• Andrew N Fleischman, Majd Tarabichi, Carol Foltz, Gabriel Makar, William J Hozack, Matthew S Austin, Antonia F Chen, and Opioid Prescription in Orthopedic Surgery after Discharge Research Group.
• Department of Anesthesia, Thomas Jefferson University, Philadelphia, PA. Electronic address: anfleischman@gmail.com.
• J. Am. Coll. Surg. 2019 Oct 1; 229 (4): 335-345.e5.

BackgroundSurgeons 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 DesignIn 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.ResultsDaily 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.ConclusionsMultimodal 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.Copyright © 2019 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

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