For Most Arthroplasty Patients, 30 Opioid Pills Should Do It

A team from Midwest Orthopaedics at Rush in Chicago studied the opioid prescription patterns for 461 consecutive new patients with painful and possibly arthritic hips or knees.

The study, “Who is prescribing opioids preoperatively? A survey of new patients presenting to tertiary care adult reconstruction clinics,” has been submitted for publication.

Craig J. Della Valle M.D., a joint replacement surgeon at Rush and study co-author explained the design and rationale of this study to OTW, “We orthopedic surgeons are high prescribers of opioid pain pills. In joint replacement, the average number of opioid pills prescribed after surgery is 90 pills and in the United States over 1 million joint replacements are performed each year.”

“Over the past several years we have had many patients come in after surgery and say they did not use all of their pills and they did not know what to do with the pills they had leftover. Thus, we decided to do a study to see if we can send patients home with fewer pills while still adequately controlling their pain.”

“In addition, many patients come in taking opioids for their arthritis-related pain. We wanted to evaluate who is prescribing these opioid pills for conservative treatment of arthritis to better target educational efforts on the adverse effects of preoperative opioid use.”

The study authors tracked 460 patients of whom 105 (22.8%) received pre-appointment opioids and 46 received only tramadol (10.0%). They found that primary care physicians were the most common prescriber (59.5%) followed by pain medicine specialists (11.3%) and orthopedic surgeons (11.3%). They also learned that more prescribers practiced in the community than an academic setting (63.8% versus 36.2%).

“The biggest misconception regarding preoperative opioids”, said Dr. Della Valle, “is that preoperative opioid use only impacts postoperative pain control. There are several studies that have been published recently that now demonstrate that preoperative opioid use not only is a risk factor for poor pain control after surgery and increased opioid use but is also a risk factor for complications such as infection and need for future revision surgery.”

“The results from our study demonstrated that a prescription of 30 5mg oxycodone immediate release is sufficient for a majority of patients undergoing hip or knee arthroplasty.”

“In addition, in our second study evaluating preoperative opioid use we found that just over 20% of all new patients presenting to our arthroplasty clinics are taking preoperative opioids. Most of these prescriptions are provided by primary care physicians, but 10% of patients received their opioid prescription from orthopedic surgeons.”

Asked what type of surgeon education needs to be implemented, Dr. Della Valle added, “Education of both patients and providers is needed. We believe that surgeons need to be better educated on the adverse effects of preoperative opioid use on postoperative outcomes after hip and knee arthroplasty. In addition, we believe that patients and surgeons need to be reassured that 30 opioid pills are adequate to control pain after hip and knee arthroplasty.”