Is an Opioid-sparing Pain Management Protocol Comparable to Standard Care Following Certain Orthopedic Surgeries?

In North America, patients undergoing orthopedic and other surgeries frequently receive prescriptions for more opioid analgesics than guidelines recommend for the postoperative period. Investigators examined an opioid-sparing postoperative pain protocol that included patient education, non-steroidal anti-inflammatory drugs, acetaminophen, and a limited amount of opioid analgesic to be used as a rescue medication. Adult patients (N=200) undergoing outpatient arthroscopic shoulder or knee surgery were randomized to the opioid-sparing protocol or standard care, and followed for 6 weeks postoperatively to assess opioid consumption, pain, patient satisfaction, opioid prescriptions, and adverse events.

• Participants had a mean age of 43; most participated in moderate or vigorous physical activity prior to their injury, and few had co-morbid chronic health conditions.
• The intervention group took far fewer opioid medications—measured in oral morphine equivalents—than the standard care group (median, 0 mg versus 40 mg, respectively), and were prescribed fewer opioid medications than the standard care group (mean, 40 mg versus 341 mg).
• There were no significant differences between groups in patient satisfaction or daily pain scores over the first 14 post-operative days, and no difference in requests for additional opioids after discharge.

Comments: By administering patient education and non-opioid analgesics, investigators achieved good post-operative pain management for healthy adults undergoing arthroscopic orthopedic surgeries. These simple and effective measures for post-operative management should be adopted more broadly. However, the implications for the opioid overdose crisis, which is currently being driven by illicitly manufactured fentanyl, should not be overstated. Practitioners and health systems must commit to improving diagnosis and treatment of opioid use disorder in addition to reducing opioid prescribing.

Aaron D. Fox, MD

Reference: NO PAin Investigators, Gazendam A, Ekhtiari S, et al. Effect of a postoperative multimodal opioid-sparing protocol vs standard opioid prescribing on postoperative opioid consumption after knee or shoulder arthroscopy: a randomized clinical trial. JAMA. 2022;328(13):1326–1335.