A Text-Messaging Program May Help Surgeons Tailor Opioid Prescriptions to Patient Needs

    Using an automated text-messaging system that regularly checked in with patients on their pain and opioid use, researchers from the Perelman School of Medicine at the University of Pennsylvania found that more than half of the opioid tablets prescribed for patients who had undergone orthopaedic or urologic procedures went unused.

    The researchers also found that most opioids are taken within the first few days following a procedure and may not be necessary to manage pain in the week following the procedure.

    Their study was published by JAMA Network Open.

    “Through simple text messaging, we highlight a method which gives clinicians the information they need to reduce prescribing and manage pain,” said co-lead author Anish Agarwal, MD, a clinical innovation manager in the Penn Medicine Center for Digital Health and an assistant professor of emergency medicine.

    “We found that more than 60% of the opioid tablets prescribed went unused, which tracks with the team’s preliminary studies. We can begin to use these data in multiple ways. One approach would be to look at trends in patient-reported use and tailor future prescribing to meet the anticipated pain for the majority of patients undergoing a specific procedure.”

    In response to the opioid crisis, using text messaging to keep track of how many prescriptions drugs patients actually take after a procedure – and to potentially right-size the amount prescribed – is relatively new but growing in popularity. The traditional ways that clinicians track their patients’ opioid use could use a boost.

    “Right now, care teams rely heavily on patient recall, which they may not be able to remember in detail; phone calls, which require a lot of effort in making the calls; or tracking from the health system ordering, which does not provide information from the patients themselves about how much they are using, and how much pain they are in,” said co-lead author Daniel Lee, MD, an assistant professor of urology.

    “So with these older methods, either the data we are getting could be inaccurate, or the way we get the data is not scalable for an entire health system.”

    Using automated text messaging systems, then, provides the opportunity for large-scale, near-real-time polling of patients. But as an emerging method, it requires study.

    With that in mind, the research team set out to test the text messaging system. Over a span of several months in 2019, they enrolled more than 900 patients – approximately 45% of those eligible – who had undergone common orthopaedic and urologic procedures, ranging from knee arthroscopy to hand fracture fixation and vasectomies to prostatectomies. participated in the study. About 80% were orthopaedic patients and just under 20% had urologic procedures.

    Participants were asked to rate their pain on a scale of 0 to 10, as well as if they felt able to manage that pain on the fourth day following their procedure. Subsequent texts went out on days 7, 14, and 21 to measure the change over time. Each text also inquired about opioid tablet use, which was matched to their initial prescription.

    As time went on, the text messages showed that the average pain scores fell among orthopaedic and urologic patients. At the same time, the ability to manage pain increased, according to patients, which seemed to be accomplished with fewer and fewer opioid pills, the study showed, and certainly far fewer than were prescribed. By day 7, most patients had actually stopped taking tablets (the average patient in the study took 0 tablets by day 7).

    The average orthopaedic surgery patient took 6 opioid tablets across the entire study period but had been prescribed 20. Among urology patients, 1 tablet was the average amount used, compared with 7 prescribed. The study showed that, across the board, 64% of patients did not use even half of their prescription, and only 21% of orthopaedic surgery patients and 11% of urology patients needed a refill a month out from their procedure.

    “Having data on our prescription of opioids and the amount that was unused is eye-opening,” said Eric Hume, MD, Director of Quality and Safety in the Department of Orthopaedic Surgery, an associate professor of orthopaedic surgery, and a senior fellow in the Leonard Davis Institute of Health Economics. “This is so much more powerful and engaging than a generic message to reduce prescribing without an eye toward patient needs.”

    The team believes that knowing the difference between prescription rates and use, along with finding this reliable way to measure that difference, will be a game-changer in pain management for surgical procedures.

    “The potential to translate these findings to tailor postoperative prescribing to patient needs and change national practice is high,” said M. Kit Delgado, MD, MS, an assistant professor of emergency medicine and epidemiology and co-chair of the Penn Medicine Opioid Task Force.

    “This study has national implications, as it shows that patients only take a fraction of the amounts that we know are prescribed on average across the country. Previously we showed the median amount of opioid pills prescribed to be 40 tablets for knee arthroscopy and 20 tablets for prostate or bladder resections.

    “We are in the process of rolling this automated text messaging platform to additional surgical groups within the health system and will continue to share [what we learn] to guide practice on a broader scale.”


    Agarwal AK, Lee D, Ali Z, et al. Patient-reported opioid consumption and pain intensity after common orthopedic and urologic surgical procedures with use of an automated text messaging system. JAMA Netw Open. 2021;4(3):e213243. doi:10.1001/jamanetworkopen.2021.3243.