CORR Insights®: The 2018 Chitranjan S. Ranawat, MD Award: Developing and Implementing a Novel Institutional Guideline Strategy Reduced Postoperative Opioid Prescribing After TKA and THA

Where Are We Now?

Orthopaedic surgeons are the third-highest opioid prescribers among physicians behind only primary-care practitioners and internists [1], and with the volume of THA and TKA procedures on the rise in the United States [3], it should come as no surprise that postoperative opioid usage for these procedures is increasing as well [5].

The current study by Wyles and colleagues [10] conveys the challenge and describes the situation: Our prescription patterns seem nearly arbitrary, and do not in general appear to follow any evidence-based prescribing guidelines. Without effective guidelines, we risk overprescribing opioids, potentially leading to addiction, missed physical therapy milestones, and complications related to opioid side effects like falls [8]. Fortunately, strategies and educational materials are available to help orthopaedic surgeons manage pain more effectively [7].

Still, the appropriate amount of pain medication for different orthopaedic procedures is largely undefined, and as such, the authors of the current study implemented opioid-prescribing procedure-specific (TKA and THA) guidelines for opioid-naïve patients at their institution. All members of the care team were given these guidelines, and the guidelines were communicated to patients before surgery and during hospitalization.

After 5 months, the authors found a nearly 50% decrease in median opioid prescription quantity, as well as smaller opioid prescription ranges, with no increase in the refill rate [10].

Where Do We Need To Go?

While creating evidence-based guidelines to combat overusage of postoperative opioids is a good step, we must understand that one size does not fit all. The challenge lies in creating guidelines that work in conjunction with our specialty’s varying pain-management techniques. We still do not know the long-term results these guidelines may produce if combined with customized orthopaedic pain-management protocols such as intra-articular catheters [4, 9] or periarticular injections [2] that surgeons have developed in their practices over their years of experience with their populations of patients, which could range from patients with no or low comorbidities (healthy) to high comorbidities (patients with cancer, diabetes, multiple fractures, or antecedent habituation to opioids).

Orthopaedic surgeons may be reluctant to introduce a novel set of guidelines that have not been studied with varying pain management protocols or in patients with varying comorbidities. Clarification of these ambiguities may be achieved through future trials, and these trials deserve funding and support. The guidelines that may develop out of such trials are more likely to gain acceptance if they adapt well to a variety of pain-management protocols and apply to the diversity of patient presentations that surgeons see in practice, including patients with more-severe comorbidities and more-complex diagnoses. As we think about such guidelines, several questions still need to be answered. The current guidelines [10] apply only to opioid-naïve patients. Will they apply to opioid-tolerant patients or patients with more-severe comorbidities? Do these guidelines affect longer-term hip or knee scores after arthroplasty? Could these guidelines be used with other orthopaedic procedures?

How Do We Get There?

Ideally, a randomized controlled multicenter trial would answer the questions above. While performing such a study would be possible, obtaining the necessary financial backing would be a major challenge.

Alternatively, a prospective study involving different pain-management protocols for patients with varying comorbidities at a single institute would yield data that could answer the questions posed above. I would also recommend a study that evaluates similar guidelines for different orthopaedic procedures where patients are under a considerable amount of postoperative pain and are likely to use postoperative opioids, such as total shoulder replacement [6].

Pursuing these two avenues of inquiry could generate enough preliminary data to justify extramural funding for the larger, multicenter trials that are badly needed.