Multimodal analgesia is superior to opiates alone after tibial fracture in patients with substance abuse history

Abstract

Objectives: To evaluate the effectiveness of multimodal analgesia in patients with a tibial shaft fracture.Design: Retrospective review.Setting: Large, urban, academic center.Patients: One hundred thirty-eight patients were evaluated before implementation of multimodal analgesia. Thirty-four patients were evaluated after implementation. All patients were treated operatively with internal fixation for their tibial shaft fracture. Patients with polytrauma were excluded.Intervention: Multimodal analgesia.Main Outcome Measures: Pain levels at rest and with movement were assessed. Morphine milligram equivalents (MMEs) dosed per patient were calculated each day. Length of stay was also documented.Results: After implementation of a multimodal analgesic program, there was a statistically significant decrease in pain score at rest (4.7-4.0, P 5 0.034) and with movement (5.8-4.8, P 5 0.007). MMEs dosed in the multimodal analgesic program correlated with pain score (R 2 5 0.5), whereas before implementation of the program, MMEs dosed were not dependent on pain score (R 2 5 0.007). Patients with a history of substance abuse had the most profound effect from this paradigm change. For those with a history of substance abuse, treatment of pain using a multimodal approach reduces MMEs dosed and length of stay (5.7-3.1 days, P 5 0.016).Conclusions: Multimodal analgesia improves patient pain scores both at rest and during movement. In patients with a history of substance abuse, multimodal analgesia not only decreases pain but also decreases length of stay and MMEs dosed to levels consistent with someone who does not have a substance abuse history.

Opioid-Sparing Nonsteroid Anti-inflammatory Drugs Protocol in Patients Undergoing Intramedullary Nailing of Tibial Shaft Fractures: A Randomized Control Trial

“…Our findings are comparable with those in other fields, such as orthopaedic trauma surgery and spine surgery, where NSAIDs have been demonstrated to reduce opioid consumption, with few adverse effects, in multiple surgical procedures. 6,7,10,17,19,29-33 Lenk et al achieved similar improvements in pain scores using an MMA regimen that included NSAIDs to treat patients with substance abuse history with tibial fractures and found that NSAIDs provide similar pain control as the standard of care and multimodal analgesic alternatives. 33 Similarly, Claus et al demonstrated that ketorolac effectively decreases opioid consumption without elevating pain scores or affecting lumbar fusion rates.…”

“…6,7,10,17,19,29-33 Lenk et al achieved similar improvements in pain scores using an MMA regimen that included NSAIDs to treat patients with substance abuse history with tibial fractures and found that NSAIDs provide similar pain control as the standard of care and multimodal analgesic alternatives. 33 Similarly, Claus et al demonstrated that ketorolac effectively decreases opioid consumption without elevating pain scores or affecting lumbar fusion rates. 17 In addition, two randomized controlled trials using combinations of acetaminophen and NSAIDs as pain management protocols in total hip arthroplasty demonstrated decreased opioid consumption without affecting pain scores during the postoperative period.…”

The Impact of Marijuana Use on Postoperative Outcomes in Abdominal-based Free Flap Breast Reconstruction

“…Recent literature on patients who underwent tibial fracture fixation revealed that those with a history of substance use experienced a more profound reduction in opioid consumption and lower pain scores with a multimodal pain regimen compared with patients without a substance use history. 49 Future studies with larger sample sizes will be necessary to elucidate whether a similar differential benefit exists for patients with a history of marijuana use specifically. As studies have shown that patient expectations affect many aspects of the execution of the ERAS protocol including length of hospital stay and postoperative opioid consumption, 50,51 preoperative discussion of pain management could be particularly important in patients with marijuana use.…”