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An opioid-sparing protocol that combines patient education with a postoperative prescription for nonopioid analgesia (plus an opioid for breakthrough pain if needed) significantly reduced opioid consumption after outpatient orthopedic surgery, researchers reported.

In a single-institution, pre-post intervention study that included more than 10,000 patients, the volume of opioids dispensed was reduced by 18%, and patients who received the intervention were almost half as likely to become chronic opioid users after their surgery.

“The results from this study confirm the findings from a recent Canadian randomized controlled trial involving 200 patients that showed a significant reduction in postoperative opioid use with a multimodal approach,” senior author Jarret Woodmass, MD, assistant professor of orthopedics at the University of Manitoba in Winnipeg, told Medscape Medical News.

“There was also a Neer Award-winning study in the United States that showed that patient education played a big role in reducing opioid consumption after shoulder surgery. These studies were done in small cohorts, so we decided to study this at the population level,” Woodmass said.

The study was published on June 18 in the Canadian Journal of Surgery.

Opioid-Naive Patients

“Orthopedic surgeries are very painful, and in the old days, patients could be given 100 tabs of oxycodone and would take them any time they felt any pain,” said Woodmass.

“But in fact, acetaminophen and ibuprofen are actually very effective with way fewer side effects. Educating patients and getting them to understand the importance of using these other modalities to reduce pain and to use opioids only after the medication and ice have failed is effective in reducing opioid use,” he added.

“This protocol allowed patients to understand that they will have some pain after surgery and that it’s normal, but that they will have over-the-counter meds with limited side effects that will help with moderate pain. However, if they are in severe pain, where these drugs are not controlling it, then I can use a limited amount of opioid to cover that short period of time,” said Woodmass.

The current study included opioid-naive patients, who were defined as those who did not fill an opioid prescription in the 6 months before their procedures, who underwent outpatient shoulder or knee surgery at the Pan Am Clinic in Winnipeg between January 2013 and December 2018 (a preintervention cohort of 8244 patients) and between July 2020 and March 2022 (a postintervention cohort of 2205 patients).

Before implementation of the opioid-sparing protocol, the surgeons at the Pan Am Clinic had been prescribing varying dosages, durations, and combinations of acetaminophen, ibuprofen, and various opioids, according to their preferences, Woodmass explained.

In the new protocol, patients were instructed to take acetaminophen and ibuprofen around the clock for the first 5 days after their surgery and to take tramadol only if they experienced intolerable breakthrough pain.

“We chose tramadol because nobody was really using it in the province before this study, so we were able to use it as a marker of protocol compliance,” said Woodmass. Patients also received a pamphlet that educated them about the risks of opioids and the effectiveness of nonopioid analgesics.

The study’s two outcomes were total morphine milligram equivalents (MME) dispensed from the date of surgery until 270 days after surgery and chronic postoperative opioid use, which was defined as filling an opioid prescription between 181 and 270 days after surgery.

After implementation of the protocol, the average MME dispensed per patient decreased by 18%. The proportion of patients continuing to fill prescriptions for opioids beyond 180 days after surgery decreased from 4.8% to 2.6%, for a relative risk reduction of 43.8%.

In addition, patients in the postintervention group remained about half as likely to continue filling opioid prescriptions 6 months after surgery as those in the preintervention group.

Setting Patients’ Expectations

Telling patients to expect pain after their surgery can be helpful, said Edward Percy, MD, a cardiac surgeon at Vancouver General Hospital in Vancouver. “I agree that setting the expectation for some postprocedural discomfort is beneficial. Certainly, the use of a multimodal strategy with acetaminophen and ibuprofen at regular intervals can go a long way to preventing the overuse of opioids for breakthrough pain. This is a great study to prove the benefits of establishing educational interventions for patients and providers,” Percy said.

“Overall, surgeons are responsible for more than half of all new opioid prescriptions. In our research in the cardiac surgery world, we found a shocking amount of variability in opioid prescription practices throughout Canada and the US. We also found that patients were using far fewer opioids at home than were being prescribed. This paper is an important addition in showing how well we can do with relatively simple interventions,” he said.

“The results are exciting in the sense that we can reduce opioid use in the short term, and that has effects on the long term. But it’s important to note that reducing opioid use, in and of itself, doesn’t really make sense as a goal,” Karim Ladha, MD, Evelyn Bateman Recipe Chair in Ambulatory Anesthesia and Women’s Health at Women’s College Hospital in Toronto, told Medscape Medical News.

“What we really want to focus on is whether we can manage patients’ pain adequately in a postoperative period and, unfortunately, they don’t have that measured in this study,” Ladha said.

“While this study provides good news that we can reduce opioid consumption, it’s important that we have other studies that ask patients how we are controlling their pain and see how they are recovering from surgery, not just simply measuring morphine equivalents,” he said.

The study was funded by the 2020 Alexander Gibson Fund for orthopedic research through the University of Manitoba. Woodmass, Percy, and Ladha reported having no relevant financial relationships.