Abstract
Background
Opiate abuse is a rapidly growing epidemic in the US, and orthopaedic surgeons are among the highest prescribers. While surgeons have relied heavily on opiates after total hip replacement (THR), our goal was to determine whether a multimodal pain regimen could improve pain control and reduce or even obligate the need for opiates.
Methods
In a cluster-randomised, crossover trial, we assigned 235 patients undergoing THR to receive either a multimodal pain regimen with a minimal opiate supply (Group A- 10 tablets only), a conventional multimodal regimen (Group B- 60 tablets), or a traditional opiate regimen without multimodal therapy (Group C- 60 tablets). Clusters were determined by surgeon, with each cluster alternating between regimens in 4-week intervals. The multimodal pain regimen comprised standing-dose acetaminophen, meloxicam, and gabapentin. Primary outcomes were VAS pain and daily opiate use for the first 30 days postoperatively. Secondary outcomes included daily assessments of satisfaction, sleep quality, and opiate-related symptoms, hip function at 1-month, and 90-day adverse events.
Results
Daily pain was significantly lower in both multimodal groups, Group A (Coeff −0.81, p=0.003) and Group B (Coeff −0.61, p=0.021). While daily opiate utilization and duration of use was also lower for both Group A (Coeff −0.77, p=0.001) and Group B (Coeff −0.30, p=0.04) compared with Group C, Group A also had significantly lower daily opiate use than Group B (Coeff −0.46, p=0.002), and few prescription refills were required in any group. Opiate-related symptoms, in particular fatigue, were significantly lower in Group A compared to Group C (p=0.005), but Group B and C did not differ (p=0.13). Additionally, both multimodal regimens improved satisfaction and sleep, and there was no difference in hip function or adverse events.
Conclusions
While a multimodal pain regimen after THR improved pain control and decreased opiate utilization, patients also receiving a minimal opiate supply had a much greater reduction in opiate use and, consequently, fewer opiate-related adverse effects. It's time to rethink traditional approaches to pain management after elective surgery.
