Opiate-sparing analgesia combats opioid epidemic without affecting pain control

American Society of Regional Anesthesia and Pain Medicine
November 13, 2018
Written by American Society of Regional Anesthesia and Pain Medicine
A minimal opiate supply, just a two-day course compared to a traditional two-week prescription, along with a scheduled-dose multimodal pain regimen after surgery limits the use of opiate medication by patients and, subsequently, opiate-related adverse effects while still providing effective pain control and high patient satisfaction, researchers from Thomas Jefferson University in Philadelphia, PA, found.

Andrew Fleischman, Majd Tarabichi, Gabriel Makar, Carol Foltz, William Hozack, Matthew Austin, and Antonia Chen received a Resident/Fellow Travel Award from the American Society of Regional Anesthesia and Pain Medicine for their abstract of the study, “Cluster-Randomized Trial of Opiate-Sparing Analgesia After Discharge From Elective Hip Surgery,” which will be presented on Friday, November 16, 2018, during the 17th Annual Pain Medicine Meeting in San Antonio, TX.

To address the U.S. opioid epidemic, physicians are evaluating widespread medical practices that could place patients at risk for chronic abuse, such as the broad reliance on opiates after elective surgery despite no clear evidence that they are more effective than nonopiate pain medications. According to the Centers for Disease Control and Prevention, the duration of the first prescription is a major predictor of risk: a two-day supply of opiates garners a 6% risk of chronic use after one year, but a two-week supply increases the risk to 25%. A scheduled-dose multimodal pain regimen, in which fixed doses of nonopiate pain medications, including acetaminophen and nonsteroidal anti-inflammatory drugs, are prescribed around the clock to prevent the onset of pain, can be a potentially safer and more effective approach.

Fleischman et al. randomly assigned patients to receive one of three medication regimens after discharge from elective hip surgery:

  • Scheduled-dose multimodal pain regimen with only a two-day supply of opiates to be used solely for emergency pain relief
  • Scheduled-dose multimodal pain regimen but with a more traditional two-week supply of opiates
  • Two-week supply of opiates and acetaminophen to be used as needed, with no scheduled-dose multimodal pain regimen (Unlike the multimodal strategy, the classic approach has been for patients to take pain medication as needed based on symptom-triggers.)
Patients were followed daily for a 30-day period, and the study results demonstrated that patients receiving a scheduled-dose multimodal pain regimen had considerably less pain, especially during the first two weeks after surgery. They also required significantly fewer opiate tablets after surgery and discontinued use of these medications earlier. In particular, patients prescribed only a two-day opiate supply used by far the least opiate medication and, consequently, had the fewest adverse effects related to opiate use (eg, fatigue) after surgery. Patients receiving a multimodal pain regimen also reported better sleep quality and were more satisfied with their experience.

“The results of this clinical trial suggest that it is time to rethink the traditional practice of prescribing a large number of opiate tablets after elective surgery,” the researchers concluded. “Not only do opiates clearly not need to be the central component of a pain regimen, but it appears that providing a smaller opiate supply may redefine patients’ expectations for how much pain they might have after surgery.”

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