Reducing Opioid Use After ACL Surgery

While the COVID-19 pandemic dominates this year’s headlines, another health crisis continues to rage as well—the opioid epidemic.

Opioids are narcotic drugs made from compounds found in the opium poppy or from similar chemicals synthesized in the lab, like morphine, oxycodone, hydrocodone, codeine, heroin, and fentanyl. These drugs work in the body’s nervous system or in certain brain receptors to decrease the intensity of pain. Used medically, they can be very effective in this regard.

But in the past two decades, almost 450,000 people in the U.S. have died by overdosing on these drugs. Opioid overdoses took nearly 47,000 lives in 2018; one-third of those deaths involved prescription opioids. Many victims are in the prime of their lives—people 25–54 years old are at greatest risk for misuse of these drugs.

The good news is that healthcare providers are playing an aggressive role in fighting this epidemic. And the overdose rate is slowly dropping, thanks to effective and committed efforts regarding awareness and intervention.

At MedStar Washington Hospital Center, my colleagues and I are empowered to be part of this solution, as we refine new approaches to orthopedic surgery that require little or no use of prescription opioids. Recently, I authored a paper reporting the results of a study in which patients had undergone anterior cruciate ligament (ACL) reconstructive surgery. The study results detailed a novel incorporation of a long-acting local pain block during knee surgery that led to a statistically significant reduction in patients’ post-surgical use of opioids.

What Are Opioids Used For?

In orthopedic injuries, pain is often quite intense. Pain management plays an important role before surgery and is essential to successful rehabilitation after it. By alleviating pain, we improve healing and mobility—resulting in better results, shorter hospital stays, and reduced costs.

For years, medical use of opioids for chronic pain post-surgery was typically endorsed as a suitable treatment. It was often felt that there was little risk of addiction if these drugs were being used to manage pain. And, although there was actually little evidence to support this belief, prescription rates increased unabated.

Today, we see the alarming consequences for many patients—overdependence and, frequently, lethal overdosing. Other side effects of opioids for pain include troubling symptoms ranging from nausea and constipation to lethargy and slowed respiration. It has become clear that the negative aspects of these narcotics far overshadow any positives. This is why my colleagues and I are putting our efforts into safe, feasible alternatives.

Managing Pain from ACL Surgery

In the operating room, we’re finding new ways to employ non-opioid pain management—and to then reduce the need for opioid use as the patient recovers. During ACL surgery, I have been using an FDA-approved long-acting local anesthetic called EXPAREL®, a preparation of liposomal bupivacaine which blocks the nerve impulses that produce pain. Bupivacaine has been used as an agent for spinal block anesthesia for decades—for example, in epidurals administered to women in labor. EXPAREL® is unique in that it lasts much longer than traditional local anesthetics.

Our study, published in the January 2021 edition of the journal Orthopedics, examined two years’ worth of outcomes in 67 ACL surgery patients. It confirmed what we already suspected: use of long-acting bupivacaine in the operating room can result in a marked decrease in the need for prescription narcotics afterwards.

Patients who had surgery without long-acting bupivacaine had an average post-surgical consumption of 66 tablets of oxycodone, a powerful opioid. In patients for whom bupivacaine was used during their procedure, post-surgery dosage was just 10 oxycodone tablets.

Patients in the long-acting bupivacaine study group were less likely to need prescription refills, and their average post-surgery pain levels were a full point lower. Some patients in our study required no narcotics after their procedure at all. These are compelling results that move us closer to opioid-free orthopedic surgery.

I use long-acting bupivacaine as part of a treatment plan that includes other non-opioid agents, such as Tylenol® (acetaminophen), Celebrex® (celecoxib), and Neurontin® (gabapentin). Each of these agents works in a different way to alleviate pain. Some also target inflammation, which is beneficial to reduce stiffness and improve the effectiveness of physical therapy.

What Is a Torn ACL?

The ACL is one of two short ligaments that form an X connecting the thighbone to the shinbone behind the kneecap. This connection stabilizes the knee during rotation.

Injury generally occurs when the foot is planted and the knee rotates past the mechanical capability of the ACL. This excess force causes a pivot injury, a rupture or tear of the ligament. This type of tear is rare in mishaps such as falls or car accidents—it tends to be a sports injury. Although many types of athletes are at risk for an ACL tear, it occurs most commonly during stop-and-start action in field sports, like soccer and football.

And it is not a subtle injury. When the ACL tears, it’s immediately apparent that something serious has happened. The tear causes pain and swelling and destabilizes the knee; most patients find themselves unable to walk unaided.

Each year, as many as 200,000 Americans experience an ACL tear. Although it’s most common in those under 30, we’re starting to see more of it in today’s older athletes. Also, women are at slightly higher risk, for reasons we don’t yet fully understand.

Rebuilding the ACL

Because the ACL is responsible for providing so much stability, the knee isn’t quite the same after the ligament tears. And the force that tears the ACL can also cause additional damage to other areas of the knee (much of which we can repair or improve during ACL repair).

When a patient’s ACL is torn, surgery is frequently the only effective treatment. Rehabilitation to strengthen the area can help, but alone it cannot fully restore joint stability. Most active and athletic people who tear an ACL want to get back in the game and, for them, surgery tends to be the best path to recovery.

When the ACL tears, it tends to shred, due to the physical characteristics of the tissue and the tension that it’s under. Although it can be repaired, it is more commonly replaced with a bit of tendon. The donor tendon can be autografted from another part of the patient’s body, generally from the kneecap or hamstring. With allograft, another alternative, the replacement tissue comes from a cadaver. No one approach is better than the other—we evaluate each injury and patient and tailor the best approach.

ACL surgery is generally performed using an arthroscope, a thin tube mounted with a camera and surgical instruments. The procedure requires just a few small incisions and is much less invasive than in years past, when long incisions fully exposed the knee joint.

Although tendons and ligaments are different, once tendon tissue is attached where the ACL used to be, it transforms to behave very much like the ligament it replaced.

ACL surgery recovery is a slow process—it may take as long as eight months. Rehabilitation is crucial to restoring stability to the knee, so managing pain and stiffness becomes essential. We generally prescribe physical therapy twice a week for two months, followed by an at-home regimen.

Moving in the Right Direction

As we’ve all become aware of the true dangers of opioids—and because our work can easily give a patient a path to misuse of these drugs—orthopedic surgeons realize they have a special responsibility to seek change.

I can confidently say that most of my patients recover well without narcotic pain medications. A number of them come to me already quite aware of the risks of narcotics, and many also know that I’m committed to reducing or eliminating the use of opioids. We explain all the options and answer patients’ questions, involving them in decisions about their surgical approach and the pain management that comes after. Most are quite willing to embrace surgery without narcotics.

When it comes to decreasing the use of opioids, things are definitely moving in the right direction. The Hospital Center is very supportive of our commitment to decrease opioid prescription and use, and my colleagues are taking a leadership role in this process. With additional studies like ours, medical professionals will understand the tremendous benefits of non-opioid treatment strategies.

There’s no better motivator than the ability to literally improve—and often save—lives.