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Melanie Cole (Host): Orthopedic surgeons have a responsibility to develop responsible opioid practices. Growing evidence has helped define an optimal number of opioids to prescribe after surgical procedures, but little evidence-based guidance exists to support specific practice patterns to decrease opioid utilization.

Welcome to Better Edge, a Northwestern Medicine Podcast for Physicians. I'm Melanie Cole andjoining me is Dr. Vehniah Tjong. She's an Assistant Professor of Orthopedic Surgery at Northwestern Medicine. Dr. Tjong, thank you so much. This is really one of those topics that is of interest to providers across the spectrum and anyone involved in procedural interventions. So as we look at the parameters for prescription of opioids in the past, and what's different now, give us a little background on the Opioid Medications for Post-Operative Pain Control Study.

Vehniah Tjong, MD (Guest): Well, here at Northwestern, we did three separate randomized controlled trials. One with patients who underwent knee arthroscopy. Another one with patients who underwent ACL reconstruction and the third on those who needed a hip arthroscopy. And what we did was we divided patients into two separate arms, prescribed them different numbers of pills to see how many they actually needed and how many were unused after the study.

And what we found was something quite different from previous studies and our original hypothesis. So what we thought was going to happen was that if we gave patients more prescription opioids, they would take more for their pain. But in fact, what we found in all three studies was that no matter how many pills we gave them, both arms required the same amount with no difference. So, quite interesting results that we were able to gather.

Host: Really? When you were describing that, I was sure that what you were saying at the beginning was correct. Of course, but wow. That is surprising. Were you at this?

Dr. Tjong: Most definitely. We did know that, especially orthopedic surgeons are guilty of over prescribing prescription opioids, but we really didn't think that patients would be able to tell us how much of their pain was stable in each surgery and how much pain pills they needed, was that amount.

Host: What an interesting study. So what did you find out as far as preoperative patient evaluation and planning as being vital to successful post-operative pain management, as well as enhanced recovery protocols to help reduce that length of stay for orthopedic surgery. Did you find that using that multimodal opioid sparing regimens were a critical component? Tell us a little bit about what you study.

Dr. Tjong: Absolutely. So there were several risk factors that we were able to identify preoperatively that, predispose people from taking a little more than their counterparts. This included patients with preoperative opioid use, patients with a family history of substance abuse, and interestingly patients who had previously taken something even like a muscle relaxant as well.

And we found that these patients all had a little higher opioid needs, compared to those who didn't have those risk factors. You talked about the multimodal pain control regimens that were used, and we found that that was of particular importance. So even medications that are non opioids, such as antiinflammatories, things like Tylenol or acetaminophen, and then also working with our anesthesia colleagues for preoperative or postoperative nerve blocks, really helped to again, decrease that patient's need for opioid use after surgery.

Host: What do you feel? This is really, as I said before, so important in the medical community today. And what do you feel are some of the clinical implications of these research findings? How will they affect pharmacy programs and orthopedic surgery, enhanced recovery all of it?

Dr. Tjong: I really think that educating the patients, that's where it all starts. And we lean a lot on our preoperative clinics, our relationship with the patients, internal medicine doctors, as well as with pharmacy to educate the patients on what we found in our studies, what's going on in the media today, and really the definition of pain. Prior to a decade ago, we used to always try to quote unquote, get ahead of the pain. So take opioids as prescribed on a routine basis. Now we know how to define pain a little bit better, and we really have to always remind patients that surgery is painful. So you're, you are expected to feel some pain, but it's in controlling that in a way that you can still function that's important in terms of how many pills to take. Definitely across the board in particular, here at Northwestern, we have decreased the amount of pills that we've prescribed postoperatively to our patients because of this study. And also the duration of use.

So anytime we talk to patients, we kind of tell them, all right, you're having your ACL done. The average individual takes around nine to 10 narcotic pills, and they only use them for about five days. So this gives the patient a little bit of expectation setting as to how much they should be taking compared to the average. One other thing I forgot to mention was that there was a subset of patients in all three studies, that required zero opioids altogether. We weren't able to actually tease out which patient factors contributed to this zero opioid use. But I think that also shed some light into, you know, reminding patients that if you don't need it, you don't have to take any, even after surgery.

Host: I would like you to come back and update us if you do tease that out, because that's a very interesting point that you made that some of them, and obviously Dr. Tjong, pain is somewhat subjective. If you have people with a higher tolerance or who just really aren't feeling the same pain now, how do you feel that this study will influence how opioids are prescribed in the future? What do you feel that this will do as far as that multimodal approach and for other providers listening, what would you like them to take away from this study?

Dr. Tjong: The big takeaways from this study are number one, really define a patient's pain and set their expectations for postoperative pain use. That starts with education. That starts with setting expectations and really be careful how many opioids you're prescribing, especially in comparison to how people have previously prescribed them in the past. And I think that by doing that, we can really advance forward into really changing the way that both patients, as well as healthcare providers really look at pain and pain control.

Host: What a great study and so important. And as I said, I hope that you will come back on and update us as we learn more, because I think not only orthopedic surgeons, but really across the board, this is one of those stewardships that we need to learn more about opioid prescription and how to break that down a little and use that multimodal approach, so much more.

Thank you, Dr. Tjong for joining us today and to refer your patient or for more information, you can always visit our website at breakthroughsforphysicians.nm.org/ortho to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for Physicians.

Please always remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.