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October 21, 2017
43029.416667 - 43029.5
Room Exhibit Hall B2 - Area E
Multimodal Pain Management in Total Hip and Knee Arthroplasty: Trends Over the Last 10 Years
Philipp Gerner, B.S., Jashvant Poeran, M.D.,Ph.D., Crispiana Cozowicz, M.D., Eva E. Mörwald, M.D., Nicole Zubizarreta, M.P.H., Madhu Mazumdar, Ph.D., Stavros G. Memtsoudis, M.D.,Ph.D.
University of Massachusetts Medical School, Worcester, Massachusetts, United States
Disclosures: P. Gerner: None. J. Poeran: None. C. Cozowicz: None. E.E. Mörwald: None. N. Zubizarreta: None. M. Mazumdar: None. S.G. Memtsoudis: Funded Research; Self; Stavros G. Memtsoudis is funded by the Anna Maria
Introduction: Over 1 million patients undergo total joint arthroplasty surgery in the United States alone every year, with the minority experiencing significant paint postoperatively. Concurrently, increasing awareness of safe opioid prescribing has created an increased interest in alternate, effective post-operative pain management. As part of an analysis of the impact of multimodal pain management (i.e. multiple drug classes or procedures to treat post-operative pain) and opioid usage, we consider how trends have changed over the last 10 years.

Methods: Patients undergoing total hip and knee arthroplasties (THA n=377,657 / TKA n=779,338) were identified using the national Premier Perspective database (2006-2014; 546hospitals). Data on utilization of opioids and a peripheral nerve block (PNB), intravenous acetaminophen, gabapentin/pregabalin, NSAIDs, COX-2 inhibitors, and ketamine was used to categorize patients into four multimodal groups: 1) only opioids, and 2-4) opioids in addition to 1, 2, or 2+ analgesic ‘modes’. Annual utilization trends and hospital characteristics associated with these groups were assessed for THA and TKA separately.

Results: Among THA patients, 17.6% (n=66,484) of patients did not get multimodal postoperative pain management while 37.2% (n=140,622), 29.0% (n=109,640), and 16.1% (n=60,911) received opioids and 1, 2 and 3 additional ‘modes’, respectively. This was 13.9% (n=108,622), 35.9% (n=279,777), 30.7% (n=239,158), and 19.5% (n=151,781) for TKA patients. With relatively modest differences in multimodal use by hospital characteristics, multimodal strategies appear to be used slightly more often in small and medium-sized (<300-499 beds) hospitals with 83-84% of THA patients in these hospitals receiving multimodal strategies (compared to 80% in larger hospitals; P<0.0001); the same pattern was seen in TKA patients. In THA, the percentage of patients not receiving multimodal pain management decreased sharply from 27.2% in 2006 to 10.1% in 2014 (P<0.0001). Conversely, the percentage of patients receiving 1, 2 or 2+ analgesic ‘modes’ in addition to opioids increased sharply; this coincided with a decrease in opioid utilization (measured in oral morphine equivalents) from an average of 304 in 2006 to 220 in 2014 among THA patients. Similar patterns were observed for TKA patients.

Conclusion: In the last 10 years, opioid use for post-operative pain has declined in patients undergoing TKA and TNA, as patients are increasingly being treated with a multimodal approach to pain control. This is especially true in small and medium sized hospitals, compared to larger hospitals. With increasing emphasis on limiting opioid use, this change displays alternate possibilities for successfully treating post-operative pain.

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