Few Patients Maximize Opioid-Sparing Medications after Orthopaedic Surgery

    A new study led by researchers from Johns Hopkins University adds to growing evidence that patients underuse non-opioid pain relievers to supplement opioid pain management after spine and joint replacement surgery.

    The study findings, which also show that patients improperly store and dispose of unused opioids, were published online ahead of print by Anesthesia & Analgesia. The report highlights the need for physicians to better educate patients on non-opioid alternatives, as well as how to properly store and dispose of opioids in the home, the researchers said.

    “We found that a very small percentage of patients use non-opioid medications such as ibuprofen and acetaminophen in addition to opioids to help manager their pain,” said first author Mark Bicket, MD, assistant professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine.

    “It’s clear we need to empower patients to ask their physicians about non-opioid pain management options, as well as call on prescribers to be more thoughtful of their prescribing practices,” Dr. Bicket said.

    He added that if pain is more frequently managed with non-opioid options, fewer opioids will need to be prescribed and patients will have less available to be lost, sold, taken by error, or accidentally discovered by a child.

    In an earlier study, Dr. Bicket reviewed a half-dozen papers and found that most opioid pills go unused and that almost all patients fail to properly dispose of the leftover medication.

    To further examine what happens to opioids after they have been prescribed, as well as to determine whether patients used non-opioid medications in conjunction with their prescribed opioid prescriptions as recommended by evidence-based guidelines, the researchers recruited 140 inpatient adult spine and joint replacement patients at The Johns Hopkins Hospital from August to November 2016. Of the 140 patients in the study:

    • 47% were women
    • 74% were white
    • The average age was 56
    • 58% reported a history of chronic pain

    Dr. Bicket and his team collected patient data, including history of substance abuse, self-reported pain scores, and preoperative opioid use, through in-person interviews and electronic health records. The researchers also conducted phone surveys 2 days, 2 weeks, 1 month, and 6 months after surgery to determine:

    • If and when patients stopped taking opioids
    • How many opioid tablets they had left
    • What non-opioid pain treatments they used
    • If they knew about and were practicing safe opioid storage and disposal per the Food and Drug Administration’s recommendations

    Very few of these patients used non-opioid medications in conjunction with opioids throughout the study period. Two days after surgery, 82% of patients reported not using non-steroidal anti-inflammatory drugs (NSAIDs), and 44% reported not using acetaminophen. Only 5% had used both NSAIDs and acetaminophen. One month after surgery, only 6% of patients reported using multiple non-opioid medications.

    In addition, 73% of patients said they had unused opioids 1 month after surgery, with 46% saying that that had 20 or more unused pills and 37% saying they had more than 200 morphine milligram equivalents (MMEs) of opioids.

    Although it is difficult to definitively say how many MMEs are dangerous to take at one time, Dr. Bicket said that 200 MME is considered by some experts as the dosage at which a patient who has never had opioids would overdose.

    One month after surgery, most patients in the study also reported unsafe storage (91%) and failure to dispose of opioids (96%) according to FDA guidelines.

    Six months after surgery, the percentage of patients who had unused opioids fell to 34%. Many still reported unsafe storage and failure to dispose of opioids (92% and 47%, respectively), with a large majority reporting they had not received instructions on how to store or dispose of opioids (83% and 75%, respectively).


    Bicket MC, White E, Pronovost PJ, Wu CL, Yaster M, Alexander GC. Opioid oversupply after joint and spine surgery: a prospective cohort study. Anesth Analg. 2018 Apr 17. doi: 10.1213/ANE.0000000000003364. [Epub ahead of print]