Feb. 17, 2022 – Nick Dawson, a 42-year-old ski instructor based in Montana, knows a thing or two about ACL repairs. He tore his anterior cruciate ligament four times and had surgery three times.
A common but painful surgery, doctors often prescribe heavy opioid therapy for pain management after the procedure. And that is exactly the course followed by the surgeons at Dawson. But with each repair, Dawson used fewer pills until he finally decided not to take them the third time around.
“The first time, I had no clear idea of what to expect from my recovery, so I took the opioids as prescribed to avoid the pain,” he says. “I experienced mood swings and found that the meds don’t really take the pain away – instead, they make you forget about the pain.”
For Dawson, what worked best was a combination of a high dose of anti-inflammatory medication and an ice pump the doctor had sent home. After his second operation, he took fewer opioids but more anti-inflammatories combined with the ice pump.
“After a few days of this approach, I quit opioids,” he says.
Finally, after the third surgery in 2012, Dawson gave up opioids altogether, even though her doctor had prescribed them.
“I understood what I didn’t like, and also what worked best,” he says. “I really wondered why the anti-inflammatory approach wasn’t what doctors were using from the start, instead of opioids.”
It seems Dawson was ahead of the curve in his self-prescribed approach. New research from the Mayo Clinic investigates whether patients recovering from ACL and rotator cuff surgery might manage pain better with drug combinations that don’t include opioids. The results are promising, and it’s a good trick.
About 3 in 10 opioid prescriptions are linked to orthopedic and spinal conditions, according to Mayo lead researcher Kelechi Okoroha, MD. The standard prescription is 30 to 60 tablets, which allows patients to last up to 2 weeks. Not using opioids after these surgeries could help reduce the high rate of opioid addiction and sometimes subsequent death.
“Some patients are just going to be more addiction-prone, even after a brief introduction,” Okoroha says.
The US Department of Health and Human Services estimates that 70,630 people died from an opioid overdose in 2019, while 10.1 million people misused the drugs.
“Opioids are quite common after surgery here in the United States,” says Okoroha. “We feel like there shouldn’t be any pain after the surgery.”
This approach and belief dates back to the mid-1990s, when OxyContin first appeared on the market as a class of “milder” opioids, marketed as less addictive. Insurance companies and doctors bought in, and in 2017 the United States experienced a public health crisis with opioid addiction. Now doctors are looking for ways to break the cycle.
Even before this series of orthopedic research, as a surgeon himself, Okoroha began researching ways to stop the use of opioids in joint replacement procedures. Finding success there — patients found the protocol as effective or better than opioids — Okoroha decided to move into other areas of orthopedic procedures to see if it could produce the same results.
Dividing their research into two studies, the Mayo team first investigated the alternative medication protocol with 62 ACL repair patients, dividing them into two groups: one using the standard opioid plan of hydrocodone and acetaminophen. With the second group, the researchers used nerve blockers, acetaminophen, muscle relaxants, and a nonsteroidal anti-inflammatory drug (NSAID).
“This provided multiple agents targeting multiple sources of pain,” says Okoroha.
Patients were asked to rate pain using the visual analogue scale (VAS), which ranges from “no pain” to “worst pain”. All patients in the non-opioid group reported satisfactory pain management and minimal side effects. This applied even a week after surgery.
The second group consisted of 40 patients receiving repair for rotator cuff surgery. Of these, 23 belonged to the traditional opioid group and 17 to 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 at every point measured.
All patients in both studies received a nerve block before surgery. Dawson says doctors used this approach during his third ACL operation.
“I felt like it helped tremendously with managing the first 24 hours of pain,” he says.
Rehabilitation remained the same after surgery for the ACL and rotator cuff study groups. Okoroha was satisfied with the results.
“The main takeaway is that we don’t have to turn to opioids after common sports surgeries,” he says. “Our thinking is that if we can apply it to these orthopedic procedures, we can also 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 receiving the experimental protocol fared slightly better.
Okoroha says further research into new pain treatment plans in other orthopedic surgeries will follow.
In the meantime, “it’s up to providers to see if their patients can manage without opioids,” he says. “If we can combine evidence with adoption, we can eventually change standard practice.”