Multimodal Pain Relief Strategy Preferable to Opioids Alone

Stavros G. Memtsoudis, MD, PhD

Patients who undergo hip and knee replacements decrease their opioid intake and have fewer opioid-related complications when they are given a multimodal pain relief strategy, according to study data.

Lead author Stavros G. Memtsoudis, MD, PhD, a senior scientist at the Hospital for Special Surgery, in New York, said this study is significant for its breadth and for the clarity of its findings.

“Multimodal approaches have been studied in the past for joint arthroplasty patients, suggesting that this type of practice is associated with better pain control,” he told MD Magazine. “These studies are usually small, institutional studies performed at academic centers.”

Memtsoudis new population-based study includes data from half a million hip replacement patients and more than 1 million knee replacement patients. The data cover the years 2006 to 2016. The goal was to find out if the benefits of a multimodal pain management approach extended to a reduction in complications and hospital stays. They also aimed to understand whether any particular multimodal analgesia (MMA) method worked best and whether any trends in prescribing could be worked out.

The study divided patients into those who were given opioids alone on the day of surgery and during recovery, versus patients who were given other options in addition to opioids. Those other modes included strategies such as peripheral nerve block, acetaminophen, gabapentin/pregabalin, non-steroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 (COX-2) inhibitors or ketamine. The study found that in 85.6% of cases, multimodal strategies were used.

The multimodal approach made a difference.

The data showed that when hip- and knee-replacement patients were given 2 or more pain relief methods, the number of opioid prescriptions they filled fell by 18.5%. Respiratory and gastrointestinal complications fell by 19% and 26%, respectively, for hip-replacement patients. In knee-replacement patients, respiratory complications fell by 6% and gastrointestinal complications dropped by 18%. Meanwhile, the average length of hospital stay dropped by 12% for hip replacements and by 9% for knee replacements.

Memtsoudis said the study wasn’t designed to elucidate why the hospital stays might be shorter, but he said there are a few possible reasons, including the reduction in complications.

“However, the use of MMA may also represent a practice which is closely linked with programs whose goal is to accelerate recovery, i.e. enhanced recovery after surgery (ERAS) programs,” he said. “These practices are known to incorporate new knowledge faster and more systematically and thus MMA may be one of the drivers of reduced [length of stay].”

It’s also not clear from the research why particular patients receive a multimodal approach and others did not. But Memtsoudis hopes the study will lead the vast majority of physicians to opt for the multimodal approach as their first strategy for most patients.

“Now that we have linked MMA to better clinical and economic outcomes, the need for wider adoption of MMA becomes an ethical one,” he said. “Knowing that this approach may be best for our patients, why don't we use it in everyone (barring contraindications such as allergies and others)?”

Memtsoudis conceded that the transition from medical journals to the clinic is often a slow one, but he hopes this study’s insights will have a faster impact, given the specter of the ongoing opioid abuse crisis.

The study, “Association of Multimodal Pain Management Strategies with Perioperative Outcomes and Resource Utilization: A Population-based Study,” was published in Anesthesiology.

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