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

Abstract

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)eacetaminophen (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 ¼ .22), number of days opioids were required (4.5 vs 6.2, P ¼ .14), 3-month opioid refill rates (12% vs 7%, P ¼ .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 ¼ 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 (b ¼ 14.1; 95% confidence interval, 5.7-22.4; P ¼ .0014) and increased pain score at 2 hours after surgery (b ¼ 1.07; 95% confidence interval, 0.064-2.07; P ¼ .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.

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

“…36,48 Furthermore, the reporting patterns of postoperative pain are likely influenced by increased pressure to develop standardized opioid prescription protocols as well as multimodal analgesic pathways. 17,20 The increasing prevalence of the 12-and 36-Item Short Form Health Surveys is reflective of the evolving recognition of the importance of physical, social, and emotional health in those with ACL injury and their influence on patient outcomes. 12 The heterogeneity observed with regard to PROs is not unique to ACL reconstruction.…”

Factors Associated With Increased Opioid Prescriptions Following Anterior Cruciate Ligament Reconstruction in Opioid-Naïve Patients

“…Opioid prescription following ACLR has been shown to be the greatest compared with other commonly performed sports medicine procedures. 13 , 15 , 20 Even so, a recent randomized controlled trial by Hartwell et al. 20 reported that in a pool of 85 patients undergoing ACLR, reduced opioid prescriptions do not affect postoperative pain or prescription refills.…”

“… 13 , 15 , 20 Even so, a recent randomized controlled trial by Hartwell et al. 20 reported that in a pool of 85 patients undergoing ACLR, reduced opioid prescriptions do not affect postoperative pain or prescription refills. Further, studies have shown that most patients stopped taking opioids by postoperative day 7 following ACLR, highlighting the building evidence that patients may require fewer opioids than is traditionally prescribed.…”

“…Further, studies have shown that most patients stopped taking opioids by postoperative day 7 following ACLR, highlighting the building evidence that patients may require fewer opioids than is traditionally prescribed. 20 , 21 …”

Lower Opioid Prescription Quantity Does Not Negatively Impact Pain Control or Patient Satisfaction After ACL Reconstruction

“…In a recent randomized trial, Moutzouros et al demonstrated equivalence in postoperative pain control when utilizing either a non-opioid multimodal pain control or a traditional opioid analgesic-based regimen after anterior cruciate ligament reconstruction (ACLR) 11 . Another study demonstrated equivalent opioid usage and postoperative pain scores when either 30 or 60 tablets of 10-mg hydrocodone plus 325-mg acetaminophen were prescribed, and suggested that 81% of patients could have had their pain medication requirements met with a 15-pill prescription 12 . However, the opioid-sparing trial did not address the usage of nonsteroidal anti-inflammatory drugs (NSAIDs) by the opioid-based treatment cohort, and neither of these trials offered a formal report or analysis of patient satisfaction with such interventions.…”