Original Article| Volume 38, ISSUE 4, P1077-1085, April 2022

Multimodal Nonopioid Pain Protocol Provides Better or Equivalent Pain Control Compared to Opioid Analgesia Following Arthroscopic Rotator Cuff Surgery: A Prospective Randomized Controlled Trial

Published:November 25, 2021DOI:


      To evaluate the efficacy of a multimodal nonopioid analgesic protocol in controlling postoperative pain compared to opioids following a primary arthroscopic rotator cuff repair.


      Seventy consecutive patients undergoing a primary rotator cuff repair were assessed for eligibility. An observer-blinded prospective randomized controlled trial was designed in accordance with the Consolidated Standards of Reporting Trials 2010 (CONSORT) statement. The two arms of the study included a multimodal nonopioid pain regimen for the experimental group, and a standard of care narcotics for the control group. The primary outcome was visual analog scale (VAS) pain scores for the first 10 postoperative days. Secondary outcomes included PROMIS-PI (Patient-Reported Outcomes Measurement Information System-Pain Interference) scale, patient satisfaction, and adverse drug events.


      Thirty patients declined to participate or were excluded, and 40 patients were included in the final analysis. A total of 23 patients were in the traditional group, and 17 patients were in the nonopioid group. Control patients on opioid pain management reported a significantly higher VAS pain score on postoperative day 1 (opioid: 5.7 ± 2, nonopioid: 3.7 ± 2.2; P = .011) and postoperative day 4 (opioid: 4.4 ± 2.7, nonopioid: 2.4 ± 2.2; P = .023). No significant difference was seen on any other postoperative day. When mixed measured models were used to control for confounding factors, the nonopioid group demonstrated significantly lower VAS and PROMIS-PI scores (P < .01) at every time point. Patients in the traditional analgesia group reported significantly more days with constipation (P = .003) and days with upset stomach (P = .020) than those in the nonopioid group.


      The present study found that a multimodal nonopioid pain protocol provided equivalent or better pain control compared to traditional opioid analgesics in patients undergoing primary arthroscopic rotator cuff repair. Minimal side effects were noted with some improvement in the multimodal nonopioid pain cohort. All patients reported satisfaction with their pain management.

      Level of Evidence

      Level I, prospective randomized controlled trial.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Belay E.S.
        • Wittstein J.R.
        • Garrigues G.E.
        • et al.
        Biceps tenotomy has earlier pain relief compared to biceps tenodesis: A randomized prospective study.
        Knee Surg Sports Traumatol Arthrosc. 2019; 27: 4032-4037
        • McCarthy M.
        US declares opioid epidemic a "national emergency.
        BMJ. 2017; 358: j3881
        • Feinberg A.E.
        • Chesney T.R.
        • Srikandarajah S.
        • Acuna S.A.
        • McLeod R.S.
        Best Practices in Surgery Group. Opioid use after discharge in postoperative patients: A systematic review.
        Ann Surg. 2018; 267: 1056-1062
        • 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
        • Jildeh T.R.
        • Taylor K.A.
        • Khalil L.S.
        • et al.
        Risk factors for postoperative opioid use in arthroscopic meniscal surgery.
        Arthroscopy. 2019; 35: 575-580
        • Jildeh T.R.
        • Taylor K.A.
        • Tramer J.S.
        • et al.
        Risk factors for postoperative opioid use in arthroscopic shoulder labral surgery.
        Arthroscopy. 2020; 36: 1813-1820
        • Moutzouros V.
        • Jildeh T.R.
        • Khalil L.S.
        • et al.
        A multimodal protocol to diminish pain following common orthopedic sports procedures: Can we eliminate postoperative opioids?.
        Arthroscopy. 2020; 36: 2249-2257
        • Jildeh T.R.
        • Okoroha K.R.
        • Kuhlmann N.
        • Cross A.
        • Abbas M.J.
        • Moutzouros V.
        Multimodal nonopioid pain protocol provides equivalent pain versus opioid control following meniscus surgery: A prospective randomized controlled trial.
        Arthroscopy. 2021; 37: 2237-2245
        • Dang A.
        • Davies M.
        Rotator cuff disease: Treatment options and considerations.
        Sports Med Arthrosc Rev. 2018; 26: 129-133
        • YaDeau J.T.
        • Soffin E.M.
        • Tseng A.
        • et al.
        A comprehensive enhanced recovery pathway for rotator cuff surgery reduces pain, opioid use, and side effects.
        Clin Orthop Relat Res. 2021; 479: 1740-1751
        • Schulz K.F.
        • Altman D.G.
        • Moher D.
        CONSORT 2010 statement: Updated guidelines for reporting parallel group randomised trials.
        BMJ. 2010; 340: c332
        • Tashjian R.Z.
        • Shin J.
        • Broschinsky K.
        • et al.
        Minimal clinically important differences in the American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale pain scores after arthroscopic rotator cuff repair.
        J Shoulder Elbow Surg. 2020; 29: 1406-1411
        • 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
        • Mandava N.K.
        • Sethi P.M.
        • Routman H.D.
        • Liddy N.
        • Haidamous G.
        • Denard P.J.
        Opioid requirement after rotator cuff repair is low with a multimodal approach to pain.
        J Shoulder Elbow Surg. 2020; 30: e399-e408
        • Syed U.A.M.
        • Aleem A.W.
        • Wowkanech C.
        • et al.
        Neer Award 2018: The effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: A prospective, randomized clinical trial.
        J Shoulder Elbow Surg. 2018; 27: 962-967
        • Sethi P.M.
        • Brameier D.T.
        • Mandava N.K.
        • Miller S.R.
        Liposomal bupivacaine reduces opiate consumption after rotator cuff repair in a randomized controlled trial.
        J Shoulder Elbow Surg. 2019; 28: 819-827
        • Theosmy E.G.
        • Bradian A.K.
        • Cheesman Q.T.
        • Radack T.M.
        • Lazarus M.D.
        • Austin L.S.
        Opioid-free arthroscopic rotator cuff repair.
        Orthopedics. 2020; : 1-5
        • Gregorian Jr., R.S.
        • Gasik A.
        • Kwong W.J.
        • Voeller S.
        • Kavanagh S.
        Importance of side effects in opioid treatment: a trade-off analysis with patients and physicians.
        J Pain. 2010; 11: 1095-1108
        • Duensing L.
        • Eksterowicz N.
        • Macario A.
        • Brown M.
        • Stern L.
        • Ogbonnaya A.
        Patient and physician perceptions of treatment of moderate-to-severe chronic pain with oral opioids.
        Curr Med Res Opin. 2010; 26: 1579-1585
        • Benyamin R.
        • Trescot A.M.
        • Datta S.
        • et al.
        Opioid complications and side effects.
        Pain Physician. 2008; 11: S105-S120
        • Kukkar A.
        • Bali A.
        • Singh N.
        • Jaggi A.S.
        Implications and mechanism of action of gabapentin in neuropathic pain.
        Arch Pharm Res. 2013; 36: 237-251
        • Calcaterra N.E.
        • Barrow J.C.
        Classics in chemical neuroscience: diazepam (valium).
        ACS Chem Neurosci. 2014; 5: 253-260
        • Warrender W.J.
        • Syed U.A.M.
        • Hammoud S.
        • et al.
        Pain management after outpatient shoulder arthroscopy: A systematic review of randomized controlled trials.
        Am J Sports Med. 2017; 45: 1676-1686
        • Duchman K.R.
        • Lemmex D.B.
        • Patel S.H.
        • Ledbetter L.
        • Garrigues G.E.
        • Riboh J.C.
        The effect of non-steroidal anti-inflammatory drugs on tendon-to-bone healing: A systematic review with subgroup meta-analysis.
        Iowa Orthop J. 2019; 39: 107-119
        • 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