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• Posted October 10, 2022

Knee, Shoulder Surgeries Without Opioids? It's Possible, Study Finds

While politicians and health officials seek solutions to an opioid epidemic that kills tens of thousands every year, doctors who prescribe the pain medications are seeking alternatives for their patients.

New research suggests one way to handle pain for minimally invasive knee or shoulder surgery could be as simple as combining three common medications: the anti-inflammatory naproxen (Aleve); pain reliever acetaminophen (Tylenol); and pantoprazole (Protonix), a proton-pump inhibitor used for gastrointestinal issues.

These medications along with counseling about pain and the risks of opioids led to similar scores for pain relief, patient satisfaction and adverse events compared to standard care, which includes opioids, the study found.

"We were impressed by the satisfied patient numbers with no significant difference, and [are] hopefully contributing to reducing the challenges we see with opioid usage across the world,"said study author Dr. Olufemi Ayeni, a professor of surgery at McMaster University in Hamilton, Ontario, Canada.

The study was inspired by conversations about the global opioid crisis, said Ayeni, who is also an orthopedic surgeon at Hamilton Health Sciences. He and his colleagues wanted to see if they could make even a small impact in addressing that challenge.

"And that triggered the research question, which was how do we treat our own patients post-surgery with medication? And when we looked across our group, we found it was very variable,"Ayeni said.

About three-quarters of the doctors informally surveyed were prescribing opioids for their patients, in varying quantities. The study team wondered if they could standardize reducing opioid use post-surgery.

The 193 patients studied were treated at one of three hospitals in Hamilton. A "control group" of 98 received opioid painkillers while 95 were prescribed the trio of naproxen, acetaminophen and pantoprazole.

Those in the non-opioid group were told about the study and advised that pain is a part of the post-surgery experience. They were permitted to ask for opioids for breakthrough pain.

Doctors monitored patients for six weeks after their minimally invasive knee or shoulder surgery.

On average, patients in the control group took 72.6 mg of opioids, compared to 8.4 mg in the opioid-sparing group. Six patients in the control group asked for medication after discharge, as did two of those in the sparing group, the study authors noted.

Ayeni said surgeons can help combat the opioid epidemic. In the United States, orthopedic surgeons performed more than 1 million operations between 2006 and 2016, he said. Canada has at least 100,000 orthopedic surgeries each year.

Reducing the number of opioids prescribed could not only curb opioid dependency, it could also shrink the reservoir of unused medications in a community. Those medications may be stolen, accidentally ingested by young children or shared by teenagers.

The U.S. Department of Health and Human Services puts some of the blame for the opioid crisis on pharmaceutical companies, who, it said, reassured the medical community in the 1990s that patients would not become dependent on these pain relievers. The drugs turned out to be highly addictive.

As orthopedic surgeries have become more refined and less invasive, Ayeni said there is less need for stronger pain medications. Prescription practices that surgeons learned in medical school have not yet caught up.

Some studies suggest that one in eight patients become addicted to the painkillers and physicians need to keep that in mind, he added.

The researchers noted that their findings are limited by the study's focus on arthroscopic surgery. Results might be different for patients with more extensive open surgeries (such as joint replacement), those who are allergic to these over-the-counter medicines, or those who already take medication for chronic pain.

Dr. Gary Stewart, an orthopedic surgeon in Atlanta who was not involved with the study, said surgeons were trained to prescribe opioids to treat pain but many are prescribing fewer now.

"I do believe now that there is a physician peer pressure," Stewart said, adding: "Judicious use is more than norm now."

Stewart noted that dosages of over-the-counter medications used in the study were higher than someone would take for a headache or simple joint pain. He pointed out that the counseling component for study participants was helpful.

Going forward, Stewart would like to see more research on opioid-reduction involving open surgical procedures and for large fractures.

"I believe those studies are coming,"he said.

Ayeni said the strategy of using different over-the-counter pain relievers targets pain through more than one pathway.

"The biggest challenge with studies such as this is knowledge translation," he said, meaning that doctors may not change prescription practices. "So, implementing it is the next big step."

He said the findings speak to the value of collaboration among orthopedic surgeons, anesthesiologists, pharmacists, nursing staff and patient representatives.

"It's another example of how collaboration across specialties, across disciplines, can really move the needle forward, so to speak, when it comes to health care,"Ayeni said.

The findings were published Oct. 4 in the Journal of the American Medical Association.

More information

The U.S. Department of Health and Human Services has more on the opioid epidemic.

SOURCES: Olufemi Ayeni, MD, PhD, professor, surgery, McMaster University, Hamilton, Ontario, Canada, and orthopedic surgeon, Hamilton Health Sciences; Gary Stewart, MD, orthopedic surgeon, Resurgens Orthopaedics, Atlanta; Journal of the American Medical Association, Oct. 4, 2022