Summary

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.

Abstract

Purpose

To evaluate the impact of a multi-modal, opioid-sparing approach to postoperative pain management compared to the current standard of care in patients undergoing arthroscopic shoulder and knee surgery.

Methods

This randomized controlled trial was performed at 3 clinical sites from March 2021 to April 2022. Adult patients undergoing outpatient arthroscopic shoulder or knee surgery were followed to 6 weeks postoperatively. The opioid-sparing group (100 participants randomized) received a prescription of 1) naproxen, acetaminophen and pantoprazole, 2) a limited “rescue prescription” of hydromorphone, and 3) a patient education infographic. The control group (100 participants randomized) received the current standard of care as per the treating surgeon, which consisted of an opioid analgesic. The primary outcome was postoperative oral morphine equivalent (OME) consumption at 6 weeks postoperatively. There were seven secondary outcomes, including pain at 2 and 6 weeks postoperatively, patient satisfaction at 6 weeks postoperatively, opioid refills at 6 weeks postoperatively, quantity of OMEs prescribed at 6 weeks postoperatively, adverse events at 6 weeks postoperatively and patient reported medication adverse effects at 2 weeks postoperatively.

Results

Among the 200 patients who were randomized (mean age, 43; 73 (38%) females), 193 (97%) of patients completed the trial. Of these 193 patients, 98 were randomized to receive the standard of care and 95 received the opioid-sparing protocol. Patients in the opioid-sparing protocol consumed significantly fewer opioids (median 0mg; IQR: 0-8.0) than patients in the control group (median: 40.0; IQR: 7.5-105.0; Z = -6.55, P < .001). Of the 6 prespecified secondary endpoints, 5 showed no significant difference. The mean amount of OMEs prescribed was 341.17mg, 95% CI: 310.2-372.1 in the standard of care group and 40.4mg; 95% CI: 39.6-41.2 in the opioid sparing group (MD 300.8mg; 95% CI: 269.4-332.3; P < .001). There were significantly more patients reported medication-related adverse effects in the standard of care group (32% vs. 19%, P = .048).

Conclusion

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.