Cluster-Randomized Trial of Opiate-Sparing Analgesia after Discharge from Elective Hip Surgery.

Abstract

BACKGROUND:

Surgeons have traditionally relied on opiates after hip replacement, despite a growing epidemic of abuse. This study assessed the efficacy of multimodal analgesia and impact of conservative opiate prescribing after discharge from hip surgery.

STUDY DESIGN:

In this cluster-randomized trial, 235 patients undergoing hip replacement (5 surgeons) received 1 of 3 discharge pain regimens: scheduled-dose multimodal analgesia with a minimal opiate supply (group A), scheduled-dose multimodal analgesia with a traditional opiate supply (group B), or a traditional pro re nata (as needed) opiate regimen alone (group C). Each of the surgeons comprised a distinct cluster and alternated in a randomized sequence between interventions. The multimodal regimen comprised fixed-schedule doses of acetaminophen, meloxicam, and gabapentin. Primary outcomes were daily visual analogue scale pain and opiate use for 30 days. Secondary outcomes included satisfaction, sleep quality, opiate-related symptoms, hip function, and adverse events. The primary intent-to-treat analysis was performed using linear mixed models.

RESULTS:

Daily pain was significantly lower in group A (coefficient [Coeff] -0.81; p = 0.003) and group B (Coeff -0.61; p = 0.021) relative to group C. Although daily opiate use in group A (Coeff -0.77; p < 0.001) and group B (Coeff -0.30; p = 0.04) was lower than group C, opiate use for group A was also lower than group B (Coeff -0.46; p = 0.002). Duration of opiate use was significantly shorter for group A (1.14 weeks) and group B (1.39 weeks) compared with group C (2.57 weeks). There were fewer opiate-related symptoms, most commonly fatigue, in group A compared with C, but groups B and C were not significantly different. Both multimodal regimens improved satisfaction and sleep, and there were no differences in hip function or adverse events.

CONCLUSIONS:

Multimodal analgesia with minimal opiates improved pain control while significantly decreasing opiate use and opiate-related adverse effects. It is time to rethink our reliance on opiates after elective operations.

• Authors: Andrew N Fleischman, Majd Tarabichi, Carol Foltz, Gabriel Makar, William J Hozack, Matthew S Austin, Antonia F Chen, Opioid Prescription in Orthopedic Surgery after Discharge Research Group
• Journal: Journal of the American College of Surgeons (J Am Coll Surg) Vol. 229 Issue 4 Pg. 335-345.e5 (10 2019) ISSN: 1879-1190 [Electronic] United States
• PMID: 31176028 (Publication Type: Comparative Study, Journal Article, Randomized Controlled Trial)
• Copyright: Copyright © 2019 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Chemical References

• Analgesics
• Analgesics, Opioid

Topics

• Aged
• Analgesics (therapeutic use)
• Analgesics, Opioid (therapeutic use)
• Arthroplasty, Replacement, Hip
• Drug Therapy, Combination
• Elective Surgical Procedures
• Female
• Humans
• Inappropriate Prescribing (prevention & control)
• Intention to Treat Analysis
• Linear Models
• Male
• Middle Aged
• Pain Measurement
• Pain, Postoperative (diagnosis, drug therapy)
• Patient Discharge
• Prospective Studies
• Treatment Outcome