Variability in Pain Management for Adolescent ACL Reconstruction Patients

RESEARCH ANALYSIS

Variability in Pain Management for Adolescent ACL Reconstruction Patients

KATHERINE JERAKIS, MS

Drexel University College of Medicine

SUMMARY POINTS

-       Pain management practices for adolescent patients exhibit great variability and lack benchmarks or guidelines. 

-       High schoolers are 33% more likely to abuse opioids by the age of 23 if they use opioids medically.

-       Formal establishment of guidelines leads to fewer opioids prescribed with similar levels of pain control.

ANALYSIS

Background

Injury to the anterior cruciate ligament (ACL) is one of the most common knee injuries. The adolescent population is particularly susceptible due to high participation rates in sports and athletic activities (1). The incidence of ACL injuries has been increasing in recent years (2). Today, about 70% of ACL injuries are treated surgically, likely due to the development of techniques better suited to the skeletally immature (2,3). With the advancement of surgical techniques that minimize interference with the physis, concerns about causing limb deformities and growth abnormalities are decreasing (3). Considered one of the more painful orthopedic procedures, ACL reconstruction commonly involves opioid prescriptions. The three goals of pain management for this procedure and population include managing pain to reduce mobility-limiting discomfort, promoting functional recovery (especially for adolescent athletes seeking to return to sport), and reducing opioid intake. The CDC recommends a 7-day limit for postoperative opioid prescriptions (4). While decades of research have gone into refining surgical techniques for the adolescent population, there is scant literature exploring best practices for their pain management.

Findings

Pain management practices for adolescent ACL reconstruction are highly variable. Only two studies addressing this procedure and population have been identified. Wagner et al. (2023) reported on the results of an online survey distributed by the Quality, Safety, and Value Initiative Committee of the Pediatric Orthopedic Society of North America to the society’s members (5). They found consensus among about 90% of respondents on the postoperative use of opioids and the perioperative use of peripheral nerve blocks. However, the type and number of opioid pills prescribed varied. The most common opioids prescribed were oxycodone (46.9%) and hydrocodone/acetaminophen (32.8%). The number of pills prescribed ranged from 0 to 40, with 46.9% of surgeons prescribing between 11 and 20 pills. Among those who used a perioperative nerve block, 81% used an adductor canal block. Preoperatively, 39.1% of surgeons reported using some form of pain management—most commonly acetaminophen (31.3%), gabapentin (21.9%), and celecoxib (10.9%). Most respondents were fellowship-trained in pediatric orthopedics, worked in the U.S., and were affiliated with academic centers. Yet, when asked what guided their decision-making, fewer than a quarter cited current research, while nearly 60% relied on prior training or experience. The variability in pain management practices raises concerns about both under- and overprescribing opioids in this population and highlights clinical decision-making as an area for improvement.

A multisite prospective study by Sadacharam et al. (2024) was recently published and also focused on the variability in perioperative pain management for adolescent ACL reconstruction (6). Again, the specifics of preoperative and perioperative practices varied. Peripheral nerve blocks were used in 86% of surgeries, split nearly evenly between single (49.7%) and multiple (50.3%) nerve blocks (6). Preoperative non-opioid medications included acetaminophen (44%), gabapentin (7%), diazepam (7%), NSAIDs (6%), and pregabalin (2%) (6). To assess postoperative pain management, the authors surveyed patients about their pain and opioid use in the days following surgery. However, it is unclear what medications were actually prescribed. The authors emphasized the widespread concern about the lack of guidelines and benchmarks for pain management in adolescents.

Although ACL reconstruction is a painful procedure, physicians should exercise caution when prescribing opioids to adolescents. Patterns of opioid use in this group are understudied, and no formal guidelines currently exist. Furthermore, adolescents are particularly vulnerable to the addictive nature of opioids. High school students are 33% more likely to misuse opioids by age 23 if they use them medically or illicitly (7). Unsurprisingly, greater prescription volumes are associated with a higher risk of developing opioid use disorder within just one year following surgery (8). Moreover, more than 1 in 10 high school students already report misusing opioids (9). Miech et al. (2015) found that individuals who go on to misuse opioids after prescription use are more likely to have had little or no prior exposure to drugs or alcohol—possibly due to the comfort and perceived safety of taking prescription opioids at home post-surgery (7). One study noted that a safe and pleasurable environment during initial drug use is a major factor for later misuse (10). Since 70% of high school seniors are drug-naive, it is essential to be mindful of opioid prescribing practices in this population (11). The risk associated with prescribing opioids to young people is real and significant.

Additionally, variability in peripheral nerve block use raises concerns, as some blocks may impair functional ability and strength in the leg postoperatively (12). The current literature largely focuses on short-term outcomes, while the effects of different nerve blocks on long-term outcomes, such as return to sport and risk of reinjury, remain poorly understood.

Discussion

While current pain management practices appear disjointed, Wyles et al. (2020) sought to establish procedure-specific guidelines to create a more cohesive pain management framework for adult orthopedic patients (13). These guidelines, developed by a multidisciplinary team, covered 14 common orthopedic procedures and categorized them into four tiers with increasing maximum pain management levels. ACL reconstruction was designated as a Tier 2 procedure. Following implementation of the guidelines, opioid prescribing dropped by 47%. Before the guidelines, only 19% of opioid prescriptions fell below the recommended limits; afterward, 69% were below guideline thresholds. Notably, there was no change in the prescription refill rate, suggesting that more restrictive prescribing still provided adequate postoperative pain control. Overall, formal establishment and implementation of procedure-specific guidelines significantly reduced opioid prescribing without compromising pain management in the adult population (13). Accordingly, the risks associated with variability and the lack of adolescent-specific guidelines could be similarly addressed through the development of such tailored protocols.

Future research should focus on developing and validating adolescent-specific, procedure-based pain management guidelines for ACL reconstruction. Long-term studies are also needed to assess the functional and psychosocial outcomes of different analgesic strategies, including opioid-sparing approaches.

REFERENCES

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2. Beck NA, Lawrence JTR, Nordin JD, DeFor TA, Tompkins M. ACL Tears in School-Aged Children and Adolescents Over 20 Years. Pediatrics. 2017;139(3). doi:10.1542/peds.2016-1877

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6. Sadacharam K, Furstein JS, Staffa SJ, et al. Multisite prospective study of perioperative pain management practices for anterior cruciate ligament reconstruction in adolescents: Society for Pediatric Anesthesia Improvement Network (SPAIN) Project Report. Reg Anesth Pain Med. Published online April 18, 2024:rapm-2024-105381. doi:10.1136/rapm-2024-105381

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8. Cahan EM, Halvorsen KC, Pham NS, et al. Opioid Represcriptions After ACL Reconstruction in Adolescents Are Associated With Subsequent Opioid Use Disorder. J Pediatr Orthop. 2023;43(4):e273-e277. doi:10.1097/BPO.000000000000234010.

9. McCabe SE, Veliz P, Wilens TE, et al. Sources of Nonmedical Prescription Drug Misuse Among US High School Seniors: Differences in Motives and Substance Use Behaviors. J Am Acad Child Adolesc Psychiatry. 2019;58(7):681-691. doi:10.1016/j.jaac.2018.11.018

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11. Miech, R. A., Johnston, L. D., Patrick, M. E., O’Malley, P. M., & Bachman, J. G. (2023). Monitoring the Future national survey results on drug use, 1975–2023: Secondary school students. Monitoring the Future Monograph Series. Ann Arbor, MI: Institute for Social Research, University of Michigan.

12. Hussain N, Brull R, Vannabouathong C, et al. Network meta-analysis of the analgesic effectiveness of regional anaesthesia techniques for anterior cruciate ligament reconstruction. Anaesthesia. 2023;78(2):207-224. doi:10.1111/anae.15873

13. Wyles CC, Hevesi M, Ubl DS, et al. Implementation of Procedure-Specific Opioid Guidelines. JB JS Open Access. 2020;5(1):e0050. doi:10.2106/JBJS.OA.19.00050