Woelber Erik, Wurster Lindsey, Brandt Sarah, Mecum Patricia, Gundle Kenneth, Anissian Lucas
and are Physician Assistants, is a Family Nurse Practitioner, and are Attending Orthopedic Surgeons, all at US Department of Veterans Affairs Portland Health Care System in Oregon. is an Orthopedic Surgery Resident, and Kenneth Gundle is an Attending Physician, both in the Orthopedic Department at Oregon Health and Sciences University in Portland.
Fed Pract. 2021 Feb;38(2):e1-e7. doi: 10.12788/fp.0092.
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.
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.
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, < .01) and total inpatient MEDs (306 mg vs 33 mg, < .01). There was less self-reported pain on postoperative day 1 in the MOJO group (5.5 vs 4.1, = .01), decreased LOS (4.4 days vs 1.1 days, < .01), fewer total ED visits (6 vs 2, < .07), and fewer discharges to skilled nursing facilities (12 vs 0, < .01).
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.
几十年来，尽管有证据表明应减少阿片类药物的使用，但在全关节置换术后的疼痛管理中，阿片类药物一直是主要用药。为限制阿片类药物的不必要处方，美国退伍军人事务部（VA）波特兰医疗保健系统全关节服务部于2018年实施了关节手术后减少阿片类药物使用（MOJO）的术后疼痛方案，以减少全膝关节置换术（TKA）后的阿片类药物使用。该方案包括减少住院和门诊阿片类药物处方、术前优化、围手术期神经阻滞的使用以及不使用止血带进行手术。
我们进行了一项回顾性病历审查，将连续接受TKA手术的前20例使用MOJO方案的患者与最后20例使用先前常规方案的患者进行了比较。结果包括住院期间阿片类药物的总使用量、每日阿片类药物使用量、90天内急诊室（ED）就诊或再入院情况、因疼痛或药物补充而拨打的电话、住院时间（LOS）以及住院期间的疼痛情况。
在每日住院吗啡当量剂量（MED）方面，MOJO方案前组与MOJO方案组之间存在显著差异（82毫克对31毫克，<0.01），住院期间MED总量也有差异（306毫克对33毫克，<0.01）。MOJO方案组术后第1天的自我报告疼痛较轻（5.5对4.1，=0.01），住院时间缩短（4.4天对1.1天，<0.01），急诊室就诊总数减少（6次对2次，<0.07），转至专业护理机构的出院人数减少（12人对0人，<0.01）。
在VA环境中，MOJO方案减少了TKA术后的阿片类药物使用，且不影响疼痛控制或增加急诊室就诊次数。所描述的框架和常规方法可能适用于其他机构和外科专科。
