February 17, 2022 — Nick Dawson, a 42-year-old ski instructor from Montana, knows a thing or two about ACL repairs. He has torn his anterior cruciate ligament four times and has had three surgeries for the injury.
A common but painful surgery, doctors often prescribe a hefty course of opioids for pain relief after the procedure. And that’s exactly the course Dawson’s surgeons took. But with each fix, Dawson used less of the pills until he finally chose to stop taking them altogether the third time.
“The first time I had no idea what to expect from my recovery, so I took the opioids as prescribed to stay ahead of the pain,” he says. “I experienced mood swings and found that the drugs didn’t really take away the pain — instead, they make you not care about the pain.”
For Dawson, a combination of a heavy dose of anti-inflammatory medication and an ice pump that the doctor sent home with him worked best. After his second surgery, he took fewer opioids, but more of the anti-inflammatory drugs combined with the ice pump.
“After a few days of that approach, I stopped taking the opioids,” he says.
Finally, after the third surgery in 2012, Dawson dropped the opioids altogether, even though his doctor had prescribed them.
“I found what I didn’t like, as well as what worked best,” he says. “I really wondered why the anti-inflammatory approach wasn’t what doctors used from the start, instead of opioids.”
It seems that Dawson was at the forefront of his self-prescribed approach. New research from the Mayo Clinic examines whether patients recovering from ACL and rotator cuff surgery can better manage pain with drug combinations that do not contain opioids. The results are promising, and that’s a good move.
About 3 out of 10 opioid prescriptions are tied to orthopedic and spine disease, according to Mayo’s lead researcher, Kelechi Okoroha, MD. The standard prescription is for 30 to 60 pills, for patients up to 2 weeks. Not using opioids after these surgeries could help reduce the high rate of opioid dependence and sometimes subsequent death.
“Certain patients will simply be more prone to addiction, even after a short introduction,” Okoroha says.
The US Health and Human Services Department estimates that 70,630 people died from opioid overdoses in 2019, while 10.1 million people abused the drugs.
“Opioids are pretty standard here in the United States after surgery,” Okoroha says. “We have the perception that there should be no pain after surgery.”
This approach and belief dates back to the mid-1990s, when OxyContin appeared on the market as a “softer” class of opioids, marketed as less addictive. Insurance companies and doctors bought in, and in 2017 the US had a public health crisis with opioid addiction. Now doctors are looking for ways to break the cycle.
Even before this round of orthopedic research, Okoroha as a surgeon himself began to look for ways to stop opioid use in joint replacement procedures. Finding success there – patients found the protocol more effective or more effective than opioids – Okoroha decided to move on to other areas of orthopedic procedures to see if he could produce the same results.
Breaking their research into two studies, the Mayo team first examined the alternative medication protocol with 62 ACL repair patients, dividing them into two groups: one using the standard opioid plan of hydrocodone and acetaminophen. In the second group, the researchers used nerve blockers, acetaminophen, muscle relaxants and a nonsteroidal anti-inflammatory drug (NSAID).
“This yielded multiple resources that targeted multiple pain sources,” explains Okoroha.
Patients were asked to rate pain using the Visual Analog Scale (VAS), which ranged from “no pain” to “worst pain.” All patients in the non-opioid group reported satisfactory pain relief and minimal side effects. This was true even a week after surgery.
The second group consisted of 40 patients who were repaired for rotator cuff surgery. Of these, 23 were in the traditional opioid group and 17 were in the non-opioid group. On days 1 and 4 after surgery, the traditional group reported significantly higher pain levels on the VAS scale. The non-opioid group scored significantly lower on every point measured.
All patients in both studies received a nerve block before surgery. Dawson says doctors used this approach during his third ACL surgery.
“I felt that helped a lot in managing pain for the first 24 hours,” he says.
Rehabilitation remained the same after surgery for both the ACL and rotator cuff study groups. Okoroha was pleased with the results.
“The most important thing is that we don’t have to turn to opioids after regular sports surgery,” he says. “Our thinking is that if we can apply it to these orthopedic procedures, we can apply it to others.”
In both studies, patients reported side effects ranging from drowsiness and dizziness to gastrointestinal symptoms. But in the rotator cuff study, patients who received the experimental protocol fared slightly better.
Okoroha says more research on the new pain treatment plans in other orthopedic surgeries will follow.
In the meantime, it’s up to health care providers to see if their patients can manage without opioids, he says. “If we can combine the evidence with adoption, we could eventually change standard practice.”
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