Introduction. Opioid abuse is a national epidemic. Traditional pain management after total knee arthroplasty (TKA) relied heavily on opioids. The evidence that in-hospital multimodal pain management (MMPM) is more effective than opioid-only analgesia is overwhelming. There has been little focus on post-discharge pain management. The purpose of this study was to determine whether MMPM after TKA could reduce opioid consumption in the 30-day period after hospital discharge. Methods. This was a prospective, two-arm, comparative study with a provider cross-over design. The first arm utilized a standard opioid-only (OO) prn regimen. The second arm utilized a 30-day MMPM regimen (standing doses of acetaminophen, metaxalone, meloxicam, gabapentin) and opioid medications prn. Surgeons crossed over protocols every four weeks. The primary outcome measure was VAS pain score. Secondary outcome measures included morphine milligram equivalents (MME) consumed, failure of the protocol, and manipulation under anesthesia (MUA). A pre-hoc power analysis was performed for the primary outcome measure and an intent-to-treat analysis was done utilizing a longitudinal mixed model. Results. There were 43 patients in the OO cohort and 39 patients in the MMPM cohort. There was no difference in the baseline demographics or preoperative scores (p=0.94). There was no clinically meaningful difference in VAS score between the two groups at any time. The average opioid consumption at 30-days was 469 and 344 MME's for the OO and MMPM cohorts, respectively (p=0.026). 19/43 (44.2%) patients in the OO cohort failed vs. 4/39 (10.3%) in the MMPM cohort (p=0.002). There was 1 MUA in the OO and none in the MMPM cohort (p=0.338). Discussion. A 30-day post-discharge multimodal pain regimen reduced opioid use after TKA. Opioid-only regimens are at an increased risk of failure to control pain. As a result of this study, multimodal pain management after hospital discharge is standard at our institution

Introduction. Over the past few decades, opioid abuse has become a major threat to public health. In 2013 alone, enough opioid prescriptions were written in the United States for every American adult to have their own bottle of pills. Since then, opioid prescribing rates and opioid related deaths have continued to grow, with over 46 people dying on average each day from prescription opioid overdoses in 2016. Orthopaedic surgeons are among the top 5 specialties in the number of opioid prescriptions written. For many common surgeries, such as total knee arthroplasty (TKA), post-discharge prescriptions are based on prescriber habits and opinion. There exists limited data-driven protocols to guide post-operative opioid prescribing practices. The purpose of this prospective study was to determine the average postoperative opioid consumption in patients undergoing primary TKA using a novel mobile text messaging platform. We hypothesized that majority of patients undergoing TKA do not properly dispose of left over pills after surgery. Methods. 95 patients undergoing primary unilateral TKA with one of nine arthroplasty surgeons at a single orthopaedic specialty hospital were prospectively enrolled. Daily pain levels and opioid consumption, and quantity and disposal patterns for left over medications were collected for six weeks following surgery using a novel mobile phone text messaging system. This system automatically queried patients twice a day, storing responses on a secure third-party host that investigators monitored and used to generate data reports in real-time. Results. Of the 95 patients enrolled, 1 was excluded for undergoing a secondary procedure in the acute postoperative data collection period. Of the remaining 94 patients, 88 (93.6%) completed the daily SMS surveys and were included in analysis. Average age was 62.0 ± 7.1 years, BMI 31.1 ± 6.2, and length of hospital stay 2.6 ± 1.2 days. The average oral morphine equivalents (OME) consumed during the 6 weeks post-surgery were 617.3 ± 350.26 mg, which corresponds to a mean consumption of 82 oxycodone 5 mg tablets per patient. For the 55(58.5%) of patients who had stopped taking opioids within 6 weeks of surgery, there were on average 196.2 mg OME left over, the equivalent of 26 oxycodone 5 mg tablets; 20% of those who stopped taking opioids had at least 367.5 mg OME left over, the equivalent of at least 49 oxycodone 5 mg tablets. Only 26.5% of patients with left over pills described an appropriate method of disposal of left over medications, with most patients storing left over pills in their homes. Conclusion. This prospectively collected data provides a benchmark for average opioid consumption after uncomplicated primary unilateral TKA. Many patients are prescribed more opioids than they require, and left-over medication is infrequently disposed of appropriately, which increases the risk for illicit diversion. Prospective collection of patient reported opioid consumption has tremendous value in the development of national postoperative guideline protocols while informing further research and strategies aimed to reduce opioid use and misuse and in predicting patient characteristics associated with increased opioid consumption after surgery