Abstract
Objectives:
The ongoing global opioid epidemic is a complex issue. With historically high levels of opioids prescribed in the perioperative period, attention has been drawn to the role of the orthopaedic surgeon in the proliferation of this epidemic. While clinical trials have demonstrated clear benefit to the implementation of patient education and alterations in surgeon prescribing to reduce opioid consumption, there is a scarcity of literature evaluating these effects at an institutional level. The purpose of this study is to evaluate the effectiveness of a multimodal opioid restriction and education protocol implemented at a Canadian sports orthopaedic surgery institution with specific focus on outpatient shoulder and knee surgeries.
Methods:
This is a retrospective pre-post intervention epidemiological study using deidentified data housed in a repository managed by the Manitoba Centre for Health Policy (MCHP). The repository contains information on the entire population of province of Manitoba, Canada (est. 1.44 million as of 2023) with respect to demographics, health, and socioeconomic factors gathered by various government administrative systems (health care, pharmaceuticals, education, housing, employment, etc.). The study population included all “opioid-naïve” patients (had not filled a prescription for opioids in the 6-months pre-surgery) that underwent shoulder or knee surgery at an orthopaedic day surgery institution between January 2013 and December 2021. Exclusion criteria were age less than 18 years, and additional orthopaedic surgery within 6 months. The intervention was the implementation in spring 2020 of a 3-pronged approach to reduce opioid use as part of a change in standard of care. An educational pamphlet was generated with input from surgeons, nurses, members of the public, and administrators to provide general information to patients about risks of opioid use and reasoning behind pain management approaches that utilize non-narcotic analgesics for acute pain control. Implementation of the pamphlet occurred in May 2020 whereby patients received the pamphlet in their postoperative information package in recovery. Concurrently, operating room and recovery room nursing staff attended an in-service on the goals of this program, and on messaging regarding analgesia and pain to be given to patients in the recovery room when the pamphlet was provided. The third element of this initiative was the implementation of a restricted prescription protocol by all surgeons at the facility by June 2020. Surgeons transitioned from their own prescription practices, which included a variety of different common medications such as Tylenol #3, Tramacet or Percocet, to adopting a standardized prescription approach including regularly scheduled acetaminophen and ibuprofen for the first 5 days followed by as needed usage, with an additional prescription of single entity Tramadol to be filled only in instances of intolerable break through pain. As a proxy for surgeon compliance with prescription protocol, the proportion of patients that filled prescriptions for Tramadol pre- and post-operative was compared. The primary outcome was the morphine milligram equivalents (MME) which was calculated based on the prescriptions filled by each patient from 48-hours prior to surgery to 180 days post-op. A binary variable was also generated indicating if a patient did or did not fill an opioid prescription between 180 and 270 days post-surgery to evaluate chronic use. If a patient did not fill any opioid prescriptions in the first 30 days after surgery, they were considered as having received no opioids related to the orthopedic procedure. For continuous data, t-tests were performed on demographic variables and MME, and for categorical data, chi-square tests were conducted. In addition, full multivariate logistic regression was used with opioid use after 180 days as the dependent variable and independent variables included timeframe (i.e., pre- or post-intervention implementation), age, sex, socioeconomic status, comorbidities, and previous mental health diagnosis.
Results:
Table 1 presents a comparison of patient characteristics pre- versus post-intervention indicating comparable age between groups but a small but significant difference in the proportion of males and females (64.7% versus 62.3% males). Compliance with the prescription protocol was high, as 71.3% of patients filled prescriptions for Tramadol post- compared to 3.3% pre-operative. MME per patient decreased significantly by 20% (325 to 263; p<0.001) supporting the hypothesis. The proportion of patients continuing to fill prescriptions for opioids at 180 days post-surgery also significantly decreased from 5.3 to 3.1% (p<0.001). Based on the logistic regression, pre-post intervention was found to be a significant predictor with an odds ratio (95% CI) of 0.57 (0.44, 0.73) when controlling for the age, sex, mental illness diagnosis, socioeconomic status, and comorbidities. This indicates that the odds of continuing to fill opioid prescriptions were 1.89 times higher before the implementation of the opioid restriction protocol than after.
Conclusions:
The volume of opioids distributed and the number of chronic opioid users were significantly reduced for outpatient shoulder and knee surgery patients following the implementation of a multimodal approach at a Canadian sports orthopaedic surgery institute. This relatively simple approach focused on patient education, consistent inter-disciplinary perioperative messaging around opioids and buy-in from all surgeons with respect to prescribing guidelines. This evidence could serve to inform other practitioners to adopt similar strategies and change the trajectory of opioid dependency resulting from early post-operative pain management.
