Newswise — CHICAGO – New research published in the Online First edition of Anesthesiology, the peer-reviewed medical journal of the American Society of Anesthesiologists (ASA), reports that after an Opioid Safety Initiative (OSI) was implemented at the Veterans Health Administration (VHA), patients undergoing knee replacement surgery were prescribed significantly less opioids with minimal impact on patients’ reported pain scores.

“The public and physicians may be concerned that, on average, populations will report higher pain scores as the pendulum swings away from chronic opioid use,” said Karthik Raghunathan, M.D., M.P.H, associate professor of anesthesiology, Duke University Medical Center, Durham, North Carolina. “However, after allowing for opioid use in the first three months after knee replacement surgery, the OSI decreased subsequent prescriptions by about 20%. At the same time, average pain scores measured over six-months after surgery were essentially unchanged. This work at the VA may inform ongoing efforts to counter the opioid epidemic across the country.”

Chronic pain is common among patients undergoing knee replacement, and the procedure is among the most frequent major operations in the nation. Although guidelines discourage long-term opioid therapy for pain management in these patients, persistent opioid use is common.

The OSI uses VA/DoD guidelines to help health care providers evaluate and manage the individual needs and preferences of veterans with chronic pain. In addition, the OSI provided a computerized dashboard that tracks opioid prescriptions at national, regional, facility and provider levels, so that the leadership at each facility can audit the data and provide feedback to staff. The OSI was rolled out nationwide in 2013, and high-dose opioid prescriptions were substantially decreased after that.  

The current study was based on group-level data from over 60,000 patients (700 to 850 patients per month) between 2010 and 2015, all undergoing total knee replacement surgery. Researchers analyzed trends in patient reported pain scores, and in chronic opioid and nonopioid prescriptions, before versus after the implementation of the OSI.

Details about the actual use of these prescriptions by Veterans is unclear. But the study found that long-term dispensing of opioid prescriptions beyond 90 days after knee replacement surgery decreased significantly (by 15 to 20%), and patient-reported outpatient pain scores increased minimally in the 6 months after discharge from the hospital (by approximately 0.2 points on a scale of 0 to 10, when compared with average preoperative pain scores). Non-opioid prescriptions were increased.

“The very slight increase in average pain scores at the population-level may be attributed to the relatively modest effect that opioids have on chronic pain after surgery,” said Dr. Raghunathan. “We also observed an increase in the use of non-opioid medications. This may ease the impact of decreasing opioid use.”


Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 53,000 members organized to raise and maintain the standards of the medical practice of anesthesiology. ASA is committed to ensuring physician anesthesiologists evaluate and supervise the medical care of patients before, during and after surgery to provide the highest quality and safest care every patient deserves. Physician anesthesiologists are experts in pain management and are at the forefront of implementing best practices and interventions to reduce opioid use.

For more information on the field of anesthesiology, visit the American Society of Anesthesiologists online at To learn more about the role physician anesthesiologists play in ensuring patient safety, visit Like ASA on Facebook; follow ASALifeline on Twitter.


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