Published 11/19/2020
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Kerri Fitzgerald
Editor’s note: The following content was originally scheduled for the AAOS Now Daily Edition, which publishes each year onsite at the AAOS Annual Meeting, but this year’s meeting in March was canceled due to COVID-19. Despite the cancellation, members can access virtual content from the Annual Meeting by visiting the Academy’s Annual Meeting Virtual Experience webpage at aaos.org/VirtualAAOS2020.
There is no standard recommendation for the number of opioids to prescribe after many surgical procedures, and previous studies have found that the number of opioids prescribed influences the number of pills consumed. In addition, unused opioids pose a risk of diversion for nonmedical use.
A study presented by Ryan Selley, MD, a resident physician in the Department of Orthopaedic Surgery at Northwestern University, as part of the Annual Meeting Virtual Experience found that the number of leftover opioid tablets after hip arthroscopy could be significantly reduced when the physician prescribed 30 tablets compared to 60 tablets, without affecting postoperative pain control. Furthermore, the study found that certain preoperative risk factors predicted postoperative opioid consumption. However, the study did not find that total tablets prescribed affected total opioid utilization.
Researchers randomized 111 consecutive patients to receive 30 (n = 59) or 60 (n = 52) tablets of hydrocodone/acetaminophen 10–325 mg following hip arthroscopy, in addition to a multimodal strategy to control pain. They collected the following information preoperatively: demographics, International Hip Outcome Tool (iHOT-12), Pain Catastrophizing Scale, and pain scores. Postoperatively, researchers contacted patients five times during a three-week period to assess Numeric Pain Rating Scale (NPRS) score, total number of tablets taken and left over, and the last day they required narcotic pain medications.
The overall average patient age was 37.7 years, 65.0 percent were female, and average BMI was 27.2 kg/m2.
There were no significant differences in demographics or preoperative questionnaire scores between the groups. Patients in the 60-tablet group had significantly more tablets left over than the 30-tablet group (49.5 versus 22.0; P < 0.001); however, there were no significant between-group differences in NPRS scores at any follow-up point. The 30- and 60-tablet groups had no significant differences in average tablets consumed (9.2 versus 10.5; P = 0.60). The 30-tablet cohort had significantly fewer prescribed tablets remaining at the time of opioid cessation compared to the 60-tablet cohort (71 percent versus 83 percent; P < 0.001).
In both groups, patients required fewer opioids than anticipated. “The main surprise was the number of pain tablets the majority of patients required. Eighty percent of patients required 14 tablets or less, and 94 percent required 30 tablets or less,” Dr. Selley said. “Prior to this study, we were prescribing 60 tablets to each patient. A large number of patients require very limited opioids postoperatively, whereas a small number of patients require a large number of opioids.”
Risk factors for increased postoperative opioid use included preoperative opioid use or muscle relaxant use within one year preoperatively.
Additionally, patients with an iHOT-12 score of ≤ 45 were more likely to utilize more than 15 tablets (odds ratio, 8.85; 95 percent confidence interval, 1.67–46.88). When analyzed as a continuous variable for every one-point decrease in iHOT-12 score, the number of tablets utilized increased by one-fourth tablet. Thus, “The iHOT-12 predicts postoperative narcotic consumption and could be used to tailor specific prescription amounts to patients,” the researchers noted.
“This study highlights our need as orthopaedic surgeons to identify the appropriate number of opioids to prescribe for individual patients for individual procedures,” Dr. Selley told AAOS Now. “If we could identify, based on preoperative risk factors, patients who may require more narcotic pain medications, we could selectively prescribe higher amounts to those patients. This would limit the number of excess opioids at risk for nonmedical use in the community.”
The study is limited by its use of patient-reported narcotic consumption. In addition, no patients in the study were currently using opioid pain medications preoperatively, which Dr. Selley said is not representative of all patients undergoing hip arthroscopy and is an identified risk factor for greater postoperative narcotic use in similar patient populations.
Dr. Selley’s coauthors of “Does Prescription Size Affect Opioid Utilization Following Hip Arthroscopy? A Prospective, Surgeon-Blinded, Randomized Control Trial” are Matthew James Hartwell, Michael A. Terry, and Vehniah K. Tjong.
Kerri Fitzgerald is the managing editor of AAOS Now. She can be reached at kefitzgerald@aaos.org.