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Table: Multimodal nonopioid postoperative pain-management regimen
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Comparable post-op pain relief for opioid- and nonopioid-based regimens following ACL reconstruction
Clinical Question
After anterior cruciate ligament reconstruction, are opioid- and nonopioid-based regimens comparable for pain control?
Bottom line
In this small study, after ACL reconstruction, opioid- and nonopioid-based regimens appear to provide comparable pain relief, although the latter was complex and requires multiple medications. Since the alternate regimen largely swapped out opioids in favor of benzodiazepines, users of that regimen will need to watch for the unintended consequence of benzodiazepine problems.
This POEM aligns with Choosing Wisely Canada recommendations. Choosing Wisely Canada's Opioid Wisely campaign aims to reduce harm associated with opioid prescribing.
2b
Reference
Study design: Randomized controlled trial (nonblinded)
Funding: Unknown/not stated
Setting: Outpatient (specialty)
Synopsis
These researchers randomized adults undergoing anterior cruciate ligament (ACL) reconstruction to either a multimodal, nonopioid postoperative analgesia regimen (described in the table below; n = 34) or to an opioid-based regimen (n=28). Those randomized to opioid-based therapy received 40 pills containing 5 mg hydrocodone plus 325 mg acetaminophen and were instructed to take 1 or 2 every 4 to 6 hours as needed for moderate to severe post-op pain. Within 2 hours before surgery, all patients received a one-time dose of 400 mg celecoxib orally, 975 mg acetaminophen orally, 300 mg gabapentin orally, 8 mg dexamethasone intravenously, and 50 mg tramadol orally. Both groups of patients had pain reductions over the 10 days following surgery, but after adjusting for possible confounders (age, sex, body mass index, graft type), the nonopioid-managed patients had slightly greater pain relief (mean difference 1.7). The authors also reported that after adjusting for those possible confounders there was no difference between the groups in their scores on the Patient-Reported Outcomes Measurement and Information System Pain Interference Short Form (an evaluation of the consequences of pain). I get nervous when the authors of a small, randomized study do statistical adjustments for possible confounders; it suggests the randomization didn’t work or the study was too small to draw meaningful conclusions.
| Postoperative Days 1–5 | |||
| Morning | Noon | Afternoon | Evening |
| Ketorolac 10 mg | Ketorolac 10 mg | Ketorolac 10 mg | Ketorolac 10 mg |
| Gabapentin 300 mg | Gabapentin 300 mg | Gabapentin 300 mg | Diazepam 5 mg |
| Diazepam 5 mg | Diazepam 5 mg | Diazepam 5 mg | |
| Acetaminophen 1000 mg | Acetaminophen 1000 mg | Acetaminophen 1000 mg | |
| Postoperative Days 6–14 | |||
| Morning | Afternoon | Evening | |
| Meloxicam 7.5 mg | Meloxicam 7.5 mg | Diazepam 5 mg | |
| Diazepam 5 mg | Diazepam 5 mg | Acetaminophen 1000 mg | |
| Acetaminophen 1000 mg | Acetaminophen 1000 mg | ||
Reviewer
Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI
Comments
Drug dosing
Thank you for the tabular display. It will help those who seek to implement this information in their practice.
Study
Are we doing anything good for the patients by substituting opioids for benzodiazepines
Post op pain control in ACL repair
There are a number of issues with this study. The study itself is very small and there are numerous confounders, as identified in the POEM. The regimen in the NSAID arm is quite complex and the potential for medication error is high (taking too much, not enough, missing doses etc)
More concerning to me, however is the heavy use of diazepam in the NSAID arm. The idea of substituting one potential addiction for another needs to be considered.
Opioid vs non-opiod analgesia after ACL reconstruction
I agree with the reviewer -- the inclusion of 15 mg of diazepam a day for 5 days, then 10 mg a day of diazepam a day for 9 days makes the non-opioid analgesic regimen in this study a nonstarter.
post op pain control
ketorolac ok
Benzo invalidates self assessment
I’d be surprised if the non-opioid group was functioning “on all cylinders”. The amnestic effect of diazepam is likely to produce some effect in the patient’s ability to assess their pain scale. “It’s there but I don’t care” would be an unsurprising response.
I see scant value in this study, it’s just a “tip of the hat” to the promulgaters of the “anything but opioids” camp.
Good POEM
Good POEM
opioids vs benzos in post op ACL surgery
benzos may be worse option