REDUCTION IN DISPENSED OPIOIDS AND CHRONIC POSTOPERATIVE OPIOID USE IN OUTPATIENT ORTHOPAEDIC PATIENTS: A POPULATION-BASED STUDY OF THE IMPLEMENTATION OF AN INSTITUTIONAL PROTOCOL

The opioid epidemic is a complex issue with multiple sources of origin and proliferating factors, including physician overprescribing. Due to the painful nature of orthopaedic procedures, orthopaedic surgeons face pressure to prescribe opioids to control pain in the peri-operative period. As such, they are some of the highest prescribers of opioids among all medical specialties. A number of studies have shown decreases in opioid prescribing by orthopaedic surgeons following introduction of legislation setting prescription limits and strategies such as patient education programs or restrictive prescription protocols. While these studies have shown good outcomes, there is a scarcity of literature evaluating these strategies at an institutional level. The purpose of this study is to evaluate the effectiveness of a multimodal opioid restriction protocol implemented at an outpatient Canadian sports orthopaedic surgery institution. This was a retrospective pre-post intervention study using deidentified data housed by a provincial government agency. All opioid naïve patients that underwent outpatient shoulder or knee surgery at our institution between January 2013 and December 2018, and July 2020 and March 2022, were included (n = 10,449). Patients who filled a prescription for opioids in the six months preceding their surgery, and those who had surgery during the implementation period, (January 2019 to June 2020) were excluded. The intervention was a three-pronged approach and included distribution of an educational pamphlet, targeted messaging by perioperative nursing staff around opioid use and a restricted prescription protocol consisting of acetaminophen, ibuprofen and a short course of tramadol for instances of intolerable break through pain. The primary outcome was morphine milligram equivalents (MME) per patient, calculated using prescriptions filled in the post-operative period and compared using a t-test. A binary variable was generated indicating if a patient filled an opioid prescription after 180 days post-surgery to evaluate chronic use. A multivariable logistic regression was performed evaluating the effect of the intervention, as well as independent variables, including age, sex, pre-existing mental health diagnoses, SEFI-2 score and Charlson Comorbidity Score. Average MME per patient decreased 18% (321 to 263; p < 0 .001). The proportion of patients filling opioid prescriptions at 180 days post-surgery decreased from 4.8 to 2.6% (p < 0 .001) for a relative risk reduction of 43.8%. The odds of filling an opioid prescription were lower after implementation of the restriction protocol (OR 0.53, p < 0 .001). Middle age, lower socioeconomic status, increased medical comorbidity and pre-existing mental health diagnoses were all associated with an increased risk of continuing to fill prescriptions for opioids at 180 days post operative. Adherence to the protocol was estimated to be high as 71% of patients used tramadol post operatively. The amount of opioids dispensed and the number of chronic opioid users were reduced for outpatients shoulder and knee surgery patients following the institution-wide implementation of a multimodal opioid reduction protocol. This protocol could serve as a model for other institutions to implement effective strategies to decrease opioid dependency resulting from early post-operative pain management.