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

2021 ◽  
Vol 9 (2) ◽  
pp. 232596712097999
Author(s):  
Ajith Malige ◽  
Joshua T. Bram ◽  
Kathleen J. Maguire ◽  
Lia W. McNeely ◽  
Theodore J. Ganley ◽  
...  
Keyword(s):  
Pain Management ◽  
Acl Reconstruction ◽  
Pain Control ◽  
Pediatric Population ◽  
Consent Form ◽  
Opioid Use ◽  
Opioid Prescribing ◽  
Prescribing Trends ◽  
Prescribe Opioid ◽  
Opioid Medications

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.

scholarly journals DECREASE PRESCRIBING OF POSTOPERATIVE OPIOIDS IN PEDIATRIC ACL RECONSTRUCTION- TREATMENT TRENDS AT A SINGLE CENTER

2021 ◽  
Vol 9 (7_suppl3) ◽  
pp. 2325967121S0006
Author(s):  
Ajith Malige ◽  
Joshua T. Bram ◽  
Kathleen J. Maguire ◽  
Lia W. McNeely ◽  
Theodore J. Ganley ◽  
...  
Keyword(s):  
Regression Analysis ◽  
Pain Management ◽  
Acl Reconstruction ◽  
Pain Control ◽  
Unique Challenge ◽  
Opioid Medication ◽  
Factors Associated ◽  
Opioid Prescribing ◽  
Medication Prescribing ◽  
Opioid Medications

Background: Pain control following ACL Reconstruction (ACLR) presents a unique challenge due to age and early rehabilitation needs. Significant efforts have been made to reduce unnecessary opioid prescribing in this vulnerable population, but few have sought to define current practices. Purpose: The purpose of this study is to describe trends in postoperative pain management and assess factors that may mitigate overutilization of opioid medications. Methods: This is a retrospective review of a series of pediatric patients (<18yo) undergoing primary ACLR within an urban academic hospital system over a 5-year period (2014-2018). The period included the gradual introduction of preoperative consenting for opioid use in minors as mandated by state law in 2016. Patient demographics, surgical details, presence of opioid consent, prescribed postoperative medications, prescriber, and indicators of inadequate pain control were collected. Trends in medication prescribing were assessed. Univariate and multivariate analyses were performed to identify factors associated with reduced postoperative opioid prescribing. Results: This study included 687 patients with a mean age of 15.1±1.9 years. The majority underwent ACL reconstruction using hamstring autograft (92.0%) at our main hospital (54.9%). Postoperatively, discharge medication prescribing was performed most frequently (38.1%) by advanced practitioners (NP/PA). While there was no change in the proportion of patients prescribed opioids (>95% of patients) over the 5 year period, the mean number of doses dispensed decreased annually (Fig. 1). This was accompanied by an increase in the annual percentage of patients prescribed oral NSAIDs and acetaminophen during that period. Preoperative opioid consent was obtained in 31.9% of the cohort and these patients received significantly fewer doses of prescribed opioids (25.0 vs. 34.6 doses, p<0.001), while still having a lower rate of uncontrolled pain prompting early unplanned contact via telephone, ED or clinic. Preoperative consenting (IRR 0.764, CI 0.634-0.920, p=0.005) and satellite surgical location (IRR 0.712, CI 0.517-0.979, p=0.037) were identified as significant predictors of decreased number of postoperative opioid doses prescribed following multivariate regression analysis (Table 2). Conclusion: Total doses of postoperative opioids prescribed for pain management in pediatric ACLR have declined in recent years, which appears related to preoperative counseling through mandated opioid consenting and paralleled by greater utilization of non-opioid medications. Continued efforts should be made to identify measures to limit overreliance on these medications and to mitigate issues related to misuse, overdose and addiction. [Figure: see text] Annual proportion of patients prescribed ibuprofen, acetaminophen and opioid medication postoperatively and the annual mean number of opioid doses prescribed. [Table: see text] Univariate and multivariate negative binomial regression analysis of factors associated with prescription of a greater number of postoperative doses of opioid medication. CI = Confidence Interval.

scholarly journals Evaluation of an Educational Outreach Campaign (IMPACT) on Pain Management Delivered to General Practices in Walsall

2021 ◽  
Vol 29 (Supplement_1) ◽  
pp. i48-i49
Author(s):  
S Visram ◽  
J Saini ◽  
R Mandvia
Keyword(s):  
Data Analysis ◽  
Pain Management ◽  
Cancer Pain ◽  
Educational Intervention ◽  
Opioid Analgesics ◽  
Educational Outreach ◽  
Opioid Prescribing ◽  
Prescribing Trends ◽  
The Impact

Abstract Introduction Opioid class drugs are a commonly prescribed form of analgesic widely used in the treatment of acute, cancer and chronic non-cancer pain. Up to 90% of individuals presenting to pain centres receive opioids, with doctors in the UK prescribing more and stronger opioids (1). Concern is increasing that patients with chronic pain are inappropriately being moved up the WHO ‘analgesic ladder’, originally developed for cancer pain, without considering alternatives to medications, (2). UK guidelines on chronic non-cancer pain management recommend weak opioids as a second-line treatment, when the first-line non-steroidal anti-inflammatory drugs / paracetamol) ineffective, and for short-term use only. A UK educational outreach programme by the name IMPACT (Improving Medicines and Polypharmacy Appropriateness Clinical Tool) was conducted on pain management. This research evaluated the IMPACT campaign, analysing the educational impact on the prescribing of morphine, tramadol and other high-cost opioids, in the Walsall CCG. Methods Standardised training material was delivered to 50 practices between December 2018 and June 2019 by IMPACT pharmacists. The training included a presentation on pain control, including dissemination of local and national guidelines, management of neuropathic, low back pain and sciatica as well as advice for prescribers on prescribing opioids in long-term pain, with the evidence-base. Prescribing trends in primary care were also covered in the training, and clinicians were provided with resources to use in their practice. Data analysis included reviewing prescribing data and evaluating the educational intervention using feedback from participants gathered via anonymous questionnaires administered at the end of the training. Prescribing data analysis was conducted by Keele University’s Medicines Management team via the ePACT 2 system covering October 2018 to September 2019 (two months before and three months after the intervention) were presented onto graphs to form comparisons in prescribing trends of the Midland CCG compared to England. Results Questionnaires completed at the end of sessions showed high levels of satisfaction, with feedback indicating that participants found the session well presented, successful at highlighting key messages, and effective in using evidence-based practice. 88% of participants agreed the IMPACT campaign increased their understanding of the management and assessment of pain, and prescribing of opioids and other resources available to prescribers. The majority (85%) wished to see this form of education being repeated regularly in the future for other therapeutic areas. Analysis of the prescribing data demonstrated that the total volume of opioid analgesics decreased by 1.7% post-intervention in the Midlands CCG in response to the pharmacist-led educational intervention. As supported by literature, the use of educational strategies, including material dissemination and reminders as well as group educational outreach was effective in engaging clinicians, as demonstrated by the reduction in opioid prescribing and high GP satisfaction in this campaign. Conclusion The IMPACT campaign was effective at disseminating pain-specific guidelines for opioid prescribing to clinicians, leading to a decrease in overall prescribing of opioid analgesics. Educational outreach as an approach is practical and a valuable means to improve prescribing by continuing medical education. References 1. Els, C., Jackson, T., Kunyk, D., Lappi, V., Sonnenberg, B., Hagtvedt, R., Sharma, S., Kolahdooz, F. and Straube, S. (2017). Adverse events associated with medium- and long-term use of opioids for chronic non-cancer pain: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews. This provided the statistic of percentage receiving opioids that present to pain centres. 2. Heit, H. (2010). Tackling the Difficult Problem of Prescription Opioid Misuse. Annals of Internal Medicine, 152(11), p.747. Issues with prescriptions and inappropriate moving up the WHO ladder.

scholarly journals Opioid Prescribing to Medicare Part D Enrollees, 2013–2017: Shifting Responsibility to Pain Management Providers

Pain Medicine ◽  
2020 ◽  
Vol 21 (7) ◽  
pp. 1400-1407 ◽  
Author(s):  
Adam N Romman ◽  
Connie M Hsu ◽  
Lin-Na Chou ◽  
Yong-Fang Kuo ◽  
Rene Przkora ◽  
...  
Keyword(s):  
Pain Management ◽  
Medicare Part D ◽  
Medical Specialty ◽  
Medicare Part ◽  
Provider Type ◽  
Cross Sectional ◽  
Part D ◽  
Opioid Prescribing ◽  
Prescribing Trends ◽  
Level Analysis

Abstract Objective To examine opioid prescribing frequency and trends to Medicare Part D enrollees from 2013 to 2017 by medical specialty and provider type. Methods We conducted a retrospective, cross-sectional, specialty- and provider-level analysis of Medicare Part D prescriber data for opioid claims from 2013 to 2017. We analyzed opioid claims and prescribing trends for specialties accounting for ≥1% of all opioid claims. Results From 2013 to 2017, pain management providers increased Medicare Part D opioid claims by 27.3% to 1,140 mean claims per provider in 2017; physical medicine and rehabilitation providers increased opioid claims 16.9% to 511 mean claims per provider in 2017. Every other medical specialty decreased opioid claims over this period, with emergency medicine (–19.9%) and orthopedic surgery (–16.0%) dropping opioid claims more than any specialty. Physicians overall decreased opioid claims per provider by –5.2%. Meanwhile, opioid claims among both dentists (+5.6%) and nonphysician providers (+10.2%) increased during this period. Conclusions From 2013 to 2017, pain management and PMR increased opioid claims to Medicare Part D enrollees, whereas physicians in every other specialty decreased opioid prescribing. Dentists and nonphysician providers also increased opioid prescribing. Overall, opioid claims to Medicare Part D enrollees decreased and continue to drop at faster rates.

2 Impact of Multimodal Analgesia on Critically Ill Burn Patients

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S5-S5
Author(s):  
Sierra R Young ◽  
Jeremiah Duby ◽  
Erin Louie
Keyword(s):  
Pain Control ◽  
Total Body Surface Area ◽  
Oral Morphine ◽  
Multimodal Analgesia ◽  
Power Calculation ◽  
Opioid Use ◽  
Icu Discharge ◽  
Opioid Medications ◽  
Oral Morphine Equivalent ◽  
The Impact

Abstract Introduction Opioids are considered the cornerstone of treatment for post-operative burn pain. However, detrimental adverse effects of opioid use include over-sedation, respiratory depression and dependence. Multimodal analgesia is an alternative method of pain control that utilizes a combination of opioid and non-opioid medications. Multimodal analgesia offers different mechanisms of action which may be beneficial in burn-injured patients. This study examines the impact of multimodal therapy for post-operative pain control in a burn intensive care unit (BICU). Methods This retrospective cohort study was performed at an academic burn center between 2012 and 2018. Consecutively admitted patients with burns greater than or equal to 10% total body surface area (TBSA) and BICU length of stay (LOS) greater than seven days were eligible for inclusion. Patients were excluded if they received an opioid continuous infusion greater than 48 hours. Patients treated with multimodal analgesia were compared to those treated with opioids alone. The total oral morphine equivalent (OME) dose was calculated for each 24-hour period for 5 days after a grafting surgery. Secondary endpoints included pain scores, BICU LOS, and ventilator days. Data analysis was performed with descriptive statistics. A power calculation determined that 60 patients per group were needed to detect a 30% difference in the primary endpoint. Results There were 100 patients in the non-multimodal group and 100 patients in the multimodal group. Mean cumulative OME dose was significantly lower in the multimodal group (1,028 mg vs. 1,438 mg, P &lt; 0.002). Patients with over 20% TBSA burns had a larger reduction in mean OME doses in the multimodal group (1,097 mg vs. 1,624 mg, P = 0.0049) compared to patients with 10% to 20% TBSA burns (949 mg vs 1,282 mg, P = 0.057). Utilizing more multimodal agents was not associated with lower OME doses. There was no difference in pain score on post-operative day 5 (5.5 + 2.3 vs. 6.2 + 2.2, P=0.07) or at ICU discharge (4.7 + 2.4 vs 4.7 + 2.8, P = 0.99). There was no difference in other secondary outcomes. Conclusions The use of multimodal analgesia significantly reduced cumulative OME doses without compromising pain control. Applicability of Research to Practice Multimodal analgesia may be a beneficial adjunct to burn pain management to mitigate opioid use without compromising pain control.

Opioid Prescribing and Use After Pediatric Umbilical Hernia Repair

2020 ◽  
pp. 000313482094738
Author(s):  
Matthew L. Lee ◽  
Lauren B. Camp ◽  
Mehul V. Raval ◽  
Eunice Y. Huang
Keyword(s):  
Adverse Events ◽  
Pain Control ◽  
Umbilical Hernia ◽  
Parent Report ◽  
Physician Education ◽  
Opioid Use ◽  
Opioid Prescribing ◽  
Education Group ◽  
Umbilical Hernia Repair ◽  
Before And After

Background Opioid overuse is a concern in adult and pediatric populations. Physician education may improve appropriate opioid prescribing and patient instruction for use. Prescribing and use of opioids for pain control after pediatric umbilical hernia (UH) repair before and after surgeon education was evaluated. This is a substudy of a multi-institutional study assessing prescribing practice before and after surgeon education. This study further assessed patient prescription filling patterns and parent report of pain control. Methods A retrospective study was performed evaluating children who underwent UH 6 months before and after an educational presentation on opioid use. Prescriptions, prescription fills, patient medication use, and pain control effectiveness were assessed. Adverse events were collected. Results There were 78 subjects in the pre-education and 99 in the post-education group. Opioid prescribed changed from 98.7% to 61.6% ( P < .0001), and nonopioid prescriptions increased following education ( P = .0063). The number of opioid prescriptions filled decreased ( P = .0296). There were limited data on opioid doses used and quality of pain control, but the post-education group showed good pain control. There was no difference in adverse events. Discussion Surgeon education on the current opioid epidemic and strategies for opioid stewardship improves opioid prescribing and use without adversely impacting pain control or clinical outcome.

scholarly journals Opioid Use in Children

2019 ◽  
Vol 24 (1) ◽  
pp. 72-75
Author(s):  
Kelly L. Matson ◽  
Peter N. Johnson ◽  
Van Tran ◽  
Evan R. Horton ◽  
Jennifer Sterner-Allison ◽  
...  
Keyword(s):  
Young Adults ◽  
Pain Management ◽  
Pediatric Population ◽  
The United States ◽  
Opioid Use Disorder ◽  
Adolescents And Young Adults ◽  
Evidence Based ◽  
Opioid Misuse ◽  
Opioid Use ◽  
Electronic Prescription

Limited guidance on opioid use exists in the pediatric population, causing medication safety concerns for pain management in children and adolescents. Opioid misuse and use disorder continue to greatly affect adolescents and young adults in the United States, furthering the apprehension of their use. Pediatric Pharmacy Advocacy Group (PPAG) recommends pharmacists contribute their knowledge to pain management in children, including the discussion of appropriate use of non-opioid alternatives for pain and when to recommend coprescribing of naloxone. PPAG also supports the review of electronic prescription drug–monitoring programs prior to opioid prescribing and dispensing by both prescribers and pharmacists. Education by pharmacists of children and their families regarding proper administration, storage, and disposal, as well as the awareness of opioid misuse and use disorder among adolescents and young adults, is key to prevention. If opioid use disorder is diagnosed, PPAG encourages improved access among adolescents to evidence-based medications including methadone, buprenorphine, and naltrexone. Furthermore, pharmacists should assist in screening and referral to evidence-based treatment.

scholarly journals Factors influencing trends in opioid prescribing for older people: a scoping review

2020 ◽  
Vol 21 ◽  
Author(s):  
Rasa Mikelyte ◽  
Vanessa Abrahamson ◽  
Emma Hill ◽  
Patricia M. Wilson
Keyword(s):  
Older Adults ◽  
Chronic Pain ◽  
Pain Management ◽  
Older People ◽  
Grey Literature ◽  
Prescribing Patterns ◽  
Opioid Prescribing ◽  
Factors Influencing ◽  
Prescribing Trends ◽  
The Uk

Abstract Aim: The review aimed to identify factors influencing opioid prescribing as regular pain-management medication for older people. Background: Chronic pain occurs in 45%–85% of older people, but appears to be under-recognised and under-treated. However, strong opiate prescribing is more prevalent in older people, increasing at the fastest rate in this age group. Methods: This review included all study types, published 1990–2017, which focused on opioid prescribing for pain management among older adults. Arksey and O’Malley’s framework was used to scope the literature. PubMed, EBSCO Host, the UK Drug Database, and Google Scholar were searched. Data extraction, carried out by two researchers, included factors explaining opioid prescribing patterns and prescribing trends. Findings: A total of 613 papers were identified and 53 were included in the final review consisting of 35 research papers, 10 opinion pieces and 8 grey literature sources. Factors associated with prescribing patterns were categorised according to whether they were patient-related, prescriber-driven, or system-driven. Patient factors included age, gender, race, and cognition; prescriber factors included attitudes towards opioids and judgements about ‘normal’ pain; and policy/system factors related to the changing policy landscape over the last three decades, particularly in the USA. Conclusions: A large number of context-dependent factors appeared to influence opioid prescribing for chronic pain management in older adults, but the findings were inconsistent. There is a gap in the literature relating to the UK healthcare system; the prescriber and the patient perspective; and within the context of multi-morbidity and treatment burden.

Expectation-setting and patient education about pain control in the perioperative setting: A qualitative study

2021 ◽  
Vol 17 (6) ◽  
pp. 455-464
Author(s):  
Josh Bleicher, MD, MS ◽  
Jordan Esplin, BS ◽  
Allison N. Blumling, MS ◽  
Jessica N. Cohan, MD, MAS ◽  
Mark Savarise, MD, MBA, FACS ◽  
...  
Keyword(s):  
Pain Management ◽  
Patient Education ◽  
Qualitative Study ◽  
Pain Control ◽  
Control Strategies ◽  
Patient Experiences ◽  
Patient Anxiety ◽  
Opioid Use ◽  
Post Operative Pain ◽  
Preoperative Expectation

Objective: Interventions aimed at limiting opioid use are widespread. These are most often targeted toward prescribers or health systems. Patients’ perspectives are too often absent during the creation of such interventions. This qualitative study aims to understand patient experiences with education about perioperative pain control, from preoperative expectation-setting to post-operative pain control strategies and ultimately opioid disposal.Design: We performed semistructured interviews focused on patient experiences in the perioperative period. Content from interview transcripts was analyzed using a constant comparative method.Setting: All participants underwent surgery at a single, academic tertiary-care center.Participants: Adult patients who had a general surgery operation in the prior 60 days.Outcome measure: Key themes from interviews about perioperative pain management, specifically related to preoperative expectation-setting and post-operative education.Results: Patients identified gaps in communication and education in three main areas: preoperative expectation setting of post-operative pain; post-operative pain control strategies, including use of opioid medications; and the importance of appropriate opioid disposal. Failure to set expectations led to either significant patient anxiety preoperatively or poor preparation for home discharge. Poor education on pain control strategies led to misinformation on when and how to use opioids. Lack of education on opioid disposal led to most participants failing to properly dispose of leftover medication.Conclusions: Gaps in education surrounding post-operative pain and opioid use can lead to patient anxiety, inappropriate use of opioids, and poor disposal rates of leftover medications. Future interventions aimed at patient education to improve pain management and opioid stewardship should be created with an understanding of patient experiences and perceptions.

Impact of the VA opioid safety initiative on pain management for cancer patients.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 102-102
Author(s):  
Mallika Marar ◽  
Vinit Nalawade ◽  
Neil Panjwani ◽  
Paul Riviere ◽  
Timothy Furnish ◽  
...  
Keyword(s):  
Pain Management ◽  
Cancer Patients ◽  
Opioid Abuse ◽  
Prescribing Patterns ◽  
Health Administration ◽  
Opioid Use ◽  
Opioid Prescribing ◽  
Ed Visits ◽  
The Impact ◽  
Safety Initiative

102 Background: Limited research exists on how risk reduction policies in response to the opioid epidemic have impacted pain management among cancer patients. This study investigated the impact of the Veteran’s Health Administration (VHA) Opioid Safety Initiative (OSI) on opioid prescribing patterns and opioid-related toxicity among patients undergoing definitive cancer treatment. Methods: This retrospective cohort study included 42,064 opioid-naïve patients receiving definitive local therapy for prostate, lung, breast, and colorectal cancer at the VHA from 2011-2016. Interrupted time series analysis with segmented regression was used to evaluate the impact of the OSI, which launched October 2013. The primary outcome was the incidence of new opioid prescriptions with diagnosis or treatment. Secondary outcomes included rates of high daily dose opioid (≥ 100 morphine milligram equivalent) and concomitant benzodiazepine prescriptions. Additional long-term outcomes included persistent opioid use, opioid abuse diagnoses, pain-related ED visits, and opioid-related admissions. Results: Prior to OSI implementation, the incidence of opioid prescriptions among new cancer patients increased from 26.7% (95% CI 25.0 – 28.4) in the first quarter (Q1) of 2011 to 50.6% (95% CI 48.3 – 53.0) in Q3 2013. There was a monthly increase in opioid prescription rate pre-OSI followed by a monthly decrease post-OSI (Table). High-dose opioid prescriptions were rare, and the monthly rate was stable before and after the OSI. Monthly incidence of concomitant benzodiazepine prescriptions was stable pre-OSI and decreased post-OSI. Persistent opioid use increased pre-OSI and decreased post-OSI. Pain-related ED visits had an incidence of 0.8% (95% CI 0.4 – 1.0) in Q1 2011, 0.3% (95% CI 0.1 – 0.6) in Q3 2013, and 1.8% (95% CI 0.9 – 2.7) in Q4 2016, with an increasing monthly rate after the OSI. At three years, the cumulative incidence of opioid abuse was 1.2% for both the pre- and post-OSI groups but opioid-related admissions were greater in the pre-OSI cohort than the post-OSI cohort (0.9% vs. 0.5%, p < 0.001). Conclusions: The OSI was associated with a decrease in new, persistent, and certain high-risk opioid prescribing as well as an increase in pain-related ED visits. Further research on patient-centered outcomes is required to optimize opioid prescribing policies for patients with cancer.[Table: see text]

scholarly journals Characterizing the Effect of Opioid Tablet Strength on Post-Operative Opioid Consumption Following ACL Reconstruction

2020 ◽  
Vol 8 (7_suppl6) ◽  
pp. 2325967120S0050
Author(s):  
Ehab Nazzal
Keyword(s):  
Acl Reconstruction ◽  
Pain Control ◽  
The United States ◽  
Opioid Consumption ◽  
Opioid Use ◽  
Lower Strength ◽  
Pain Scores ◽  
Post Operative Pain ◽  
Tablet Strength ◽  
Management Protocol

Objectives: Prescription opioid abuse continues to be a national crisis in the United States. Orthopaedic surgeons contribute significantly to this crisis, prescribing nearly a tenth of annual opioid prescriptions. With Anterior Cruciate Ligament (ACL) reconstruction being a common orthopaedic procedure performed at high volumes, understanding how physician opioid prescribing practices affects patient post-operative opioid utilization is of critical importance to curbing the orthopaedic contribution to the opioid epidemic. We aimed to assess how opioid tablet strength affects post-operative opioid consumption following ACL reconstruction. We hypothesized that prescribing a lower strength opioid tablet would not adversely influence post-operative pain or increase opioid consumption Methods: All data was collected prospectively from patients undergoing ACL reconstruction at a single academic ambulatory surgery center.All patients received the same peri-operative pain management protocol, which consisted of an adductor canal block at the time of surgery, Naprosyn 500 mg to be taken as needed, and pre-operative opioid education that outlined safe opioid use practice. Percocet was prescribed at two dosages in a consecutive fashion. Between March 2018 to October 2018, patients received Percocet at a strength of 7.5 mg (7.5 mg Oxycodone/325 Acetaminophen). From November 2018 to May 2019, patients received prescriptions at a dose of 5 mg. At the first post-operative clinic visit, patients completed a survey describing the quantity of opioid tablets consumed, days of postoperative opioid use, and opioid-related adverse effects. In addition, patients used a smart-phone application to assess post-operative pain on a numeric rating scale from post-operative day (POD) 1 to POD 6. Results: 148 patients were prospectively enrolled. 78 (51.3%) received Percocet at a strength of 7.5 mg per tablet and 69 (46.9%)received Percocet at a strength of 5 mg. The median age was 23 years (interquartile range: 18-36) and 49.7% were female. The 7.5 mg cohort took an average of 12.4 tablets (±7.0), while the 5 mg cohort took an average of 8.6 (±7.4) tablets, a 3.7 tablet decrease (p=0.002). Both cohorts consumed opioids for the same amount of post-operative days (5mg cohort: 3.1 days, 7.5mg cohort: 3.5 days; p=0.289). The incidence of opioid related side effect were equivalent between the 5 mg and 7.5 mg cohorts, which included constipation (34.8% and 34.6%, p=0.983), euphoria (5.8% v. 10.3%, p=0.324), nausea/vomiting (13.0% v. 16.7%, p=0.539), fatigue (2.9% v. 6.4%, p0.319), and pruritus (2.9% v. 5.1%, p=0.495). There was no difference in post-operative numeric pain scores in the 5 mg vs. the 7.5 mg cohort (POD 1: 5.7 ±1.9 vs. 5.4 ± 2.0, p=0.633; POD 6: 3.3 ± 2.1 vs. 2.9 ± 1.8, p=0.726). Conclusion: Prescribing a lower strength of oxycodone after ACL reconstruction did not increase pain scores or opioid consumption.This suggests that it is possible to achieve similar pain control while lowering the total opioid prescribed. These finding support future research focusing on optimizing pain control at minimal opioid doses.

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