Can We Eliminate Opioid Medications for Postoperative Pain Control? A Prospective, Surgeon-Blinded, Randomized Controlled Trial in Knee Arthroscopic Surgery

Abstract

Background: Orthopaedic surgeons have a responsibility to develop responsible opioid practices. Growing evidence has helped define an optimal number of opioids to prescribe after surgical procedures, but little evidence-based guidance exists to support specific practice patterns to decrease opioid utilization. Hypothesis: After knee arthroscopic surgery with partial meniscectomy, patients who were provided a prescription for opioids and instructed to only fill the prescription if absolutely necessary for pain control would take fewer opioids than patients with opioids automatically included as part of a multimodal approach to pain control prescribed at discharge. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Patients undergoing arthroscopic partial meniscectomy were provided multimodal pain control with aspirin, acetaminophen, and naproxen and randomized to receive oxycodone as either included with their multimodal pain medications (group 1) or given an optional prescription to fill (group 2). Patients were contacted at time points up to 1 month after surgery to assess opioid utilization and medication side effects. The mean number of tablets utilized was the primary outcome measure, with a 50% reduction defined as a successful outcome. Results: A total of 105 patients were initially enrolled, and 95 (91%; 48 in group 1 and 47 in group 2) successfully completed the study. There was no significant reduction in the number of tablets utilized between groups 1 and 2 (3.5 vs 4.5, respectively; P = .45), days that opioids were required (2.2 vs 3.2, respectively; P = .20), or postoperative pain at any time point. The group with the option to fill their prescription had significantly fewer unused tablets remaining than the group with opioids included as part of the multimodal pain control regimen (75% of potentially prescribed tablets vs 82% of prescribed tablets; P < .001). Overall, 37% of patients did not require any opioids after surgery, and 86% used ≤8 tablets. Conclusion: Patients required a minimal number of opioids after knee arthroscopic surgery with partial meniscectomy. There was no difference in the number of tablets utilized whether the opioid prescription was included in a multimodal pain control regimen or patients were given an option to fill the prescription. Offering optional opioid prescriptions in the setting of a multimodal approach to pain control can significantly reduce the number of unused opioids circulating in the community. Registration: NCT03876743 (ClinicalTrials.gov identifier)

Vitamin C in orthopedic practices: Current concepts, novel ideas, and future perspectives

“…Acetaminophen is preferred over NSAIDs or opioids due to its good safety profile, but high doses should be avoided in patients with underlying liver disorders 19,20 . High dose acetaminophen is often part of perioperative pain control regimens in combination with local nerve blocks, opioids or NSAIDS 21,22 …”

“…In comparison to opioids and NSAIDs, vitamin C supplementation is relatively safe and low‐cost 21 . Some studies have found that high‐dose vitamin C (1.5–2 g/day) can cause digestive distress and increased risk of kidney stone formation 22–24 .…”

“…19,20 High dose acetaminophen is often part of perioperative pain control regimens in combination with local nerve blocks, opioids or NSAIDS. 21,22 Recently, there have been studies evaluating the role of vitamin C supplementation in the postoperative recovery and the prevention of CRPS. [23][24][25] There is moderate evidence supporting the use of vitamin C following distal radius fracture (DRF) to prevent CRPS, a rare chronic condition characterized by unexplained pain and swelling, hot flashing, and decreased joint mobility.…”

“…In comparison to opioids and NSAIDs, vitamin C supplementation is relatively safe and low-cost. 21 Some studies have found that high-dose vitamin C (1.5-2 g/day) can cause digestive distress and increased risk of kidney stone formation. [22][23][24] While evidence of its impact of kidney stone formation is conflicting, a tolerable upper limit of 2000 g/day of vitamin C has been set.…”

Ketamine Supplementation To Bupivacaine For Knee Arthroscopy: A Meta-Analysis of Randomized Controlled Trials

“…Insu cient pain control may result in prolonged hospital stay and delayed discharge [7][8][9]. Various analgesia methods has been developed to target the routes of nerves and various neurotransmitters to inhibit hyperalgesia and nociception, which may improve in ammatory and neurogenic conditions [10,11].…”