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A Multimodal Protocol to Diminish Pain Following Common Orthopedic Sports Procedures: Can We Eliminate Postoperative Opioids?

      Purpose

      To determine whether postsurgical pain, measured by the visual analog scale (VAS), following common orthopaedic sports procedures could be managed effectively with a nonopioid multimodal analgesic protocol.

      Methods

      This prospective study evaluated a custom multimodal nonopioid pain protocol in patients undergoing common orthopaedic sports procedures by a single fellowship-trained orthopaedic sports surgeon from May 2018 to December 2018. Procedures included anterior cruciate ligament reconstruction, rotator cuff repair, arthroscopic partial meniscectomy, and labrum repair. The nonopioid pain protocol consisted of preoperative analgesics, intraoperative local infiltration analgesia, and a postoperative pain regimen. Patient pain was immediately reported after surgery and 1 week postoperatively using the VAS, whereas rescue opioids (oxycodone 5 mg) used were recorded using a prescription opioid journal. Statistical analysis of patient VAS scores, demographic correlations, and comparison between opioid rescue users versus nonusers was performed.

      Results

      A total of 141 patients were included. One week following surgery, patients reported a mean VAS level of 3.2 ± 2.3 and required on average 2.6 ± 3.6 breakthrough oxycodone pills (8.6 ± 12.0 morphine equivalents). Forty-five percent of patients did not require any breakthrough prescription opioids and reported satisfaction with pain management. Patients who required opioids were more likely to have a history of anxiety/depression (44.2% vs 23.8%, P = .012) and reported greater pain scores as compared with nonusers (3.94 ± 2.5 vs 2.41 ± 1.75, P = .016). The most common side effect of the pain protocol was feeling drowsy (23.5%). All patients were satisfied with their pain management postoperatively.

      Conclusions

      A multimodal, nonopioid pain protocol was found to be effective in managing postoperative pain following common orthopedic sports procedures. Patients were found to have low levels of pain, require minimal rescue opioids, and had no severe side effects related to the protocol. These results suggest a nonopioid alternative to pain management following common orthopedic sports procedures.

      Level of Evidence

      Level IV, prospective case series
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      References

        • Baker D.W.
        History of The Joint Commission's Pain Standards: Lessons for today's prescription opioid epidemic.
        JAMA. 2017; 317: 1117-1118
        • Gomes T.
        • Tadrous M.
        • Mamdani M.M.
        • Paterson J.M.
        • Juurlink D.N.
        The burden of opioid-related mortality in the United States.
        JAMA Netw Open. 2018; 1e180217
        • Jones C.M.
        • Lurie P.
        • Woodcock J.
        Addressing prescription opioid overdose: Data support a comprehensive policy approach.
        JAMA. 2014; 312: 1733-1734
        • Schoenfeld A.J.
        • Jiang W.
        • Chaudhary M.A.
        • Scully R.E.
        • Koehlmoos T.
        • Haider A.H.
        Sustained prescription opioid use among previously opioid-naive patients insured through TRICARE (2006-2014).
        JAMA Surg. 2017; 152: 1175-1176
        • Sabatino M.J.
        • Kunkel S.T.
        • Ramkumar D.B.
        • Keeney B.J.
        • Jevsevar D.S.
        Excess opioid medication and variation in prescribing patterns following common orthopaedic procedures.
        J Bone Joint Surg Am. 2018; 100: 180-188
        • Trasolini N.A.
        • McKnight B.M.
        • Dorr L.D.
        The opioid crisis and the orthopedic surgeon.
        J Arthroplasty. 2018; 33: 3379-3382 e3371
        • Mall N.A.
        • Chalmers P.N.
        • Moric M.
        • et al.
        Incidence and trends of anterior cruciate ligament reconstruction in the United States.
        Am J Sports Med. 2014; 42: 2363-2370
        • Jensen A.R.
        • Cha P.S.
        • Devana S.K.
        • et al.
        Evaluation of the trends, concomitant procedures, and complications with open and arthroscopic rotator cuff repairs in the Medicare population.
        Orthop J Sports Med. 2017; 5 (2325967117731310)
        • Herzog M.M.
        • Marshall S.W.
        • Lund J.L.
        • Pate V.
        • Mack C.D.
        • Spang J.T.
        Trends in Incidence of ACL reconstruction and concomitant procedures among commercially insured individuals in the United States, 2002-2014.
        Sports Health. 2018; 10: 523-531
        • Frank R.M.
        • Chalmers P.N.
        • Moric M.
        • Leroux T.
        • Provencher M.T.
        • Romeo A.A.
        Incidence and changing trends of shoulder stabilization in the United States.
        Arthroscopy. 2018; 34: 784-792
        • Abrams G.D.
        • Frank R.M.
        • Gupta A.K.
        • Harris J.D.
        • McCormick F.M.
        • Cole B.J.
        Trends in meniscus repair and meniscectomy in the United States, 2005-2011.
        Am J Sports Med. 2013; 41: 2333-2339
        • Pitchon D.N.
        • Dayan A.C.
        • Schwenk E.S.
        • Baratta J.L.
        • Viscusi E.R.
        Updates on multimodal analgesia for orthopedic surgery.
        Anesthesiol Clin. 2018; 36: 361-373
        • Beaussier M.
        • Sciard D.
        • Sautet A.
        New modalities of pain treatment after outpatient orthopaedic surgery.
        Orthop Traumatol Surg Res. 2016; 102: S121-S124
        • Carrier C.S.
        • Garvey K.D.
        • Brook E.M.
        • Matzkin E.G.
        Patient satisfaction with nonopioid pain management following knee arthroscopic partial meniscectomy and/or chondroplasty.
        Orthopedics. 2018; 41: 209-214
        • McLaughlin D.C.
        • Cheah J.W.
        • Aleshi P.
        • Zhang A.L.
        • Ma C.B.
        • Feeley B.T.
        Multimodal analgesia decreases opioid consumption after shoulder arthroplasty: A prospective cohort study.
        J Shoulder Elbow Surg. 2018; 27: 686-691
        • Uquillas C.A.
        • Capogna B.M.
        • Rossy W.H.
        • Mahure S.A.
        • Rokito A.S.
        Postoperative pain control after arthroscopic rotator cuff repair.
        J Shoulder Elbow Surg. 2016; 25: 1204-1213
        • Elkassabany N.M.
        • Wang A.
        • Ochroch J.
        • Mattera M.
        • Liu J.
        • Kuntz A.
        Improved quality of recovery from ambulatory shoulder surgery after implementation of a multimodal perioperative pain management protocol.
        Pain Med. 2019; 20: 1012-1019
        • Daniels S.D.
        • Garvey K.D.
        • Collins J.E.
        • Matzkin E.G.
        Patient satisfaction with nonopioid pain management following arthroscopic partial meniscectomy and/or chondroplasty.
        Arthroscopy. 2019; 35: 1641-1647
        • Helmerhorst G.T.
        • Vranceanu A.M.
        • Vrahas M.
        • Smith M.
        • Ring D.
        Risk factors for continued opioid use one to two months after surgery for musculoskeletal trauma.
        J Bone Joint Surg Am. 2014; 96: 495-499
        • Cho C.H.
        • Song K.S.
        • Min B.W.
        • et al.
        Multimodal approach to postoperative pain control in patients undergoing rotator cuff repair.
        Knee Surg Sports Traumatol Arthrosc. 2011; 19: 1744-1748
        • Ip H.Y.
        • Abrishami A.
        • Peng P.W.
        • Wong J.
        • Chung F.
        Predictors of postoperative pain and analgesic consumption: A qualitative systematic review.
        Anesthesiology. 2009; 111: 657-677
        • Costelloe C.
        • Burns S.
        • Yong R.J.
        • Kaye A.D.
        • Urman R.D.
        An analysis of predictors of persistent postoperative pain in spine surgery.
        Curr Pain Headache Rep. 2020; 24: 11
        • Hozumi J.
        • Sumitani M.
        • Nishizawa D.
        • et al.
        Resistin is a novel marker for postoperative pain intensity.
        Anesth Analg. 2019; 128: 563-568
        • Jarrell J.
        • Robert M.
        • Giamberardino M.A.
        • Tang S.
        • Stephenson K.
        Pain, psychosocial tests, pain sensitization and laparoscopic pelvic surgery.
        Scand J Pain. 2018; 18: 49-57
        • Rice D.A.
        • Kluger M.T.
        • McNair P.J.
        • et al.
        Persistent postoperative pain after total knee arthroplasty: A prospective cohort study of potential risk factors.
        Br J Anaesth. 2018; 121: 804-812
        • Richebe P.
        • Capdevila X.
        • Rivat C.
        Persistent postsurgical pain: Pathophysiology and preventative pharmacologic considerations.
        Anesthesiology. 2018; 129: 590-607
        • Kumar K.
        • Gulotta L.V.
        • Dines J.S.
        • et al.
        Unused opioid pills after outpatient shoulder surgeries given current perioperative prescribing habits.
        Am J Sports Med. 2017; 45: 636-641
        • Rodgers J.
        • Cunningham K.
        • Fitzgerald K.
        • Finnerty E.
        Opioid consumption following outpatient upper extremity surgery.
        J Hand Surg Am. 2012; 37: 645-650
        • Kim N.
        • Matzon J.L.
        • Abboudi J.
        • et al.
        A prospective evaluation of opioid utilization after upper-extremity surgical procedures: Identifying consumption patterns and determining prescribing guidelines.
        J Bone Joint Surg Am. 2016; 98: e89
        • Wojahn R.D.
        • Bogunovic L.
        • Brophy R.H.
        • et al.
        Opioid consumption after knee arthroscopy.
        J Bone Joint Surg Am. 2018; 100: 1629-1636
        • Etcheson J.I.
        • Gwam C.U.
        • George N.E.
        • Virani S.
        • Mont M.A.
        • Delanois R.E.
        Patients with major depressive disorder experience increased perception of pain and opioid consumption following total joint arthroplasty.
        J Arthroplasty. 2018; 33: 997-1002
        • Sun E.C.
        • Darnall B.D.
        • Baker L.C.
        • Mackey S.
        Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period.
        JAMA Intern Med. 2016; 176: 1286-1293
        • Leroux T.S.
        • Saltzman B.M.
        • Sumner S.A.
        • et al.
        Elective shoulder surgery in the opioid naive: Rates of and risk factors for long-term postoperative opioid use.
        Am J Sports Med. 2019; 47: 1051-1056
        • Rubenstein W.
        • Grace T.
        • Croci R.
        • Ward D.
        The interaction of depression and prior opioid use on pain and opioid requirements after total joint arthroplasty.
        Arthroplast Today. 2018; 4: 464-469
        • Wittbrodt E.T.
        • Gan T.J.
        • Datto C.
        • McLeskey C.
        • Sinha M.
        Resource use and costs associated with opioid-induced constipation following total hip or total knee replacement surgery.
        J Pain Res. 2018; 11: 1017-1025