Standardized Opioid Prescription Protocol Reduces Opioid Consumption After Total Joint Arthroplasty

Abstract

Introduction: Previous studies demonstrate routine overprescription of pain medications after total joint arthroplasty (TJA). A standardized reduced opioid prescription protocol for TJA was initiated at our institution, which we hypothesized would lead to a reduction in opioid consumption compared with patients who had surgery before initiation of the new protocol. Methods: We evaluated 97 consecutive opioid-naive patients undergoing primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) using a standardized opioid prescription protocol (standardized group). A control subject group consisted of 99 patients undergoing TKA and THA just before the adaptation of the standardized prescribing protocol (historic group). Postoperatively, patients brought their remaining pain medication to their 1-month follow-up visit. The number of pills consumed was counted and converted into oral morphine equivalents (OME). Current pain level and the need for pain medication refill was assessed. Results: Among TKA patients, mean opioid consumption in the standardized group (48.5 pills; 432 OME) was markedly less than the historic group (76.2 pills; 903 OME) (both P , 0.01). Refills were required in 50% of the standardized group and 29% of the historic group (P = 0.038). Average pain scores for the standardized and historic groups were 2.3 and 3.2, respectively (P = 0.057). Among THA patients, mean opioid consumption in the standardized group (19.1 pills; 200 OME) was markedly less than the historic group (41.3 pills; 504 OME) (both P , 0.01). Refills were required in 16% of the standardized group and 8% of the historic group (P = 0.263). Average pain scores for the standardized and historic groups were 1.7 and 1.8, respectively (P = 0.608). Discussion: Initiation of a standardized opioid prescribing protocol after TJA for opioid-naive patients led to a reduction in opioid consumption, but resulted in an increased need for refills.

Opioid-Prescribing Practices Between Total Knee and Hip Arthroplasty in an Outpatient Versus Inpatient Setting

“…20 In another study, patients who underwent TKA in an IP setting were prescribed 115 opioid pills and consumed 76 of those, and patients who underwent THA in that setting were given 94 pills and consumed 41 of those. 21 The findings of this study agree with the findings of both of these previous studies in that TKA has higher amounts of opioids prescribed and consumed when compared with THA, but the amounts of opioids prescribed and consumed in this study across both procedures is lower in comparison. This could be due to the internal implementation and process improvements throughout our institution.…”

“…18 With the United States being in the midst of an opioid epidemic, 19 it is important to understand the full implications surrounding opioids in TKA and THA. Numerous studies have looked at prescribing and consumption of opioids for TKA and THA in the IP settings 20-22 ; however, to the knowledge of the current authors, there have not been studies comparing opioid prescription and consumption for TKA and THA specifically in the OP setting or studies comparing the OP ASC to the IP setting.…”

Cryoneurolysis before Total Knee Arthroplasty in Patients With Severe Osteoarthritis for Reduction of Postoperative Pain and Opioid Use in a Single-Center Randomized Controlled Trial

“…while another study found that for every 1 pill prescribed, patients were likely to consume an additional~0.5 pill after total joint arthroplasty [17,18]. Further, standardized opioid prescription protocols have been previously shown to facilitate reduced opioid use [19]. Together, these data suggest that a standardized multimodal pain management regimen is important for improving patient outcomes.…”

Changes in postoperative inpatient and outpatient opioid utilization after pharmacist‐led order set standardization and education for total knee and hip replacement at an academic medical center

“…Previous literature suggests that strategies that limit postoperative opioid prescribing reduce the quantity of pills and oral MED prescribed by 36% and 41%, respectively. 6,18 We estimated 80 patients would be needed to detect a 40% difference in cumulative MED prescribed at discharge with a two-sided α level of .05 and power of 80%. At 80 patients, our study would also be powered to detect a 2-point absolute difference between postoperative pain scores among the two cohorts, the minimal clinically important difference.…”

“…Several guidelines provide evidence-based recommendations on opioid prescribing to limit postoperative opioid exposure, optimize multimodal analgesia, and reduce potential harm from chronic opioid exposure. 2,[6][7][8] States have implemented laws limiting the number of opioids prescribed upon discharge from acute care settings, mandating prescription monitoring program (PMP) use, and alerting providers to patients who may be seeing multiple doctors for opioid prescriptions. 9 Payers have adopted strict coverage limits for opioid-naïve patients and high-risk prescribing (eg, co-prescribing benzodiazepines at high doses above a morphine equivalent dose [MED] of 90).…”