JAMA Associate Editor Anthony Charles, MD, MPH, gives editorial insight into a randomized clinical trial investigating if a multimodal opioid-sparing postoperative pain protocol reduces opioid consumption compared with standard opioid prescribing after arthroscopic knee or shoulder surgery, published in the October 4, 2022, issue of JAMA.
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I'm Anthony Charles, Chief of Trauma, Critical Care and Emergency General Surgery at the University of North Carolina at Chapel Hill, and Associate Editor for Surgery at JAMA.
In its October 4, 2022, issue, JAMA published a randomized clinical trial that addresses the critical question in postoperative pain management, specifically, the effect of a Multimodal Opioid-Sparing Protocol versus standard opioid prescribing on postoperative opioid consumption.
The current standard of care for postoperative pain management is a postoperative opioid prescription that aligns with the treating surgeon’s current prescribing habits and the procedure performed. It typically includes opioids such as oxycodone, codeine, and hydromorphone, ranging from 20 to 80 tablets to be taken as needed. Surgeon prescribing preference results in wide variability. An alternative approach that can achieve the same level of postoperative pain control while minimizing the use of opioids is desirable.
This randomized clinical trial was performed at 3 clinical sites in Ontario, Canada. 200 patients undergoing outpatient arthroscopic shoulder or knee surgery were enrolled and followed for 6 weeks postoperatively. 100 patients were randomized to the opioid-sparing group, and they received a prescription of naproxen, acetaminophen, and pantoprazole; they also received a limited “rescue prescription” of hydromorphone, and a patient education infographic. The control group of 100 participants received the current standard of care as per the treating surgeon, which consisted of an opioid analgesic. The primary outcome was total outpatient postoperative opioid consumption at 6 weeks. Secondary outcomes were pain level, patient satisfaction, opioid refills, the quantity of oral morphine equivalents prescribed at the time of hospital discharge, and adverse events at 6 weeks.
98 patients in the standard care group and 95 in the opioid-sparing protocol group completed the trial. The authors found that patients in the opioid-sparing protocol group consumed significantly fewer opioids than patients in the control group. Of the 5 pre-specified secondary endpoints, 4 showed no significant difference. The mean amount of oral morphine equivalents prescribed at discharge was 341.2mg in the standard of care group and 40.4mg in the opioid-sparing group. The authors conclude that among patients who underwent arthroscopic knee or shoulder surgery, a multimodal opioid-sparing postoperative pain management protocol, compared to standard opioid prescribing, significantly reduced postoperative opioid consumption over 6 weeks.
In my opinion, this study is practice changing. Studies show that opioids prescribed during and after surgery can increase the risk of chronic opioid use in all patients. The development of new persistent opioid use after surgery has recently been identified as a common postoperative complication. Up to 14.7% of opioid-naive patients may develop persistent postoperative opioid use. This randomized clinical trial establishes the utility of postoperative multimodal opioid-sparing intervention with non-steroidal anti-inflammatory analgesics, acetaminophen, and patient education. Therefore, it should change postoperative prescribing patterns and variability among orthopedic and non-orthopedic surgeons.
In my opinion, this study is generalizable. Though this study was limited to knee and shoulder arthroscopy, the implications of the findings are applicable to postoperative pain management across the board, particularly when viewed within the larger context of excessive opioid prescribing.
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