POSTOPERATIVE PAIN MANAGEMENT

Two high and three moderate quality articles (Jildeh, 2022; Hofmann-Kiefer, 2008; Chillemi, 2024; Oh, 2018; Yun, M. J. 2012), addressed a variety of individual and multimodal pain management modalities. Based on this literature, it is clear that any one of a variety of non-opioid medications and/or modalities has a positive impact on patient pain control in the post-operative period. It should be noted that most of the literature validated a singular approach against a singular control group and did not perform a direct comparison against all other options. Similarly, indirect comparisons of the literature review findings using network meta-analysis were not statistically feasible. This led to the inability to rank order pain management modalities in a “most effective” to “least effective” manner. Additionally, there is heterogeneity within the literature with regard to the use of and type of regional anesthetic, which may influence the amount of and timeline for oral pain medication following surgery. Because of this, the guideline development group framed the pain management recommendations as a more general list of pain management modalities, both singular and multimodal, which exhibited comparative efficacy, as compared to their within-study comparisons. Further, higher level studies are needed in order to encourage multi-modal, opiate-sparing pain medicine regimes moving forward.

Hofmann-Kiefer, 2008 (High-Quality) compared pain scores as well as functional outcomes between patients who received patient-controlled interscalene block (PCISB) and those who received patient-controlled IV opioid-based analgesia (PCA) after open shoulder surgery. In the PCISB group, pain outcomes (Constant Pain Score, Overall VAS pain, VAS pain at rest, and VAS pain during activity), fentanyl consumption, and averages for nausea and/or vomiting were significantly better than in the PCA group.

Jildeh, 2022 (High-Quality) compared VAS scores, PROMIS scores, patient satisfaction, and adverse drug events in the early post-operative period (post-op days 1-10) between patients who received a multimodal non-opiate IV program (ketorolac, gabapentin, methocarbamol, acetaminophen) and those who received oral opioids (oxycodone) after arthroscopic rotator cuff surgery. In the multimodal group, the average days of constipation and nausea, as well as pain levels on postoperative days 1 and 4, were significantly lower than in the oxycodone group.

Yun, 2012 (Moderate-Quality) compared outcomes between patients who received subacromial patient-controlled analgesia (SA-PCA w/ ropivacaine) and those who received intravenous patient-controlled analgesia (IV-PCA w/ fentanyl, ketorolac, and ondansetron) after arthroscopic rotator cuff repair. In the SA-PCA group, requested bolus dose at 8hrs postop, frequency of bolus dose at 4 hours postop, postop nausea, VAS Pain at 1hr postop, and postop patient satisfaction were significantly better than in the IV-PCA group.

Defining multimodal therapy as using multiple but different modalities of pain management therapies simultaneously in the same post-operative period, the study group was able to arrive at the second multimodal pain management recommendation (recommendation B). The evidence assessing multimodal pain management supported the use of multimodal pain management treatment compared to a single modal approach.

Risks and Harms of Implementing this Recommendation
While the study group’s conclusion that there are various successful options of both singular and multimodal post-operative pain management has moderate strength of evidence, the analysis did not include a risk-benefit comparison of options. Each individual medication or modality carries its own inherent risks and benefits which should be taken into account by the health care provider prescribing the intervention.

Future Research
The analysis of this question has exposed the need for future research particularly into the pros and cons of each medication, modality, and multimodal program, in comparison to each other. The collective data and indirect comparisons from the high-quality articles cited in this recommendation could be used to perform a network meta-analysis, providing valuable information to best guide future management.