Opioid-free pain management pathway may yield similar pain outcomes as opioid pathway
Key takeaways:
- An opioid-free protocol yielded noninferior pain scores vs. an opioid-containing protocol at 24 hours after orthopedic surgery.
- The opioid-free group also had improved comfort and satisfaction scores.
According to published results, a novel opioid-free pathway may provide noninferior pain management compared with an opioid-containing pathway during the perioperative period in patients undergoing orthopedic surgery.
“On average, patients treated with an opioid-free pain protocol experienced pain levels at 24 hours that were statistically noninferior to those for patients treated with an opioid-containing protocol,” Robby Turk, MD, MBA, and colleagues at OrthoCarolina wrote in the study. “Significantly more patients in the opioid-free group self-reported satisfaction with pain control and comfort levels at multiple time points during the postoperative recovery period.”
Turk and colleagues performed a randomized controlled trial of 315 patients (mean age, 63.6 years) who underwent common, elective orthopedic surgeries, such as spine surgery, first carpometacarpal arthroplasty, hallux valgus or hallux rigidus correction, total or reverse shoulder arthroplasty and total hip arthroplasty. Turk and colleagues randomly assigned 157 patients to receive an opioid-free pain management protocol and 158 patients to receive an opioid-containing pain management protocol.
The primary outcome for noninferiority analysis was numeric rating scale (NRS) pain scores at 24 hours at surgery. Turk and colleagues also assessed NRS pain scores at 6 hours, 12 hours, 2 weeks, 6 weeks and 1 year after surgery. Other outcomes included total opioids consumed in the opioid-containing group (in morphine milligram equivalents), readmissions and complications.
Turk and colleagues found pain scores in the opioid-free group (NRS = 2) were statistically noninferior to pain scores in the opioid-containing group (NRS = 4) at 24 hours. In addition, they found decreased pain scores in opioid-free group at 12 hours and at 2 weeks compared with the opioid-containing group. They noted pain scores at 6 hours, 6 weeks and 1 year were similar between the groups.
Patients who received the opioid-free protocol had significantly greater comfort scores at 24 hours and satisfaction scores at 6 weeks compared with the opioid-containing group. Turk and colleagues found no significant differences in rates of unplanned readmissions or complications between the groups.
“We recommend that this completely opioid-free perioperative pain protocol be strongly considered for interested patients undergoing elective orthopedic surgical procedures,” Turk and colleagues concluded.
Perspective
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Recognizing the importance of decreasing opioids in orthopedic pain management and building off the established evidence that opioids are over-prescribed in orthopedic surgery, Robby Turke, MD, MBA, colleagues and the CORE Study Group present a randomized control trial evaluating an opioid-free vs. an opioid-containing postoperative pain management protocol.
Turk and colleagues essentially challenge whether opioids are needed at all for pain management after orthopedic surgery. Their study is strengthened by its prospective and randomized design, use of multimodal pain regiments in both arms while primarily only controlling for opioid inclusion, extensive follow-up from 6 hours to 1 year postop and inclusion of five highly varied but common surgeries spanning several orthopedic subspecialties – anterior cervical discectomy and fusion, thumb basal joint arthroplasty, hallux valgus or rigidus correction, total shoulder arthroplasty and total hip arthroplasty.
Their dramatic results confirm not only that a nonopioid pain management regimen is as good as those containing opioids across these five disparate orthopedic surgeries, but that using a nonopioid multimodal pain management regimen was superior the first 24 hours to 6 weeks postoperatively, which is generally the window of highest postoperative pain. I applaud their highly meaningful and far-reaching study and anticipate its incorporation in pain management regimens by practicing orthopedic surgeons can broadly decrease reliance on opioids and potential opioid abuse postoperatively.
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