Abstract
Objectives:
Opioid prescriptions following anterior cruciate ligament reconstruction (ACLR) vary substantially.1-3 Expert panel guidelines recommend up to 50 pills for ACLR with many surgeons refilling 40 or more tablets.1,3 The CDC warns that a five-day supply is sufficient to develop opiate dependence.4 Current recommendations are based on consensus rather than evidence and place a vulnerable population at risk for opiate misuse.2,3 Orthopaedic surgeons do not possess evidence driven regimens for opioid prescriptions following ACLR.5,6 The purpose of this study was to develop evidence-based prescription guidelines for ACLR. We hypothesized that patients would require fewer opioids than traditional guidelines suggest with a high rate of patient satisfaction.
1. Beck, J.J., et al., Prospective Study of Acute Opioid Use After Adolescent Anterior Cruciate Ligament Reconstruction Shows No Effect From Patient- or Surgical-Related Factors. J Am Acad Orthop Surg, 2020.
2. Wyles, C.C., et al., Implementation of Procedure-Specific Opioid Guidelines: A Readily Employable Strategy to Improve Consistency and Decrease Excessive Prescribing Following Orthopaedic Surgery. JB JS Open Access, 2020.
3. Stepan, J.G., et al., Development of an Institutional Opioid Prescriber Education Program and Opioid-Prescribing Guidelines: Impact on Prescribing Practices. J Bone Joint Surg Am, 2019.
4. Shah A HC, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017:265-269.
5. Reider, B. Opioid Epidemic. Am J Sports Med, 2019.
6. Morris BJ, Mir HR. The opioid epidemic: Impact on orthopaedic surgery. J Am Acad Orthop Surg 2015;23: 267-271.
Methods:
This multicenter prospective study enrolled 46 patients undergoing ACLR. Subject demographics and opioid prescriptions were recorded at the time of enrollment. All patients were given instructions and education on opiate use. All patients followed the same perioperative, multimodal analgesic regimen (Table 1). Following surgery, patients were given postoperative “Pain Journals” to document visual analog scale (VAS) pain scores and to track their daily opioid consumption for the first 7 postoperative days (PODs) and on postoperative visit (POV) at 14 days. No changes were made to existing prescribing habits, postoperative physical rehabilitation, or surgical methodology.
Results:
35 patients were included in this analysis. Mean subject age was 39 years old. 46% of patients were male; 54% of patients were female. Patients were prescribed a median of 15 oxycodone 5 mg pills and consumed a median of 2 pills postoperatively. Mean postoperative opioid consumption was 5 pills (range 0 to 31 pills). 42% of patients consumed 0 opioid pills; 77% of patients consumed ≤ 5 opioid pills; 73% of patients discontinued opioid use after POD 2 (Figure 1). Patients reported a mean daily VAS value of 2.5 of 10; mean satisfaction with pain management was high at 4.16/5 on a Likert satisfaction score. Overall, patients consumed a mean 28% of their opioid prescriptions, leaving 230 opioid pills not consumed.
Conclusions:
This study suggests that current expert panels may be recommending an unrequired volume of opioids. As the third largest prescriber of opiate medication, orthopedic surgeons are charged with reducing the risk of opiate dependence, particularly in the ACLR vulnerable population.6 Based on our findings, patients only require 15 Oxycodone 5mg tablets following ACLR. Despite this lower volume prescription, mean pain scores remained below 3/10, patient satisfaction with pain control remained high, and 72% of opiate medication prescribed was not used.
