Decreasing Opioids & Increasing Multimodal Pain Prescription in Opioid Naïve Orthopaedic Trauma Patients – The Power of a Standardized Protocol

From the 2021 HVPAA National Conference

Alexandra Dunham (Johns Hopkins School of Medicine), Zachary Enumah, Kent Stevens, Travis Rieder, Casey Humbyrd, Babar Shafiq

Background

Post-operative prescribing practices have relied heavily on opioids for pain management, particularly in orthopaedic trauma. To reduce opioid use and improve pain management we developed a standardized, multimodal pain treatment protocol for opioid naïve orthopaedic trauma patients undergoing a single stage surgery.

Objectives

We sought to:

  • Establish feasibility of our protocol
  • Characterize its impact on prescribing patterns

Methods

A cohort of orthopaedic trauma patients treated by a single surgeon at our large, tertiary academic center were identified from our trauma database. Patients treated before (1/1/17-12/31/17) versus after (7/1/18-8/31/19) implementation of the protocol were compared. We compared type of pain medications and quantity of opioids prescribed at discharge and at each post-operative visit up to 3 months.

Results

In the pre-implementation cohort of 89 patients, 86 were prescribed an opioid at discharge, averaging 465 MME (morphine milligram equivalents). Nine patients (10%) were prescribed the full multimodal complement. Of this cohort, 21 patients were prescribed an opioid refill at the 2-week visit, averaging 560 MME; 9 patients at the 6-8-week visit, averaging 600 MME; and 2 patients at 3-months, averaging 225 MME.

In the post-implementation cohort of 102 patients, 95 were prescribed an opioid at discharge, averaging 273 MME (40% reduction). 54 patients were prescribed the full multimodal complement (53%). Post-implementation, there was convergence and reduced variability in opioid prescription amount at time of discharge. Eleven patients were prescribed an opioid refills at the 2-week visit, averaging 368 MME (34% reduction); 5 patients at the 6-8-week follow up, averaging 170 MME (72% reduction); and 3 patients at the 3-month follow up, averaging 305 MME (36% increase).

Conclusion

There was an overall reduction in MME prescribed at time of discharge and through follow-up. Furthermore, there was an increase in frequency to prescribing non-narcotic multimodal pain therapies.

Clinical Implications

Implementation of a standardized, multimodal pain treatment protocol for opioid naïve orthopaedic trauma patients at a large level 1 trauma center is effective at decreasing post-operative opioid prescription amounts and can be easily implemented across a diverse set of orthopaedic injuries.