Study: Multiple pain relievers after joint, knee replacements ease opioid use

By Allen Cone  |  March 2, 2018 at 4:21 PM
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March 2 (UPI) -- Patients not strictly taking opioids for pain relief after total hip or knee replacement can decrease their reliance on the drug and have fewer complications, according to a new study.

Researchers determined that multiple methods are a more effective way to treat pain during recovery than opioids alone, according to a study published Friday in the journal Anesthesiology.

"Patients need to be aware that there are ways to treat their pain during and after surgery in addition to opioids," Dr. Stavros G. Memtsoudis, director of critical care services in the Department of Anesthesiology at the Hospital for Special Surgery in New York, said in a press release. "If the doctor prescribes more than one type of medicine for your pain, it may reduce your need for opioids."

Opioids are powerful pain medications but have many unwanted side effects, including nausea, vomiting and drowsiness, and can lead to addiction.

Opioids -- prescription opioid-based painkillers, and illicit forms such as heroin -- killed more than 42,000 people in 2016, more than any year on record, according to the Centers for Disease Control and Prevention. Forty-percent of all opioid overdose deaths involved a prescription opioid.

"Opioids may have a role to play during and immediately after surgery, but we've been relying on them too much," Memtsoudis said.

Researchers examined a nationwide database for information on joint replacement surgeries performed at 546 hospitals. They examined the types of pain relievers used between 2006 and 2016 in 512,393 hip replacements and 1,028,069 knee replacements.

They compared patients' pain relief, including strictly opioids, as well as a combination of one or more additional pain management methods, such as peripheral nerve block, acetaminophen, gabapentin/pregabalin, non-steroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors or ketamine.

The multimodal approach was used in 85.6 percent of cases.

Hip patients who received more than two methods of pain relief in addition to opioids decreased the drug's use 18.5 percent after surgery. They also had 19 percent fewer respiratory complications, 26 percent fewer gastrointestinal complications and a 12 percent decline in hospital length of stay, compared with patients receiving opioids alone.

The results were similar with total knee patients. With the same multi-analgesic on average they had an 18.5 percent decrease in opioid prescriptions, 6 percent fewer respiratory complications, 18 percent fewer gastrointestinal complications and 9 percent drop in hospital length of stay.

Using multiple pain relievers did not, however, decrease the cost of hospitalization.

The most effective pain relievers in this approach seemed to be NSAIDs and COX-2 inhibitors, including the greatest reduction in opioid prescriptions and complication risk, the researchers said. The peripheral nerve block in a multimodal regimen also was effective.

"This study does not answer the question of what combinations of analgesic approaches are best -- we would need to conduct a much more complicated analysis, because there are so many potential combinations of drugs to consider," Memtsoudis said. "But our findings do encourage the combined use of multiple analgesic modalities during and after surgery. Each of these drugs work on different parts of the pain pathway, so by using more than one medicine, we are attacking pain on many different levels."

Memtsoudis added there is an effective limit to the number of analgesic methods, though.

"We think three or four is probably the maximum -- more than that may only increase drug-related side effects," Memtsoudis said. "Future studies are needed to identify optimal multimodal regimens and patient subgroups most likely to benefit from each combination."

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