Multimodal Pain Management in Older Elective Arthroplasty Patients

Abstract

Background:Pain management after elective arthroplasty in older adults is complicated due to the risk of undertreatment of postoperative pain and potential adverse effects from analgesics, notably opioids. Using combinations of analgesics has been proposed as potentially beneficial to achieve pain control with lower opioid doses.Objective:We compared a multimodal pain protocol with a traditional one, in older elective arthroplasty patients, measuring self-rated pain, incidence of postoperative delirium, quantity and cost of opioid analgesics consumed.Methods:One hundred fifty-eight patients, 70 years and older, admitted to tertiary care for elective arthroplasty were prospectively assessed postoperative days 1–3. Patients received either traditional postoperative analgesia (acetaminophen plus opioids) or a multimodal pain protocol (acetaminophen, opioids, gabapentin, celecoxib), depending on surgeon preference. Self-rated pain, postoperative delirium, and time to achieve standby-assist ambulation were compared, as were total opioid doses and analgesic costs.Results:Despite receiving significantly more opioid analgesics (traditional: 166.4 mg morphine-equivalents; multimodal: 442 mg morphine equivalents; t = 10.64, P < .0001), there was no difference in self-rated pain, delirium, or mobility on postoperative days 1–3. Costs were significantly higher in the multimodal group (t = 9.15, P < .0001). Knee arthroplasty was associated with higher pain scores than hip arthroplasty, with no significant difference in opioid usage.Conclusion:A multimodal approach to pain control demonstrated no benefit over traditional postoperative analgesia in elective arthroplasty patients, but with significantly higher amounts of opioid consumed. This poses a potential risk regarding tolerability in frail older adults and results in increased drug costs.

Pain, Opioid Intake, and Delirium Symptoms in Adults Following Joint Replacement Surgery

“…These may include opioid medications in combination with other pharmacological and nonpharmacological pain management measures (Chou et al, 2016). Nevertheless, research findings are contradictory regarding the role of opioid medications in the development of delirium (Brooks, Freter, Bowles, & Amirault, 2017; Lynch et al, 1998; Morrison, Flanagan, Fischberg, Cintron, & Siu, 2009). Results from a systematic review that examined the role of postoperative analgesia in delirium and cognitive decline found no evidence to support the etiological impact of opioids on the development of delirium, with the exception of meperidine (H.…”

Multimodal Pain Management for Major Joint Replacement Surgery

“…In an effort to decrease opioid dependency, practitioners are turning to multimodal pain management, which involves the use of multiple analgesic agents and techniques that act on different pain mechanisms to provide pain relief and improve quality of life with less opioid consumption (Brooks, Freter, Bowles, & Amirault 2017). In addition to decreasing opioid use, multimodal pain management techniques used postoperatively reduce prolonged sedation for the orthopedic surgical patient.…”

“…Table 1 outlines the techniques utilized for multi-modal pain management therapies for the orthopedic surgery patient which often include NSAIDS such as aspirin, naproxen, ketorolac, celecoxib, meloxicam, diclofenac, and ibuprofen (Donahue, Bradbury, Zychowicz, & Muckler, 2018; Brooks, Fretter, Bowles, & Amirault, 2017; Song, 2017; Canata, Casale, & Chiey, 2016; Chou, et al, 2016; ASA 2012). Analgesia resulting from NSAID administration is due to inhibited synthesis and release of prostaglandins and inhibited cyclooxygenase 2 (COX-2) that results in a suppressed inflammatory response (Elmallah, et al, 2018).…”

Potential Novel Strategies for the Treatment of Dental Pulp-Derived Pain: Pharmacological Approaches and Beyond

“…Multimodal drug therapy is achieved by combining drugs with complementary mechanisms of action with the aim of reducing postoperative pain (Brooks et al, 2017; Matute Crespo and Montero Matamala, 2017). When treating moderate to severe pain, combination pharmacotherapy may be an effective alternative to treat pain and improve patient recovery times (Ganda, 2008).…”