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Multimodal Opioid-Sparing Protocol After Knee or Shoulder Arthroscopy

Compared with standard opioid prescribing in 193 patients after arthroscopic knee or shoulder surgery, a multimodal opioid-sparing postoperative pain management protocol significantly reduced postoperative opioid consumption, a study shows. The opioid-sparing protocol included naproxen, acetaminophen, and pantoprazole; a limited rescue prescription of hydromorphone; and a patient educational infographic. The standard care group received opioid analgesia as prescribed by the surgeon in this multicenter trial from Ontario.

With a primary outcome of postoperative oral morphine equivalent (OME) consumption at 6 weeks after surgery, significantly fewer opioids were used by patients on the opioid-sparing protocol (median, 0 mg) than in the standard care group (median, 40 mg). “The mean amount of OMEs prescribed was 341.2 mg (95% CI, 310.2-372.2) in the standard care group and 40.4 mg (95% CI, 39.6-41.2) in the opioid-sparing group (mean difference, 300.8 mg; 95% CI, 269.4-332.3; P < .001),” write the authors. “There was no significant difference in adverse events at 6 weeks (2 events [2.1%] in the standard care group vs 3 events [3.2%] in the opioid-sparing group), but more patients reported medication-related adverse effects in the standard care group (32% vs 19%, P = .048).”

“Multimodal analgesic protocols for postoperative pain control have demonstrated efficacy across several surgical domains,” the authors note. “The underlying premise is that concurrent administration of multiple analgesics results in an additive effect and has the potential to reduce opioid consumption while maximizing pain control. NSAIDs are potent analgesics that form a cornerstone of multimodal analgesic protocols. Although NSAIDs carry risks, they were well tolerated in the current study and may be considered a first-line analgesic for patients without contraindications. Similarly, acetaminophen represents an effective nonopioid analgesic that has an additive effect when used in conjunction with NSAIDs. The use of a primarily nonopioid multimodal analgesic protocol in the current study reduced total opioid consumption and patient-reported adverse effects from medication.”

Source: JAMA