THA Patients Don’t Need a 2-Week Supply of Opioids to Achieve Good Pain Control
To address the opioid epidemic in the US, orthopaedic surgeons are evaluating whether certain common practices could place patients at risk for chronic opioid abuse, such as the broad reliance on opioids after elective procedures despite no clear evidence that they are more effective than non-opioid pain medications. According to the Centers for Disease Control and Prevention, the duration of the first prescription has been found to be a major predictor of risk: A 2-day supply of opioids is associated with a 6% risk of chronic use after 1 year, while a 2-week supply increases the risk to 25%. 
With that in mind, researchers from The Rothman Institute and Thomas Jefferson University in Philadelphia, Pennsylvania, investigated whether a multimodal pain management regimen that restricted opioids to a 2-day supply is a safer and more effective approach than the traditional 2-week opioid prescription for patients undergoing elective total hip arthroplasty (THA).
They found that it is: The 2-day course of opioids provided effective pain control and high patient satisfaction when supplemented by a scheduled-dose multimodal pain management regimen in which fixed doses of non-opioid drugs (acetaminophen, meloxicam, and gabapentin) were prescribed around the clock to prevent the onset of pain.
The study was presented during The Hip Society/American Association of Hip & Knee Surgeons Specialty Day and received The Hip Society’s 2019 Otto Aufranc Award.
For the cluster-randomized, crossover study, 235 THA patients were randomly assigned to receive 1 of 3 medication regimens after discharge:
- Group A: Scheduled-dose multimodal pain management regimen with a 2-day supply of an opioid to be used solely for emergency pain relief
- Group B: Scheduled-dose multimodal pain management regimen but with a more traditional 2-week supply of an opioid
- Group C: 2-week supply of an opioid and acetaminophen to be used as needed, with no scheduled-dose multimodal pain management regimen
Patients were followed daily for 30 days to evaluate pain levels and opioid use. The researchers also assessed opioid-related adverse effects, satisfaction, sleep quality, and hip function.
The researchers found that patients in Groups A and B (the 2 multimodal pain management regimens) had considerably less pain than patients in Group C, especially during the first 2 weeks after surgery. Patients in Groups A and B also required significantly fewer opioid tablets after surgery and discontinued use of the opioid earlier than patients in Group C.
Patients in Group A, not surprisingly, took the least amount of opioids and, consequently, had the fewest opioid-related adverse effects after surgery. Opioid-related adverse effects were similar in Groups B and C.
Patients in Groups A and B also reported better sleep quality and were more satisfied with their experience than patients in Group C.
“The results of this clinical trial suggest that it is time to rethink the traditional practice of prescribing a large number of opiate tablets after elective surgery,” the researchers concluded. “Not only do opiates clearly not need to be the central component of a pain regimen, but it appears that providing a smaller opiate supply may also redefine patients’ expectations for how much pain they might have after surgery.”
Fleischman AN, Tarabichi M, Makar G, Foltz C, Hozack WJ, Austin MS, Chen AF. The 2019 Otto Aufranc Award: Cluster-Randomized Trial of Opiate-Sparing Analgesia after Discharge from Elective Hip Surgery. Presented at The Hip Society/AAHKS Specialty Day, March 16, 2019, Las Vegas, Nevada.
Fleischman AN, Tarabichi M, Makar G, Foltz C, Hozack WJ, Austin MS, Chen AF. Cluster-Randomized Trial of Opiate-Sparing Analgesia After Discharge From Elective Hip Surgery (Paper 21). Presented at the AAHKS Annual Meeting, November 1-4, 2018, Dallas, Texas.
Fleischman AN, Tarabichi M, Makar G, Foltz C, Hozack WJ, Austin MS, Chen AF. Cluster-Randomized Trial of Opiate-Sparing Analgesia After Discharge From Elective Hip Surgery (Abstract 6002; recipient of a Resident/Fellow Travel Award). Presented at the 17th Annual Pain Medicine Meeting, November 15-17, 2018, San Antonio, Texas.
- Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long-term opioid use – United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017 Mar 17;66(10):265-269. doi: 10.15585/mmwr.mm6610a1.