{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,28]],"date-time":"2026-10-28T01:25:11Z","timestamp":1793150711649,"version":"4.5.0"},"reference-count":38,"publisher":"American Medical Association (AMA)","issue":"13","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA"],"published-print":{"date-parts":[[2022,10,4]]},"abstract":"Importance<\/jats:title>In arthroscopic knee and shoulder surgery, there is growing evidence that opioid-sparing protocols may reduce postoperative opioid consumption while adequately addressing patients\u2019 pain. However, there are a lack of prospective, comparative trials evaluating their effectiveness.<\/jats:p><\/jats:sec>Objective<\/jats:title>To evaluate the effect of a multimodal, opioid-sparing approach to postoperative pain management compared with the current standard of care in patients undergoing arthroscopic shoulder or knee surgery.<\/jats:p><\/jats:sec>Design, Setting, and Participants<\/jats:title>This randomized clinical trial was performed at 3 clinical sites in Ontario, Canada, and enrolled 200 patients from March 2021 to March 2022 with final follow-up completed in April 2022. Adult patients undergoing outpatient arthroscopic shoulder or knee surgery were followed up for 6 weeks postoperatively.<\/jats:p><\/jats:sec>Interventions<\/jats:title>The opioid-sparing group (100 participants randomized) received a prescription of naproxen, acetaminophen (paracetamol), and pantoprazole; a limited rescue prescription of hydromorphone; and a patient educational infographic. The control group (100 participants randomized) received the current standard of care determined by the treating surgeon, which consisted of an opioid analgesic.<\/jats:p><\/jats:sec>Main Outcomes and Measures<\/jats:title>The primary outcome was postoperative oral morphine equivalent (OME) consumption at 6 weeks after surgery. There were 5 secondary outcomes, including pain, patient satisfaction, opioid refills, quantity of OMEs prescribed at the time of hospital discharge, and adverse events at 6 weeks all reported at 6 weeks after surgery.<\/jats:p><\/jats:sec>Results<\/jats:title>Among the 200 patients who were randomized (mean age, 43 years; 73 women [38%]), 193 patients (97%) completed the trial; 98 of whom were randomized to receive standard care and 95 the opioid-sparing protocol. Patients in the opioid-sparing protocol consumed significantly fewer opioids (median, 0 mg; IQR, 0-8.0 mg) than patients in the control group (median, 40.0 mg; IQR, 7.5-105.0; z<\/jats:italic>\u2009=\u2009\u22126.55; P<\/jats:italic>\u2009&amp;lt;\u2009.001). Of the 5 prespecified secondary end points, 4 showed no significant difference. The mean amount of OMEs prescribed was 341.2 mg (95% CI, 310.2-372.2) in the standard care group and 40.4 mg (95% CI, 39.6-41.2) in the opioid-sparing group (mean difference, 300.8 mg; 95% CI, 269.4-332.3; P<\/jats:italic>\u2009&amp;lt;\u2009.001). There was no significant difference in adverse events at 6 weeks (2 events [2.1%] in the standard care group vs 3 events [3.2%] in the opioid-sparing group), but more patients reported medication-related adverse effects in the standard care group (32% vs 19%, P<\/jats:italic>\u2009=\u2009.048).<\/jats:p><\/jats:sec>Conclusions and Relevance<\/jats:title>Among patients who underwent arthroscopic knee or shoulder surgery, a multimodal opioid-sparing postoperative pain management protocol, compared with standard opioid prescribing, significantly reduced postoperative opioid consumption over 6 weeks.<\/jats:p><\/jats:sec>Trial Registration<\/jats:title>ClinicalTrials.gov Identifier: NCT04566250<\/jats:ext-link><\/jats:p><\/jats:sec>","DOI":"10.1001\/jama.2022.16844","type":"journal-article","created":{"date-parts":[[2022,10,4]],"date-time":"2022-10-04T11:06:07Z","timestamp":1664881567000},"page":"1326","source":"Crossref","is-referenced-by-count":81,"title":["Effect of a Postoperative Multimodal Opioid-Sparing Protocol vs Standard Opioid Prescribing on Postoperative Opioid Consumption After Knee or Shoulder Arthroscopy"],"prefix":"10.1001","volume":"328","author":[{"name":"The NO PAin Investigators","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew","family":"Duong","sequence":"additional","affiliation":[{"name":"The NO PAin Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea K.","family":"Ponniah","sequence":"additional","affiliation":[{"name":"The NO PAin Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Caitlin","family":"VanDeCapelle","sequence":"additional","affiliation":[{"name":"The NO PAin Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Franca","family":"Mossuto","sequence":"additional","affiliation":[{"name":"The NO PAin Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eric","family":"Romeril","sequence":"additional","affiliation":[{"name":"The NO PAin Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Steve","family":"Phillips","sequence":"additional","affiliation":[{"name":"The NO PAin Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Herman","family":"Johal","sequence":"additional","affiliation":[{"name":"The NO PAin Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jamal","family":"Al-Asiri","sequence":"additional","affiliation":[{"name":"The NO PAin Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel","family":"Tushinski","sequence":"additional","affiliation":[{"name":"The NO PAin Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas J.","family":"Wood","sequence":"additional","affiliation":[{"name":"The NO PAin Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Devin","family":"Peterson","sequence":"additional","affiliation":[{"name":"The NO PAin Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew","family":"Denkers","sequence":"additional","affiliation":[{"name":"The NO PAin Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anthony","family":"Adili","sequence":"additional","affiliation":[{"name":"The NO PAin Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vickas","family":"Khanna","sequence":"additional","affiliation":[{"name":"The NO PAin Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jaydeep","family":"Moro","sequence":"additional","affiliation":[{"name":"The NO PAin Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Imad","family":"Kashir","sequence":"additional","affiliation":[{"name":"The NO PAin Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Grace","family":"Mwakijele","sequence":"additional","affiliation":[{"name":"The NO PAin Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Darren","family":"Young Shing","sequence":"additional","affiliation":[{"name":"The NO PAin Investigators"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aaron","family":"Gazendam","sequence":"additional","affiliation":[{"name":"Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Seper","family":"Ekhtiari","sequence":"additional","affiliation":[{"name":"Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nolan S.","family":"Horner","sequence":"additional","affiliation":[{"name":"Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicole","family":"Simunovic","sequence":"additional","affiliation":[{"name":"Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Moin","family":"Khan","sequence":"additional","affiliation":[{"name":"Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Darren L.","family":"de SA","sequence":"additional","affiliation":[{"name":"Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kim","family":"Madden","sequence":"additional","affiliation":[{"name":"Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Olufemi R.","family":"Ayeni","sequence":"additional","affiliation":[{"name":"Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","reference":[{"issue":"6","key":"joi220101r1","doi-asserted-by":"publisher","first-page":"595","DOI":"10.1016\/j.amjmed.2017.12.045","article-title":"Backstories on the US opioid epidemic: good intentions gone bad, an industry gone rogue, and watch dogs gone to sleep.","volume":"131","author":"deShazo","year":"2018","journal-title":"Am J Med"},{"issue":"S1","key":"joi220101r2","doi-asserted-by":"publisher","first-page":"e10","DOI":"10.1111\/anae.v75.S1","article-title":"Postoperative pain management: time to get back on track.","volume":"75","author":"Quinlan","year":"2020","journal-title":"Anaesthesia"},{"issue":"3","key":"joi220101r3","doi-asserted-by":"publisher","first-page":"180","DOI":"10.2106\/JBJS.17.00672","article-title":"Excess opioid medication and variation in prescribing patterns following common orthopaedic procedures.","volume":"100","author":"Sabatino","year":"2018","journal-title":"J Bone Joint Surg Am"},{"issue":"5","key":"joi220101r4","doi-asserted-by":"publisher","first-page":"e153","DOI":"10.1016\/j.amepre.2018.06.008","article-title":"Opioid prescribing by specialty and volume in the US.","volume":"55","author":"Guy","year":"2018","journal-title":"Am J Prev Med"},{"issue":"5","key":"joi220101r5","doi-asserted-by":"publisher","first-page":"1043","DOI":"10.1177\/0363546518819780","article-title":"Risk of prolonged opioid use among opioid-na\u00efve patients after common shoulder arthroscopy procedures.","volume":"47","author":"Gil","year":"2019","journal-title":"Am J Sports Med"},{"issue":"12","key":"joi220101r6","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2019.17315","article-title":"US geographical variation in rates of shoulder and knee arthroscopy and association with orthopedist density.","volume":"2","author":"Jain","year":"2019","journal-title":"JAMA Netw Open"},{"issue":"4","key":"joi220101r7","doi-asserted-by":"publisher","DOI":"10.7759\/cureus.7856","article-title":"Narcotic prescriptions following knee and shoulder arthroscopy: a survey of the Arthroscopy Association of Canada.","volume":"12","author":"Ekhtiari","year":"2020","journal-title":"Cureus"},{"issue":"4","key":"joi220101r8","doi-asserted-by":"publisher","DOI":"10.2106\/JBJS.OA.18.00033","article-title":"Monitoring postoperative opioid use following simple arthroscopic meniscectomy: a performance-improvement strategy for prescribing recommendations and community safety.","volume":"3","author":"Gardner","year":"2018","journal-title":"JB JS Open Access"},{"issue":"3","key":"joi220101r9","doi-asserted-by":"publisher","first-page":"636","DOI":"10.1177\/0363546517693665","article-title":"Unused opioid pills after outpatient shoulder surgeries given current perioperative prescribing habits.","volume":"45","author":"Kumar","year":"2017","journal-title":"Am J Sports Med"},{"issue":"6","key":"joi220101r10","doi-asserted-by":"publisher","first-page":"1887","DOI":"10.1007\/s00167-020-06256-2","article-title":"Perioperative nonopioid analgesia reduces postoperative opioid consumption in knee arthroscopy: a systematic review and meta-analysis.","volume":"29","author":"Gazendam","year":"2020","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"issue":"6","key":"joi220101r11","doi-asserted-by":"publisher","first-page":"1641","DOI":"10.1016\/j.arthro.2019.03.028","article-title":"Patient satisfaction with nonopioid pain management following arthroscopic partial meniscectomy and\/or chondroplasty.","volume":"35","author":"Daniels","year":"2019","journal-title":"Arthroscopy"},{"issue":"3","key":"joi220101r12","doi-asserted-by":"publisher","first-page":"864","DOI":"10.1016\/j.arthro.2018.09.018","article-title":"The utility of oral nonsteroidal anti-inflammatory drugs compared with standard opioids following arthroscopic meniscectomy: a prospective observational study.","volume":"35","author":"Pham","year":"2019","journal-title":"Arthroscopy"},{"issue":"14","key":"joi220101r13","doi-asserted-by":"publisher","first-page":"3794","DOI":"10.1177\/03635465211045394","article-title":"Can we eliminate opioids after anterior cruciate ligament reconstruction? a prospective, randomized controlled trial.","volume":"49","author":"Moutzouros","year":"2021","journal-title":"Am J Sports Med"},{"issue":"7","key":"joi220101r14","doi-asserted-by":"publisher","first-page":"2237","DOI":"10.1016\/j.arthro.2021.02.043","article-title":"Multimodal nonopioid pain protocol provides equivalent pain versus opioid control following meniscus surgery: a prospective randomized controlled trial.","volume":"37","author":"Jildeh","year":"2021","journal-title":"Arthroscopy"},{"issue":"11","key":"joi220101r15","doi-asserted-by":"publisher","first-page":"2445","DOI":"10.1016\/j.jse.2021.07.008","article-title":"Multimodal nonopioid pain protocol provides equivalent pain control versus opioids following arthroscopic shoulder labral surgery: a prospective randomized controlled trial.","volume":"30","author":"Jildeh","year":"2021","journal-title":"J Shoulder Elbow Surg"},{"issue":"1","key":"joi220101r16","first-page":"1","article-title":"Protocol for a multicenter randomized controlled trial comparing a non-opioid prescription to the standard of care for pain control following arthroscopic knee and shoulder surgery.","volume":"22","author":"NO PAin Investigators","year":"2021","journal-title":"BMC Musculoskelet Disord"},{"issue":"8","key":"joi220101r18","doi-asserted-by":"publisher","first-page":"2249","DOI":"10.1016\/j.arthro.2020.04.018","article-title":"A multimodal protocol to diminish pain following common orthopedic sports procedures: can we eliminate postoperative opioids?","volume":"36","author":"Moutzouros","year":"2020","journal-title":"Arthroscopy"},{"issue":"24","key":"joi220101r19","doi-asserted-by":"publisher","first-page":"E895","DOI":"10.1503\/cmaj.201915","article-title":"Managing postoperative pain in adult outpatients: a systematic review and meta-analysis comparing codeine with NSAIDs.","volume":"193","author":"Choi","year":"2021","journal-title":"CMAJ"},{"issue":"1-2","key":"joi220101r21","doi-asserted-by":"publisher","first-page":"95","DOI":"10.1016\/S0304-3959(97)00005-5","article-title":"The visual analogue pain intensity scale: what is moderate pain in millimetres?","volume":"72","author":"Collins","year":"1997","journal-title":"Pain"},{"issue":"3","key":"joi220101r23","doi-asserted-by":"publisher","first-page":"424","DOI":"10.1093\/bja\/aew466","article-title":"Measuring acute postoperative pain using the visual analog scale: the minimal clinically important difference and patient acceptable symptom state.","volume":"118","author":"Myles","year":"2017","journal-title":"Br J Anaesth"},{"issue":"6","key":"joi220101r24","doi-asserted-by":"publisher","first-page":"1004","DOI":"10.1016\/j.jamcollsurg.2018.01.058","article-title":"Post-discharge opioid prescribing and use after common surgical procedure.","volume":"226","author":"Fujii","year":"2018","journal-title":"J Am Coll Surg"},{"issue":"3","key":"joi220101r25","first-page":"205","article-title":"Practical tips for surgical research: how to optimize patient recruitment.","volume":"53","author":"Thoma","year":"2010","journal-title":"Can J Surg"},{"issue":"7","key":"joi220101r26","doi-asserted-by":"publisher","first-page":"691","DOI":"10.1001\/jamasurg.2017.0898","article-title":"Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques: a review.","volume":"152","author":"Wick","year":"2017","journal-title":"JAMA Surg"},{"issue":"7","key":"joi220101r27","doi-asserted-by":"publisher","first-page":"659","DOI":"10.2106\/JBJS.21.00466","article-title":"What\u2019s important: a rallying call for nonsteroidal anti-inflammatory drugs in musculoskeletal pain: improving value of care while combating the opioid epidemic.","volume":"104","author":"Hung","year":"2021","journal-title":"J Bone Joint Surg Am"},{"issue":"9","key":"joi220101r28","doi-asserted-by":"publisher","first-page":"730","DOI":"10.7326\/M19-3601","article-title":"Management of acute pain from non-low back, musculoskeletal injuries: a systematic review and network meta-analysis of randomized trials.","volume":"173","author":"Busse","year":"2020","journal-title":"Ann Intern Med"},{"issue":"4","key":"joi220101r29","doi-asserted-by":"publisher","first-page":"1170","DOI":"10.1213\/ANE.0b013e3181cf9281","article-title":"Combining paracetamol (acetaminophen) with nonsteroidal anti-inflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain.","volume":"110","author":"Ong","year":"2010","journal-title":"Anesth Analg"},{"issue":"4","key":"joi220101r30","doi-asserted-by":"publisher","first-page":"1077","DOI":"10.1016\/j.arthro.2021.11.028","article-title":"Multimodal nonopioid pain protocol provides better or equivalent pain control compared to opioid analgesia following arthroscopic rotator cuff surgery: a prospective randomized controlled trial.","volume":"38","author":"Jildeh","year":"2022","journal-title":"Arthroscopy"},{"issue":"1","key":"joi220101r31","doi-asserted-by":"publisher","DOI":"10.1001\/jamasurg.2018.4234","article-title":"Association of opioid prescribing with opioid consumption after surgery in Michigan.","volume":"154","author":"Howard","year":"2019","journal-title":"JAMA Surg"},{"issue":"2","key":"joi220101r32","doi-asserted-by":"publisher","first-page":"145","DOI":"10.1001\/jamainternmed.2018.5419","article-title":"Association of opioid prescriptions from dental clinicians for US adolescents and young adults with subsequent opioid use and abuse.","volume":"179","author":"Schroeder","year":"2019","journal-title":"JAMA Intern Med"},{"issue":"24","key":"joi220101r33","doi-asserted-by":"publisher","first-page":"2465","DOI":"10.1001\/jama.2019.6125","article-title":"Association between quantity of opioids prescribed after surgery or preoperative opioid use education with opioid consumption.","volume":"321","author":"Farley","year":"2019","journal-title":"JAMA"},{"issue":"1","key":"joi220101r35","doi-asserted-by":"publisher","first-page":"e33","DOI":"10.1016\/j.asmr.2019.10.006","article-title":"Preoperative patient education may decrease postoperative opioid use after meniscectomy.","volume":"2","author":"Andelman","year":"2019","journal-title":"Arthrosc Sports Med Rehabil"},{"issue":"6","key":"joi220101r36","doi-asserted-by":"publisher","first-page":"962","DOI":"10.1016\/j.jse.2018.02.039","article-title":"Neer Award 2018: the effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: a prospective, randomized clinical trial.","volume":"27","author":"Syed","year":"2018","journal-title":"J Shoulder Elbow Surg"},{"issue":"5","key":"joi220101r37","doi-asserted-by":"publisher","first-page":"1573","DOI":"10.1016\/j.arthro.2021.02.029","article-title":"Opioid sparing through patient education programs is the future for sports medicine and arthroscopic surgery to optimize outcome.","volume":"37","author":"Rossi","year":"2021","journal-title":"Arthroscopy"},{"issue":"9","key":"joi220101r38","doi-asserted-by":"publisher","first-page":"1743","DOI":"10.1016\/j.jse.2020.04.036","article-title":"The effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: a prospective, randomized clinical trial-2-year follow-up.","volume":"29","author":"Cheesman","year":"2020","journal-title":"J Shoulder Elbow Surg"},{"key":"joi220101r34","volume-title":"The CBHSQ Report","author":"Lipari","year":"2017"},{"key":"joi220101r17","unstructured":"CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. The EQUATOR Network. Updated November 25, 2021. Accessed March 19, 2022. https:\/\/www.equator-network.org\/reporting-guidelines\/consort\/"},{"key":"joi220101r20","unstructured":"About CDC\u2019s opioid prescribing guideline. Centers for Disease Control and Prevention. Published March 18, 2022. Accessed March 31, 2022. https:\/\/www.cdc.gov\/opioids\/providers\/prescribing\/guideline.html"},{"key":"joi220101r22","unstructured":"HCAHPS: patients\u2019 perspectives of care survey. Centers for Medicare & Medicaid Services. Accessed November 13, 2020. https:\/\/www.cms.gov\/medicare\/quality-initiatives-patient-assessment-instruments\/hospitalqualityinits\/hospitalhcahps"}],"container-title":["JAMA"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jama\/articlepdf\/2796947\/jama_gazendam_2022_oi_220101_1670867012.74072.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,12,13]],"date-time":"2022-12-13T11:06:36Z","timestamp":1670929596000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jama\/fullarticle\/2796947"}},"subtitle":["A Randomized Clinical Trial"],"short-title":[],"issued":{"date-parts":[[2022,10,4]]},"references-count":38,"journal-issue":{"issue":"13","published-print":{"date-parts":[[2022,10,4]]}},"URL":"https:\/\/doi.org\/10.1001\/jama.2022.16844","relation":{},"ISSN":["0098-7484"],"issn-type":[{"value":"0098-7484","type":"print"}],"subject":[],"published":{"date-parts":[[2022,10,4]]}}}