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Limiting opioids for postoperative pain management

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Two recent studies revealed a pain management regimen without opioids offered the same pain relief as common prescription opioids.

Opioids can help patients manage pain, but can also be highly addictive with likelihood of a life long dependency rising just after five days of prescription opioid use — increasing risk of eventual addiction and overdose. 

Worldwide, about 500,000 deaths are attributable to drug use, according to the World Health Organization (WHO). More than 70 per cent of these deaths are related to opioids, with more than 30 per cent of those deaths caused by overdose. According to WHO estimates, approximately 115,000 people died of opioid overdose in 2017. Opioid overdoses that do not lead to death are several times more common than fatal overdoses.

"The challenge for surgeons is to minimise opioid use while optimising patients' pain control after surgery," says Kelechi Okoroha, M.D., a Mayo Clinic orthopedic surgeon and sports medicine specialist. Dr Okoroha is the senior author of both studies.

Orthopedic and spine conditions account for about 3 in 10 opioid prescriptions, and surgeons can "significantly decrease opioid-related deaths by limiting opioid prescriptions," explains Dr Okoroha 

Researchers created an approach to managing pain that eliminated opioids after common sports surgeries. In the first study, participants had undergone knee surgery to reconstruct their anterior cruciate ligament (ACL). In the second study, participants had undergone surgery to repair their rotator cuff. All received a nerve block before surgery.

In each study, one group of participants received a standard opioid regimen to manage pain. The other group took part in a pain management approach without opioids. The nonopioid regimen included pain relievers, nonsteroid anti-inflammatory drugs and muscle relaxants.

Both studies found that the nonopioid regimen provided at least the same if not more pain control and patient satisfaction, compared with the standard opioid regimen, and the most common side effects were drowsiness, dizziness and gastrointestinal symptoms. In the rotator cuff study, participants who received the nonopioid regimen reported slightly lesser side effects than those who received the opioid regimen.

"It's a multimodal approach. Before surgery, we might give you a nerve block, and then we give you these multiple medications after surgery that should manage your pain medications such as acetaminophen to target pain, NSAIDS (nonsteroidal anti-inflammatory drugs) to target postoperative inflammation, and muscle relaxants to control muscle cramps and spasms," says Dr. Okoroha. "What we found is that using this multimodal approach, we're able to manage patients' pain with limited or no opioid use after common sports surgeries."

Dr Okoroha says one way Mayo Clinic is working to limit opioids is offering patients alternatives to traditional pain management.

"I think this is really game-changing research," Dr. Okoroha says. "We've found that it is effective in common sports surgeries. So our plan is to implement it in other surgeries and hopefully decrease the opioid burden worldwide."

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