EXECUTIVE SUMMARY

Opioid use declined by 75% with a standardized opioid-sparing protocol employed in total joint arthroplasty patients, according to the authors of a new study.

  • The opioid-sparing protocol included the use of oral Tylenol and Toradol.
  • Patients were discharged with aspirin, Mobic, and Tylenol.
  • Opioids were used sparingly for breakthrough pain.

A new study shows that a standardized opioid-sparing protocol in total joint arthroplasty can result in a dramatic reduction in opioid use. The pilot study demonstrated that patients in the narcotic-sparing cohort consumed 75% fewer morphine milligram equivalents (MMEs) within the hospital setting.1

“We decided to do a trial of an opioid-sparing protocol with same-day discharge total hip replacements, which our facility currently does in the hospital,” says Roy I. Davidovitch, MD, Julia Koch associate professor of orthopedic surgery at the NYU School of Medicine and director of the outpatient joint replacement program and The New York Hip Institute at OrthoManhattan. “We instituted a protocol based on starting pre-op medications the day before.”

Patients take 1 gram of oral Tylenol every eight hours before an operation. Then, patients receive an anti-inflammatory. On the day of surgery, in the preoperative area, they receive another anti-inflammatory and undergo a spinal anesthetic that does not contain any opiates, Davidovitch explains.

“We would inject an opiate-free cocktail into the soft tissues during the procedure, which includes bupivacaine, and then we also injected long-lasting bupivacaine that would last two to three days,” he says. “The cocktail also has Toradol.”

Patients receive IV Tylenol. In the postoperative area, they do not receive opiates until their pain is at a level 6 or higher, he adds.

“We start with 15 mg of tramadol PO,” Davidovitch says. “But the important piece is we educate the patient and nursing staff to assess their pain relative to their preoperative pain level.”

For instance, if a patient reports in the preoperative time frame that the pain is an average of level 7 or 8, and the postoperative pain is in the range of 5 or 6, then the patient’s pain has been reduced without introducing new opiates.

“We would ask the patient if it would make sense to try to avoid opiates postoperatively,” Davidovitch says. “A lot of pain is anxiety about impending pain.”

Also, patients sometimes feel that they should not experience any pain after surgery. “We want them at a tolerable level of pain or discomfort,” Davidovitch notes.

When patients are discharged, they can go home with 81 mg aspirin taken twice a day for DVT prophylaxis as well as to help with pain. Patients also take Mobic once a day, and they receive Tylenol (up to 3 grams per day), Davidovitch adds.

“We tell patients to take Tylenol on a standing basis,” Davidovitch says. “Whether or not their pain is high or low, they should keep on taking it.”

The theory is that if patients maintain a high basal level of Tylenol in the bloodstream at all times, then it prevents fluctuations in pain, Davidovitch explains.

“If pain spikes above that level, then we send the patients home on 12 pills of tramadol, 50 mg, without any refills,” Davidovitch says. “It’s one of the weakest opioids and has no street value, which is why we use it.”

With a nation focused on the opioid epidemic, the opioid-sparing protocol offers an alternative pathway to managing patients’ pain after total knee arthroplasty and total hip arthroplasty.

In addition to decreasing narcotic use, the protocol helps maintain consistent clinical outcomes, length of stay, discharges, and Hospital Consumer Assessment of Healthcare Providers and Systems scores.1

REFERENCE

  1. Clair AJ, Luthringer T, Feng J, et al. Decreasing the opioid footprint in total joint arthroplasty: One institution’s evidence-based progression toward a standardized opioid sparing protocol. Poster presented at the American Academy of Orthopaedic Surgeons 2019 Annual Meeting, March 12-16, 2019, Las Vegas.