Characterizing the Effect of Opioid Tablet Strength on Post-Operative Opioid Consumption Following ACL Reconstruction
Authors: Nazzal Ehab 
Published: July 2020

Objectives:

Prescription opioid abuse continues to be a national crisis in the United States. Orthopaedic surgeons contribute significantly to this crisis, prescribing nearly a tenth of annual opioid prescriptions. With Anterior Cruciate Ligament (ACL) reconstruction being a common orthopaedic procedure performed at high volumes, understanding how physician opioid prescribing practices affects patient post-operative opioid utilization is of critical importance to curbing the orthopaedic contribution to the opioid epidemic. We aimed to assess how opioid tablet strength affects post-operative opioid consumption following ACL reconstruction. We hypothesized that prescribing a lower strength opioid tablet would not adversely influence post-operative pain or increase opioid consumption

Methods:

All data was collected prospectively from patients undergoing ACL reconstruction at a single academic ambulatory surgery center.All patients received the same peri-operative pain management protocol, which consisted of an adductor canal block at the time of surgery, Naprosyn 500 mg to be taken as needed, and pre-operative opioid education that outlined safe opioid use practice. Percocet was prescribed at two dosages in a consecutive fashion. Between March 2018 to October 2018, patients received Percocet at a strength of 7.5 mg (7.5 mg Oxycodone/325 Acetaminophen). From November 2018 to May 2019, patients received prescriptions at a dose of 5 mg. At the first post-operative clinic visit, patients completed a survey describing the quantity of opioid tablets consumed, days of postoperative opioid use, and opioid-related adverse effects. In addition, patients used a smart-phone application to assess post-operative pain on a numeric rating scale from post-operative day (POD) 1 to POD 6.

Results:

148 patients were prospectively enrolled. 78 (51.3%) received Percocet at a strength of 7.5 mg per tablet and 69 (46.9%)received Percocet at a strength of 5 mg. The median age was 23 years (interquartile range: 18-36) and 49.7% were female. The 7.5 mg cohort took an average of 12.4 tablets (±7.0), while the 5 mg cohort took an average of 8.6 (±7.4) tablets, a 3.7 tablet decrease (p=0.002). Both cohorts consumed opioids for the same amount of post-operative days (5mg cohort: 3.1 days, 7.5mg cohort: 3.5 days; p=0.289). The incidence of opioid related side effect were equivalent between the 5 mg and 7.5 mg cohorts, which included constipation (34.8% and 34.6%, p=0.983), euphoria (5.8% v. 10.3%, p=0.324), nausea/vomiting (13.0% v. 16.7%, p=0.539), fatigue (2.9% v. 6.4%, p0.319), and pruritus (2.9% v. 5.1%, p=0.495). There was no difference in post-operative numeric pain scores in the 5 mg vs. the 7.5 mg cohort (POD 1: 5.7 ±1.9 vs. 5.4 ± 2.0, p=0.633; POD 6: 3.3 ± 2.1 vs. 2.9 ± 1.8, p=0.726).

Conclusion:

Prescribing a lower strength of oxycodone after ACL reconstruction did not increase pain scores or opioid consumption.This suggests that it is possible to achieve similar pain control while lowering the total opioid prescribed. These finding support future research focusing on optimizing pain control at minimal opioid doses.