Pain management: Patient-centered approach enhances satisfaction of joint replacement
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Perioperative pain management has undergone a remarkable transformation as more orthopedic procedures are routinely performed on an outpatient basis. Adequate pain relief can significantly impact patient compliance and overall satisfaction.
The pain management process begins when the decision is made to proceed with surgery. Preoperative discussions must include comprehensive details about the procedure, recovery and potential risks. The goal is to establish patient expectations that align with the reality of postoperative recovery, providing a smooth transition to complete independence.
Outpatient joint replacement
Multimodal analgesia, which is an approach that combines different medications and physical therapies to manage acute pain, is now considered the gold standard for most orthopedic procedures. Initially introduced by innovative surgeons more than 20 years ago, outpatient joint replacements have become commonplace with overwhelmingly positive patient outcomes. Initially, critics argued outpatient joint replacement surgery would compromise patient care, suggesting the transition from hospital to home would increase risks, including inadequate pain management. However, studies and patient feedback have demonstrated higher patient satisfaction and smoother recovery processes.
As orthopedic surgeons, we now know the benefits of outpatient joint replacements are undeniable, especially with personalized and patient-centered pain management. Effective perioperative pain management is essential to ensure safe, comfortable and successful outpatient joint replacement. Identifying patients at risk for increased postoperative pain, such as patients with a history of smoking, mental health disorders or substance abuse, is crucial. Patients undergoing revision surgery are also likely to have more pain than they experienced with a primary procedure. Surgeons who overlook these factors may find themselves frustrated when standard protocols fail to adequately manage patients’ pain.
Rather than applying a “one-size-fits-all” approach, orthopedic surgeons must recognize each patient’s unique physical and psychological factors influence recovery. Mental health screenings can help identify patients who need additional support to enhance their postoperative outcomes. It is not just about treating the joint, but it is also addressing the entire patient holistically to improve their experience and recovery.
Recent advancements
Recent advancements in perioperative care have highlighted the importance of nutrition in managing surgical stress and pain. Enhanced Recovery After Surgery programs, initially designed for high-stress general surgery and cardiac procedures, are routinely used in orthopedic care. Nutritional supplementation, which begins 2 to 4 weeks before surgery and continues postoperatively, has been shown to improve patient outcomes. Preoperative electrolytes and glucose supplements can enhance anesthesia care and pain tolerance on the day of surgery. Such practices, when combined with preoperative acetaminophen and anti-inflammatory medications, contribute to better pain management and faster recovery.
One of the most valuable advancements in perioperative care is the development of safe, consistent and effective regional anesthesia. Ultrasound-guided regional blocks, now standard in anesthesia training programs, have revolutionized joint replacement surgery. While there are numerous benefits to the block, the most influential is the ability to minimize or eliminate the use of opioid pain medication and its adverse effects so most patients can recover quicker and be safely discharged home within 2 hours of leaving the OR. Other drugs that help with perioperative pain management include corticosteroids. Tranexamic acid also helps to reduce pain by limiting blood loss. These approaches directly align with patient safety and overall satisfaction, which should be at the forefront of any treatment plan.
When patients return home after joint replacement surgery, the environment should be optimized for recovery. This includes having meals and nutritional support readily available, a safe space to rest and all necessary pain medications prepared. While the first few postoperative days generally require opioid use, a well-structured multimodal pain management plan can minimize the duration of opioid prescriptions. Regular use of acetaminophen and anti-inflammatory medications, such as celecoxib, combined with cryotherapy offer a holistic approach to pain relief.
Opioids
Despite the anxiety of prescribing opioid medication, it is essential not to forget that cutting bone with a saw and surgically dissecting soft tissues are painful for every patient. Adequate pain management is critical to recovery, and opioids, when used responsibly and for short periods, remain an essential tool to manage postoperative pain. Patients undergoing hip replacement may only require a few days of opioid treatment, while patients undergoing knee or shoulder replacements may need up to a week or longer.
The opioid epidemic has led to stricter regulations around opioid prescriptions, with some surgeons promoting the possibility of an opioid-free or opioid-sparing approach. While the intent behind such programs is understandable, these appear to be more surgeon-centric than patient-centric. A blanket approach to limiting opioids fails to consider the unique needs of each patient, and there is no substantial evidence that severely limiting short-term opioid prescriptions after joint replacement significantly reduces long-term addiction rates.
We must balance the need to manage acute surgical pain effectively with legitimate concerns about opioid abuse. CDC guidelines advocate for the use of short-acting opioids in combination with nonopioid therapies tailored to the patient’s needs. Many patients can taper off opioids within a week of their joint replacement procedure. Still, protocol-driven restrictions on opioid use, especially for procedures known for significant postoperative pain, can lead to unnecessary suffering and poor patient experiences.
Trap of ‘one-size-fits-all’ approach
Orthopedic surgeons must remain sensitive to the current environment of opioid use, but this should not come at the expense of patient care. A patient-centered approach to pain management — one that combines multimodal analgesia with responsible opioid use based on patient-specific factors and recognized levels of pain after specific procedures — will enhance patient satisfaction and safety.
In our effort to manage postoperative pain responsibly, we must avoid falling into the trap of a “one-size-fits-all” approach or overly restrictive policies. Orthopedic surgeons severely limiting the use of opioids after joint replacement will have an insignificant impact on society’s struggle with chronic opioid addiction. We should not solely use that rationale when caring for our joint replacement patients.
Multimodal analgesia, when combined with personalized opioid prescriptions and perioperative nutritional support, offers the best outcomes for patients undergoing joint replacement. By focusing on each patient’s needs rather than relying on rigid protocols, we can ensure our care is genuinely patient-centric, leading to better outcomes and higher patient satisfaction.
- References:
- https://www.cdc.gov/media/releases/2022/p1103-Prescribing-Opioids.html. Accessed: Sept. 9, 2024.
- https://www.cdc.gov/overdose-prevention/hcp/clinical-care/initiating-opioid-therapy.html. Accessed: Sept. 9, 2024.
- Dowell D, et al. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep. 2022;71(No. RR-3):1–95;doi:http://dx.doi.org/10.15585/mmwr.rr7103a1.
- For more information:
- Anthony A. Romeo, MD, is the Chief Medical Editor of Healio | Orthopedics Today. He can be reached at Healio, 6900 Grove Road, Thorofare, NJ 08086; email: orthopedics@healio.com.
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