STANDARDIZED MULTIMODAL ANALGESIA MANAGEMENT PROTOCOL REDUCES TOTAL OPIOID INTAKE FOLLOWING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION SURGERY

With the current opioid epidemic, multimodal analgesia management combines various analgesic drug classes and/or techniques for an optimal therapeutic approach. The objective of this study was to compare pain and analgesic use pre- and post-implementation of a standardized postoperative analgesia management protocol in those undergoing ACL reconstruction. Patients were part of a larger prospective cohort study launched in November 2018 comparing 2-year outcomes of three autografts in ACL reconstruction. A standardized multimodal postoperative analgesia management protocol was initiated in January 2020 providing an opportunity to compare analgesia use and pain before (PRE group) and after implementation (POST group). This protocol included education of recovery room nurses, verbal and written education of patients, and a discharge prescription which included acetaminophen, nonsteroidal anti-inflammatories (NSAID) and Tramadol. The protocol emphasized taking scheduled acetaminophen and NSAIDs, and using opioids for breakthrough pain. Prior to this implementation, postoperative pain treatment upon discharge was left to the surgeon's discretion. Patients recorded pain on a 10 cm VAS scale and recorded medication use in a standard logbook for 14 days postoperative as “number of tablets” and “dosage of each tablet” specified. Magnitude of pain at Day 1- and -14 were compared for PRE versus POST controlling for graft-type using a General Linear Model. Mean total number of opioid, NSAID, and acetaminophen tablets recorded were compared between groups using t-tests. Acetaminophen contained within an opioid (i.e., tramacet, percocet) were accounted for as both an opioid and an acetaminophen. The number of patients in each group taking opioids at 14-days post-operative is compared using a chi-squared test. 91 patients underwent surgery prior to (PRE) and 142 after implementation (POST) of the multimodal analgesia management protocol. Peak pain for both groups was similar with a mean of 6.2±2.3 (Day 2 am) versus 6.5±2.6 (Day 1 am), for PRE and POST, respectively, and had subsided by Day 14, 1.6±1.5 versus 1.9±1.9 (p=0.145). There was no interaction with respect to graft type. There was a significant decrease in the total number of opioids taken following the implementation of the standardized protocol, 36.7 ±23.2 PRE versus 23.9±23.7 POST (p < 0.001). There was a converse shift in NSAIDS, 10.5±22.4 PRE versus 30.0±24.9 POST (p < 0.001). Acetaminophen use did not change with 47.3±28.5 PRE and 46.2±34.1 POST. There was no statistical difference between the number of patients taking opioids at 14-days, 21% (19/91) PRE versus 13% (19/142) POST (p=0.09). The implementation of a multi-modal postoperative analgesic management protocol reduced the number of opioids taken at 14-days post ACL reconstruction without having an impact magnitude of pain.