Multimodal Pain Management Approach Decreases Postsurgical Opioid Requirements

A novel anesthesiologist-led program was found to significantly reduce opioid requirements among older, high-risk, opioid-tolerant individuals undergoing surgical interventions, according to the results of a study published in Pain Reports.

The Peri-OPerative Pain Management, Education & De-escalation (POPPMED) intervention has been ongoing at the Austin Hospital in Australia since 2017. The POPPMED program comprises behavioral interventions, acute opioid reduction or rotation, and use of multimodal and ketamine analgesia to achieve the lowest possible dosage of long-term opioids. Eligible patients (n=102) were receiving 50 mg or more oral morphine equivalent daily dosage (OMEDD) prior to surgery. Discharge OMEDDs were compared with preoperative prescriptions for this population, as well as with patients who received care prior to initiation of the POPPMED intervention (n=94).

The mean age of patients in the intervention and control cohorts was 62 and 59 years; 36% and 4% were men, and 81 and 70 patients had American Society of Anesthesiologists risk scores of 3, respectively. Interventions included orthopedic (46%), abdominal (20%), spinal (20%), breasts (5%), cranial neurosurgery (3%), and other minor surgical procedures (6%).

Among the intervention cohort, 67% of patients received perioperative infusion of ketamine 0.1 to 0.2 mg/kg/h, 44% of patients received regional analgesia, and 31% of patients underwent acute opioid rotation. Among the opioid rotation cohort, medications included tapentadol (38%), hydromorphone (25%), methadone (16%), buprenorphine (9%), morphine (6%), and oxycodone (3%).

On postoperative days 1 to 3, the 11-point numeric rating scale (NRS) area under the curve (AUC) measurements for pain on movement and at rest were not significantly different for the intervention and control groups. At discharge, participants in the POPPMED group received a higher OMEDD than individuals in the control group (median, 90 mg vs 22 mg; P <.0001).

Among the POPPMED group, the median preoperative OMEDD was 115 mg, which was decreased significantly at discharge to 90 mg (P <.0001). Stratified by baseline opioid use, the cohort that used 90 mg OMEDD or less (18%) received a nonsignificant increase in opioid dose at discharge compared with baseline (median, 62 mg vs 79 mg; P =.17). The cohort that used more than 90 mg OMEDD (82%) decreased their dose significantly (median, 150 mg vs 98 mg; P <.0001). At 6 to 12 months after surgery, OMEDD had decreased to 60 mg (P <.0001).

This study was limited by its nonrandomized design and the fact that participants in the comparator cohort were not at high risk of receiving a high OMEDD at discharge.

These data indicated that a multimodal intervention achieved opioid prescription dose reduction following surgery among patients who had high preoperative opioid use. The authors emphasized, “No single intervention from the service has a statistically significant effect alone, confirming that multiple biological interventions together with nonexpert application of basic psychological support in the form of patient education, reassurance, and engagement can achieve sustained postoperative OMEDD reduction.”