Risk Factors for Increased Consumption of Narcotics After Hip Arthroscopy

A Prospective, Randomized Control Trial

Ryan S. Selley, MD; Matthew J. Hartwell, MD; Bejan A. Alvandi, MD; Michael A. Terry, MD; Vehniah K. Tjong, MD

Disclosures

J Am Acad Orthop Surg. 2021;29(12):527-536. 

In This Article

Abstract and Introduction

Abstract

Introduction: No accepted standard exists regarding the number of opioids to prescribe after many surgical procedures, and previous literature has indicated that the number of opioids prescribed influences the total number of pills consumed. The goal of this study was to investigate whether prescribing less opioids after hip arthroscopy results in less total postoperative utilization without compromising analgesia and identify risk factors for increased use.

Methods: This study randomized 111 patients to receive either 30 or 60 tablets of hydrocodone/acetaminophen 10 to 325 mg after hip arthroscopy. Demographic information, pain instruments, and scores including International Hip Outcome Tool (iHOT-12) were collected preoperatively. Postoperatively, patients were contacted over the course of 3 weeks to determine their Numeric Pain Rating Scale scores, total number of tablets taken/leftover, and the last day that they required narcotic pain medications, which were calculated and compared for each group. Preoperative variables that increased the risk of higher narcotic pain medication requirements were assessed.

Results: Patients in the 60-tablet group had significantly more tablets leftover than the 30-tablet group (49.5 versus 22.0, P < 0.001) and had no significant difference in Numeric Pain Rating Scale scores at 24 hours, 48 hours, or final follow-up. The 30- and 60-tablet groups demonstrated no significant difference in average tablets consumed (9.2 and 10.5, P = 0.60), respectively. Risk factors for increased postoperative opioid use included preoperative opioid use (B = 12.62, 95% confidence interval [CI], 6.28–18.96, P < 0.001) or muscle relaxant use (B = 22.45, 95% CI, 7.59–37.31, P < 0.0036) within 1 year preoperatively. Preoperative iHOT-12 scoring also significantly predicted postoperative opioid consumption in this cohort (B = −0.25, 95% CI, −0.45 to −0.036, P < 0.022).

Conclusion: The number of leftover tablets after hip arthroscopy can be significantly reduced by prescribing 30 tablets compared with 60 tablets without affecting postoperative pain control. Total tablets prescribed in this cohort did not affect total opioid utilization. Preoperative factors including opioid or muscle relaxant use and iHOT-12 scores can be used to predict postoperative opioid requirements.

Introduction

Perioperative pain management is an important aspect of quality patient care. Opioid pain medications are increasingly being used for pain control and are an important component of providing adequate analgesia in the postoperative setting. Opioids allow patients to undergo operations that otherwise may be intolerable secondary to untreated postoperative pain. As such, physicians in the United States write over 250 million prescriptions for painkillers per year with orthopaedic surgeons prescribing an estimated 7.7% of all opioids.[1,2] Increased usage has led to unintended negative consequences for individuals and society. It is estimated that 46 people die each day from an overdose of prescription painkillers.[1] Individual use can lead to the development of tolerance, long-term addiction, and systematic adverse effects including nausea, vomiting, constipation, oversedation, and respiratory depression, all of which can lead to worse treatment outcomes.[1,3]

Further issues arise when opioids are misused; it is estimated that nontherapeutic use has increased threefold in recent years.[4] In the United States alone, the estimated annual direct and indirect cost of opioid prescription misuse is $53.4 billion.[5] The federal government and the American Academy of Orthopaedic Surgeons have publicly recognized this epidemic and raised a call for clinicians to more responsibly prescribe opiate pain medications via evidenced-based guidelines.[6,7]

As such, identifying the appropriate number of narcotics to prescribe in conjunction with a multimodal pain control strategy for specific procedures is essential. From 2004 to 2009, a 365% increase in the rate of hip arthroscopy was observed.[8] The patients most commonly undergoing these procedures were in their 20s and 30s; this is also the same cohort of patients that is at the highest risk of nonprescription opioid abuse.[8,9] Considerable variability prevails among surgeons with respect to the amount of opioids prescribed for the same procedure; as a result, many patients are left with excess unused medication.[10] Leftover prescription opioids are at risk of diversion to family and friends for nonmedical use.[11] Furthermore, research has shown a link between prescription quantity and higher opioid consumption; Howard et al[12] reported patients using 0.53 more pills for every additional pill prescribed.

As arthroscopic procedures in the hip are increasing in frequency, it is important to precisely quantify the number of narcotics that are necessary for appropriate postoperative analgesia. We hypothesized that (1) patients who received smaller narcotic prescriptions would have no change in postoperative analgesia or functional scores and would use fewer narcotic tablets and (2) preoperative demographic factors could predict increased opioid consumption postoperatively.

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