Multimodal Pain Management Protocol Research Articles

Clinical impact of a multimodal pain management protocol for loop ileostomy reversal.

As introduced, multimodal pain management bundle for ileostomy reversal may be considered to reduce postoperative pain and hospital stay. The aim of this study was to evaluate clinical efficacy of perioperative multimodal pain bundle for ileostomy. Medical records of patients who underwent ileostomy reversal after rectal cancer surgery from April 2017 to March 2020 were analyzed. Sixty-seven patients received multimodal pain bundle protocol with ileostomy reversal (group A) and 41 patients underwent closure of ileostomy with conventional pain management (group B). Baseline characteristics, including age, sex, body mass index, American Society of Anesthesiologists classification, diabetes mellitus, and smoking history, were not significantly different between the groups. The pain score on postoperative day 1 was significant lower in group A (visual analog scale, 2.6 ± 1.3 vs. 3.2 ± 1.2; P = 0.013). Overall consumption of opioid in group A was significant less than group B (9.7 ± 9.5 vs. 21.2 ± 8.8, P < 0.001). Hospital stay was significantly shorter in group A (2.3 ± 1.5 days vs. 4.1 ± 1.5 days, P < 0.001). There were no significant differences between the groups in postoperative complication rate. Multimodal pain protocol for ileostomy reversal could reduce postoperative pain, usage of opioid and hospital stay compared to conventional pain management.

ASO Author Reflections: Integrating Multimodal Pain Management Protocols into ERAS for Patients Undergoing CRS-HIPEC.

ASO Author Reflections: Integrating Multimodal Pain Management Protocols into ERAS for Patients Undergoing CRS-HIPEC.

The Efficacy of Preoperative Video-Based Opioid Counseling on Postoperative Opioid Consumption After Total Knee Arthroplasty: A Prospective Randomized Controlled Trial

BackgroundThere are myriad strategies to reduce opioid consumption after total knee arthroplasty (TKA). Recent studies have suggested that preoperative counseling may reduce opioid use after a variety of orthopedic procedures. The purpose of this study was to investigate whether preoperative video-based patient education regarding opioid use and abuse reduces opioid consumption after TKA. MethodsIn this prospective randomized controlled trial, patients were randomized before TKA to either receive preoperative video-based counseling or not. Counseling involved a pretaped 5-minute video that educated patients on statistics regarding the “opioid epidemic” and discussed safe use and alternatives to opioids after TKA. There were no significant differences in baseline patient demographics between groups. All patients received a similar multimodal perioperative pain management protocol and completed a daily diary for 2 weeks postoperatively. Diary records measured pain levels using a visual analog score, opioid consumption, side effects experienced, and patient opinion and satisfaction regarding their pain control. ResultsPatients in the counseling group consumed significantly less morphine milligram equivalents on postoperative days 0 to 3 (78.8 versus 106.1, P = .020) and in week one postoperatively (129.9 versus 180.7, P = .028), with a trend of less consumption over 2 weeks postoperatively (186.9 versus 239.1, P = .194). There were no significant differences in the number of patients requiring refills, side effects, or daily pain levels between the 2 groups. ConclusionsThis study found significantly decreased opioid consumption within the first week after TKA in patients who received preoperative video counseling.

Decreased Opioid Prescription With Low Pain Scores After Urethroplasty: Using a Simplified, Multimodal, Opioid Minimization Pain Protocol

ObjectivesTo implement a simplified, opioid-minimized, multimodal pain management (MPM) protocol (Figure 1) and assess its effectiveness of reducing opioid dispersion while maintaining low postoperative complications, patient-reported pain, and patient-reported interference with quality of life (QOL) for men undergoing urethroplasty. Methods95 men at a single academic center from October 2020-October 2023 received a urethroplasty. We retrospectively reviewed the prior standard pain management (SPM) cohort before August 2021, then prospectively studied the MPM cohort after August 2021. For the SPM cohort, we collected postoperative day (POD) 1 pain scores from our EMR. For the MPM cohort, we obtained a validated pain and QOL assessment in the early postoperative period. The SPM cohort’s POD 1 pain scores were compared with the MPM cohort’s POD 2 pain scores. Opioid dispensation records were queried from the Prescription Monitoring Program. Results75 MME fewer opioids in the MPM cohort were prescribed than the SPM cohort (0 (interquartile range [IQR]: 0-0) vs. 75 (IQR:0-150), p<0.001, respectively). Patients with opioid discharge prescriptions fell from 50% in the SPM cohort to 11% in the MPM cohort (p<0.001). Early postoperative pain scores remained low and showed no significant difference between the cohorts. Pain’s interference with QOL measures remained low. Complications were rare across both cohorts. ConclusionThis simplified, multimodal analgesia protocol effectively decreases postoperative pain and opioid dispersion without affecting QOL outcomes after urethroplasty. This pain regimen can be easily adopted to decrease the use of postoperative opioids in men undergoing urethroplasty.

A Novel Multimodal Postoperative Pain Protocol for 1- to 2-Level Open Lumbar Fusions: A Retrospective Cohort Study.

There has been increased interest in exploring methods to reduce postoperative pain without opioid medications. In 2015, a multimodal analgesia protocol was used involving the perioperative use of celecoxib, gabapentin, intravenous acetaminophen, lidocaine, and liposomal bupivacaine. Overall, the goal was to reduce the utilization of scheduled opioids in favor of nonopioid pain management. The results of a consecutive series of 1- to 2-level open primary lumbar fusions were compared to a cohort of patients after the implementation the perioperative multimodal pain management protocol. Primary endpoints included patient-reported pain scores and secondary endpoints included length of stay. There were 87 patients in the preprotocol cohort and 184 in the protocol cohort. Comparing protocol and preprotocol patients, there were no significant differences in patient demographics. There was significantly average lower pain in the protocol group on postoperative day (POD) 1 (4.50 vs 5.00, P < 0.02) and POD2 (4.42 vs 5.50, P < 0.03). There was a lower pain score on POD0 (4.80 vs 5.00), but it was only clinically significant. There was a correlation between pain and duration of surgery in the preprotocol patients (POD0 R = 0.23, POD1 R = 0.02, POD2 R = 0.38), but not in the protocol patients (POD0 R = -0.05, POD1 R = -0.08, POD2 R = -0.04). There was a shorter length of stay in the protocol cohort (2.0 vs 3.0, P < 0.01). Finally, there was an approximately 35% reduction in morphine milligram equivalents of opioids in the protocol vs preprotocol cohorts (36.2 vs 57.0, P < 0.05). Our novel multimodal pain management protocol significantly reduced postoperative pain, length of stay, and opioid consumption in this patient cohort. Opioid usage correlated to pain in the protocol patients, while the preprotocol patients had no correlation between opioid use and pain medication. In this study, we demonstrated that preoperative and intraoperative analgesia can reduce postoperative pain medication requirements. Furthermore, we introduced a novel concept of a correlation of pain with opioid consumption as a marker of effective pain management of breakthrough pain.

The efficacy and safety of duloxetine for the treatment of patients after TKA or THA: A systematic review and meta-analysis.

Duloxetine, a serotonin-norepinephrine dual reuptake inhibitor, may improve analgesia after total joint arthroplasty (TJA). However, there is still no consensus on its effectiveness and safety. We conducted the meta-analysis to investigate the analgesic effect and safety of duloxetine for the treatment of patients received total knee or hip arthroplasty. Pubmed, Cochrane Central Registry for Clinical Trials, Embase, OVID, Web of Science, and Google Scholar were searched using a predetermined search strategy from inception to September 21, 2022. Only randomized controlled trials of duloxetine in treatment of patients after total knee or hip arthroplasty were included. Data collection and extraction, quality assessment, and data analyses were performed according to the Cochrane standards. A total of 8 randomized controlled trials with 739 patients were included in the literature review of postoperative pain and adverse effects. The result of meta-analysis showed statistically significant lower opioid requirement with duloxetine (P < .05) for the different postoperative period. Duloxetine group had significant reductions in visual analog score for the 24-hour (walking: WMD = -0.98; 95% confidence interval [CI] = -1.69 to -0.26, P = .007; resting: WMD = -1.06; 95%CI = -1.85 to -0.27, P = .008) and 1-week (walking: WMD = -0.96; 95%CI = -1.42 to -0.50, P < .001; resting: WMD = -0.69; 95%CI = -1.22 to -0.16, P = .01); knee injury and osteoarthritis outcome score over 3-month (WMD = 2.94; 95%CI = -0.30 to 6.18, P = .008) and complication (odds ratio = 4.74; 95%CI = 0.23 to 96.56, P = .01) postoperative period compared with the control group. However, no difference on numeric rating scale (P > .05) for the different postoperative period; visual analog score (P > .05) for the 6-week or 3-month and knee injury and osteoarthritis outcome score (P > .05) for the 6-week postoperative period. Furthermore, it did not increase the incidence of adverse effects (odds ratio = 0.87; 95%CI = 0.72 to 1.05, P = .15). Duloxetine could decrease the opioids consumption and relieve early postoperative pain without increasing the risk of adverse medication effects in patients undergoing total knee or hip arthroplasty. Considering the ongoing opioid epidemic, duloxetine could act as a good supplement in multimodal pain management protocol for patients undergoing total joint arthroplasty.

Risk factors of liposomal bupivacaine failure in managing postoperative pain following shoulder surgery

BackgroundAmidst a national opioid crisis, increased focus has been placed on reducing opioid consumption. Novel multimodal pain protocols including the use of liposomal bupivacaine (LB) have shown success in minimizing opioid usage after orthopedic surgery. There is disputing evidence of the effectiveness of LB use in shoulder surgery and the purpose of our study was to analyze the risk factors and determinants of LB failure for postoperative pain control after orthopedic shoulder surgeries. MethodsA retrospective review of 121 patients undergoing shoulder surgery treated by 2 fellowship-trained shoulder surgeons at a single institution was performed from 2018-2020. All patients received a standardized multimodal pain management protocol that included an LB interscalene block. Local infiltration of LB was also administered at closure. Visual analog scales (VASs) were administered at 24, 48, 72 hours, and 7 days postoperatively. LB failure was defined as visual analog scale score >7 any time within the 7-day postoperative period. Twenty-one patients were included in the liposomal bupivacaine failure (LBF) group and 100 in the liposomal bupivacaine success (LBS) group. Patient demographics, pain scores, and opioid consumption were compared between groups. ResultsBaseline characteristics were comparable, except the LBF cohort had a greater proportion of females (P = .03). The LBF group had 20% of patients with a history of chronic opioid use compared to none in the LBS group (P = .003). Logistic regression showed strong and independent associations between failure of LB and performing surgeon, chronic opioid use, gender, and history of prior surgery. Patients in the LBF group had an average of 20 total morphine equivalents 7-14 days following surgery compared to 0 total morphine equivalents (P = .002) in the LBS group, and an average of 2.9 opioid prescriptions within the first 6 months compared to 1.7 in the LBS group (P = .028). ConclusionPerforming surgeon, gender, history of opioid use, and prior surgeries were all identified as strong, independent predictor variables of LB failure. In this study, performing surgeon is likely indicative of the impact of differences in patient education on postoperative pain expectations and alternate treatments. We recommend that surgeons incorporate further preoperative patient education, and to take into account, the specific risk factors when deciding to incorporate LB into their multimodal postoperative pain management plan for patients undergoing shoulder surgery.

Raising the Bar: Multimodal Analgesia with Transdermal Lidocaine for Nuss Repair of Pectus Excavatum Decreases Length of Stay and Opioid Use

IntroPain management for minimally invasive (Nuss) repair of pectus excavatum (PE) is challenging, particularly as the judicious use of opioids has become a patient safety priority. Multi-modal pain management protocols are increasingly used, but there is limited experience using transdermal lidocaine patches (TLP) in this patient population. MethodsPediatric anesthesiologists and surgeons in a children's hospital within a hospital designed a multi-modal perioperative pain management protocol for patients undergoing Nuss repair of PE (IRB00068901). The protocol included use of TLP in addition to other adjuncts such as methadone, gabapentin, and NSAIDS. Following initiation of the protocol charts were reviewed retrospectively, comparing outcomes before and after implementation of the protocol. ResultsForty-nine patients underwent a Nuss procedure between 2013 and 2022, 15 prior to initiation of the protocol and 34 after. Patient demographics and operative length were similar between the two groups. Average length of stay decreased from 4.7 to 3.3 days and reported opioid use at the time of the first outpatient post-op visit dropped from 60% to 24% (p < 0.05). Morphine milligram equivalents (MME) usage was decreased following implementation during hospital admission, at discharge, and at first post-operative visit (464 vs. 169, 1288 vs. 218, and 214 vs. 56, respectfully, p < 0.05). There were no ED visits or readmissions <30 days related to post-operative pain. ConclusionPost-operative opioid usage and hospital length of stay were decreased after initiation of the protocol. Transdermal lidocaine patches may be a helpful adjunct to minimize narcotic requirements after repair of pectus excavatum. Level of EvidenceLevel II.

The Role of Liposomal Bupivacaine in Multimodal Pain Management following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis: Faster and Farther with Less Opioids.

Retrospective controlled cohort. To evaluate the effect of intraoperative liposomal bupivacaine (LB) infiltration on post-surgical pain management in adolescent idiopathic scoliosis (AIS) patients by analyzing postoperative opioid consumption, ambulation, and length of stay (LOS). Optimal postoperative pain control for AIS patients undergoing posterior spinal fusion (PSF) is challenging. Multimodal pain management protocols provide adequate analgesia while decreasing opioid consumption. LB was recently approved for pediatric patients; however, use in AIS patients is understudied. 119 consecutive patients with AIS who underwent PSF were included. Patients were divided into 2 groups: patients who received LB as erector spinae block in addition to the standard postoperative pain management protocol (Group A), and patients who received only the standard postoperative pain protocol (Group B). Oral morphine equivalents, intravenous opioid and valium consumption, pain scores (VAS), nausea/vomiting, ambulation distance and LOS were assessed. Group A experienced significantly lower total opioid consumption compared to Group B (44.5mg vs. 70.2mg). Morphine use was lower in Group A on post operative day (POD) 0, and oxycodone use was lower in Group A on PODs 1 and 2. There was a higher proportion of patients who used only oral opioids in Group A (81% vs. 41%). Of patients requiring any intravenous opioids, 79% did not receive LB. A significantly higher proportion of LB patients were discharged on POD 2 (55% vs. 27%); therefore, LOS was shorter for Group A. Group A ambulated further postoperatively. There were no differences in pain scores, valium requirements or nausea/vomiting. LB was associated with decreased total opioid use, shorter LOS, and improved ambulation in AIS patients undergoing PSF. Including LB in multimodal pain management protocols proved effective in reducing opioid use while increasing mobilization in the immediate postoperative period. III Retrospective controlled cohort.

Development of a multimodal pain management protocol and inpatient consult service for parturients diagnosed with opioid use disorder (OUD) undergoing cesarean delivery

Development of a multimodal pain management protocol and inpatient consult service for parturients diagnosed with opioid use disorder (OUD) undergoing cesarean delivery

Evaluation of a multidisciplinary, multimodal pain management protocol following pancreas transplantation.

Patients undergoing solid-organ transplantation demonstrate pain arising from both the surgical intervention and pre-existing comorbidities. High levels of opioid use both pre- and post-transplant are associated with unfavorable transplant outcomes. Patient education, multimodal therapy, and discharge planning have all been demonstrated to reduce opioid use after transplant. This is a single-center, retrospective study analyzing patients before and after implementation of a multimodal, multidisciplinary pain management protocol. Morphine milligram equivalents (MMEs) use during the index transplant hospitalization and the need for opioids at discharge was compared between the pre- and post-protocol groups. A total of 52 patients were included in the study, 31 in the pre and 21 in the post-protocol groups. Inpatient MME use was reduced from 135.5 to 67.5 MMEs after protocol implementation. Additionally, the number of patients discharged on opioids following transplant decreased from 90.3% to 47.6%. Pain scores, length of stay (LOS), and return of bowel function was not different between groups. The implementation of a multimodal, multidisciplinary pain management protocol significantly decreased opioid use during the post-surgical hospitalization and in the 6 months following transplantation. A combination of non-opioid analgesics, patient education, and discharge planning can be beneficial elements in pancreas transplant pain management.

Effect of a Postoperative Multimodal Opioid-Sparing Protocol vs Standard Opioid Prescribing on Postoperative Opioid Consumption After Knee or Shoulder Arthroscopy

In arthroscopic knee and shoulder surgery, there is growing evidence that opioid-sparing protocols may reduce postoperative opioid consumption while adequately addressing patients' pain. However, there are a lack of prospective, comparative trials evaluating their effectiveness. To evaluate the effect of a multimodal, opioid-sparing approach to postoperative pain management compared with the current standard of care in patients undergoing arthroscopic shoulder or knee surgery. This randomized clinical trial was performed at 3 clinical sites in Ontario, Canada, and enrolled 200 patients from March 2021 to March 2022 with final follow-up completed in April 2022. Adult patients undergoing outpatient arthroscopic shoulder or knee surgery were followed up for 6 weeks postoperatively. The opioid-sparing group (100 participants randomized) received a prescription of naproxen, acetaminophen (paracetamol), and pantoprazole; a limited rescue prescription of hydromorphone; and a patient educational infographic. The control group (100 participants randomized) received the current standard of care determined by the treating surgeon, which consisted of an opioid analgesic. The primary outcome was postoperative oral morphine equivalent (OME) consumption at 6 weeks after surgery. There were 5 secondary outcomes, including pain, patient satisfaction, opioid refills, quantity of OMEs prescribed at the time of hospital discharge, and adverse events at 6 weeks all reported at 6 weeks after surgery. Among the 200 patients who were randomized (mean age, 43 years; 73 women [38%]), 193 patients (97%) completed the trial; 98 of whom were randomized to receive standard care and 95 the opioid-sparing protocol. Patients in the opioid-sparing protocol consumed significantly fewer opioids (median, 0 mg; IQR, 0-8.0 mg) than patients in the control group (median, 40.0 mg; IQR, 7.5-105.0; z = -6.55; P < .001). Of the 5 prespecified secondary end points, 4 showed no significant difference. 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). 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). Among patients who underwent arthroscopic knee or shoulder surgery, a multimodal opioid-sparing postoperative pain management protocol, compared with standard opioid prescribing, significantly reduced postoperative opioid consumption over 6 weeks. ClinicalTrials.gov Identifier: NCT04566250.

Opiate Free Multimodal Pain Pathway in Elective Foot and Ankle Surgery: A Prospective Study

Category: Bunion; Other Introduction/Purpose: Orthopedic surgeons frequently prescribe and overprescribe narcotic pain medications during the postoperative period, despite our increased understanding of the opioid crisis. In an effort to minimize narcotic analgesia and its potential side effects, opiate free multimodal pain pathways have been developed with promising results. However, there is a lack of published literature looking at opiate free multimodal pain protocols for elective outpatient foot and ankle surgeries. At our institution we have been implementing a novel opiate free multimodal post-operative pain protocol for elective outpatient foot and ankle surgeries. The purpose of this study was to explore the efficacy, feasibility, outcomes and satisfaction of an opioid-free, multimodal postoperative pathway in patients undergoing elective outpatient foot and ankle surgery. Methods: This study was approved by our IRB and was a prospective study. Data was collected from December 1st, 2020 through February 9th, 2022 for patients who underwent a primary elective outpatient foot and ankle surgery including bunion correction surgery with or without a lesser toe procedure(s). These patients completed a comprehensive opioid-free, multimodal pain management protocol and a follow up with one of two fellowship trained orthopedic foot and ankle surgeons. The multimodal treatment protocol included oral Lyrica, Tylenol, Toradol and flexeril to begin POD#0. Mobic was given to POD #4 once Toradol was completed. All data was collected in a prospective manner. At POD#1, #3, and #8, patients were contacted to collect VAS scores, complications, ED and Urgent care visits, and pain medication needs. At two week follow up these were again collected in addition to overall satisfaction rates. Results: 33 patients enrolled with a mean age of 55 (19-81) years old. The average follow up was 11.5 weeks. On POD#1, #3, #8, and at 2 week follow up our patients’ average VAS pain score was a 4.0, 2.5, 1.6, and 1.4 out of 10, respectively. 18% of patients required narcotics within the first 2 weeks, but by 2 weeks no patients were taking narcotics. No patients visited an ED or urgent care during the first 2 weeks post operatively. Common side effects were drowsiness/tiredness and constipation. Only 4 reported nausea or GI upset at 2 week follow up. Overall, 91% were satisfied with their pain control, 78% would follow the same protocol again, and 82% would recommend this pain management regimen to others. Conclusion: An opioid-free, multimodal pain management pathway is a safe and effective option in properly selected patients undergoing elective outpatient foot and ankle surgery with a very low risk of requiring rescue opioids, having significant side effects, and/or needing an ED or urgent care evaluation within the first 2 week post operative period.

Intravenous Morphine Infusion versus Thoracic Epidural Infusion of Ropivacaine with Fentanyl after the Ravitch Procedure-A Single-Center Cohort Study.

Objective. To compare the efficacy of analgesia with intravenous infusion of morphine and thoracic epidural infusion of ropivacaine with fentanyl in pediatric patients after the Ravitch procedure. Methods. Postoperative analgesia was achieved by intravenous morphine infusion with a dose of 0.02–0.06 mg/kg per hour (intravenous group, n = 56) or thoracic epidural infusion of 0.2% ropivacaine and fentanyl 5 µg/mL with a flow rate of 0.1 mL/kg per hour (epidural group, n = 40). Furthermore, the multimodal pain management protocol included paracetamol, non-steroidal anti-inflammatory drugs, and metamizole as a rescue drug. The primary outcomes included pain scores (according to the Numerical Rating Scale, range 0–10), while the secondary outcomes included consumption of the rescue drug, anxiety, postoperative side effects, and patient satisfaction. The observation period lasted from postoperative day 0 to postoperative day 3. Results. Median average and maximal pain scores at rest, during deep breathing, and coughing were significantly lower in the intravenous group compared to the epidural group (p < 0.05). The effect size was medium (Cohen’s d ranged from 0.5 to 0.7). Patients receiving morphine required significantly lower numbers of metamizole doses than in the epidural group (median 1 vs. 3; p = 0.003; Cohen’s d = 0.6). Anxiety, postoperative side effects, and patient satisfaction were similar in both groups (p > 0.05). Conclusions. An intravenous infusion of morphine may offer better postoperative analgesia than a thoracic epidural infusion of ropivacaine with fentanyl.

Regional anesthesia for acute and subacute orthopedic trauma: A review

• Multimodal pain control has become the standard of care for management of orthopedic trauma. • This paper describes use of regional aesthesia for surgical intervention of extremity fractures in patients who present following traumatic injury as part of a multimodal pain management protocol. • Types of, indications for, and outcomes of both upper and lower extremity peripheral nerve blocks will be reviewed. Pain management in the setting of acute and subacute orthopedic trauma can be challenging. Due to the recent focus on the rising opioid epidemic, as well as the adverse side of effects of opioid pain medication, multimodal pain control has become the standard of care for management of orthopedic trauma, particularly during operative fixation. The purpose of this paper is to report on the use of regional anesthesia for surgical intervention of extremity fractures in patients who present following traumatic injury as part of a multimodal pain management protocol. Types of, indications for, and outcomes of both upper and lower extremity peripheral nerve blocks will be reviewed.

Less Is More: A Multimodal Pain Management Strategy Is Associated With Reduced Opioid Use in Hospitalized Trauma Patients

IntroductionAdequate pain control is critical to the management and recovery of acutely injured patients. Opioids are associated with various adverse effects, and drug overdose is the leading cause of injury-related death in the United States. We hypothesized that a multimodal pain management protocol would reduce opioid use while still optimizing pain control. MethodsThe study included the preanalysis (August 2017-September 2018) and postanalysis (October 2018-August 2019) of a multimodal pain management strategy implemented in hospitalized adult patients admitted to the trauma service at a single American College of Surgeons-verified level-1 trauma center. Patients less than 18 y of age, pregnant patients, or imprisoned patients were excluded. The primary endpoint was opioid prescription on discharge (morphine milligram equivalent [MME]). The secondary endpoints included inpatient MMEs, nonopioid adjunct use, and pain scores. Subgroup analysis evaluating opioid use based on Injury Severity Score groups (mild, moderate, or severe) and by the Abbreviated Injury Scale body region was performed. ResultsThere were 1755 patients in the PRE group and 1723 patients in the POST group. MMEs prescribed on discharge decreased from median 15 (interquartile range: 37.5) to 1.2 (interquartile range: 22.5) (P < 0.001). More patients in the POST group were discharged opioid-free (44% versus 37%, P < 0.001). There was a significant increase in the use of all nonopioid pain medications. Pain scores did not change. Subgroup analysis revealed a significant decrease in discharge MMEs in mild and moderate Injury Severity Score groups and in all injured body regions except the chest. ConclusionsThe implementation of a multimodal pain management protocol in trauma patients targeting scheduled nonopioid medications and patient education is feasible and is associated with reduced opioid amount prescribed on discharge, without compromising pain control.

Striking a Balance With Opioid Use for Pain Management After Thoracic Surgery

Pain management for patients undergoing thoracic surgery is of paramount importance. As many as one-third of patients undergoing thoracic surgery, regardless of approach, may develop chronic pain 1 Bayman E.O. Parekh K.R. Keech J. Selte A. Brennan T.J. A prospective study of chronic pain after thoracotomy. Anesthesiology. 2017; 126: 938-951 Crossref PubMed Scopus (124) Google Scholar defined as pain related to surgery lasting at least 3 months. An independent predictor of chronic pain is pain intensity during the early postoperative period. 1 Bayman E.O. Parekh K.R. Keech J. Selte A. Brennan T.J. A prospective study of chronic pain after thoracotomy. Anesthesiology. 2017; 126: 938-951 Crossref PubMed Scopus (124) Google Scholar Therefore optimal pain management immediately after surgery is crucial. Furthermore 14% of lung cancer resection patients become new persistent opioid users, meaning they fill an opioid prescription for surgery and at least 1 additional prescription 3 months after surgery. 2 Brescia A.A. Harrington C.A. Mazurek A.A. et al. Factors associated with new persistent opioid usage after lung resection. Ann Thorac Surg. 2019; 107: 363-368 Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar Surgeons must strike a balance with opioids by prescribing them judiciously as part of a multimodal analgesia strategy to optimize postoperative pain management while minimizing risk of prolonged use. As eloquently stated by Travis Rieder, PhD, bioethicist, in his book entitled, In Pain, “We don’t have a prescription opioid problem; we have a pain problem that opioids happen to play a significant role in.” (page 157). 3 Rieder T. In Pain: A Bioethicist’s Personal Struggle with Opioids. HarperCollins, 2019 Google Scholar Multimodal Pain Management Protocol to Decrease Opioid Use and to Improve Pain Control After Thoracic SurgeryThe Annals of Thoracic SurgeryVol. 114Issue 6PreviewOpioid addiction continues to be a devastating problem in our communities, and up to 40% of patients begin their addiction with legally prescribed opioids after injury or surgical procedure. An opioid-free multimodal pain regimen was developed with the goal of decreasing opioid exposure while maintaining adequate pain control. Full-Text PDF

Multimodal Pain Management Protocol to Decrease Opioid Use and to Improve Pain Control After Thoracic Surgery

BackgroundOpioid addiction continues to be a devastating problem in our communities, and up to 40% of patients begin their addiction with legally prescribed opioids after injury or surgical procedure. An opioid-free multimodal pain regimen was developed with the goal of decreasing opioid exposure while maintaining adequate pain control. MethodsA retrospective single-institution study was conducted of 313 consecutive patients undergoing minimally invasive lobectomy before (n = 211) and after (n = 102) implementation of an opioid-free protocol from 2016 to 2020. Data analysis was conducted on preoperative characteristics, postoperative opioid use at set time points (postoperative day 0, postoperative days 1 to 7, and total stay), pain scores, discharge with opioid prescription, and postoperative outcomes. ResultsPatients on the opioid-free protocol had significantly lower average total morphine milligram equivalents at all time points. In addition, 56% of patients in the opioid-free group received no oral opioids at all, and 91% did not receive a patient-controlled analgesia pump. Average pain scores were significantly lower in the opioid-free protocol patients along with percentage of time spent with pain scores <3 and <6. With implementation of the protocol, 62% of patients are discharged without an opioid prescription compared with only 7% previously. ConclusionsImplementation of an opioid-free protocol led to a significant decrease in the use of postoperative opioids at all time points while improving overall management of pain. In addition, most patients are discharged with no home opioid prescription, decreasing a potential source of community opioid spread.

Analgesic effect of perioperative duloxetine in patients after total knee arthroplasty: a prospective, randomized, double-blind, placebo-controlled trial

BackgroundTo investigate the analgesic effect of perioperative use of duloxetine in patients received total knee arthroplasty (TKA).MethodThis prospective randomized, double-blind, placebo-controlled trial study was registered in the Chinese Clinical Trial Registry (ChiCTR2000033910). 100 patients were finally enrolled. The hospital pharmacy prepared small capsules containing either duloxetine or starch (placebo) which were all identical in appearance and weight (50:50). The 100 enrolled patients were given a capsule (containing either 60 mg duloxetine or 60 mg placebo) every night before sleep since preoperative day 2 till postoperative day 14 (17 days in all) by a nurse who were not involved in this trial. Other perioperative managements were the same in the two groups. The primary outcome was the VAS score, including rVAS (visual analogue scale at rest) and aVAS (visual analogue scale upon ambulation) throughout the perioperative period. The secondary outcomes included opioid consumption, range of motion, including both active range of motion (aROM) and passive range of motion (pROM) and adverse events. The patients were followed up everyday until 7 days after TKA, afterwards, they were followed up at the time of 3 weeks and 3 months after TKA.ResultrVAS in duloxetine group were significantly less than placebo group throughout the postoperative period: 4.7 ± 2.3 vs 5.9 ± 2.6 (P = 0.016) at 24 h postoperative; 2.1 ± 1.6 vs 2.8 ± 1.7 (P = 0.037) at 7 days postoperative. In terms of aVAS, similarly, duloxetine group had less aVAS than placebo group throughout the postoperative period: 6.2 ± 2.1 vs 7.1 ± 2.2 (P = 0.039) at 24 h postoperative; 3.3 ± 1.7 vs 4.1 ± 2.0 (P = 0.034) at 7 days postoperative. Patients in duloxetine group consumed significantly less opioids per day than the placebo group: 24.2 ± 10.1 g vs 28.5 ± 8.3 g (P = 0.022) at 24 h postoperative; 2.7 ± 2.5 g vs 4.1 ± 2.6 g (P = 0.007) at 7 days postoperative. aROM in duloxetine group were significantly better than placebo group until postoperative day 6, the aROM became comparable between the two groups: 110.2 ± 9.9° in duloxetine group vs 107.5 ± 11.5° in control group (P = 0.211). In terms of pROM, duloxetine group had significantly better pROM until postoperative day 5, the pROM became comparable between the two groups: 103.8 ± 12.1° in duloxetine group vs 99.5 ± 10.8° in control group (P = 0.064). No significant difference was found between the two groups in the rates of dizziness, bleeding, sweating, fatigue and dryness of mouth. In the placebo group, more patients got nausea/vomiting and constipation (P < 0.05). However, in terms of drowsiness, duloxetine group was reported higher rate (P < 0.05).ConclusionSeveral other RCTs have already mentioned the analgesic effect of duloxetine, but not in the immediate postoperative period. In this study, we found duloxetine could reduce acute postoperative pain in the immediate postoperative period and decrease the opioids consumption as well as accelerating postoperative recovery, without increasing the risk of adverse medication effects in patients undergoing TKA. Duloxetine could act as a good supplement in multimodal pain management protocol for patients undergoing TKA.Trial registration statementThis study was registered in the Chinese Clinical Trial Registry (ChiCTR2000033910). The date of registration was 06/16/2020.

Impact of a Multimodal Analgesia Protocol in an Intensive Care Unit: A Pre-post Cohort Study.

Introduction Opioids are the mainstay of pain management in critically ill patients. However, recent attention to their adverse effects in the intensive care unit (ICU) has led to the use of strategies that aim to reduce these side effects. Among these strategies, there are multimodal analgesia protocols, which prioritize pain management and employ a combination of different analgesics to spare excessive doses of opioids and sedatives in continuous infusion.ObjectiveThe objective of this study is to evaluate the impact of a multimodal analgesia protocol on clinical outcomes and consumption of sedatives and analgesics in two intensive care units.Methods We conducted a single-center, quasi-experimental, retrospective, and prospective cohort study comparing clinical outcomes and consumption of sedatives and analgesics before and after the implementation of a multimodal pain management protocol in critically ill adult patients. We included 465 patients in 2017 (pre-intervention group) and 1508 between 2018 and 2020 (post-intervention group).ResultsIn the analysis of the primary outcome, there was a significant reduction in mortality between 2017 and 2020 (27.7% - 21.7%, p=0.0134). There was no statistical difference in mechanical ventilation time or concerning the infection rate. Patients who received the multimodal analgesia protocol had a decrease of 24% regarding mean fentanyl intake and a progressive reduction in morphine milligram equivalents (MME) (8.4% - 19%). There was an increasing trend in the use of adjuvant analgesics and morphine in preemptive and therapeutic analgesia.ConclusionThe implementation of a multimodal pain control protocol significantly reduced morbidity and mortality and the use of opioids in the ICU.