Postoperative Pain and Opioid Use Following Surgical Treatment of Ankle Fractures

Category: Trauma Introduction/Purpose: Currently there is an epidemic in the United States regarding opioid abuse. This has resulted in strict government prescribing regulations throughout the country and increasing efforts by orthopaedic surgeons to better manage postoperative narcotic analgesia. Non-steroidal anti-inflammatory drugs (NSAIDs) can serve as a powerful adjunct in managing postoperative pain and in turn minimize the need for opioid medications. It has recently been shown that ketorolac can be used after open reduction and internal fixation (ORIF) of ankle fractures without interfering with bone healing. Therefore, we set out to evaluate whether including ketorolac in the postoperative drug regimen reduces opioid consumption and pain after ORIF of ankle fractures. Methods: 128 patients undergoing ORIF of an ankle fracture were prospectively randomized to treatment with or without ketorolac. Patients also had the option to simultaneously undergo regional anesthesia. Patients assigned to the treatment group were given 30 mg of IV ketorolac intraoperatively; prescribed 20 tablets of ketorolac 10 mg PO Q6 H and 30 tablets of Oxycodone/Acetaminophen 5/325 Q4-6 H PRN. Patients assigned to the control group were given 30 tablets of oxycodone/acetaminophen 5/325 Q4-6 H PRN only. A survey was distributed via Research Electronic Data Capture (REDCap) on postoperative days 1-7. Patients were asked to report their daily opioid consumption, pain level using the Visual Analog Scale (VAS), satisfaction with pain management, and side effects. Intention-to-treat analysis was performed. Normality of data was tested using the Shapiro-Wilk test. Differences between the control and treatment groups were tested using Mann-Whitney U or Student’s t-tests. Results: 105/128 (82%) patients with mean BMI of 29.3 completed all study requirements. 54 received ketorolac with opioid medication and 51 received opioids alone. 43 men (41%) and 62 women (59%) participated with mean age of 48 years. Patients receiving ketorolac required less oxycodone/acetaminophen (p<0.013) and reported less pain (p<0.048) during postoperative days 1 and 2 compared to control patients(Figure 1). While opioid consumption did not significantly differ after day 2, patients treated with ketorolac maintained less pain (days 1-4, p<0.028); better sleep (days 1-5, p<0.037); lower frequency of pain (days 1-3; p<0.017); and greater satisfaction with pain management (days 1-3, p<0.047). Hypersensitivity was significantly less on day 1 (p=0.036) and paresthesias on day 3 (p=0.011). Surprisingly, there was no difference in nausea/constipation between groups (p>0.139). Conclusion: The addition of ketorolac to the postoperative drug regimen significantly reduced pain, while decreasing the use of opioid medication following ORIF of ankle fractures early in the postoperative period. Better pain management during postoperative days 1 and 2 is particularly important because patients on average consume the most opioids during this time. With the assurance that ketorolac does not interfere with bone healing, this NSAID is a valuable tool for helping patients manage postoperative pain with less narcotic analgesia.

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Can the implementation of the Opioid Start Talking form impact the amount of opioid use in patients after ankle fracture repair?

Journal of Opioid Management ◽

10.5055/jom.2021.0673 ◽

2021 ◽

Vol 17 (5) ◽

pp. 397-404

Author(s):

Benjamin Best, DO ◽

Alan Afsari, MD ◽

Rajan Sharma, DO ◽

James T. Layson, DO ◽

Marek Denisiuk, DO

Keyword(s):

Ankle Fracture ◽

Final Analysis ◽

Fracture Repair ◽

Ankle Fractures ◽

P Value ◽

Prescription Database ◽

Opioid Epidemic ◽

Opioid Use ◽

Opioid Prescription ◽

Significant Difference

Objective: As part of 2018 legislation aimed at fighting the opioid epidemic, the Michigan Department of Health and Human Services (MDHHS) published the “Opioid Start Talking” (OST) Form on June 1, 2018. We examined if the implementation of the OST form led to an identifiable decrease in patient opioid use. Specifically, we examined the opioid prescription quantities in patients who sustained ankle fractures that required open reduction internal fixation (ORIF).Design: Retrospective. Hospital medical records and Michigan Automated Prescription Database (MAPS) were analyzed for similar ankle fracture patients operated on by two surgeons prior to and after the initiation of the OST form. Records allowed us to track opioid filling through MAPS for 120 days after surgery in two groups: preimplementation (PRE) and post-implementation (POST) OST groups. The gathered data were analyzed by the investigators along with a staff statistician.Setting: Single-institution orthopedic practice.Patients, participants: Seventy eight patientsMain outcome measure: Average morphine milligram equivalent (MME) per patient encounter.Results: Seventy eight patients were included in the final analysis after applying the exclusion criteria. There were 38 patients in the pre-OST form period and 40 in the post-OST form period groups. The pre-OST and post-OST groups were well matched between the two surgeons. There was no evidence of a statistically significant difference found in the median MME between patients from the pre-period group to the post-period group (median 59 vs 50, P = 0.61). In regard to the injury pattern, the bimalleolar MME median was 50 (38 = 25th percentile, 67 = 75th percentile; min-max 0-175) and the trimalleolar median MME was 63 (39 =25% percentile, 81 = 75th percentile; min-max 0-249) with a P value of 0.20.Conclusions: Overall, the administration of the OST form to patients with ankle fractures did not result in a decrease in MMEs prescribed within 120 days of surgery. Although it is a start in the battle against the opioid epidemic, further evaluation of the effectiveness of the OST form is necessary.

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SAFE AND EFFECTIVE PAIN CONTROL FOR GERIATRIC PATIENTS: A MULTIDISCIPLINARY APPROACH DURING THE OPIOID EPIDEMIC

Innovation in Aging ◽

10.1093/geroni/igz038.1490 ◽

2019 ◽

Vol 3 (Supplement_1) ◽

pp. S401-S402

Author(s):

Tatyana Gurvich

Keyword(s):

Quality Of Life ◽

Pain Management ◽

Physical Therapy ◽

Integrative Medicine ◽

The United States ◽

Opioid Use ◽

Prescribing Practices ◽

Opioid Prescription ◽

Pain Medications

Abstract Opioid use is at a crisis level. According to the CDC, an estimated 20 % of patients presenting to physician offices with non-cancer pain receive an opioid prescription (1). According to the Administration on Aging and Substance Abuse and Mental Health Services Administration, the population of older adults who misuse opioids is expected to double by 2020. Today’s mandate to reduce opioid use and to manage patients safely with adjuvant medications comes with many challenges in geriatrics. Many patients have comorbidities which limit the use of adjuvant pain medications. A careful balance must be achieved, in order to provide good pain management and improve quality of life in this patient population. This symposium will explore multidisciplinary approaches to managing pain in geriatrics to reduce opioid use and manage safe opioid use where necessary. Pharmacological strategies for adjusting dosing and managing compliance will be discussed. Cooperative education to improve prescribing practices along with patient education to improve safe use, are important elements. Adjunct use of physical therapy and integrative medicine are also discussed as viable and effective adjuncts or alternatives to traditional pain management. You will learn how to use medications safely, utilize physical therapy to its maximum potential and learn more about innovative integrative medicine techniques, all of which decrease pain and improve function and most importantly quality of life. (1) Daubresse M, Chang HY, Yu Y, et al. Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 200-2010. Med Care 2013; 51:870-8

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Stemming the Tide of Opioid Addiction—Dramatic Reductions in Postoperative Opioid Requirements Through Preoperative Education and a Standardized Analgesic Regimen

Military Medicine ◽

10.1093/milmed/usz279 ◽

2019 ◽

Vol 185 (3-4) ◽

pp. 436-443 ◽

Cited By ~ 2

Author(s):

Rowan R Sheldon ◽

Jessica B Weiss ◽

Woo S Do ◽

Dominic M Forte ◽

Preston L Carter ◽

...

Keyword(s):

Patient Satisfaction ◽

Pain Management ◽

Postoperative Pain ◽

Pain Control ◽

Inclusion Criteria ◽

Opioid Use ◽

Opioid Prescription ◽

Management Protocol ◽

Patient Reported ◽

Nonopioid Analgesics

Abstract Introduction Surgery is a known gateway to opioid use that may result in long-term morbidity. Given the paucity of evidence regarding the appropriate amount of postoperative opioid analgesia and variable prescribing education, we investigated prescribing habits before and after institution of a multimodal postoperative pain management protocol. Materials and Methods Laparoscopic appendectomies, laparoscopic cholecystectomies, inguinal hernia repairs, and umbilical hernia repairs performed at a tertiary military medical center from 01 October 2016 until 30 September 2017 were examined. Prescriptions provided at discharge, oral morphine equivalents (OME), repeat prescriptions, and demographic data were obtained. A pain management regimen emphasizing nonopioid analgesics was then formulated and implemented with patient education about expected postoperative outcomes. After implementation, procedures performed from 01 November 2017 until 28 February 2018 were then examined and analyzed. Additionally, a patient satisfaction survey was provided focusing on efficacy of postoperative pain control. Results Preprotocol, 559 patients met inclusion criteria. About 97.5% were provided an opioid prescription, but prescriptions varied widely (256 OME, standard deviation [SD] 109). Acetaminophen was prescribed often (89.5%), but nonsteroidal anti-inflammatory drug (NSAID) prescriptions were rare (14.7%). About 6.1% of patients required repeat opioid prescriptions. After implementation, 181 patients met inclusion criteria. Initial opioid prescriptions decreased 69.8% (77 OME, SD 35; P < 0.001), while repeat opioid prescriptions remained statistically unchanged (2.79%; P = 0.122). Acetaminophen prescribing rose to 96.7% (P = 0.002), and NSAID utilization increased to 71.0% (P < 0.001). Postoperative survey data were obtained in 75 patients (41.9%). About 68% stated that they did not use all of the opioids prescribed and 81% endorsed excellent or good pain control throughout their postoperative course. Conclusions Appropriate preoperative counseling and utilization of nonopioid analgesics can dramatically reduce opioid use while maintaining high patient satisfaction. Patient-reported data suggest that even greater reductions may be possible.

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A Biofeedback Enhanced Adaptive Virtual Reality Environment for Managing Surgical Pain and Anxiety

International Journal of Semantic Computing ◽

10.1142/s1793351x20400152 ◽

2020 ◽

Vol 14 (03) ◽

pp. 375-393

Author(s):

Vishnunarayan Girishan Prabhu ◽

Laura Stanley ◽

Robert Morgan

Keyword(s):

Virtual Reality ◽

Pain Management ◽

Postoperative Pain ◽

Low Frequency ◽

Preoperative Anxiety ◽

Opioid Use ◽

Opioid Prescription ◽

Attention Restoration ◽

Increased Risk

Pain and anxiety are common accompaniments of surgery, and opioids have been the mainstay of pain management for decades, with about 80% of the surgical population leaving the hospital with an opioid prescription. Moreover, patients receiving an opioid prescription after short-stay surgeries have a 44% increased risk of long-term opioid use, and about one in 16 surgical patients becomes a long-term user. Current opioid abuse and addiction now place the US in an “opioid epidemic,” and calls for alternative pain management mechanisms. To mitigate the preoperative anxiety and postoperative pain, we developed a virtual reality (VR) experience based on Attention Restoration Theory (ART) and integrated the user’s heart rate variability (HRV) biofeedback to create an adaptive environment. A randomized control trial among 16 Total Knee Arthroplasty (TKA) patients undergoing surgery at Patewood Memorial Hospital, Greenville, SC demonstrated that patients experiencing the adaptive VR environment reported a significant decrease in preoperative anxiety ([Formula: see text]) and postoperative pain ([Formula: see text]) after the VR intervention. These results were also supported by the physiological measures where there was a significant increase in RR Interval (RRI) ([Formula: see text]) and a significant decrease in the low frequency (LF)/high frequency (HF) ratio ([Formula: see text]) and respiration rate (RR) ([Formula: see text]).

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Multimodal analgesia for postoperative pain in Asia: a review of evidence with clinical focus on dexketoprofen and tramadol/dexketoprofen ﬁxed-dose combination

10.22514/sv.2021.210 ◽

2021 ◽

Keyword(s):

Pain Management ◽

Postoperative Pain ◽

Postoperative Period ◽

Opioid Analgesic ◽

Postoperative Pain Management ◽

Multimodal Analgesia ◽

Fixed Dose ◽

Opioid Use ◽

Asian Patients ◽

Anti Inflammatory

The majority of patients who have undergone surgery experience moderate-to-severe postoperative pain. Asian patients tend to under-report pain and are consequently under-treated. Poor postoperative pain management increases the risk of morbidity, prolonged opioid use, lower quality of life outcomes and the risk of chronic post-surgical pain. Multimodal analgesia is the cornerstone of postoperative pain management. Non-steroidal anti-inflammatory drugs are considered a core component of multimodal analgesia due to their anti-inflammatory and analgesic properties. Use of a consistent non-steroidal anti-inflammatory throughout the postoperative period can help to achieve and maintain adequate pain relief. This review investigates the use of multimodal analgesia in postoperative pain management in Asia, with a focus on clinicians’ experience with dexketoprofen as a non-steroidal anti-inflammatory therapy throughout the postoperative period and its combination as fixed dose with Tramadol, a centrally acting synthetic opioid analgesic, in Asian patients, when necessary.

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Opioid Prescribing Patterns of the American Orthopaedic Foot & Ankle Society

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00236 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0023

Author(s):

Noortje Hagemeijer ◽

Gabrielle Donahue ◽

Gijs Helmerhorst ◽

Daniel Guss ◽

Gino Kerkhoffs ◽

...

Keyword(s):

United States ◽

Pain Management ◽

Postoperative Pain ◽

Management Practices ◽

Postoperative Pain Management ◽

The United States ◽

Prescribing Patterns ◽

Foot And Ankle ◽

Opioid Prescribing ◽

American Orthopaedic

Category: Other Introduction/Purpose: Amid the current opioid epidemic in the United States, surgeons are forced to more carefully manage postoperative pain prescriptions. Despite the enthusiastic engagement of physicians, politicians and the general public, however, clear guidelines for opioid prescribing postoperatively still do not exist, including after foot and ankle surgery. Given the ablity to improve patient outcomes by decreasing treatment variability in other realms of medicine, this study sought to quantify the postoperative opioid prescribing regimens of American foot and ankle surgeons as an initial step towards understanding prescription patterns and establishing a baseline regimen from which future guidelines may stem. Methods: A total of 1235 active and candidate members of the American Orthopaedic Foot & Ankle Society (AOFAS) from the United States and Canada were invited to fill out a postoperative pain management survey using a Research Electronic Data Capture (REDCap) web-based application. Surgeons were asked to report on their pain prescription regimens, including type and number of pills, after nine common foot and ankle procedures rated as minor, moderate, or major in severity. The presence of a regional block anesthesia was also recorded. Opioid prescriptions were then converted to the equivalent of 5 mg oxycodone pills for standardization and inter-prescriber comparison. Results: Two hundred twenty-four (18%) surgeons completed the survey. Because of highly skewed data results are reported as medians and the range. Postoperative opioid prescriptions, given in oxycodone 5 mg pill equivalents, were as follows: 39 (8-133) pills for minor procedure, 45 (10-180) pills for a moderate soft tissue procedure, 53 (16-186) pills for a moderate bony procedure, and 60 (20-200) pills for a major bony procedure. Conclusion: Wide variation between surgeons was noted in postoperative pain management. Median prescription opioid doses vary from 39 to 60 oxycodone pills depending on procedure type. It is likely that the amount of opioids prescribed is excessive for adequate pain management, especially for smaller procedures. We propose a post-operative pain regimen that limits the number of pills prescribed based on studies from other surgical specialties. Future studies are necessary to assess the efficacy of current postoperative pain management practices and to guide improved pain management that limits the use of opioids where possible.

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Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations

Otolaryngology ◽

10.1177/0194599821996297 ◽

2021 ◽

Vol 164 (2_suppl) ◽

pp. S1-S42 ◽

Cited By ~ 2

Author(s):

Samantha Anne ◽

James “Whit” Mims ◽

David E. Tunkel ◽

Richard M. Rosenfeld ◽

David S. Boisoneau ◽

...

Keyword(s):

Pain Management ◽

Postoperative Pain ◽

Guideline Development ◽

The United States ◽

Management Plan ◽

Opioid Use Disorder ◽

Opioid Use ◽

First Line ◽

Guideline Development Group ◽

Development Group

Objective Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families. Purpose The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan. The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients. Action Statements The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method. The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.

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Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations Executive Summary

Otolaryngology ◽

10.1177/0194599821996303 ◽

2021 ◽

Vol 164 (4) ◽

pp. 687-703

Author(s):

Samantha Anne ◽

James “Whit” Mims ◽

David E. Tunkel ◽

Richard M. Rosenfeld ◽

David S. Boisoneau ◽

...

Keyword(s):

Pain Management ◽

Postoperative Pain ◽

Guideline Development ◽

The United States ◽

Management Plan ◽

Opioid Use Disorder ◽

Opioid Use ◽

First Line ◽

Guideline Development Group ◽

Development Group

Objective Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families. Purpose The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan. The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients. Action Statements The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method. The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.

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Participants with mild, moderate, or severe pain following total hip arthroplasty. A sub-study of the PANSAID trial on paracetamol and ibuprofen for postoperative pain treatment

Scandinavian Journal of Pain ◽

10.1515/sjpain-2020-0141 ◽

2021 ◽

Vol 0 (0) ◽

Author(s):

Luma Mahmoud Issa ◽

Kasper Højgaard Thybo ◽

Daniel Hägi-Pedersen ◽

Jørn Wetterslev ◽

Janus Christian Jakobsen ◽

...

Keyword(s):

Postoperative Pain ◽

Total Hip Arthroplasty ◽

Hip Arthroplasty ◽

Severe Pain ◽

Pain Treatment ◽

Opioid Analgesic ◽

Opioid Use ◽

Mild Pain ◽

Total Hip ◽

Pain Scores

AbstractObjectivesIn this sub-study of the ‘Paracetamol and Ibuprofen in Combination’ (PANSAID) trial, in which participants were randomised to one of four different non-opioids analgesic regimen consisting of paracetamol, ibuprofen, or a combination of the two after planned primary total hip arthroplasty, our aims were to investigate the distribution of participants’ pain (mild, moderate or severe), integrate opioid use and pain to a single score (Silverman Integrated Approach (SIA)-score), and identify preoperative risk factors for severe pain.MethodsWe calculated the proportions of participants with mild (VAS 0–30 mm), moderate (VAS 31–60 mm) or severe (VAS 61–100 mm) pain and the SIA-scores (a sum of rank-based percentage differences from the mean rank in pain scores and opioid use, ranging from −200 to 200%). Using logistic regression with backwards elimination, we investigated the association between severe pain and easily obtainable preoperative patient characteristics.ResultsAmong 556 participants from the modified intention-to-treat population, 33% (95% CI: 26–42) (Group Paracetamol + Ibuprofen (PCM + IBU)), 28% (95% CI: 21–37) (Group Paracetamol (PCM)), 23% (95% CI: 17–31) (Group Ibuprofen (IBU)), and 19% (95% CI: 13–27) (Group Half Strength-Paracetamol + Ibuprofen (HS-PCM + IBU)) experienced mild pain 6 h postoperatively during mobilisation. Median SIA-scores during mobilisation were: Group PCM + IBU: −48% (IQR: −112 to 31), Group PCM: 40% (IQR: −31 to 97), Group IBU: −5% (IQR: −57 to 67), and Group HS-PCM + IBU: 6% (IQR: −70 to 74) (overall difference: p=0.0001). Use of analgesics before surgery was the only covariate associated with severe pain (non-opioid: OR 0.50, 95% CI: 0.29–0.82, weak opioid 0.56, 95% CI: 0.28–1.16, reference no analgesics before surgery, p=0.02).ConclusionsOnly one third of participants using paracetamol and ibuprofen experienced mild pain after total hip arthroplasty and even fewer experienced mild pain using each drug alone as basic non-opioid analgesic treatment. We were not able, in any clinically relevant way, to predict severe postoperative pain. A more extensive postoperative pain regimen than paracetamol, ibuprofen and opioids may be needed for a large proportion of patients having total hip arthroplasty. SIA-scores integrate pain scores and opioid use for the individual patient and may add valuable information in acute pain research.

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