What is the recommended analgesia plan for patients on discharge after Anterior Cruciate Ligament (ACL) reconstruction, including baseline and opioid (long-acting and short-acting) management?

Optimal Analgesia Plan for Discharge After ACL Reconstruction

For patients undergoing ACL reconstruction, the optimal discharge analgesia plan should include a multimodal approach with scheduled NSAIDs and acetaminophen as baseline therapy, with short-acting opioids provided only as rescue medication for breakthrough pain, avoiding long-acting opioids entirely. 1

Baseline Analgesia (Non-Opioid Foundation)

Primary Components:

• NSAIDs: Schedule regularly, not as needed

  • Ibuprofen 400-800 mg every 8 hours OR
  • Diclofenac 50 mg every 8 hours OR
  • Naproxen 250-375 mg every 12 hours

• Acetaminophen: Schedule regularly, not as needed

  • 1000 mg every 6 hours (maximum daily dose: 4000 mg)

Rationale:

The combination of NSAIDs and acetaminophen provides superior analgesia through different mechanisms of action. Research shows that ibuprofen alone provides better pain control than acetaminophen alone after ACL reconstruction, though the combination doesn't necessarily outperform ibuprofen by itself 2. This scheduled non-opioid foundation is critical for minimizing opioid requirements.

Opioid Management

Short-Acting Opioids (For Breakthrough Pain Only):

• Oxycodone 5 mg every 4-6 hours as needed for breakthrough pain
  • Limit quantity: 10-15 tablets total
  • Clear instructions: "Use only when pain is not controlled by NSAIDs and acetaminophen"

Long-Acting Opioids:

• Not recommended for routine post-ACL reconstruction pain management
• Associated with higher risk of prolonged use and dependency
• No evidence supporting improved outcomes compared to short-acting opioids used appropriately

Adjunctive Measures

Strongly Recommended:

• Cryotherapy: Regular application of ice or cooling system
  • 20 minutes on/60 minutes off while awake
  • Reduces inflammation and pain without medication side effects

Additional Considerations:

• If available, liposomal bupivacaine injection during surgery significantly reduces post-discharge opioid requirements 3
• Local instillation analgesia (LIA) during surgery decreases 24-hour opioid consumption and improves pain control 4

Patient Education (Critical Component)

• Provide clear written instructions on:
  1. Taking scheduled NSAIDs and acetaminophen even when pain is controlled
  2. Using opioids only for breakthrough pain
  3. Safe opioid storage and disposal of unused medication
  4. Expected pain trajectory and management strategies
  5. Warning signs requiring medical attention

Common Pitfalls to Avoid

1. Over-reliance on opioids: Many prescribed opioids go unused or are used inappropriately 3
2. Inadequate non-opioid foundation: Failure to schedule NSAIDs and acetaminophen regularly
3. Prescribing long-acting opioids: Increases risk of dependency without clear benefit
4. Insufficient patient education: Leads to medication misuse and poor pain control
5. Neglecting cryotherapy: Simple but effective non-pharmacological intervention

By implementing this structured approach with emphasis on non-opioid medications as the foundation and limited short-acting opioids for breakthrough pain only, patients can achieve effective pain control while minimizing opioid exposure and associated risks.