Multimodal Pain Management Reduces Opioid Use, Prescriptions after TJA

    A multimodal approach to pain management was associated with a decrease in opioid use, opioid prescriptions, and common opioid-related complications compared with the use of opioids alone in patients undergoing total joint arthroplasty (TJA), according to a study published in the Online First edition of Anesthesiology.

    Opioids’ unwanted side effects – nausea, vomiting, and drowsiness – can hinder a patient’s recovery from TJA, prompting interest in multimodal therapies that manage pain while also reducing the amount of opioids prescribed. “Opioids may have a role to play during and immediately after surgery, but we’ve been relying on them too much,” said lead author Stavros G. Memtsoudis, MD, PhD, director of critical care services in the Department of Anesthesiology and senior scientist at the Hospital for Special Surgery in New York.

    Using Premiere Perspective – a nationwide database that includes information on joint replacement surgeries performed at 546 hospitals – Dr. Memtsoudis and his colleagues examined types of analgesics used between 2006 to 2016 in 512,393 total hip arthroplasty (THA) patients and 1,028,069 total knee arthroplasty (TKA) patients.

    They compared patients who received opioids alone during surgery, on the day of surgery, or during recovery with those who received multimodal therapy. Multimodal techniques are increasingly being used in knee and hip replacement surgery to improve pain control — in this study, multimodal pain therapy was used in 85.6% of cases.

    Compared with patients receiving opioids alone, patients undergoing THA who received more than 2 methods of pain relief in addition to opioids experienced:

    • Up to an 18.5% decrease in opioid prescriptions after surgery
    • 19% fewer respiratory complications
    • 26% fewer gastrointestinal complications
    • A 12% decrease in hospital length of stay

    Similarly, TKA patients who received more than 2 methods of pain relief in addition to opioids experienced:

    • Up to an 18.5% decrease in opioid prescriptions
    • 6% fewer respiratory complications
    • 18% fewer gastrointestinal complications
    • A 9% decrease in hospital length of stay

    Use of multiple analgesics did not, however, lead to decreased hospitalization costs.

    Non-steroidal anti-inflammatory drugs and COX-2 inhibitors seemed to be the most effective modalities used in multimodal regimens, resulting in the greatest reduction in opioid prescriptions and complication risk. Using a peripheral nerve block in a multimodal regimen was also found to be effective in reducing complications and opioid prescriptions. 

    However, Dr. Memtsoudis noted, “this study does not answer the question of [which] 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.

    “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 1 medicine, we are attacking pain on many different levels.”

    Future studies are needed to identify the maximum number of analgesic methods effective in improving outcomes. 

    “We think 3 or 4 is probably the maximum — more than that may only increase drug-related side effects,” Dr. Memtsoudis said. “Future studies are needed to identify optimal multimodal regimens and patient subgroups most likely to benefit from each combination.”


    Memtsoudis SG, Poeran J, Zubizarreta N, et al. Association of multimodal pain management strategies with perioperative outcomes and resource utilization: a population-based study. Anesthesiology. Published Online First on March 1 2018. doi:10.1097/ALN.0000000000002132