Poster 108: Narcotic Use Following Knee Arthroscopy in Adolescent Patients: A Prospective Evaluation

OBJECTIVES: The practice of prescribing opioid medication prescribing has been at the forefront of national attention due to the opioid epidemic that affects the United States. (1,2) Over-prescribing of opioid medication has led to non-medical use of these medications. (3) In 2015, 276,000 adolescents were current non-medical users of pain relievers with 122,000 having an addiction to prescription pain relievers.(4) Physicians are also prescribing more opioid medication to the adolescent population. From 1997-2007 the prescribing rate of opioids to adolescents and young adults nearly doubled.(5) Knee arthroscopy is one of the most common orthopedic procedures performed and is being performed in the adolescent population with more frequency.(6,7) Pain relief following arthroscopic procedures about the knee is an ongoing topic of interest. Studies have shown that the number of opioids prescribed following knee arthroscopy has gone up.(8) In the adolescent population, there is a relative paucity of literature which guides physicians on how to best treat post-operative pain following knee arthroscopy. (9-11) The goal of this study was to prospectively evaluate the use of opioid medication following knee arthroscopy in adolescent patients aged 10-18. With this information we hope to develop an effective dosing regimen following knee arthroscopy in adolescents in order to help prevent over-prescribing for these common procedure. METHODS: Approval for this study was obtained by our Institutional Review Board. The adolescent patients of the senior surgeon at a single institution were identified pre-operatively prior to undergoing outpatient knee arthroscopy and parental consent was obtained, and where appropriate, patient assent in order to participate in this study. Inclusion criteria for this study included age 10-18 and procedures eligible for inclusion were diagnostic arthroscopy, plica excision, loose body removal, debridement, chondroplasty, meniscal repair and/or partial meniscectomy. Exclusion criteria included chronic narcotic use, revision knee surgery and knee arthroscopy with any ligament reconstruction or bony osteotomy. During the surgery, general anesthesia was used and no nerve blocks were utilized. Incision sites were injected with local anesthetic, either marcaine or lidocaine, whichever was available, due to medication shortages. Patients were prescribed fifteen hydrocodone/acetaminophen 5/325 mg every 6 hours as needed. Additionally, they were prescribed ten promethazine 25 mg every 8 hours as needed for nausea and vomiting. The patients were allowed and encouraged to take over the counter non-opioid medication as necessary instead of their narcotic medication. Patients were given a pain diary in which they recorded their daily post-operative pain (based on a faces of pain scale of 1-10) at the time that they took pain medication. The patients recorded the number of pills taken and the times at which these pills were taken. They also recorded any side effects and any over the counter medication that was taken. The data sheets were brought into the patient’s first post-operative visit at 1 week post operatively. If the patient was still requiring narcotic medication at that time, then they continued documenting the data until they stopped requiring narcotic medication and this data was brought to the 6 week visit. The data from the pain diary was used to calculate the average and total number of narcotic and non-narcotic pills used as well as the number of post-operative days narcotic pain medication was used utilized. RESULTS: Fifty adolescent patients were included in this prospective study. Of the fifty patients included, thirty-five (70%) had fully completed their pain diary. Table 1 shows the demographic information for the patient cohort who fully completed their pain diary. The average age was 14.2 years and included 23 females and 12 males. Narcotic usage amongst the patient cohort is shown in Table 2. The total number of 5 mg hydrocodone-acetaminophen pills taken ranged from 0-14 with 55% of patients taking 0-5 and 82% taking less than 10 narcotic pills post-operatively. The average and median number of narcotic pills taken was 5.41 and 5, respectively. Therefore, on average, patients used approximately 36% of their prescribed opioid medication. In our cohort, 74.3% of patients had stopped taking narcotics by post-operative day 3 and 97.1% had stopped narcotic usage by post-operative day 5. All patients had discontinued narcotic usage by post-operative day 6. Figure 1 is a graph which shows the post-operative days pills were taken. No post-operative narcotic refills were needed. Non-narcotic usage was seen in 74.3% of our patient cohort and over the counter ibuprofen was most commonly used by patients in isolation or in combination with another non-narcotic medication (96.2%). The average number of non-narcotic pills taken were 15.6 with a range of 0-61. The vast majority (97%) of patients had discontinued non-narcotic usage by post-operative day 6. CONCLUSIONS: After knee arthroscopy in adolescent patients the average and median number of post-operative 5-mg hydrocodone-acetaminophen pills required was 5.41 and 5, respectively. The vast majority (82%) required less than 10 total narcotic pills. In our cohort, 97% of patients had discontinued narcotic use by post-operative day 5 and all patients by post-operative day 6. No patients required refills of pain medication. The results of this study should help to guide physicians treating post-operative pain in this vulnerable patient population.