Abstract
This cohort study investigates the association between reducing the number of opioid tablets prescribed after anterior cruciate ligament (ACL) reconstruction and postoperative opioid consumption and between preoperative opioid use education about nonopioid pain strategies and duration and quantity of opioid use.
Prescribing a greater quantity of opioids than needed after surgery has been associated with the development of addiction.1 Lowering default opioid prescription quantities in an electronic medical record system has been shown to reduce the amount of opioids prescribed after surgery.2 However, the effect of reduced prescription quantities on actual patient opioid consumption remains undetermined. Additionally, patient education may also play a role in decreasing excess postoperative opioid use.3 We assessed whether reducing the number of opioid tablets prescribed would decrease postoperative opioid consumption, and whether preoperative opioid use education would further reduce the amount taken.
Methods
All data were collected prospectively from adolescent and adult patients undergoing anterior cruciate ligament reconstruction at a single academic ambulatory surgery center as part of a quality improvement initiative. Institutional review board approval was obtained for the quality improvement initiative and the need for informed consent was waived. At the clinic visit occurring in the third postoperative week, patients completed a survey describing opioid tablets consumed, days of postoperative opioid use, and opioid-related adverse effects. Refills within 2 months were obtained from electronic medical records and the state prescription drug monitoring program.
Patients were nonrandomly separated into 3 cohorts based on the date of surgery. Patients undergoing surgery between December 2016 and July 2017 were given 50 tablets of Percocet (7.5-mg oxycodone/325-mg acetaminophen; 1-2 tablets every 4-6 hours as needed). Patients undergoing surgery between August 2017 and February 2018 were given 30 tablets. From March 2018 to September 2018, scripted opioid use education was given to a cohort of patients receiving 30 tablets. The educational session, which outlined appropriate opioid use and alternative pain control strategies, was delivered by athletic trainers at the preoperative clinic visit and the surgeon in the preoperative holding area and reinforced by nursing staff in the postoperative holding area. There were no changes in patient selection for surgery, personnel, surgical technique or materials, or anesthesia and postoperative rehabilitation protocols during these periods.
The number of opioid tablets taken and the days of opioid use were compared between the 50- and 30-tablet (no education) groups and between the 30-tablet groups (no education vs education). Differences in categorical variables were assessed with χ2 or Fischer exact tests. t Tests or Wilcoxon rank-sum tests were used to compare parametric and nonparametric continuous data. A 2-sided P < .05 was considered statistically significant. Analysis was performed with SPSS.
Results
The response rate was 98%. Of the 264 patients in the study, 109 received 50 tablets, 77 received 30 tablets and no education, and 78 received 30 tablets and education. The mean age was 25 years and 49% were male. There were no significant differences in patient demographics between cohorts (Table 1).
Table 1. Patient Demographics and Comorbidities.
| Characteristics | No. (%) | P Value | ||
|---|---|---|---|---|
| 50 Tablets (n = 109) | 30 Tablets | |||
| No Education (n = 77) | Education (n = 78) | |||
| Age, mean (SD), y | 25.4 (11.5) | 25.5 (11.7) | 26.0 (11.0) | .94 |
| Body mass index, mean (SD)a | 24.4 (4.7) | 24.6 (4.0) | 24.1 (4.8) | .73 |
| Operative time, mean (SD), min | 80 (20) | 84 (18) | 79 (18) | .28 |
| Sex | ||||
| Male | 53 (48.6) | 40 (51.9) | 37 (47.4) | .84 |
| Female | 56 (51.4) | 37 (48.1) | 41 (52.6) | |
| Race/ethnicityb | ||||
| White | 68 (62.4) | 48 (62.3) | 50 (64.1) | >.99 |
| Black | 17 (15.6) | 13 (16.9) | 12 (15.4) | |
| Other | 24 (22.0) | 16 (20.8) | 16 (20.5) | |
| Current opioid usec | 2 (2.6) | 1 (1.3) | 2 (1.8) | .84 |
| Taking medication for anxiety, depression, or ADHD | 9 (8.3) | 6 (7.8) | 7 (9.0) | .96 |
| Any alcohol use | 31 (28.4) | 21 (27.3) | 25 (32.1) | .79 |
| Current tobacco use | 3 (2.8) | 2 (2.6) | 3 (3.8) | .88 |
| Comorbidities | 9 (8.3) | 8 (10.4) | 6 (7.7) | .82 |
| Insurance | ||||
| Private | 107 (98.2) | 73 (94.8) | 76 (97.4) | .58 |
| Medicaid | 0 | 2 (2.6) | 1 (1.3) | |
| Self-pay | 2 (1.8) | 1 (1.3) | 1 (1.3) | |
Abbreviation: ADHD, attention-deficit/hyperactivity disorder.
Calculated as weight in kilograms divided by height in meters squared.
Self-reported race/ethnicity included to show similarity of groups; race/ethnicity defined by participant.
For acute preoperative pain; no patients were taking long-term opioid therapy prior to surgery.
Patients receiving 50 tablets consumed a mean of 25.4 tablets, while those given 30 tablets and no education consumed a mean of 15.6 tablets (difference, 9.8 [95% CI, 6.2-13.5] tablets; P < .001). Patients receiving 50 tablets took opioids for a significantly greater number of postoperative days compared with those receiving 30 tablets and no education (5.8 vs 4.5 days; difference, 1.2 [95% CI, 0.09-2.4] days) (Table 2).
Table 2. Opioid Utilization and Adverse Effects Following Surgery.
| 50 Tablets (n = 109) | 30 Tablets and No Education (n = 77) | 30 Tablets and Education (n = 78) | 50 Tablets vs 30 Tablets and No Education | 30 Tablets and No Education vs 30 Tablets and Education | |||
|---|---|---|---|---|---|---|---|
| Difference (95% CI) | P Value | Difference (95% CI) | P Value | ||||
| Tablets taken, mean (SD)a | 25.4 (13.8) | 15.6 (8.5) | 12.4 (7.0) | 9.8 (6.2-13.5) | <.001 | 3.2 (0.6-5.7) | .02 |
| Days of opioid use, mean (SD)b | 5.8 (4.6) | 4.5 (2.9) | 3.5 (2.3) | 1.2 (0.09-2.4) | .03 | 1.0 (0.2-1.9) | .02 |
| Took all tablets prescribed, No. (%) | 8 (7.3) | 6 (7.8) | 4 (5.1) | .91 | .53 | ||
| Refill of opioid medication, No. (%)c | 6 (5.5) | 4 (5.2) | 3 (3.8) | .93 | .72 | ||
| Adverse effects, No. (%)d | |||||||
| Constipation | 60 (55.0) | 29 (37.7) | 27 (35.6) | .02 | .69 | ||
| Fatigue | 18 (16.5) | 5 (6.5) | 5 (6.4) | .04 | .98 | ||
| Nausea or vomiting | 31 (28.4) | 14 (18.2) | 13 (16.7) | .11 | .80 | ||
| Postoperative day of survey administration, mean (SD) | 20.3 (6.3) | 21.4 (7.9) | 20.9 (5.4) | .75 | .81 | ||
Tablets taken compared with a t test.
Days of opioid use compared with Wilcoxon rank-sum test.
Refill within 2 months of surgery obtained through electronic medical record and state prescription drug monitoring program; all other information obtained through survey.
Selected from a list including constipation, fatigue, nausea/vomiting, and euphoria; there was no statistical difference in euphoria between groups.
Patients receiving 30 tablets and preoperative education consumed a mean of 12.4 tablets (difference compared with 30 tablets and no education, 3.2 [95% CI, 0.6-5.7] tablets; P = .02). Patients receiving education took opioids for significantly fewer postoperative days (4.5 vs 3.5 days; difference, 1.0 [95% CI, 0.2-1.9] days) (Table 2).
Rates of self-reported constipation and fatigue were lower in the cohorts receiving 30 tablets compared with the 50-tablet cohort. There was no difference in medication refills among cohorts (Table 2).
Discussion
Prescribing fewer tablets was associated with lower postoperative opioid consumption following anterior cruciate ligament reconstruction. Education was associated with lower duration and quantity of postoperative opioid use. An effort to conserve medication and make the prescription last may be the psychological mechanism driving these results.
Because the study was survey based, recall bias is a potential limitation. Furthermore, this study was limited to a single procedure at a single site, the patient cohort was young, and patients were not randomized, raising the possibility of selection bias.
In this study, half of prescribed opioids were consumed in each group, suggesting that prescribing even less might further reduce opioid use. Further investigation should evaluate whether similar opioid stewardship and education protocols would be successful in other patient populations.
Section Editor: Jody W. Zylke, MD, Deputy Editor.
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