As the United States grapples with rising rates of opioid abuse and drugs overdose deaths, the findings may come as good news.
Following ACL surgery, Advil and other nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen (Tylenol) and muscle relaxants appear to provide patients with the same degree of pain management as prescribed opioids such as morphine, hydrocodone or oxycodone, concluded the small study.
“Opioid medication can be helpful in managing high levels of pain when prescribed appropriately,” explains study co-author Dr. Kelechi Okoroha. He is an orthopedic surgeon and sports injury specialist at the Mayo Clinic in Minneapolis.
“However, when used for long periods of time, opioids can be addictive,” Okoroha warned. And “when used incorrectly, or in high doses, opioids can have side effects, including drowsiness, confusion, delayed breathing and even death.”
Drug-related deaths in the United States are at an all-time high, the U.S. Centers for Disease Control and Prevention reported this month – 100,000 drug-related deaths between April 2020 and April 2021. This represents a 30% jump from the previous year. And more than three-quarters of these deaths have been attributed to opioid use alone.
For many people, opioids addiction start using legal prescription painkiller after surgery. Orthopedic and spinal conditions make up almost 28% of all opioids prescriptions issued in the United States, the research team said in background notes. This has led experts to look for safer ways to reduce post-surgical discomfort.
ACL surgery is a common surgery, and “knee surgery can cause high levels of pain,” Okoroha said.
But the good news is that the new study shows that “with appropriate multimodal management, we can make this pain bearable,” while eliminating the use of opioids, he added.
The findings were recently published online in the American Journal of Sports Medicine.
For the study, Okoroha’s team tested their pain management protocol with 34 patients undergoing ACL surgery between February 2019 and January 2020.
All were offered opioid-free pain medication after surgery, including NSAIDs, acetaminophen, and muscle relaxants. Pain levels 10 days after starting pain treatment were compared to those of 28 other patients treated with an opioid medication.
The researchers found that pain relief was the same across both groups, with no significant differences in terms of side effects (addiction risk aside), even after taking into account age, gender, and body mass index (a standard indicator of obesity status).
The findings do not surprise one expert who was not part of Okoroha’s study team.
“I actually had both of my ACLs rebuilt, so I know the associated pain well,” says Dr. David Katz, director of the Yale University Prevention Research Center, in New Haven, Connecticut. “I believe I used opioids for a day or two both times, and then quickly switched to non-opioid treatment.”
That treatment went beyond medication. “An automatic, cooling compress around the surgical site provided the greatest relief,” Katz said.
“Based on personal experience, I am not at all surprised that opioids can be omitted from the regimen while maintaining comparable pain management,” he added.
Nevertheless, Katz expressed certain reservations about the current study’s approach.
“The regime in this study does not impress me so much, to be brutally honest,” he said. “It avoids opioids, which can be dangerously addictive, but includes a benzodiazepine (Valium) that can be dangerously addictive. And there is no mention of non-medication options, like the refrigeration compress I described,” Katz noted.
“As the site begins to heal, there is also a case for gentle massage. Real ‘multimodal’ pain relief is not just different medications. It should also include non-medication options that also work,” he suggested.
Yet Katz did not completely reject the work. “In general, opioids are overused, while many chronic pain is undertreated. So there is definitely a need to broadcast any advance that can help address these dual threats,” he said.
There is more about opioids and related risks at the US Centers for Disease Control and Prevention.
SOURCES: Kelechi R. Okoroha, Managing Director, Orthopedic Surgeon and Sports Injury Specialist, Sports Medicine Division, Mayo Clinic, Minneapolis; David Katz, MD, MPH, Director, Yale University Prevention Research Center, New Haven, Conn .; American Journal of Sports Medicine, 20 October 2021, online