Managing post-surgical pain without opioids

Feb. 09, 2022

Mayo Clinic's multimodal pain protocol avoids the use of opioids while successfully managing patients' pain after the most common orthopedic sports procedures.

"As health care providers, we are in a unique position to have a large impact on the opioid epidemic by limiting our prescriptions of these drugs. We have a chance to improve quality of life and to save lives," says Kelechi R. Okoroha, M.D., an orthopedic surgeon at Mayo Clinic Orthopedics and Sports Medicine in Minneapolis.

Mayo Clinic currently uses the nonopioid pain protocol for anterior cruciate ligament (ACL) reconstructions, meniscus surgeries, and labral and rotator cuff repairs. "We're hoping to expand it to all of sports medicine and to other areas of orthopedics," Dr. Okoroha says.

The protocol comprises preoperative analgesics, intraoperative local infiltration analgesia and a postoperative pain regimen. In a study published in the August 2020 issue of Arthroscopy: The Journal of Arthroscopic & Related Surgery, Dr. Okoroha and colleagues demonstrated that a similar protocol resulted in low levels of pain and minimal use of rescue opioids. "We found that patients required only one or two doses of narcotics postoperatively," Dr. Okoroha says.

Follow-up prospective, blinded, randomized clinical trials are underway comparing the multimodal nonopioid pain protocol to standard-of-care pain management in each of the four types of sports medicine procedures. The meniscus surgery study, published in the July 2021 issue of Arthroscopy: The Journal of Arthroscopic & Related Surgery, found that the multimodal nonopioid protocol provided equivalent pain control compared to opioids. Similar results were obtained in the other three studies, which will be published in the future. "In essence, we were able to manage patients' postoperative pain without opioids," Dr. Okoroha says.

Synergy between elite and nonelite athletes

As a team physician for the Minnesota Timberwolves, Dr. Okoroha assists with optimizing performance and the management of injuries for National Basketball Association players.

"Ultimately, we're trying to keep our players on the court and off the sidelines," he says. "But there's a definite synergy with the treatment of other athletes. In high-level athletics, we're always looking for new and improved treatment techniques. We can extrapolate what works for those athletes to our nonelite athletes."

That commitment to maximizing players' health and performance extends to female athletes. Dr. Okoroha has co-authored studies that document the effects of orthopedic injuries on the careers of Women's National Basketball Association (WNBA) athletes.

One study, published in the June 2021 issue of Orthopaedic Journal of Sports Medicine, found that WNBA athletes with a history of an ACL tear before professional play had decreased game utilization throughout their careers, despite having statistical performance similar to that of healthy controls. Another study, published in the March 2021 issue of Orthopaedic Journal of Sports Medicine, found that most WNBA players who sustained an Achilles tendon rupture had shorter careers compared with those of healthy controls.

"It's important to do the same level of research in female athletes as in our male athletes," Dr. Okoroha says. "Female athletes are at increased risk of certain injuries — including ACL tears — but our research efforts in female athletes are limited compared with those in males. Our role as researchers is to find ways to prevent those injuries."

Dr. Okoroha is also at the forefront of Mayo Clinic's efforts to increase diversity among health care providers. Historically, orthopedic surgery has had a low percentage of specialists who are female or people of color. Mayo Clinic is now participating in Nth Dimensions, an organization founded by orthopedic surgeons to increase diversity in the specialty. Nth Dimensions pairs rising second-year medical students with orthopedic surgeon mentors. A former Nth Dimensions scholar, Dr. Okoroha now serves as a mentor at Mayo Clinic.

"Our mentees get a great exposure to all aspects of orthopedics," he says. "They are able to see patients in the clinic, shadow surgeries and gain research experience. We hope this reinforces our mentees' desires to become orthopedic surgeons."

Nth Dimensions scholars also receive guidance on applying to residencies. "Between 90% and 95% of Nth Dimensions scholars match with an orthopedic residency," Dr. Okoroha says. "Nth Dimensions is a great fit for Mayo Clinic because Mayo has made a real commitment to increasing diversity, particularly in orthopedics."

For more information

Mayo Clinic Orthopedics and Sports Medicine. Mayo Clinic.

Moutzouros V, et al. A multimodal protocol to diminish pain following common orthopedic sports procedures: Can we eliminate postoperative opioids? Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2020;36:2249.

Jildeh TR, et al. Multimodal nonopioid pain protocol provides equivalent pain versus opioid control following meniscus surgery: A prospective randomized controlled trial. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021;37:2237.

Tramer JS, et al. Association of prior anterior cruciate ligament tear with decreased career longevity in Women's National Basketball Association. Orthopaedic Journal of Sports Medicine. 2021;9:23259671211009248.

Tramer JS, et al. Effect of Achilles tendon rupture on player performance and longevity in Women's National Basketball Association players. Orthopaedic Journal of Sports Medicine. 2021;9:2325967121989982.

Refer a patient to Mayo Clinic.