Minimizing Opioids After Joint Operation: Protocol to Decrease Postoperative Opioid Use After Primary Total Knee Arthroplasty

Abstract

BACKGROUND: For decades, opioids have been the mainstay in pain management after total joint arthroplasty despite evidence that their use should be curtailed. To limit unnecessary prescribing of opioids, the US Department of Veterans Affairs (VA) Portland Health Care System Total Joints Service implemented the Minimizing Opioids After Joint Operation (MOJO) postoperative pain protocol in 2018 to reduce opioid use following total knee arthroplasty (TKA). This protocol included reductions of inpatient and outpatient opioid prescribing, preoperative optimization, use of perioperative nerve blocks, and surgery without a tourniquet. METHODS: We performed a retrospective chart review that compared the first 20 consecutive patients undergoing TKA using the MOJO protocol with the last 20 patients using the prior routine. Outcomes included total inpatient opioid use, daily opioid use, emergency department (ED) visits or readmissions within 90 days, phone calls for pain or medication refills, length of stay (LOS), and pain during inpatient hospital stay. RESULTS: There were significant differences between the pre-MOJO and the MOJO groups with regard to daily inpatient morphine equivalent dose (MED) (82 mg vs 31 mg, P < .01) and total inpatient MEDs (306 mg vs 33 mg, P < .01). There was less self-reported pain on postoperative day 1 in the MOJO group (5.5 vs 4.1, P = .01), decreased LOS (4.4 days vs 1.1 days, P < .01), fewer total ED visits (6 vs 2, P < .07), and fewer discharges to skilled nursing facilities (12 vs 0, P < .01). CONCLUSIONS: The MOJO protocol reduced postoperative opioid use after TKA in the VA setting without compromising pain control or increasing ED visits. The framework and routines described are potentially applicable to other institutions and surgical specialties.