www.consultqd.clevelandclinic.org:Managing Postoperative Pain in the Orthopaedic Patient Without Opioids

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www.consultqd.clevelandclinic.org:Managing Postoperative Pain in the Orthopaedic Patient Without Opioids

Managing Postoperative Pain in the Orthopaedic Patient Without Opioids

What is the orthopaedic surgeon’s role in preventing escalation of a national crisis

By Vani J. Sabesan, MD; Danielle Malone, MPH; Kiran Chatha, MD

Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services Policy

Ninety Americans die of an opioid overdose daily, and while the United States represents only 5 percent of the global population, it is responsible for 80 percent of global opioid consumption and use 99 percent of the global hydrocodone supply. Opioid abuse is a systemic and pervasive problem that presents a challenge for all medical specialties and especially orthopaedists, whose patients often require marked pain management postoperatively.

Orthopaedic surgeons are the third-highest prescribers of opioid-based medications. Recognizing our role and responsibilities in balancing pain management with helping patients avoid opioid dependency, a group of forward-thinking Cleveland Clinic Florida physicians is looking at ways to stem the tide.

Multimodal pain management for shoulder surgery

Growth rates of total shoulder arthroplasty (TSA) are comparable to those of total hip and knee procedures in the U.S. As these numbers rise, postoperative pain management and optimization of outcomes are critical. Multimodal pain management is the current standard of care for TSA patients, incorporating anti-inflammatories, opioids, other analgesic medications and regional nerve blocks. One option for non-narcotic extended postoperative pain management is continuous interscalene nerve blocks (CISB). These have many advantages, but associated risks have led to exploration of alternatives, such as long-acting liposomal bupivacaine (LB). This agent has gained popularity for its potential to provide extended postoperative pain relief with fewer side effects.

We performed a prospective, randomized clinical trial to assess the efficacy of LB, and found significant reduction in opioid use at 18-24 hours after surgery (P = 0.017). The LB group had equivalent narcotic usage, pain scores and time to first narcotic rescue compared to the gold standard CISB group, but with fewer complications and cost, demonstrating that LB provides an excellent option for postoperative pain relief for shoulder arthroplasty patients (see chart below).

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