A Non-Opioid Way to Pain Relief After Knee, Shoulder Surgeries
Two new studies on pain relief suggest there is a safer alternative to addictive opioid painkillers after knee and shoulder surgery.
The findings dovetail with changes to voluntary federal guidelines for prescribing opioid painkillers proposed by the U.S. Centers for Disease Control and Prevention last week. The proposal urges doctors to prescribe non-opioid therapies whenever possible.
"These studies demonstrated that an alternative non-opioid pain regimen was just as effective in managing postoperative pain following ACL and rotator cuff surgery compared with traditional opioid medication," said Dr. Kelechi Okoroha, lead author of both studies. He's an orthopedic surgeon at the Mayo Clinic's orthopedics and sports medicine facility in Minneapolis.
In one study, 62 patients had knee surgery to reconstruct their anterior cruciate ligament (ACL), and the second study included 40 people who had surgery to repair the rotator cuff in their shoulders.
Everyone received a nerve block before surgery. In both studies, one group received an opioid for pain, while the other received non-opioid pain relievers such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and/or drugs targeting nerve pain.
Both studies found the non-opioid regimen provided as much -- if not more -- pain control and satisfaction as opioids for the first 10 days after surgery.
The various medications target different types of pain, Okoroha said.
"Acetaminophen and NSAIDs are used to target the pain cascade and postoperative inflammation, respectively," he said. "Gabapentin is used to address nerve-related pain and methocarbamol [Robaxin] can control muscle cramps and spasms."
This strategy eliminates the use of opioids, which are highly addictive and have led to a nationwide epidemic of overdoses. Orthopedic and spine conditions account for about 3 in 10 opioid prescriptions, Okoroha said.
The new approach may also help people undergoing other types of surgery to avoid opioids and their risks, he said.
"The regimen has been found to be effective in common sports surgeries but could be expanded to a wider range of procedures," Okoroha said.
In both studies, the most common side effects were drowsiness, dizziness and gastrointestinal symptoms. In the shoulder study, participants who received the non-opioid regimen reported fewer side effects than those who took opioids.
Two outside experts welcomed the findings.
"The opioid epidemic still exists, and some people do become addicted after postoperative use of opioids," said Dr. Adam Yanke, an orthopedic surgeon at Rush University Medical Center in Chicago.
He stressed that opioids aren't all bad, however. They can be highly effective at reducing pain when given in small doses after big surgeries.
"The two studies certainly demonstrate that at least early on, many patients can do well without opioids after surgery," Yanke said, adding that this approach may help people get back on their feet faster, too. Many now go home the same day as their joint replacement surgery, making it important to provide a pain relief regimen that won't cause them to get dizzy or fall.
The new approach dramatically cuts back on side effects and risks seen with opioids, agreed Dr. Faye Rim, a physiatrist and pain management specialist at Hospital for Special Surgery in New York City.
"While there are more medications to take with this approach compared to an opioid, there may be less adverse reactions such as constipation, nausea and over-sedation, and there is less concern for dependence or withdrawal symptoms when stopping these medications as well," she said.
This regimen could work for any painful procedure, Rim said.
"Patients must be in agreement and acknowledge the risks and benefits for a non-opioid protocol, and have realistic expectations for the postoperative period," she added.
The shoulder surgery study was published recently in Arthroscopy: The Journal of Arthroscopic and Related Surgery, and the ACL surgery was detailed in The American Journal of Sports Medicine.
The U.S. Department of Health and Human Services provides more information on alternatives to opioids for pain relief.
SOURCES: Kelechi Okoroha, MD, orthopedic surgeon and sports medicine specialist, Mayo Clinic, Minneapolis; Adam Yanke MD, PhD, sports medicine orthopedic surgeon, assistant director, Cartilage Restoration Center, Rush University Medical Center, Chicago; Faye Rim, MD, physiatrist, pain management specialist, Hospital for Special Surgery, New York City; Arthroscopy: The Journal of Arthroscopic and Related Surgery, Nov. 25, 2021; The American Journal of Sports Medicine, Dec. 1, 2021