CARE Trial: Patient Education Reduces Opioid Use After ACL Reconstruction

Commentary Anterior cruciate ligament (ACL) reconstruction is a widely performed orthopaedic procedure, but managing postoperative pain remains challenging due to the common reliance on opioids1. Opioid overprescription has been cited as one of the contributors to the current overdose crisis2. Consequently, the medical community is seeking alternative pain management strategies that reduce opioid consumption without compromising patient outcomes. The CARE trial by Packer et al. provides a compelling model of how opioid-limiting education can transform postoperative pain management. Instead of promoting proactive opioid use to “stay ahead of pain,” the CARE trial protocol was to instruct patients to consume opioids only for unbearable pain. This approach aligns with the findings of Thompson et al.3, who demonstrated that educational interventions can significantly modify opioid prescribing practices, emphasizing a conservative, patient-centered approach to pain management. The CARE trial is a randomized controlled study conducted at a single academic institution, focusing on opioid-naïve patients undergoing primary ACL reconstruction. This homogeneous patient population allowed for a clear assessment of the educational intervention’s impact. The primary outcome, total morphine equivalents (TMEs) consumed over a 90-day postoperative period, was an objective measure of opioid use. Additionally, the study’s twice-daily assessments of pain and sleep quality during the first 2 weeks after surgery provided a deeper understanding of early recovery, extending insights from the previous NO PAin trial4. A key innovation of the CARE trial was reframing opioid use. By advising patients to reserve opioids for unbearable pain, the trial challenged traditional pain management paradigms and advocated for multimodal, non-opioid strategies, such as nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, cryotherapy, and bracing. The NO PAin trial previously demonstrated that opioid-sparing multimodal protocols reduced opioid consumption after arthroscopic procedures4, and the CARE trial extends this concept to ACL reconstruction, showing that educational interventions can reduce opioid use without negatively impacting pain control or patient satisfaction. Despite its strengths, the CARE trial has limitations. The single-center design may restrict the generalizability of its findings, as patient demographics and institutional practices vary. Furthermore, incomplete daily reporting of opioid use, pain, and sleep quality presented challenges, although statistical modeling and prescription monitoring data mitigated some uncertainty. The unblinded nature of the trial, with both patients and surgeons aware of group assignments, may have introduced performance bias that influenced clinical decision-making. The study by Thompson et al. on opioid prescribing for standard arthroscopic procedures underscores the variability in baseline practices, highlighting the need for targeted educational interventions to standardize opioid prescribing3. The implications of the CARE trial are broad. Clinically, it offers a practical framework for reducing opioid use without compromising patient comfort or satisfaction. The results prompt questions about optimizing patient education and multimodal analgesia to further minimize opioid reliance5. Future research could expand inclusion criteria to include patients at higher risk for opioid dependence—such as those with prior opioid use or revision surgery—and extend follow-up durations to assess long-term outcomes. Given the low opioid consumption observed in the CARE trial, the study also raises the possibility of opioid-free pain management protocols for selected populations. Educationally, the CARE trial serves as a model for evidence-based practice. Its findings emphasize the value of patient counseling in reducing opioid use and provide a framework for training future health-care providers. Incorporating lessons from the trial into medical and surgical curricula will help clinicians balance effective pain management with the urgent need to mitigate opioid-related harm. Together with the NO PAin trial, the CARE trial strengthens the case for a paradigm shift in clinical practice. By demonstrating that multimodal, opioid-sparing interventions reduce opioid consumption without sacrificing patient comfort or satisfaction, these studies challenge longstanding prescribing practices and set the stage for safer, more effective pain management protocols4,5. In conclusion, the CARE trial represents a significant step forward in postoperative pain management, showing that opioid-limiting education and counseling can reduce opioid consumption after ACL reconstruction. While the trial had limitations, its strengths provide a solid foundation for future research and improvements in clinical practice. As our understanding of multimodal pain management evolves, integrating these insights into routine practice will be crucial in optimizing patient care and addressing the opioid crisis.