Addictive opioid painkillers aren't the only option for patients seeking relief following anterior cruciate ligament (ACL) knee reconstruction, researchers say.
As the United States wrestles with skyrocketing rates of opioid abuse and drug overdose deaths, the findings may come as good news.
After ACL surgery, Advil and other nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen (Tylenol) and muscle relaxers appear to offer the same degree of pain control to patients as prescription opioids like morphine, hydrocodone or oxycodone, the small study concluded.
"Opioid medications can be helpful in managing high levels of pain when appropriately prescribed," explained study co-author Dr. Kelechi Okoroha. He is an orthopedic surgeon and sports injury specialist with the Mayo Clinic in Minneapolis.
"However, when used for long periods of time, opioids can be addicting," Okoroha cautioned. And "when used incorrectly, or in high doses, opioids can have side effects, including drowsiness, confusion, slowed breathing and even death."
Drug overdose 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 fatalities between April 2020 and April 2021. This represents a 30% jump over the prior year. And more than three-quarters of these deaths were attributed to opioid use alone.
For many people, opioid addiction starts with legitimate prescription painkiller use after surgery. Orthopedic and spine conditions account for nearly 28% of all opioid prescriptions issued in the United States, the research team said in background notes. That has led experts to seek safer means of minimizing post-surgical discomfort.
ACL surgery is a common operation, 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 tolerable," while eliminating opioid use, he added.
The findings were published online recently in the American Journal of Sports Medicine.
For the study, Okoroha's team tested their pain management protocol with 34 patients who underwent ACL surgery between February 2019 and January 2020.
All were offered opioid-free pain medicines post-op, including NSAIDs, acetaminophen and muscle relaxers. Pain levels 10 days after pain treatment began were compared with those of 28 other patients treated with an opioid medication.
The investigators determined that pain relief was the same across both groups, with no appreciable differences in terms of side effects (addiction risk aside), even after accounting for age, gender and body mass index (a standard indicator of obesity status).
The findings don't surprise one expert who was not part of Okoroha's study team.
"I have actually had both of my ACLs reconstructed, so I know the associated pain well," said Dr. David Katz, director of the Yale University Prevention Research Center, in New Haven, Conn. "I believe I used opioids for a day or two both times, and then quickly transitioned to non-opioid treatment."
That treatment went beyond medication. "An automated, cooling compress around the surgical site provided the greatest relief," said Katz.
"Based on personal experience, I am not at all surprised that opioids can be omitted from the regimen, while preserving comparable pain management," he added.
Nevertheless, Katz expressed some reservations about the current study's approach.
"The regimen in this study does not impress me all that much, to be brutally honest," he said. "It avoids opioids, which can be dangerously habit-forming, but includes a benzodiazepine (Valium), which can be dangerously habit-forming. And there is no mention of non-medication options, such as the cooling compress I described," Katz noted.
"As the site starts to heal, there is a case for gentle massage as well. Truly 'multimodal' pain relief is not just different medications. It should include non-medication options that work, too," he suggested.
Still, Katz didn't dismiss the work entirely. "In general, opioids are overused, while a lot of chronic pain is undertreated. So there is certainly a need to broadcast any advance that can help address these dual threats," he said.
More information
There's more on opioids and related risks at the U.S. Centers for Disease Control and Prevention.
SOURCES: Kelechi R. Okoroha, MD, orthopedic surgeon and sports injury specialist, division of sports medicine, Mayo Clinic, Minneapolis; David Katz, MD, MPH, director, Yale University Prevention Research Center, New Haven, Conn.; American Journal of Sports Medicine, Oct. 20, 2021, online
