Trends in Pain Management for Knee Replacement

    Preliminary results from a study presented at ANESTHESIOLOGY 2015 show the evolving nature of pain management for TKA, with less emphasis on IV PCA and more emphasis on non-opioid analgesics as part of multimodal analgesia approach.

    Utilizing a large national database, a research team from the Hospital for Special Surgery and the Icahn School of Medicine at Mount Sinai studied trends in perioperative use of opioids, non-opioid analgesics, and nerve blocks in total knee arthroplasty (TKA) and total hip arthroplasty (THA).

    Their preliminary findings, presented at the ANESTHESIOLOGY 2015 annual meeting, addressed pain management in TKA and showed:

    • A shift in the types of opioids used
    • An increase in the use of peripheral nerve blocks, intravenous (IV) acetaminophen, and gabapentinoids
    • A decline in the use of IV patient-controlled analgesia (PCA)

    “With large-scale data lacking on characteristics of postoperative pain control strategies, our objective was to analyze trends and patterns in pain management for these very frequent surgical procedures,” said lead author Jashvant Poeran, MD, PhD, from the Department of Population Health Science & Policy at Icahn School of Medicine at Mount Sinai in New York.

    “In particular, trends in the utilization of opioids – which are linked to adverse events such as respiratory depression, nausea/vomiting and ileus – were of major interest to us,” he continued. “We wanted to understand trajectories in care and how opioid-sparing techniques such as non-steroidal medication use and peripheral nerve blocks may have influenced trends.”

    Findings in TKA

    For their retrospective cohort study, the research team utilized the claims-based Premier Perspective database to extract data from 2006 to 2013, which included over 1 million TKAs and THAs from 540 hospitals.

    For TKA, they found an increase in the use of hydromorphone (oral and IV), oral morphine, and oral oxycodone and a decrease in the use of oral hydrocodone, IV meperidine, and IV morphine.

    Utilization of peripheral nerve blocks increased from 15.3% in 2006 to 24.5% in 2013. Interestingly, there was a sharp decline in the use of IV PCA, from 51.3% in 2006 to 19.2% in 2013, which Dr. Poeran called a “quite remarkable” finding.

    Other findings showed increased use of other non-opioid analgesics given on the day of surgery, especially IV acetaminophen, which was not used in 2006 (0%) and rose to 25.7% in 2013. Likewise, pregabalin increased from 0.8% to 10.6% and gabapentin from 3.6% to 14.8% during the study period.

    “The significant uptake of IV acetaminophen since its approval in 2010, despite questions regarding its utility in proportion to its cost, was noteworthy,” Dr. Poeran said. “Furthermore, the increased administration of anticonvulsants by a several fold within the study period is a remarkable development.”

    He added that with regard to meperidine, “it seems that due to increasingly dreaded side effects and interactions associated with the use of this particular medication, it is falling out of favor in the US.”

    Although results for THA were not reported, the researchers said similar patterns were observed in this population.

    Evolving Pain Management

    Dr. Poeran said the preliminary results of their study show that postoperative pain management for orthopaedic procedures like TKA and THA is evolving, with less emphasis on IV PCA and more emphasis on non-opioid analgesics as part of multimodal analgesia approach.

    Could changes in the overall landscape of healthcare in the US have played a role in the evolution of pain management? Dr. Poeran says it is a distinct possibility.

    “While speculative at this point, these changes could be attributable to several recent developments in healthcare,” he said. “The increasing volume in orthopedic surgery has caused significant economic and logistic strain on healthcare.

    “This burden and recent scientific findings have sparked changes in pain management strategies and facilitated the implementation of fast-track programs in orthopedic surgery.”

    Adequate pain control and patient satisfaction are closely tied to the push toward early mobilization and patient discharge, Dr. Poeran noted. Because multimodal analgesia addresses multiple sites of the pain pathway, there is less reliance on opioids, with a subsequent reduction in side effects. Patients are out of bed, moving around, and ready to be discharged sooner.

    “An important factor in this context is the increasing utilization of regional anesthesia techniques, with excellent results in pain control for these particular procedures,” Dr. Poeran said.

    “Therefore, there could be a shift toward earlier oral opioid and adjunctive pain medication in combination with regional anesthesia leading to subsequent reduction in IV PCA and IV morphine consumption.”

    Next Steps

    Dr. Poeran and his colleagues next intend to further analyze the opioid-sparing effect of multimodal analgesia and link trends to outcomes.

    “These findings are preliminary results, and the subsequent steps will be to implement multivariable analysis specifically aiming at potential opioid-sparing effects and evaluating whether trends in opioid consumption are linked to potential opioid-related outcomes,” Dr. Poeran said.

    “In this context we hypothesize that in cases with higher use of opioids, there will be a higher rate of complications, an increase in length of hospital stays, and higher hospitalization costs.”


    Poeran P, Cozowicz C, Zubizarreta N, Ozbek U, Mazumdar M, Memtsoudis SG. National trends in postoperative pain management after hip and knee arthroplasties. Presented at ANESTHESIOLOGY 2015 Annual Meeting of the American Society of Anesthesiologists, October 24-28, 2015, San Diego, California. Abstract A4116.