Effect of a Postoperative Multimodal Opioid-Sparing Protocol vs Standard Opioid Prescribing on Postoperative Opioid Consumption After Knee or Shoulder Arthroscopy: A Randomized Clinical Trial

• Published in: JAMA : the journal of the American Medical Association 2022-10, Vol.328 (13), p.1326-1335
• Main Authors: Gazendam, Aaron, Ekhtiari, Seper, Horner, Nolan S, Simunovic, Nicole, Khan, Moin, de SA, Darren L, Madden, Kim, Ayeni, Olufemi R
• Format: Article
• Language: English
• Subjects: Acetaminophen; Acetaminophen - adverse effects; Acetaminophen - therapeutic use; Adult; Adverse events; Analgesics; Analgesics, Non-Narcotic - adverse effects; Analgesics, Non-Narcotic - therapeutic use; Analgesics, Opioid - adverse effects; Analgesics, Opioid - therapeutic use; Anti-Ulcer Agents - adverse effects; Anti-Ulcer Agents - therapeutic use; Arthroscopy; Clinical Protocols; Clinical trials; Drug Therapy, Combination; Evaluation; Female; Humans; Hydromorphone - adverse effects; Hydromorphone - therapeutic use; Knee; Knee Joint - surgery; Male; Morphine; Naproxen; Naproxen - adverse effects; Naproxen - therapeutic use; Narcotics; Ontario; Opioids; Original Investigation; Pain; Pain management; Pain, Postoperative - drug therapy; Pain, Postoperative - etiology; Pantoprazole - adverse effects; Pantoprazole - therapeutic use; Paracetamol; Patient Education as Topic; Patient satisfaction; Patients; Postoperative Care; Shoulder; Shoulder Joint - surgery; Surgery
• ISSN: 0098-7484; 1538-3598
• DOI: 10.1001/jama.2022.16844

IMPORTANCE: 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. OBJECTIVE: 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. DESIGN, SETTING, AND PARTICIPANTS: 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. INTERVENTIONS: 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. MAIN OUTCOMES AND MEASURES: 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. RESULTS: 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