Study protocol: randomized controlled trial of opioid-free vs. traditional perioperative analgesia in elective orthopedic surgery

Opioid-Sparing Protocols in Hand Surgery: Successes and Opportunities

The opioid epidemic has been a defining crisis in American health care. Many attempts to address the epidemic have focused on issues around opioid prescribing. Legislation at the state and federal levels has been passed; however, the results from these policies have been mixed. Changes to prescription workflows alongside patient and provider education have also had some success. Within hand surgery in particular, recent progress has been made toward promoting opioid-sparing regimens for postoperative pain, including nonopioid and limited-opioid protocols. These regimens offer promise particularly in the setting of ambulatory surgeries, especially soft tissue procedures, and potentially in more invasive and complicated surgical settings. However, there are downsides and failures from these protocols that must be addressed, such as limited data on bony and complex soft tissue procedures, minimal diversity on published alternatives for limited regimens, and times when multimodal approaches are not adequate. Future work should focus on developing opioid-sparing protocols for more complex procedures as well as identifying patients at risk of requiring more comprehensive pain management approaches even for relatively minor procedures.

An Opioid-Free Perioperative Pain Protocol Is Noninferior to Opioid-Containing Management: A Randomized Controlled Trial

BACKGROUND

In recent years, orthopaedic surgeons have attempted to decrease opioid consumption through multimodal pain management. However, a limited effort has been made to eliminate opioids entirely in the perioperative period. The purpose of this study was to compare the efficacy and safety of a novel opioid-free pain management pathway with that of an opioid-containing pathway across 5 common orthopaedic subspecialty surgical procedures.

METHODS

In a 1:1, unblinded fashion, 315 patients were randomized to a perioperative pain management pathway that was either opioid-free (n = 157) or opioid-containing (n = 158). Pain was measured with a numeric rating scale (NRS) for pain of 0 to 10 at 6 hours, 12 hours, 24 hours (the primary outcome assessing noninferiority), 2 weeks, 6 weeks, and 1 year after the surgical procedure. Data on patient characteristics, deviations from the pain management pathway, morphine milligram equivalents (MME), readmissions, adverse events, and patient-reported outcomes were collected.

RESULTS

There were 315 patients in the final group, with a mean age of 63.6 years. Of the patients in the study, 59.7% were female, 85.7% were White, 12.4% were Black/African-American, 1.0% were Hispanic/Latino, 0.6% were American Indian, and 0.3% were unknown. At 24 hours, the median NRS for pain in the opioid-free group (2 [interquartile range (IQR), 0 to 4]) was statistically noninferior (p < 0.0001) to the opioid-containing group (4 [IQR, 2 to 6]). Pain levels were significantly lower in the opioid-free group than in the opioid-containing group at 12 hours (p = 0.0173) and 2 weeks (p = 0.0003). Pain scores at 6 hours, 6 weeks, and 1 year were similar. Patients in the opioid-free group reported significantly greater comfort at 24 hours (p = 0.0392) and higher satisfaction with pain control (p = 0.0355) at 6 weeks. There were no reported adverse events or unplanned readmissions. Demographic characteristics were similar between the 2 groups.

CONCLUSIONS

Across 5 common orthopaedic subspecialty procedures, an opioid-free pain management pathway was safe and effective and provided noninferior pain control at 24 hours compared with the opioid-containing pathway.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Opioid-Free Analgesia is Safe and Effective in Anterior Cervical Spine Surgery: A Randomized Controlled Trial

STUDY DESIGN

Randomized controlled trial (RCT).

OBJECTIVE

Compare the efficacy of a multimodal, opioid-free (OF) pain management pathway with a traditional opioid-containing (OC) pathway in patients undergoing anterior cervical procedures.

SUMMARY OF BACKGROUND DATA

Previous studies have compared opioid-based pain regimens to opioid-sparing regimens following cervical spine surgery, but have been limited by high rates of crossover, retrospective designs, reliance on indwelling pain catheters, opioid utilization for early postoperative analgesia, and/or a lack of patient-reported outcome measures.

METHODS

This is a RCT in which patients were allocated to either an OF or OC perioperative pain management protocol. Eligible study participants included adult (age up to 18 y) patients who underwent primary, 1-level or 2-level anterior cervical surgery [anterior cervical discectomy and fusion (ACDF), anterior cervical disc arthroplasty (ACDA), or hybrid (ACDF and ACDA at different levels)] for degenerative pathology. The primary outcome variable was subjective pain level at 24 hours postoperative. The final study cohort consisted of 50 patients (22 OF, 28 OC).

RESULTS

Patients in the OF group reported lower median postoperative pain levels at 6 hours (4 for OF vs. 7 for OC; P =0.041) and 24 hours (3 for OF vs. 5 for OC; P =0.032). At 2-week and 6-week follow-up, pain levels were similar between groups. Patients in the OF group reported greater comfort at 12 hours (9 for OF vs. 5 for OC; P =0.003) and 24 hours (9 for OF vs. 5 for OC; P =0.011) postoperatively. Notably, there were no significant differences in patients' reported pain satisfaction, overall surgical satisfaction, or overall sense of physical and mental well-being. In addition, there were no significant differences in falls, delirium, or constipation postoperatively.

CONCLUSIONS

A multimodal OF pain management pathway following anterior cervical surgery for degenerative disease results in statistically noninferior pain control and equivalent patient-reported outcome measures compared with a traditional OC pathway.

Acute Perioperative Pain Management of the Orthopaedic Patient: Guidance for Operationalizing Evidence Into Practice

Orthopaedic surgery often results in pain, with less than half of patients reporting adequate relief. Unrelieved acute pain occurring after surgery increases the risk of negative sequelae, including delayed healing, increased morbidity, pulmonary complications, limited rehabilitation participation, anxiety, depression, increased length of stay, prolonged duration of opioid use, and the development of chronic pain. Interventions that are individualized, evidence-informed, and applied within an ethical framework improve healthcare delivery for patients, clinicians, and healthcare organizations. Recommendations for using the principles of effective pain management from preoperative assessment through discharge are detailed, including recommendations for addressing barriers and challenges in applying these principles into clinical practice.

Opioid-Free Analgesia Provides Pain Control Following Thumb Carpometacarpal Joint Arthroplasty

BACKGROUND

We hypothesized that an opioid-free (OF), multimodal pain management pathway for thumb carpometacarpal (CMC) joint arthroplasty would not have inferior pain control compared with that of a standard opioid-containing (OC) pathway.

METHODS

This was a single-center, randomized controlled clinical trial of patients undergoing primary thumb CMC joint arthroplasty. Patients were randomly allocated to either a completely OF analgesic pathway or a standard OC analgesic pathway. Patients in both cohorts received a preoperative brachial plexus block utilizing 30 mL of 0.5% ropivacaine that was administered via ultrasound guidance. The OF group was given a combination of cryotherapy, anti-inflammatory medications, acetaminophen, and gabapentin. The OC group was only given cryotherapy and opioid-containing medication for analgesia. Patient-reported pain was assessed with use of a 0 to 10 numeric rating scale at 24 hours, 2 weeks, and 6 weeks postoperatively. We compared the demographics, opioid-related side effects, patient satisfaction, and Veterans RAND 12-Item Health Survey (VR-12) results between these 2 groups.

RESULTS

At 24 hours postoperatively, pain scores in the OF group were statistically noninferior to, and lower than, those in the OC group (median, 2 versus 4; p = 0.008). Pain scores continued to differ significantly at 2 weeks postoperatively (median, 2 versus 4; p = 0.001) before becoming more similar at 6 weeks (p > 0.05). No difference was found between groups with respect to opioid-related side effects, patient satisfaction, or VR-12 results.

CONCLUSIONS

A completely opioid-free perioperative protocol is effective for the treatment of pain following thumb CMC joint arthroplasty in properly selected patients.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Postoperative Pain Control Following Shoulder Arthroplasty: Rethinking the Need for Opioids

The use of opioid pain medication regimens to control perioperative pain has led to significant patient and societal consequences. There are several alternative, opioid-sparing and opioid-minimizing pain regimens that have been shown to provide equal, if not superior, pain relief with fewer secondary consequences. This article provides an in-depth review of the current evidence regarding efficacy, safety, and feasibility of a perioperative opioid-sparing clinical pathway for patients undergoing shoulder arthroplasty.

Pain-management protocol aimed at reducing opioids following total knee arthroplasty does not negatively impact patient satisfaction

BACKGROUND

Prior research has demonstrated that the prescription of opioid medications may be associated with the desire to treat pain in order to achieve favorable patient satisfaction. The purpose of the current study was to investigate the effect of decreased opioid prescribing following total knee arthroplasty (TKA) on survey-administered patient satisfaction scores.

METHOD

This study is a retrospective review of prospectively collected survey data for patients who underwent primary elective TKA for the treatment of osteoarthritis (OA) between September 2014 and June 2019. All patients included had completed Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS) survey information. Patients were stratified into two cohorts based on whether their surgery took place prior to or subsequent to the implementation of an institutional-wide opioid-sparing regimen.

RESULTS

Of the 613 patients included, 488 (80%) were in the pre-protocol cohort and 125 (20%) in the post-protocol cohort. Rate of opioid refills (33.6% to 11.2%; p < 0.001) as well as length of stay (LOS, 2.40 ± 1.05 to 2.13 ± 1.13 days; p = 0.014) decreased significantly after protocol change while rate of current smokers increased significantly (4.1% to 10.4%; p = 0.011). No significant difference was observed in "top box" percentages for satisfaction with pain control (Pre: 70.5% vs Post: 72.8%; p = 0.775).

CONCLUSIONS

Protocols calling for reduced prescription of opioids following TKA resulted in significantly lower rates of opioid refills, and were associated with significantly shorter LOS, while causing no statistically significant deleterious changes in patient satisfaction, as measured by HCAPS survey. LOE: III.

CLINICAL RELEVANCE

This study suggests that HCAPS scores are not negatively impacted by a reduction in postoperative opioid analgesics.

Is Patient Geography a Risk Factor for Chronic Opioid Use After ACDF?

The social and medical implications intrinsic to patient zip codes with high opioid fatality may reveal residence in these locations to be a risk factor predicting chronic opioid use after anterior cervical discectomy and fusion (ACDF). The purpose of this study is to determine if residence in Pennsylvania zip codes with high incidence of opioid overdose deaths is a risk factor for chronic postoperative opioid use after ACDF. Preoperative opioid usage did not vary meaningfully between high- and low-risk zip code groups. Patients in high-risk opioid overdose zip codes were significantly more likely to exhibit chronic postoperative opioid use. The Kaplan-Meier curve demonstrated that opioid discontinuation was less probable at any postoperative time for patients residing in high opioid fatality zip codes. Logistic regression found opioid tolerance, smoking, and depression to predict extended opioid use.

Opioid-free shoulder arthroplasty is safe, effective, and predictable compared with a traditional perioperative opiate regimen: a randomized controlled trial of a new clinical care pathway

BACKGROUND

Opiate-based regimens have been used as a foundation of postoperative analgesia in orthopedic surgery for decades, and the vast majority of orthopedic patients in the United States receive postoperative opioid prescriptions. Both the safety and efficacy of opioid use in orthopedic patients have been questioned because of mounting evidence that postoperative opioid use can be detrimental to outcomes and patient satisfaction. The purpose of this study is to compare a new, opioid-free pain management pathway with a traditional opioid-containing, multimodal pathway in patients undergoing shoulder arthroplasty.

METHODS

This is a single-center randomized clinical trial in which 67 patients who underwent shoulder arthroplasty were allocated into 2 treatment arms: either a completely opioid-free, multimodal perioperative pain management pathway (OF), or a traditional opioid-containing perioperative pain management pathway (OC). Pain was measured on a numeric rating scale from 0 to 10 at 6-, 12-, 24-hour, 2-week, and 6-week time points. Deviations from the OF pathway, morphine milligram equivalents, readmissions, and opioid-related side effects were analyzed.

RESULTS

Pain levels were significantly lower in the OF group at 12 hours, 24 hours, and 2 weeks. At 12 hours, the median pain rating was 0 compared with a median pain rating of 3 in the OC group (P = .003). At 24 hours, the OF group reported a median pain rating of 1 and the OC group reported a median pain rating of 4 (P < .001). The median pain rating at the 2-week time point in the OF group was 2 compared with 4 in the OC group (P = .006). Median pain ratings were similar between the OF group and the OC group at the 6-week time point. The median pain rating in the OF group at 6 weeks was 1, compared with 1.5 in the OC group. Of the 35 patients in the OF pathway, 1 required a rescue opioid medication for left cervical radiculopathy that ultimately necessitated cervical spine fusion after recovery from right shoulder arthroplasty, and 1 was noted to have taken an opioid medication, diverted from a prior prescription, at the 2-week visit. The morphine milliequivalents received in the OF group was 20 compared with 4936.25 in the OC group. There were no readmissions in the OF pathway, and no differences between the groups with regard to constipation, falls, or delirium.

CONCLUSION

A multimodal, opioid-free perioperative pain management pathway is safe and effective in patients undergoing total shoulder arthroplasty and offers superior pain relief to that of a traditional opioid-containing pain management pathway at 12 hours, 24 hours, and 2 weeks postoperatively.