The Impact of Restricting Opioid Use in Total Joint Arthroplasty Patients
Orthopaedic surgeons have traditionally been among the top prescribers of opioids.  To help prevent misuse and abuse of these drugs, the American Academy of Orthopaedic Surgeons (AAOS) issued an information statement on opioid use in orthopaedic patients to encourage standardized, practice-specific opioid protocols that would: 
- Establish the amount and duration of opioids a practice’s surgeons would prescribe for acute injuries, postoperative pain, and chronic pain
- Limit the size of prescriptions based on the practice’s established guidelines
- Limit the use of extended-release opioids for acute pain from an injury or surgical procedure
- Restrict the use of opioids in preoperative and non-surgical patients
Nearly 4 years later, have these recommendations had an impact on opioid prescribing?At the University of Iowa Hospitals and Clinics, the answer is yes, according to a study presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons. The study has also been published online ahead of print by the Journal of Arthroplasty. 
Timothy S. Brown, MD, and his colleagues implemented an opioid prescription protocol for primary total hip and total knee arthroplasty patients in 2018 based on the AAOS recommendations. For this study, they compared prescription patterns and patient outcomes among 282 pre-protocol patients and 117 post-protocol patients who underwent primary total joint arthroplasty between 2017 and 2018. Opioid use was recorded as morphine milligram equivalents (MMEs) and patient outcomes were evaluated with KOOS Jr, HOOS Jr, and PROMIS scores.
Outcomes were found to be similar between groups, as was opioid use in the hospital. At discharge, however, pre-protocol patients received:
- Significantly larger initial prescriptions: 751.5±296.6 MMEs vs 387.3±202.2 MMEs (P<0.01)
- Significantly more refills: 0.5±0.8 refills vs 0.3±0.5 refills (P=0.02)
- A larger overall quantity of opioids through refills: 253.0±447 MMEs vs. 84.0±166 MMEs (P<0.01)
The amount of opioids they were prescribing pre-protocol was a big surprise to Dr. Brown and his colleagues. “We were prescribing a lot of opiates to our patients,” Dr. Brown said. “The prescriptions varied widely, from 40 pills to 200-plus pills.”
With the opioid protocol, they now 40 5-mg oxycodone tablets at discharge, along with 40 50-mg tramadol tablets as a backup medication to be used once the patient is weaning from oxycodone.
Interestingly, Dr. Brown and his colleagues received more phone calls about pain and medication refills before instituting the protocol: 0.7±1.4 calls/patient pre-protocol versus 0.4±0.7 calls/patient post-protocol (P=0.02). This was another surprise in the study but could be attributed to the education they are doing in conjunction with the protocol.
“We have a preoperative class before each patient has an elective total joint replacement,” Dr. Brown said. “During the class we spend time discussing opiate medications: their dangers, safe use, and appropriate weaning.”
The in-hospital protocol has also changed to de-emphasize opioids, and they make sure patients and the nursing staff know that:
- Opioids should only be given as needed, not as part of routine pain management.
- Other modalities – acetaminophen, celecoxib, gabapentin, aspirin, and ice – should be used together to control pain.
Dr. Brown said that patient satisfaction has not changed since implementation of the practice’s opioid protocol – a key point for surgeons considering a similar change in their opioid protocols. “Implementing the AAOS recommendations for opiate medications following total joint arthroplasty can be done without significant stress to your patients or your practice,” Dr. Brown said.
Holte A, Carender CN, Noiseux NO, Otero JE, Brown T. Instituting a Restrictive Opioid Prescribing Protocol for Primary Total Hip and Knee Arthroplasty: One Institution’s Experience (Paper 752). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.
- Volkow ND, McLellan TA, Cotto JH, Karithanom M, Weiss SR. Characteristics of opioid prescriptions in 2009. JAMA. 2011 Apr 6;305(13):1299-301. doi: 10.1001/jama.2011.401.
- American Academy of Orthopaedic Surgeons. AAOS Information Statement: Opioid Use, Misuse, and Abuse in Orthopaedic Practice. Information Statement 1045. October 2015. Accessed April 10, 2019.
Holte AJ, Carender CN, Noiseux NO, Otero JE, Brown TS. Restrictive opioid prescribing protocols following total hip arthroplasty and total knee arthroplasty are safe and effective. J Arthroplasty. 2019 Feb 20. pii: S0883-5403(19)30160-3. doi: 10.1016/j.arth.2019.02.022. [Epub ahead of print]