Talk Description
Author: Chad Abbot, ASA Trainee Member, ANZCA Trainee, Australia
Introduction:
Opioids are prescribed with increasing frequency post knee arthroplasty surgery, despite associations with adverse outcomes with respect to length of hospital stay, patient reported outcomes, mortality and morbidity, and increased revision risk [1].
The importance of targeting postoperative prescribing practice as a preventative intervention has been demonstrated in a 2020 ANZCA study, where 59% of adult patients undergoing elective or emergency surgery were dispensed opioid analgesics on discharge with the majority (70%) having leftover opioids at 14 days post-surgery [2].
Aims:
1. Assess the prescribing of opioids for patients following orthopaedic surgery at SJOG Midland
2. Assess patient’s post-operative pain scores at 3 and 6-months
3. Assess patients’ post-operative opioid requirements following orthopaedic surgery at SJOG Midland.
Methods:
The assessed patient population consisted of 109 post-operative orthopaedic surgical patients having undergone total knee replacement between 1st November 2022 and 14th February 2023 at St John of God (SJOG) Midland Hospital.
Patient data was collected via two methods:
1. Patient demographic and opioid prescribing data was gathered from medical discharge summaries written by the treating orthopaedic team at SJOG Midland.
2. Audit tool: A 5-question survey gathered information regarding opioid prescribing practice at SJOG Midland, patient pain scores and patient opioid use up until 3- and 6-months following surgery. Patients were contacted and interviewed using the following questions:
1. What were your pain scores at 3- and 6-months post-surgery?
2. Are you still using opioid analgesia at 3- and 6-months post-surgery?
3. Do you have leftover opioids medications?
4. Did you dispose of your excess opioid medications?
5. Was extra opioid supply sought after discharge?
Ethics approval was sought from SJOG HREC, but was waived as the study was deemed a quality improvement project (email confirmation 1 July 2024). As such there was no sensitive data, no invasive testing, and the reported results were pooled with full endorsement of SJOG.
Results and Discussion:
Patients’ pain scores improved during their recovery, 4.16/10 at 3-months and 2.25/10 at 6-months post-surgery. The number of patients using opioids reduced following surgery; 8 patients (9%) were using opioids pre-operatively and only 4 (4%) were using opioids at 6-months post-surgery. 24 patients (27%) obtained a repeat script for opioid medications during follow up appointments.
The 2022 ANZCA Position statement on acute pain management [3] recommends avoiding prescribing more than one week’s supply of opioids following surgery.
At SJOG Midland, 62 patients (69%) receiving slow-release tablets were prescribed over 1 week’s supply (14 tablets). Immediate release tablets were generally prescribed more conservatively – in most patients (81%) less than 1 week’s supply (28 tablets) was prescribed. This suggests that immediate and slow-release tablets are prescribed in equivalent amounts.
The ANZCA Position statement [3] similarly recommends avoiding prescribing long-acting opioids following surgery. Of patients surveyed, only 12 (13%) disposed of medications when no longer required, suggesting it may be beneficial to reduce supply of opioids patients are discharged with.
Conclusion:
Opioid prescribing practice on discharge of post total knee replacement patients at SJOG Midland was largely performed well by anaesthetic and orthopaedic teams, demonstrated by improving patient pain scores and appropriate opioid use post-operatively. However, given the large degree of unused discharge medications, it is possible to reduce the quantity of opioid medications patients are discharged with.
References:
1. Rozell J, Courtney P, Dattilo J, Wu C, Lee G. Preoperative opiate use independently predicts narcotic consumption and complications after Total joint arthroplasty. J. Arthroplasty 2017; 32: 2658–62.
2. Allen ML, Kim CC, Braat S, et al. Post-discharge opioid use and handling in surgical patients: A multicentre prospective cohort study. Anaesthesia and Intensive Care. 2020;48(1):36-42.
3. ANZCA. Acute Pain Management: Scientific Evidence. 5th Edition. 2020. Chapter 8.13. Page 621.