patients refilled an opioid prescription postoperatively. Thirty-three patients (12.3%) required a refill after 2 weeks postoperatively, and no patients refilled after 21 months postoperatively. Fifty-seven patients (21%) received an opioid prescription in the 2 years following surgery that was unrelated to their ACL reconstruction. Increased age, higher body mass index (BMI), government insurance, current or prior tobacco use history, preoperative opioid use, and greater number of medical comorbidities were significantly associated with refilling a prescription opioid. Higher BMI and government insurance were independent predictors of refilling. Higher preoperative TMEs and surgeon were independent predictor of greater refill TMEs. In the opioid-naïve subgroup of 177 patients, only higher BMI was a predictor of refilling, and only greater comorbidities was a predictor of greater refill TMEs. The results demonstrate that preoperative opioid use was associated with postoperative opioid refills and higher refill TMEs in a dose-dependent fashion. A higher percentage of patients received an opioid prescription for reasons unrelated to the ACL reconstruction than refilled a prescription after the first 2 weeks postoperatively.

Scheduled, Simultaneous Dosing of Pregabalin, Celecoxib, and Acetaminophen Markedly Reduces or Eliminates Opioid Use After ACL Reconstruction Using Allograft or Hamstring Tendon Autograft: A Randomized Clinical Trial

BACKGROUND

Opioid analgesics continue to be prescribed after ambulatory surgery despite untoward adverse effects, risk of overdose, and association with substance use disorder.

PURPOSE/HYPOTHESIS

The purpose was to investigate the use of a novel system to provide scheduled and simultaneous dosing of acetaminophen, celecoxib, and pregabalin after anterior cruciate ligament reconstruction (ACLR). It was hypothesized that this system would markedly reduce pain and opioid use compared with existing best practice.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Included were 100 patients scheduled for elective, primary ACLR using allograft or hamstring tendon autograft. Selection criteria included age between 18 and 65 years and weight between 65 and 120 kg. Exclusion criteria were a known allergy to any drug used in the study or the use of opioid analgesics before surgery. Patients in the intervention group received a blister pack with scheduled, simultaneous doses of acetaminophen, celecoxib, and pregabalin; patients were also given oxycodone 5 mg as needed for breakthrough pain. Patients in the control group were prescribed ibuprofen and oxycodone 5 mg/acetaminophen 325 mg as needed for pain. The primary outcome measure was pain. Secondary outcomes were nausea, itching, and daily oxycodone use. Patients were asked to quantify their average pain at rest, nausea, and itching on an 11-point verbal scale (from 0 to 10). These data were recorded for 6 days during daily telephone contacts with patients after hospital discharge.

RESULTS

Cumulative results for 6 days showed significantly lower values in the intervention group compared with the control group for pain (median [interquartile range], 28 [14-35] vs 35 [28-41], respectively; P = .009) and oxycodone use (median [interquartile range] number of tablets, 0 [0-2] vs 8 [1.25-16], respectively; P < .001). Based on these data, the upper tolerance limits for the number of oxycodone tablets required by 90% of patients in the intervention and control groups were 8 tablets and 30 tablets, respectively. Cumulative results for nausea and itching were also significantly lower for the intervention group. Most patients in the intervention group used no opioids during recovery.

CONCLUSION

Simultaneous dosing of 3 nonopioid analgesics resulted in reduced postoperative pain and markedly lower opioid use.

REGISTRATION

NCT04015908 (ClinicalTrials.gov identifier).

Liposomal Bupivacaine Decreases Post-Operative Opioid Use after Anterior Cruciate Ligament Reconstruction: A Review of Level I Evidence

Introduction

Anterior Cruciate Ligament tears are common after a non-contact injury and several thousand reconstructions (ACLR) occur yearly in the United States. Multimodal pain management has evolved greatly to include nerve blocks to minimize physical therapy losses post-operatively, pericapsular and wound injections, and other adjunctive measures. However, there is a surprisingly high use of opioid use after ACLR.

Objective

The purpose of present investigation is to summarize the current state of knowledge regarding opioid use after ACLR and to synthesize the literature regarding the use of liposomal bupivacaine and its potential to reduce post-operative opioid use in ACLR patients.

Methods

The literature search was performed in Mendeley. Search fields were varied until redundant. All articles were screened by title and abstract and a preliminary decision to include an article was made. A full-text screening was performed on the selected articles. Any question regarding the inclusion of an article was discussed by three authors until an agreement was reached.

Results

Eighteen articles summarized the literature around the opioid epidemic in ACL surgery and the current context of multimodal pain strategies in ACLR. Five primary articles directly studied the use of liposomal bupivacaine as compared to reasonable control options. There remains to be over prescription of opioids within orthopedic surgery. Patient and prescriber education are effective methods at decreasing opioid prescriptions. Many opioid pills prescribed for ACLR are not used for the correct purpose. Several risk factors have been identified for opioid overuse in ACLR: American Society of Anesthesiologists score, concurrent meniscal/cartilage injury, preoperative opioid use, age < 50, COPD, and substance abuse disorder. Liposomal bupivacaine is effective in decreasing post-operative opioid use and reducing post-operative pain scores as compared to traditional bupivacaine. LB may also be effective as a nerve block, though the data on this is more limited and the effects on post-operative therapy need to be weighed against the potential therapeutic benefit. LB is associated with significantly greater costs than traditional bupivacaine.

Discussion

The role for opioid medications in ACLR should continue to decrease over time. Liposomal bupivacaine is a powerful tool that can reduce post-operative opioid consumption in ACLR.

Prescribing Fewer Opioids After Rotator Cuff Repair and Anterior Cruciate Ligament Reconstruction Lowers Opioid Consumption Without Impacting Patient-Reported Pain Scores

Purpose

To develop a standardized opioid prescribing schedule (SOPS) following anterior cruciate ligament reconstruction (ACLR) and rotator cuff repair (RCR) and evaluate postoperative opioid consumption alongside Patient-Reported Outcome Measurement Information System (PROMIS) pain interference scores.

Methods

A prospective observational study was performed on all patients undergoing primary ACLR and RCR from March 2019 to October 2021. Patients taking opioids preoperatively and revision ACLR and RCR were excluded. PROMIS 6B questionnaires were administered before and after implantation of the SOPS initiated on December 15, 2019. Opioid consumption was determined by email surveys. Hypothesis testing was performed with Mann–Whitney U test.

Results

A total of 599 patients met inclusion criteria with 188 patients (71 ACLR and 117 RCR) completing surveys. Before the initiation of SOPS, the average number of oxycodone 5-mg tablets prescribed for ACLR was 44.6 (95% confidence interval [CI] 42.4-46.9) and for RCR was 44.7 (95% CI 42.7-46.8). The average usage was 23.1 (95% CI 16.9-29.2) and 22.1 (95% CI 16.2-28.0), respectively. Following SOPS of 30 tablets of oxycodone 5 mg for ACLR and 40 tablets for RCR, the average number of tablets prescribed significantly decreased for both procedures (P < .01 for ACLR and RCR), and the average consumption decreased to 20.5 (95% CI 16.6-24.4) and 18.6 (95% CI 14.6-22.5), respectively. PROMIS 6B responses did not demonstrate statistically significant changes following SOPS.

Conclusions

The results of the present study demonstrate that the implementation of a SOPS reduced postoperative opioid prescribing amounts and consumption without significant impacting PROMIS pain interference scores for ACLR and RCR, supporting the possibility to decrease and standardize opioid prescribing following common sports medicine procedures.

Level of Evidence

III: Retrospective, comparative, therapeutic study.

Opioid Use After Simple Arthroscopic Knee Surgery

BACKGROUND

Evidence-based prescribing guidelines are lacking for opioids after most orthopaedic surgical procedures.

HYPOTHESIS

Opioids are commonly overprescribed after simple knee arthroscopy.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A cohort of 174 patients who underwent simple arthroscopic knee surgery were prospectively evaluated using data from the Outcome Management and Evaluation database. All patients received 10 combined hydrocodone 5 mg and acetaminophen 325 mg pills postoperatively. Patients were excluded if they (1) had revision surgery, (2) had concomitant complex surgery (eg, ligament surgery, osteotomy), (3) had current opioid use, (4) had open surgery for removal of hardware, (5) or had bilateral knee surgery. Total opioid consumption was reported at the first postoperative visit, and a distribution was created based on patient response. Based on the distribution, patients were separated into low (0-2 pills) versus high (3 or more pills) opioid consumption groups for evaluating risk factors for opioid use. The risk factors included were age, body mass index, smoking status, education level, baseline pain (Knee injury and Osteoarthritis Outcome Score pain subscale [KOOS Pain]), and baseline mental health (Veterans RAND 12-Item Health Survey Mental Component Score), as well as intraoperative findings such as synovial characteristics and extent of osteoarthritis in the multivariate model.

RESULTS

Total opioid consumption ranged from 0 to 19 pills. The median pill count was 2 (25th; 75th interquartile range, 0; 4). Of total patients, 59% were categorized as having low opioid consumption, and the remaining 41% were in the high opioid consumption group. Only 23 patients (13.2%) took 6 or more pills. Preoperative pain as measured by KOOS Pain score was a significant predictor of high opioid consumption postoperatively (odds ratio, 0.97; 95% CI, 0.95-0.99; P = .003).

CONCLUSION

The clinically relevant conclusion is that opioids are overprescribed after simple arthroscopic knee surgery. Based on distribution, the authors recommend that 4 pills be prescribed after simple arthroscopic knee surgery. After accounting for confounding variables, preoperative pain was associated with higher postoperative opioid consumption.

An integrated educational and multimodal approach to achieving an opioid-free postoperative course after arthroscopic rotator cuff repair

Background

In the realm of shoulder surgery, arthroscopic rotator cuff repair (RCR) is one of the most painful procedures and is often associated with higher opioid consumption. The purpose of this study was to evaluate effectiveness of preoperative and postoperative patient education and multimodal pain management to achieve an opioid-free postoperative recovery after RCR.

Methods

Sixty patients who underwent RCR were divided in 2 groups. All patientsreceived an interscalene nerve block and multimodal pain management. The opioid intervention group (OIG) in addition received preoperative education on expectations of pain, non opioid pain protocols, and alternate therapiesto minimize pain as well as customized postoperative instructions. Patients were compared on pain levels, opioid consumption, and outcomes scores preoperatively and at 48 hours, 2 weeks, and final follow-up. Patient-reported outcomes and opioid usage were compared and analyzed using student’s t-tests and logistic regression.

Results

At 48 hours, 15% of OIG patients reported use of rescue opioids after surgery compared with 100% of control group patients. Zero percent of OIG patients reported opioid use at 2 weeks compared to 90% of control group patients (P = .0196). Patients in both groups showed significant improvements in all outcome scores (P ≤ .05). At 6 weeks, functional, Constant, and satisfaction outcome scores were all higher in the OIG (P < .05). At last follow-up, there were no significant differences for all patient-reported outcomes between groups.

Conclusions

Application of patient education tools and innovative multimodal pain management protocols successfully eliminates the need for opioids while maintaining excellent patient satisfaction and outcomes.

Opioid-Free Arthroscopic Rotator Cuff Repair

Rotator cuff repair is known to cause significant pain, and therefore opioids are often prescribed postoperatively. The United States is currently experiencing an opioid epidemic, and prescription opioids are considered a gateway drug to opioid abuse and addiction. Orthopedic surgeons are looking for alternative means to control pain. The purpose of this study was to evaluate the efficacy of an opioid-free postoperative pain protocol in patients following an arthroscopic rotator cuff repair. A prospective study of 36 consecutive patients was performed. Patient demographics, prior narcotic consumption, past medical history, and visual analog scale (VAS) pain score were collected. All patients received an opioid-free postoperative pain protocol, including education, premedication, interscalene nerve blockade, and intraoperative injection, and were discharged with ketorolac, zolpidem, and acetaminophen. A sealed envelope containing an oxycodone prescription was also received at discharge. Patients were instructed only to fill the oxycodone prescription if they had uncontrolled pain. The primary outcomes were filling of the oxycodone prescription and use. Secondary outcomes were VAS pain scores and patient satisfaction scores. Sixty-seven percent of patients successfully completed opioid-free arthroscopic rotator cuff repair. Patients who did not use oxycodone had lower pain scores overall when comparing each postoperative day. By the first postoperative visit, patients who did not take oxycodone also demonstrated higher satisfaction with their pain management. This study demonstrates that with appropriate multimodal pain management, the majority of willing patients can undergo rotator cuff repair without use of opioids. [Orthopedics. 2021;44(2):e301-e305.].

Collaborative Creation of Regional Opioid-Prescribing Guidelines in Orthopaedics: Description of a Process, Measurement of Its Effectiveness, and Impact on Patient Satisfaction at a Participating Institution

Background:

Interventions designed to decrease opioid prescribing in orthopaedics have been effective when employed by specific institutions, subspecialties, and procedures. The objectives of this study were to examine the effectiveness of developing regional guidelines on opioid-prescribing practices after common orthopaedic surgical procedures, to determine whether compliance with the guidelines varied by procedure, and to measure the effect of the guidelines on patient satisfaction. All objectives were assessed at 1 participating institution.

Methods:

In February 2018, 53 orthopaedic surgeons representing 8 practices in Western New York attended a summit meeting to collaboratively create regional opioid-prescribing guidelines for 70 common orthopaedic procedures; these guidelines were later distributed electronically to all orthopaedists in Western New York. We retrospectively examined opioid-prescribing practices for adults undergoing an orthopaedic surgical procedure performed by 1 large practice in October 2017, 4 months before the summit meeting (776 patients), and in July 2018, 5 months after the summit meeting (653 patients). The number of opioid pills prescribed postoperatively and patient satisfaction were compared before and after the summit meeting using t tests.

Results:

The overall mean number of opioid pills (and standard deviation) prescribed postoperatively decreased from 69.5 ± 45.5 pills before the summit to 43.3 ± 28.0 pills after the summit (p < 0.0001). Sports medicine surgeons reduced the number of pills prescribed for anterior cruciate ligament reconstruction, arthroscopic rotator cuff repair, knee arthroscopy with meniscectomy, and shoulder arthroscopy with decompression; and adult reconstruction surgeons reduced the number of pills prescribed for total hip and knee arthroplasty. There was no change in the number of pills prescribed for lumbar spine fusion or implant removal. Satisfaction with the provider did not differ from before to after the summit; 75% of patients in the pre-summit group and 76% of patients in the post-summit group reported receiving excellent service (p = 0.62).

Conclusions:

The creation of regional opioid-prescribing guidelines in a collaborative fashion was assessed at 1 participating institution and was found to be effective at reducing the number of opioid pills prescribed by the orthopaedic surgeons participating in the project without affecting patient satisfaction, but adherence to the guidelines varied by procedure.

A Work in Progress: National Opioid Prescription Reductions Across Orthopaedic Subspecialties in a Contemporary Medicare Sample of 5,026,911 Claims

INTRODUCTION

As the opioid epidemic continues in the United States, efforts by orthopaedic surgeons to reduce opioid prescriptions remain critical. Although previous studies have demonstrated reductions in prescriptions across surgical specialties, there is limited information regarding contemporary trends in opioid prescriptions across orthopaedic subspecialties. Our analysis sought to estimate the frequency and trends of opioid prescriptions among Medicare Part D enrollees.

METHODS

The Medicare Provider Utilization and Payment Data: Part D Prescriber Public Use Files from Centers of Medicare and Medicare from 2014 to 2018 were analyzed. These data were merged with the National Provider Identifier Registry to identify the subspecialty of providers. Prescriber opioid prescription rate, days per claim, and claims per patient were calculated. Temporal trends were tested using linear regression. Poisson regression was used to calculate annual adjusted incidence rate ratios while controlling for year, surgeon sex, average patient comorbidity risk score, and average patient age.

RESULTS

We analyzed 5,026,911 opioid claims prescribed to 2,661,762 beneficiaries. Among all orthopaedic surgeons, the opioid prescription rate per 100 beneficiaries significantly decreased over the study period from 52.99 (95% CI, 52.6 to 53.37) to 44.50 (44.06 to 44.93) (P = 0.002). This decrease was observed for each subspecialty (all P values < 0.05). Similar significant reductions were appreciated across cohorts in the number of claims per beneficiary (all P values < 0.05). The opioid prescription rate among all orthopaedic surgeons and each subspecialty decreased significantly over the study period after controlling for various patient and surgeon characteristics (all P values < 0.05).

CONCLUSION

Orthopaedic surgeons across subspecialties have reduced their rates of opioid prescriptions over recent years. Although increased prescription-limiting legislation, alternative methods of pain control, and prescriber reeducation regarding the correct quantity of opioids needed for postoperative pain relief, ongoing research, and efforts are needed to translate these reductions into clinically meaningful changes.

Perioperative Pain Management in Ambulatory and Inpatient Shoulder Surgery

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Acetaminophen is an effective addition to a multimodal pain regimen; however, evidence to support intravenous versus oral administration requires further evaluation.

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While nonsteroidal anti-inflammatory drugs are a valuable addition to a multimodal pain strategy, concerns regarding their effect on healing after certain procedures (i.e., rotator cuff repair) in select patients may preclude their use.

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The use of perioperative gabapentinoids have varied results for pain control, and additional research is warranted to support their use after certain shoulder procedures.

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Opioid-prescribing should be limited and reserved for severe postoperative pain. When prescribed, opioids should be taken at the lowest possible dose and for the shortest period.

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Centrally acting analgesics such as tramadol have been shown to be as effective as opioids and have a lower risk of complications.

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Nerve blocks are an excellent addition to multimodal pain management strategies. Longer-lasting formulations of perioperative single-shot injections and indwelling catheters may reduce rebound pain.

Editorial Commentary: Opioid Sparing Through Patient Education Programs Is the Future for Sports Medicine and Arthroscopic Surgery to Optimize Outcome

Opioid research in sports medicine and arthroscopic surgery has exploded in the last few years. The literature definitively shows that preoperative opioid usage-in so-called opioid exposed, tolerant, and familiar patients-increases postoperative usage, readmission rates, and medical complications, yielding poorer outcome. Strategies to combat the deleterious effects of preoperative opioid use should be used to include ownership and acknowledgment of the problem, adherence to opioid prescribing protocols, and use of a multimodal anesthesia program that can mitigate the adverse effects by limiting abuse and preventing potential poor outcome. Adding patient education programs to change patient modifiable risk factors shows promise while simultaneously optimizing appropriate patient expectations that are linked to increased outcome. Thus, opioid mitigation, sparing, or altogether avoidance through improved education programs and opioid prescribing protocols will likely be the future of sports medicine and arthroscopic surgery to optimize patient outcome.

Reducing Superfluous Opioid Prescribing Practices After Brain Surgery: It Is Time to Talk About Drugs

BACKGROUND

Opioids are prescribed routinely after cranial surgery despite a paucity of evidence regarding the optimal quantity needed. Overprescribing may adversely contribute to opioid abuse, chronic use, and diversion.

OBJECTIVE

To evaluate the effectiveness of a system-wide campaign to reduce opioid prescribing excess while maintaining adequate analgesia.

METHODS

A retrospective cohort study of patients undergoing a craniotomy for tumor resection with home disposition before and after a 2-mo educational intervention was completed. The educational initiative was composed of directed didactic seminars targeting senior staff, residents, and advanced practice providers. Opioid prescribing patterns were then assessed for patients discharged before and after the intervention period.

RESULTS

A total of 203 patients were discharged home following a craniotomy for tumor resection during the study period: 98 who underwent surgery prior to the educational interventions compared to 105 patients treated post-intervention. Following a 2-mo educational period, the quantity of opioids prescribed decreased by 52% (median morphine milligram equivalent per day [interquartile range], 32.1 [16.1, 64.3] vs 15.4 [0, 32.9], P < .001). Refill requests also decreased by 56% (17% vs 8%, P = .027) despite both groups having similar baseline characteristics. There was no increase in pain scores at outpatient follow-up (1.23 vs 0.85, P = .105).

CONCLUSION

A dramatic reduction in opioids prescribed was achieved without affecting refill requests, patient satisfaction, or perceived analgesia. The use of targeted didactic education to safely improve opioid prescribing following intracranial surgery uniquely highlights the ability of simple, evidence-based interventions to impact clinical decision making, lessen potential patient harm, and address national public health concerns.

Reduced Opioid Prescription After Anterior Cruciate Ligament Reconstruction Does Not Affect Postoperative Pain or Prescription Refills: A Prospective, Surgeon-Blinded, Randomized, Controlled Trial

Purpose

To investigate opioid utilization after anterior cruciate ligament (ACL) reconstruction in the setting of a multimodal pain regimen and assess the feasibility of prescribing fewer opioids to achieve adequate postoperative pain control.

Methods

Patients undergoing ACL reconstruction in conjunction with a multimodal approach to pain control were randomized to receive either 30 or 60 tablets of hydrocodone (10 mg)–acetaminophen (325 mg). Patients were contacted at multiple time points up to 21 days after surgery to assess opioid utilization and medication side effects. We compared the mean number of tablets used between groups as the primary outcome. Preoperative variables associated with an increased risk of higher opioid pain medication requirements were also assessed.

Results

The final analysis included 43 patients in the 30-tablet group and 42 in the 60-tablet group. There was no significant difference between groups in the number of tablets consumed (9.5 vs 12.2, P = .22), number of days opioids were required (4.5 vs 6.2, P = .14), 3-month opioid refill rates (12% vs 7%, P = .48), or postoperative pain control at any point up to 21 days after surgery. The 30-tablet group had a significantly smaller proportion of unused tablets compared with the 60-tablet group (69% of prescribed tablets [910 tablets] vs 80% of prescribed tablets [2,027 tablets], P < .001). Opioids were required after surgery by 91% of patients (n = 77), and 81% could have had their pain medication requirements met with a prescription for 15 tablets. Risk factors for increased postoperative opioid use included a family history of substance abuse (β = 14.1; 95% confidence interval, 5.7-22.4; P = .0014) and increased pain score at 2 hours after surgery (β = 1.07; 95% confidence interval, 0.064-2.07; P = .037).

Conclusions

Orthopaedic surgeons may significantly reduce the number opioid tablets prescribed after ACL reconstruction without affecting postoperative pain control or refill rates.

Level of Evidence

Level I, randomized controlled trial.

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.

Decreased Prescribing of Postoperative Opioids in Pediatric ACL Reconstruction: Treatment Trends at a Single Center

Background:

Anterior cruciate ligament (ACL) injury is common in the pediatric population. Pain control after ACL reconstruction (ACLR) presents a unique challenge due to age and early rehabilitation needs. Pain management practices are believed to have evolved in recent years to limit unnecessary exposure to risks associated with opioid use in this vulnerable population.

Purpose:

To describe trends in postoperative opioid prescribing and assess factors including obtaining consent for opioid prescribing for minors that may have mitigated excessive prescription of opioids.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This is a retrospective review of a consecutive series of pediatric patients (<18 years) undergoing primary ACLR within an urban academic hospital system over a 5-year period (2014-2018). The study period included the gradual introduction of preoperative consenting for opioid use in minors as mandated by state law in 2016. Patient characteristics, surgical details, presence of a signed consent form to prescribe opioid medications, prescribed postoperative medications, prescriber, and indicators of inadequate pain control were collected. Univariate and multivariate analyses were performed to determine factors associated with reduced postoperative opioid prescribing.

Results:

This study included 687 patients with a mean age of 15.1 ± 1.9 years, with less than one-third of patients having preoperative consent forms to prescribe opioid medications. Postoperative prescribing trends demonstrated a decline in the number of opioid doses provided and increased utilization of nonopioid medications. Patients who received preoperative opioid counseling and signed a consent form were prescribed fewer opioids and had a smaller number of unscheduled contacts for poorly controlled pain. Univariate analyses identified multiple predictors of the number of opioid doses prescribed postoperatively. Obtaining preoperative consent to prescribe opioids and ambulatory surgery center location were found to be independent predictors of prescribed doses in the multivariate analysis.

Conclusion:

The quantity of opioid medication prescribed for pain management after pediatric ACLR at our institution has declined in recent years. This appears to be, in part, related to state-mandated preoperative counseling about opioid use, signing of a consent form by the parent(s) or guardian(s) to prescribe opioids to minors, and encouragement toward the use of nonopioid medications when possible. Preoperative opioid use discussions in the pediatric population may be useful in reducing opioid overprescription and utilization in this population.

Implementation of a Standardized Post-Cesarean Delivery Order Set with Multimodal Combination Analgesia Reduces Inpatient Opioid Usage

Background: Opioid use has emerged as a leading cause of death in the US. Given that 1 in 300 opioid-naive patients exposed to opioids after cesarean birth will become persistent users, hospitals should strive to limit exposure to these medications. We set out to evaluate whether transitioning to a standardized order set based on multimodal combination analgesic therapy decreases the exposure to opioids after cesarean delivery. Methods: Our health system’s post-cesarean pain management electronic medical record (EMR) order set was changed from standing NSAIDs (Ibuprofen 600 mg every 6 h) and additional acetaminophen and opioid medications (Oxycodone 5 mg/acetaminophen 325 mg every 3 h or Oxycodone 10 mg/acetaminophen 650 mg every 6 h for moderate and severe pain, respectively) as needed (PRN) to a multimodal combination therapy with acetaminophen (975 mg every 6 h) and NSAIDs (Ibuprofen 600 mg every 6 h) as primary analgesics and opioids PRN (Oxycodone immediate release (IR) 5 mg every 3 h for moderate to severe pain). We performed a retrospective analysis across seven hospitals comparing inpatient opioid use, administration of other analgesics, and severe pain episodes (pain score ≥ 7) between the patients who were treated before and after implementation of the multimodal order set. Chi square and Student t-test were used for statistical analysis with significance determined as p < 0.05. Results: A total of 12,898 cesarean births were included (8696 prior and 4202 after implementation). The multimodal order set was associated with marked decrease in the incidence of post cesarean opioid use (45.4% vs. 67.5%; p < 0.0001), lower average opioid dose (26.7 mg vs. 36.6 mg of oxycodone; p < 0.0001), and increased dose of acetaminophen (8422 mg vs. 4563 mg; p < 0.0001), while severe pain scores were less frequent (46.3% vs. 56.6%, p < 0.0001). Conclusions: Multimodal analgesic therapy for post-cesarean pain management reduces inpatient opioid use while improving pain control. Incorporation of a multimodal order set as a default in the EMR facilitates effective and widespread implementation on a large scale. Obstetric units should consider standardizing post-cesarean pain management orders to include routine (not PRN) multimodal combination therapy with acetaminophen and NSAIDs as primary analgesics.

Editorial Commentary: Opioids After Orthopaedic Surgery: Who Needs 'Em?

Multimodal analgesia protocols have been developed to reduce the number of opioids prescribed after orthopaedic surgery, although no previous studies have examined the effectiveness of a nonopioid multimodal analgesia protocol following common sports medicine procedures. Clinicians should feel assured that this type of strategy can be effective at reducing pain and the number of opioids needed for breakthrough pain with minimal side effects and without compromising patient satisfaction. The use of rescue opioids is associated with pain level, procedure type, and psychiatric illness.

Editorial Commentary: How to Reduce Postoperative Shoulder Pain in Your Practice-Stick to Instability and Opioid-Naive Patients

Preoperative opioid use independently predicts persistent postoperative use after most surgical procedures, and surgery on the shoulder (and labrum specifically) is no exception. Thoughtful preoperative counseling of patients regarding the risks of continued postoperative opioid use, dangers of long-term narcotic use, expectations for postoperative pain control, and potential negative effect on postoperative outcomes is time-consuming and not easy. It is important to note that we have yet to determine whether preoperative opioid users can be restored to an opioid-naive state regarding the associated superior patient-reported outcomes observed postoperatively. Indications for surgery are important predictors of outcomes as well-athletes we treat for shoulder instability do not often present with pain unless associated with an acute instability event. Therefore, postoperative pain and opioid use are not commonly concerns if the indication for surgery is not pain related. The same cannot be said for SLAP tears.

Editorial Commentary: Emergency Department Evaluation After Hip Arthroscopy Occurs More than Expected: Here's Where Patient Education and a Multimodal Approach to Pain Management Can Be Helpful

Hip arthroscopy is known to be a relatively safe procedure with a limited and unique set complications and low hospital readmission rates. Many patients, however, may seek emergency department evaluation after surgery for postoperative pain or complaints unrelated to the most commonly cited complications, such as traction neuropraxia. It is important to recognize and understand the reasons why patients seek medical care after surgery because many of these encounters may be preventable with optimization of perioperative multimodal pain control regimens and proper patient education regarding their expected postoperative course. Patients with barriers to health care access, such as Medicare and Medicaid patients, may be at higher risk for emergency department evaluation of their problems after surgery and clinicians should consider providing additional counseling to these patients regarding when and how to seek medical evaluation after surgery.

Risk Factors for Opioid Use After Patellofemoral Stabilization Surgery: A Population-Based Study of 1,316 Cases

BACKGROUND

Orthopaedic surgeons remain the third-highest group of opioid prescribers among physicians in the United States, accounting for 8% of all opioid prescriptions. The purpose of this study was to identify risk factors for opioid consumption and opioid prescription refills after patellofemoral stabilization surgery. We hypothesized that preoperative opioid use and younger age would be independent risk factors for postoperative opioid use.

METHODS

Patients undergoing primary patellar stabilization surgery between 2007-2017 in the Humana Inc. administrative claims database were identified using Current Procedural Terminology (CPT) codes for patellofemoral stabilization procedures (CPT-27420, 27422, 27427,27418). Patients were categorized into opioid naive (N-OU) and those who filled opioid prescriptions within 3 months prior to surgery (OU). Patients in the OU cohort were further categorized into those who filled prescriptions at 1-3 months before surgery (C-OU) and those who filled opioid prescriptions only in the month preceding surgery (A-OU). Descriptive statistics and multivariate analyses were performed to identify risk factors for postoperative opioid use at 3 and 12 months using the open-source R software (www.r-project.org) housed within PearlDiver.

RESULTS

A total of 1,316 eligible patients were included. One year postoperatively, there was a greater risk of opioid consumption in the OU cohort (OU vs N-OU: 22.2% vs 4.1%; Relative Risk [RR]: 1.233; 95% CI: 1.172- 1.298; P< 0.0001). C-OU (OR: 5.74; 95% CI: 3.75- 8.9; P< 0.0001), obesity (OR: 1.76; 95% CI: 1.14- 2.69; P = 0.0099), and preoperative diagnosis of depression or anxiety (OR: 1.83; 95% CI: 1.01- 3.25; P = 0.0435) were independent risk factors for opioid use at 12 months postoperatively. Younger age (age <30) was associated witha lower risk of opioid use at 3 months (OR: 0.3, 95% CI: 0.21- 0.44; P< 0.0001) and 12 months (OR: 0.29; 95% CI: 0.17- 0.46; P< 0.0001) postoperatively.

CONCLUSIONS

Preoperative opioid utilization significantly increased opioid prescription filling following patellofemoral stabilization surgery. Patient-specific variables including obesity and preoperatively diagnosed depression or anxiety also increased the risk of postoperative opioid utilization. Given the relatively young age and high activity level of patients undergoing patellofemoral stabilization surgery, heightened awareness of patient-specific factors must be considered when selecting appropriate pain management regimens postoperatively.Level of Evidence: III.