This Consensus Statement provides recommendations on the prescription of pain medication at discharge from hospital for opioid-naïve adult patients who undergo elective surgery. It encourages health care providers  to (1) use nonopioid therapies and reduce the prescription of opioids so that fewer opioid pills are available for diversion and (2) educate patients and their families/caregivers about pain management options after surgery to optimize quality of care for postoperative pain.These recommendations apply to opioid-naïve adult patients who undergo elective surgery. This consensus statement is intended for use by health care providers involved in the management and care of surgical patients.A modified Delphi process was used to reach consensus on the recommendations. First, the authors conducted a scoping review of the literature to determine current best practices and existing guidelines. From the available literature and expertise of the authors, a draft list of recommendations was created. Second, the authors asked key stakeholders to review and provide feedback on several drafts of the document and attend an in-person consensus meeting. The modified Delphi stakeholder group included surgeons, anesthesiologists, residents, fellows, nurses, pharmacists, and patients. After multiple iterations, the document was deemed complete. The recommendations are not graded because they are mostly based on consensus rather than evidence. Minimize the prescription of opioids and encourage the use of nonopioid therapies for postoperative pain to ensure that fewer opioid-containing tablets are available for diversion.Educate patients and their families/caregivers on pain management options in relation to functional recovery.The aim of this consensus statement is to make recommendations for the prescription of pain medication at discharge from hospital for opioid-naïve adult patients who have undergone an elective surgical procedure. This consensus statement aims to encourage health care providers toMinimize the use of opioids for postoperative pain.Maintain an acceptable level of postoperative pain control while minimizing the use of opioids.Reduce the number of opioid-containing tablets available for diversion or hoarding.These recommendations apply to opioid-naïve adult patients who undergo elective surgery.Patients who are at high risk of persistent postoperative opioid use (see recommendation 2) should be seen preoperatively by an anesthesiologist or a member of the pain team to develop a perioperative pain management plan. The consensus statement may be utilized in high-risk patients who are opioid naïve, provided that follow-up is arranged postdischarge  given their increased risk of persistent opioid use.This consensus statement is intended for use by health care providers involved in the management and care of surgical patients, including surgeons, anesthesiologists, nurses, pain teams, pharmacists, allied health professionals, and residents and fellows.The rationale for developing a consensus statement on the management of postoperative pain was largely based on the rising public health concern over the opioid crisis. This can be contrasted with past efforts to avoid opioid use by patients to prevent undesirable side effects. Opioids remain an excellent option for the treatment of acute pain, but if not prescribed responsibly and without proper patient education regarding storage and safe disposal, they can become an easy target for diversion.1 This consensus statement directly impacts the overprescription of opioids following surgery and creates a framework for opioid-naïve patients presenting for elective surgery. It tackles the issue of diversion and provides a proactive solution for the perioperative world.To date, the estimated the amount of opioids that remain unused after elective adult surgery can be greater than 80%.Though the risk of persistent opioid use and/or the development of an opioid use disorder in elective patients following surgery is low, perioperative practitioners/surgeons must respond to the crisis and act proactively and responsibly by modifying our practices and creating best practices. The authors have taken extreme care in balancing patient well-being with the need for appropriate pain control in the opioid-naïve elective surgery patient . As the gatekeepers of opioid access through prescribing, it is imperative that all health care workers involved in the chain of prescribing and dispensing become familiar with safe practices that will protect the public from potential harm or an unnecessarily excessive exposure to opioids.A scoping review of the published literature was conducted to determine whether guidelines for the prescription of opioids after surgery existed. Key words included “opioid,” “multimodal pain management,” “postoperative pain management,” “guidelines,” “clinical practice,” “standards,” and “postoperative.” Though there were many published articles documenting current practice and the need for guidelines; there was limited published literature to guide practice on minimizing the amount of opioids prescribed after elective surgery for opioid-naïve patients. Due to the limited information found, the next step was to review the gray literature, society websites, and hospital websites to determine whether there were guidelines on the prescription of opioids after surgery. This search produced more results.A master list of all recommendations from each article was compiled by one author (E.P.) and the authors met to discuss the recommendations (or lack thereof). The authors then created draft recommendations based on previously published guidelines and expert opinion.Best Practice in Surgery Newsletter, which goes out to key stakeholders across the province of Ontario. Surgeons and anesthesiologists who responded also recommended pharmacists, nurses, and nurse practitioners from their hospital, who were then invited to join the working group. The working group members are listed as authors on this document.Once a complete list of draft recommendations was developed by the authors, an email invitation was sent to all staff surgeons, anesthesiologists, and residents at the University of Toronto Departments of Surgery and Anesthesia to be part of the opioid working group. The working group would be responsible for the development of the consensus statement recommendations as well as drafting the supporting evidence. An open call was also sent out in the A modified Delphi process was used to gain consensus on the recommendations due to the lack of available evidence. As part of this process, an invitation was sent via email to all staff surgeons and anesthesiologists associated with the University of Toronto Departments of Anesthesiology and Surgery to invite them to be part of the modified Delphi process. In the invitation, we also requested that surgeons and anesthesiologists extend an invitation to nurses and pharmacists who are interested in postoperative pain management. Lastly, members from the Best Practice in Surgery Patient Advisory Committee were invited to participate. In total, 40 persons agreed to be part of the modified Delphi process. This group included surgeons, anesthesiologists, pharmacists, nurses, and patients.The modified Delphi process included reviewing several iterations of the consensus document as well as attending an in-person meeting. The first step of the process was for the stakeholders’ group to review a draft consensus statement with recommendations and send feedback prior to the in-person meeting. The working group then reviewed the comments and feedback and made changes as necessary.The next step was to host an in-person stakeholder meeting that included members of the working group as well as the stakeholders who agreed to be part of the modified Delphi process. The stakeholder consensus meeting was held in November 2018 with participants from University of Toronto–affiliated hospitals as well as other Canadian content experts. The recommendations and supporting evidence were reviewed and discussed in person until consensus was reached or a plan for modification was decided. The document was then further refined based on the discussion and was sent to the same stakeholder group for review. The working group members met again to address the feedback and made any necessary changes.A near-final draft was then circulated to all end users of the consensus statement, including staff surgeons and anesthesiologists at University of Toronto–affiliated hospitals as well as current residents and fellows from surgery and anesthesiology. Overall, the document was sent to more than 1000 people for review.Due to the lack of available evidence, these consensus statement recommendations were not graded as is customary for clinical practice guidelines because the majority of the recommendations are based on local consensus and expert opinion.Patient education•Expectations regarding functional recovery • Realistic pain management goals • Multimodal pain management options • Possible interaction of patient’s current medications and their potential interactions with opioids • Risk of potential opioid side effects, overdose, and development of a dependence or addiction• Safe opioid use and discontinuation• Risk factors for opioid use disorder .1.1.1. This information should be reinforced and reviewed prior to discharge.1.1. Patients and their families and/or caregivers should be provided with written and verbal information on their pain management options preoperatively, including:There is limited evidence available to support this recommendation. However, despite the lack of randomized controlled trials supporting the use of patient education to assist with pain management, almost all hospitals provide their patients with patient education materials outlining pain management options. This fact highlights the importance and necessity of informing patients and their families/caregivers preoperatively in order to assist them in managing their expectations postoperatively.2 Patients were randomized into the intervention group (received education at intervention) vs. control group . After controlling for demographics, the authors found that patients who received the educational intervention had significantly lower anxiety scores based on the State-Trait Anxiety Inventory (P < 0.001).2 The authors also found that patients in the intervention group reported significantly lower pain scores on postoperative day 1 .2Of the few published studies, most found that preoperative education materials did reduce postoperative pain and reduce patients’ anxiety. Lee et al. conducted a randomized controlled trial with 86 patients undergoing lumbar spinal surgery.4 In addition to receiving presurgical education on pain and opioid use, patients may benefit from presurgical training in psychological skills that can be used to reduce pain intensity, pain unpleasantness, pain catastrophizing, and anxiety. Before surgery and associated pain onset is an ideal time for learning because patients are motivated to reduce postsurgical pain and opioid use and have clearer minds for learning because pain and medications that reduce concentration and increase drowsiness are not yet impacting them. Presurgical psychological interventions can include one or more of the following psychological modalities: mindfulness interventions (including breathing techniques)5; clinical hypnosis interventions (including deep relaxation and hypnotic suggestions for lasting comfort)6; cognitive behavioral therapy skills training 7; acceptance and commitment therapy skills training 3; and dialectical behavior therapy skills  to reduce implicit or explicit use of opioid medications to regulate emotions in patients who are vulnerable to emotional dysregulation when stressed.8 In addition, medical and nursing staff can be trained in medical communication that is mindful of the psychological suggestions implicit in everyday language in order to reduce anxiety and pain intensity after surgery.9 The interventions listed above can also be utilized to reduce discomfort and anxiety after surgery while patients are in hospital. Due to the mind–body pathways involved in pain perception, learning and practicing these psychological skills can reduce opioid use while keeping patients more comfortable.There is evidence that psychological interventions can reduce opioid use after surgery, though research in this burgeoning area is in early stages.10 and support from the Canadian Patient Safety Institute have developed a patient information sheet on the use of opioids.11The recommendations that are presented above are the result of reviewing patient education materials and consulting with experts as well as brochures and pamphlets available on hospital websites that outline the information that should be given to patients. The recommendations were also discussed by a group of key stakeholders and consensus was reached. Despite the limited available evidence, there is strong consensus that preoperative education is beneficial for patients and is an essential element of improved pain management with opioid medications after surgery. The Institute for Safe Medication Practices Canada in collaboration with many organizations1.2.1. Store opioids in a secure place to prevent theft or accidental exposure.1.2.2. Keep opioids out of sight and reach of children and pets.1.2.3. Do not keep opioid medications for when they “might” be needed.1.2.4. Do not throw opioids into household trash where children and pets may find them.1.2.5. Do not flush opioids down the toilet.1.2.6. Return expired, unused, or used opioids to a pharmacy for proper disposal.1.2 Patients should be provided with written and verbal information prior to discharge on the safe storage and disposal of unused opioids in accordance with Health Canada’s recommendations.The task of educating patients rests with the entire medical team. In some hospitals, residents take the lead; in others, the acute pain service or physician assistants lead. It is at the discretion of each hospital system to decide how information is dispensed and by whom, based on their custom and means.12 The most prominent concerns stem from inappropriate use and diversion. Diversion is when drugs from a licit channel  are transferred to an illicit channel  for illegal use or distribution.The Institute for Safe Medication Practices Canada in collaboration with the Canadian Patient Safety Institute developed and released a document in June 2018 to assist providers across Canada in minimizing the potential accidents that may arise when medications, specifically opioids, are improperly stored and/or disposed of.13 It is thus suggested that medications be stored above counter height and ideally in a locked cabinet. Hoarding of opioid medications by patients in anticipation of a day when they “might” be needed should be discouraged, because this will increase the potential for diversion of these tablets.It is recommended to store opioids out of sight and reach of children. Studies have shown that children are at increased risk because they may accidentally ingest medications if they have access to them.2. Risk factors for persistent postoperative opioid use• Surgical procedures associated with significant nerve damage that may put patients at risk to develop neuropathic pain• History of or concurrent anxiety and/or depression and/or high levels of pain catastrophizing and/or posttraumatic stress disorder• Use of medications for depression and/or anxiety • Currently or previously followed and treated for chronic pain under medical supervision• History of drug use, smoking, and/or alcohol use disorder (previously or currently)• Low socioeconomic status• Aged 18–30 years old.2.1. Preoperatively, patients should be assessed for the following risk factors because they may be at increased risk for persistent postoperative opioid use:With regards to safe disposal, it is strongly recommended that unused medication should be returned to the patient’s local pharmacy. Disposing of these medications in other ways has been shown to have adverse effects. If the medications are disposed in the trash, it is still possible for children or pets to access them. In addition, they may be available for diversion. Additionally, flushing medications is a risk to the environment and has health risks.14 Opioids remain essential for many patients with respect to treating moderate to severe acute pain after major surgery.15 Beyond the common opioid-related side effects , some patients go on to develop longer term persistent opioid use,16 which negatively impacts their postsurgical quality of life.18 Long-term use is also associated with increased risks of injury,19 cardiac events,20 and overdose.21For the hundreds of millions of persons who provide or receive care for major surgical procedures annually, the treatment of acute postoperative pain and its treatment with opioids have become a hot topic.15 Alam and colleagues reported that patients who received an opioid prescription within 7 days of surgery were 44% more likely to be long-term opioid users at 1 year.18 Of note, in the United States, there was a 402% increase in individual opioid use from 1997 to 2007, a significant portion of which stemmed from chronic use after initiation of treatment.22 A study of 39,140 patients who underwent major surgery  in Ontario from 2003 to 2011 showed that 49.2% received a prescription for opioids at discharge. By 3 months postsurgery, more than 3% of previously opioid-naïve patients continued to fill prescriptions for opioids.23 This suggests that for some patients presenting for major surgery, the use of opioids postoperatively for acute pain can carry on well into the postdischarge period.Research aiming to understand the risk factors associated with the conversion from short-term to long-term use of opioids after surgery is ongoing. Studies have identified that the initial opioid prescription is a risk for unwarranted persistent use that increases one’s risk for misuse, opioid-induced hyperalgesia, mood disorders, and endocrine disturbances.23 In a recent study, males younger than 30 years of age were identified as a high-risk population for the escalation of their opioid dose postdischarge.24 The use of medications such as benzodiazepines, selective serotonin reuptake inhibitors, and angiotensin-converting enzyme inhibitors preoperatively was also associated with increased risk for persistent postoperative opioid use.23 Low socioeconomic status has been estimated based on patients’ neighborhood median income in a national census.25 It may be helpful for the preoperative assessment or pharmacy team to conduct a best possible medication history to identify patients at risk for potential drug interactions.A significantly higher risk for prolonged opioid use is seen in patients of younger age and lower income, as well as in those with comorbidities such as lung disease, diabetes, and heart failure.27 Smoking may be an important modifiable risk factor for pain intensity and opioid use after surgery.28A common finding in the literature is that current and previous tobacco use is associated with the risk of intense acute pain and persistent opioid use.29 is a questionnaire that is usually used to assess an adult’s propensity to develop an opioid use disorder in the setting of chronic pain. It uses a point system to stratify risk based on factors such as a history of personal or family drug abuse, age, psychiatric history, and a history of childhood sexual abuse. It may be awkward to screen each patient coming for surgery for such issues, but in the case of high suspicion (such as high requirements for opioids) postoperatively, use of the tool may be appropriate.2.1.1. If a patient is at risk for persistent opioid use, a tailored opioid-sparing perioperative pain management plan should be developed by the perioperative team  preoperatively.The Opioid Risk Tool, which can be easily sourced on the Internet,30 Therefore, patients with a pain problem taking opioids prior to surgery  could benefit from specialized pain services.31 The current consensus statement is not suited to patients already consuming opioids prior to surgery. As noted above, extra care should be taken for procedures known to be associated with a higher risk of persistent opioid use. Clarke et al. found that accounting for all demographic and comorbid factors, patients who underwent thoracic surgery procedures had a 2.5-fold higher risk of requiring opioids long term compared to patients having any other surgical procedure.23 Sun et al., using U.S. administrative health claims databases, found that patients who had surgery had a higher persistent use of opioids 1 year after surgery compared to nonsurgical patients.32 At 1 year, 1.4% individuals who had had a total knee arthroplasty were taking opioids, compared to 0.136% of nonsurgical patients.32The perioperative period provides a critical window to address opioid use, particularly in patients with a history of chronic pain and presurgical opioid use. No other factor is as consistently related to the development of future pain problems as is concurrent pain.24 Following presurgical assessment, patients about to undergo higher risk surgeries that have a higher incidence of chronic pain and/or persistent opioid use should be assessed by a specialized pain service/practitioner.343.1. Nonopioid therapy should be the first-line of treatment for pain. Therapies can be pharmacological  or nonpharmacological .3. Discharge prescriptions for pain management after elective surgerySpecialized care for individuals that comprehensively addresses the potential problems of patients at high risk of persistent postoperative opioid use should occur throughout the perioperative time period: (1) preoperatively, (2) postoperatively in hospital, and (3) postoperatively in an outpatient setting and should be modeled at institutions that offer major surgical interventions.33The World Health Organization’s pain management ladder is the model followed generally around the world in the postoperative setting. This model suggests the use of nonopioids such as NSAIDS and acetaminophen prior to introducing weak opioids and then stronger opioids.opioid sparing that has been recognized for decades).35–44 In 2018, Memtsoudis et al., after a retrospective analysis of 1,540,462 arthroplasties, demonstrated an inverse relationship between the number of nonopioid modalities employed and total dose of opioids used postsurgically.45There is significant literature to support multimodal analgesia (given the synergistic effects of different classes of medications) rather than sole opioid use with recognition that reduced opioid doses are needed in patients receiving nonopioid analgesia , and acupuncture are lacking, these modalities are thought to inhibit pain signals by activating neurons in the spinal cord that directly block the conduction of such signals. In the case of cold therapy, slowing of signal conduction is also proposed,61–64 Evidence for cold therapy exists so far only in randomized controlled trials for a variety of surgical procedures, including hernia repair, A-V fistula creation, and dental surgery.65–73 Other methods also need further study even though they are endorsed by various institutions.75Of all of the techniques, acupuncture’s supportive body of evidence is the largest and includes mostly positive findings as found through meta-analyses and systematic reviews. Low numbers of studies of heterogenous design and quality limit the reliability of data, however, and more studies are needed to reach a consensus.3.2. Patients should be discharged with a prescription for the following adjunct pain medications unless contraindicated:• Acetaminophen 1 g PO TID to QID for 7 days then PRN.• NSAIDS  PO for 3 days then PRN.3.2.1. Patients should be counseled on how to take scheduled medications and advised to stop taking these medications after 7 days if they are expected to have a rapid recovery or after 14 days if they are expected to have a moderate or long-term recovery.Lack of movement postoperatively can lead to muscle tightness and pain. Physiotherapists work with patients to alleviate kinesiophobia and restore function using multiple tools. Stretching, acupuncture, scar tissue massage, myofascial release, exercise prescription, education on using mobility aids, and/or a prescription regarding using certain equipment in patients daily lives provide the basis of good postoperative physiotherapy care.76 They have a lower profile of adverse effects in comparison to opioids, and their cost and availability are other advantages. Memtsoudis et al. have further reinforced their value, showing that of all the nonopioid pharmacologic analgesic modalities, NSAIDS are the most effective at reducing opioid consumption for orthopedic joint surgery.45Acetaminophen and NSAIDS are fundamental starting points for pain management in the hierarchy of analgesic drugs. The World Health Organization’s guidelines for acute pain management state that these two drug categories should be first-line pharmacologic agents, with opioids being additive, if there is need for further analgesia.77 When used together with NSAIDS, however, both drugs are more effective than when used on their own.79Sole acetaminophen therapy has been shown to relieve moderate pain for several hours while decreasing the overall dose of opioids.81 Caution is suggested for patients over 75 years old, however, because gastrointestinal and surgical site bleeding has been shown to occur in this age group. Caution is also advised for patients with colonic anastomoses because studies have suggested increased anastomotic leakage with NSAID use. In such cases, use should be at the surgeon’s discretion.82 Care must also be taken not to exceed the recommended dosages of each drug and to always rule out contraindications before starting. Contraindications to NSAID use include peptic ulcer disease, gastroesophageal reflux disease, inflammatory bowel disease, bleeding abnormality, congestive heart failure, uncontrolled hypertension, pregnancy in the third trimester, and a history of NSAID-associated asthmatic attack. NSAIDs should also be avoided in patients on drugs that may interact with them, such as anticoalgulants and cyclosporine. Celecoxib can be substituted for an NSAID if there is a history of peptic ulcer disease.There has been debate in the past about possible renal impairment and postoperative bleeding with the use of NSAIDS, but systematic reviews have shown these drugs to be nonthreatening to normally functioning kidneys and benign with respect to hemostasis.82 In this study, low doses of NSAIDs  taken for less than 2 weeks were not shown to increase the odds of nonunion.83 Several other studies also suggest that short courses of NSAIDs do not affect nonunion rates.85 However, no sufficiently powered randomized controlled trial has yet been performed to definitively prove whether or not NSAIDs affect bone healing. It is therefore suggested that preference be given to short courses of low-dose NSAIDs following orthopedic procedures where there is a risk of nonunion  and that consideration be given to avoiding NSAIDs in patients at high risk of nonunion.There continues to be debate within the orthopedic literature regarding the impact of NSAIDs on bone healing, with concern about the potential for increased rates of nonunion. Though the literature is not conclusive, a recently published meta-analysis reported increased odds of nonunion  in orthopedic patients taking high doses or long courses of NSAIDs following fracture osteotomy and fusion surgeries.86 This may provide additional support for the use of short courses of low-dose NSAIDs even in patients at risk of nonunion, if this permits reduced opioid use.Interestingly, a recent study has also implicated opioid use in the development of fracture nonunion among trauma patients, with the odds of nonunion being higher for most of the opioid medications when compared with acute NSAID use.87 The scheduled acetaminophen course duration should mirror the opioid course duration. NSAID scheduled dosing is advised for 3 days by our panel, with the intent to avoid side effects such as gastritis and gastric ulceration, which are more likely with prolonged use of nonselective cyclooxygenase inhibitors. Prescribers, nurses, and pharmacists should counsel patients on how to take scheduled medications  and educate patients that concomitant pain medications can be taken together.3.3.1. Patients should receive the same opioid analgesic that they received in hospital to ensure tolerability.3.3.2. Patients who did not receive opioids in the last 24 h of their hospital stay should not be given a prescription for opioids.3.3.3. Day surgery patients should be prescribed medications for patients with an expected rapid recovery as illustrated in 3.3. Patients should receive a prescription for opioid-containing tablets based on their consumption in hospital during the previous 24 h.Scheduled dosing is recommended in order to maintain drug levels and thereby the analgesic and opioid-sparing effects.89–93Theisen et al. recently highlighted research on opioid overprescribing, recording a range of 37% to 71% of opioid pills prescribed being unused in the postoperative discharge period for various surgery types.94 although they were not necessarily prescribed to them.Overprescribing by surgeons has been called into question with respect to fueling the opioid crisis. Studies have shown that even a single prescription can be linked to chronic use regardless of surgery type and that up to 80% of heroin addicts were first introduced to opioids through prescriptions,96 A practical means of deciding “how much” is to check the patient’s in-hospital usage within the last 24 h and use this as a guide to determine the daily prescribing dose. Osmundson et al. compared this approach to a standardized opioid prescription of 30 oxycodone 5 mg pills given to women post cesarean section.95 Of the 127 women included, those given individualized perscriptions were prescribed less opioids and used half the amount of the opioids prescribed compared to those who were given the standard prescription. Those not needing opioids in hospital were not prescribed any opioids postdischarge.96In view of the various dangers posed, our panel recommends a personalized approach for prescribing opioids in the postdischarge period.97 Hill et al. went on to recommend 15 opioid-containing pills for patients using one to three pills, 30 for those using four or more pills, and none for those not requiring any in the 24 h prior to discharge. Their mathematical model is designed to cover analgesic needs while keeping opioid prescribing to a minimum.96 Our panel’s final recommendation takes into consideration further models of prescription estimation as well as duration of therapy.Using the final 24 h for prescribing estimation was suggested by Hill et al. after analyzing 333 cases of a wide range of operations, including minor procedures such as inguinal hernia repair and major ones such as colon surgery.98 This is still meant to be used merely as a guide and not representative of absolute conversion values  for surgical inpatients.Despite published tables suggesting conversion factors to be used in calculating equipotent doses for different opioids, we strongly suggest prescribing the same opioid that the patient used while in hospital. Conversion tables are variable and the conversions can be unreliable. Opioids also have different receptor affinities, and this is complicated further by interindividual variability in opioid metabolism and sensitivity and concurrent patient comorbidity. At present, pain specialists are guided by a two-step calculation derived by Fine and Partenoy when switching opioids.The standardization of processes can be an attractive concept adopted in an effort to seek simplification and speed on a busy surgical unit. In some cases, discharge prescriptions may be written as part of a preparatory package, even before the procedure takes place.101 Supplying a patient with more opioids than is needed is a possibility when prewriting prescriptions and can potentially contribute to diversion.Though this may appear to improve efficiency, its practice in the current context of an opioid crisis is discouraged. One should keep in mind that opioids bear high street value and are often subject to diversion.102 One study even cited an estimate of 71% of diverted drugs being acquired through family or friends.103An analysis of all opioid related deaths at St. Michaels Hospital, Toronto, in 2016 showed that of all deaths among those with no active opioid prescription, 18% tested positive for hydromorphone, 17% for oxycodone, and 17% for morphine.101Writing an opioid prescription without knowing the exact dose required by a patient may represent a “license” for more drugs than needed and open a pathway to drug access and diversion. One news report stated that nearly 9 million doses of prescription drugs were reported “missing” between 2012 and 2017 in Canada, with the majority of the drugs being opioids. This information alone serves as a good indication of the level of caution that needs to be taken with opioid prescription and even unused prescription pads.3.5. Patients who are given a prescription for opioid-containing tablets should be instructed to fill the prescription only if their pain is not well managed with other therapies or if they are having difficulty completing activities of daily living secondary to pain.Waiting for the day of discharge and making a calculated decision on exactly how many opioids to prescribe is the best way to meet the analgesic needs of the patient while protecting the public from unnecessary exposure to the drugs.104In the past, no pain in the postoperative recovery period was regarded by some institutions as the theoretical “gold standard” for patients. With the increase of regional anesthesia techniques, “no pain” may be achievable in a subset of patients; however, many do not have access to these techniques, and the chase for “no pain” has likely provided impetus to the overprescribing of opioids.105 Though no pain would be ideal, it is unreasonable to expect that someone just having received a major incision will have absolutely no discomfort even after receiving painkillers.The goal of pain management in the postoperative period is to keep the patient comfortable enough  to maintain functionality.106Recognizing the need for redefinition of the goals of pain management in order to stem the tide of opioid overprescription and addiction, the U.S. Joint Commission developed 19 elements of performance that accredited national hospitals were expected to meet by January 2018. Proper control of pain was emphasized to be reflected in a patient’s ability to achieve functionality goals. Goals in this case are dynamic concepts and change from day to day depending on expected ability. Taking full breaths comfortably on the first day following major abdominal surgery, for example, would be acceptable, as opposed to walking to the bathroom comfortably a few days later.108Australia and New Zealand have also been incorporating a “functional activity scale” in pain assessments, and Great Britain uses the “dreaming” concept or the general ability to drink, eat, and mobilize in the postoperative period.3.6.1. Patients with an expected rapid recovery (resume regular activities within 2 weeks from discharge) should be prescribed enough opioid-containing tablets for 0–3 days following discharge (maximum 12 opioid-containing tablets).3.6.2. Patients with an expected moderate recovery (resume regular activities within 4 weeks from discharge) should be prescribed opioid-containing tablets for a maximum of 7 days following discharge (maximum 30 opioid-containing tablets).3.6.3. Patients with an expected long-term recovery (resume regular activities longer than 4 weeks from discharge) should be prescribed opioid-containing tablets for a maximum of 14 days following discharge (maximum 60 opioid-containing tablets).3.7. A part-fill or second prescription should be given to patients with an expected moderate or long term recovery (recommendations 3.6.2 and 3.6.3) to reduce the number of opioid-containing tablets distributed at one time (see Appendix for sample prescriptions).3.6. Opioid prescribing should be based on expected functional recovery (provided the patient has not exceeded the dose below in the past 24 h if applicable) See Regardless of the school of thought, the principle remains the same: Less emphasis on traditional pain scores and more focus on function is the rational approach to assessment. Expectations of pain management should be set out from the very inception at the preoperative consult, and patients should be told that as long as they can function, within reason, with nonopioids postdischarge, they should not fill a prescription for opioids that might have been given.109.There are two main variables in opioid prescribing: One is the total opioid dose used for the entire course postdischarge and the second is the number of days that the opioids are used. Both Shah and Bratt have published evidence that links duration of opioid use with later chronic use110 Brat et al. found that each refill and additional week of opioid use was associated with an increase in the rate of misuse by 44.0%.1 Although Shah et al. related long-term use to initial high doses of opioid , Sekhri et al. noted that the number of refill requests was not linked to this factor.111 Thus, the length of the first opioid exposure seems to be the underlying factor linked to chronic use.Shah et al. noted an incidence of long-term use (use for more than 1 year) in 13.5% of persons whose first episode of use was for ≥8 days (for various types of acute pain), and this increased to 29.9% when the first episode of use was for ≥31 days.109 They theorized that the optimum duration of therapy was between the observed median prescription length and the earliest discontinuation of use of refill prescriptions. Using this model, 4 to 9 days for general surgery procedures, 4 to 13 days for women’s health procedures, and 6 to 15 days for musculoskeletal procedures were suggested as the average initial lengths of opioid prescription.112To date, there is no global consensus on the length of the duration of therapy for each surgical procedure. Scully et al., however, tracked general trends in opioid needs for more than 200,000 patients following several operation types in an effort to propose a reference point for initiating therapy.95 and Hill et al.96 was discussed previously. Theils et al. also performed an extensive multicenter analysis on opioid requirements following 25 common surgical procedures, leading to the Mayo Clinic’s detailed outline of prescribing low-, standard, and high-dose regimens, including separate guidelines for orthopedic surgery.93With respect to the number of pills to be prescribed, the use of the last 24-h period in hospital to estimate the number of prescribed pills as espoused by Osmundon et al.3.8. The prescription for opioid-containing tablets should have an expiry date of 30 days from the date of discharge (see Appendix for a sample prescription).After comparative review of available data and discussion that incorporated longstanding experience in the field, our panel recommends the above as a guide to initial opioid prescribing in the postdischarge period. We believe that this guide will serve to balance the analgesic needs of most patients with the societal need to keep opioid exposure at a minimum. The consensus statement should be used in accordance with the categorization of various procedures in 113–115 This leaves a gaping loophole for the legal acquisition of opioids that were prescribed but for which the prescription was not filled for the purpose of postoperative pain management.According to Canadian law, as long as a prescription bears no expiry date, it may be filled within 1 year of the date it was written.• Morphine 5 mg, PO q4h PRN for 3 days then q8h PRN.• Hydromorphone 1 mg, PO q4h PRN for 3 days then q8h PRN.• Tramadol 50 mg, PO q4h PRN for 3 days then q8h PRN.• Oxycodone 5 mg, PO q4h PRN for 3 days then q8h PRN.3.9. If opioid-containing tablets are prescribed, they should be short-acting opioids at the lowest effective dose, with the lowest potency, for the shortest duration. Patients should be prescribed one of the following opioid-containing tablets:This represents a dangerous situation, and until laws are readjusted, our panel recommends clear indication of expiry of an opioid prescription 30 days after it is issued. A 1-month period should be adequate for a patient to assess the need for the supplementary medication. If severe pain reemerges after this period, a consult with one’s surgeon for reassessment would be appropriate, and any needed prescriptions could be reissued at this point. Implementation of this practice is intended to effect reduction in the amount of circulating opioids available for diversion.*Oxycodone and tramadol are not covered by the Ontario Drug Benefit and will be paid out of pocket by patients.116In 2016, the Centers for Disease Control issued guidelines on opioid use for chronic pain and advised: “When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than 7 days will rarely be needed.”The pharmacokinetics of different drug formulations justify the use of immediate-release rather than continuous-release formulations. Immediate-release opioids usually have a peak effect at 45 to 60 min as opposed to continuous-release formulations, which peak at around 3 h. The use of immediate-release opioids therefore affords the user quicker assessment of the effect with the ability to titrate the dose within a reasonable amount of time. Waiting for longer-acting opioids to have their full effect may encourage patients who are in pain to stack doses to their detriment.117In 2015, Miller et al. published a study of patients prescribed opioids in the United States using the Veterans database. After propensity score matching, they found that those prescribed long-acting opioids on initiation of therapy were twice as likely to experience accidental overdose than those prescribed short-acting opioids. The overdose events were noted to be most frequent in the first 2 weeks of therapy, no doubt likely associated with troubleshooting dose titration.118 Codeine was therefore not included in the list of suggested opioids.The above dosages represent estimated equi-analgesic amounts of opioids that are currently available in Canada. As discussed previously, these doses do not represent perfect values but are rough figures using multiplication coefficients derived from a debatable and relatively small database. No current evidence exists at present to suggest prescription of one opioid in preference to another, although we do know that interpatient variability due to genetic differences in receptors and opioid affinity is a reality. Ultrarapid metabolism of codeine to morphine (in people who carry the gene that facilitates this process) can lead to inadvertent overdose.4.1 Surgeons should ask their patients at follow-up about their postoperative pain and opioid use. Patients should be instructed to return unused opioids to their local pharmacy at the time of their follow-up if they are not being used.4. Follow-up and long-term opioid useOur panel suggests the above as a guide only for healthy opioid-naïve adults. As mentioned before, opioid prescribing should be individualized and take into consideration factors such as patient comorbidity, age, and weight when making a final decision.110 The surgeon should therefore be on the alert when a second or third opioid prescription is requested.It is incumbent upon all opioid-prescribing physicians to monitor their patients’ opioid use. It is expected that as healing continues, the dose of opioids needed would become progressively less. A lack of decreasing need for opioids or an increasing need for them may indicate early signs of a persistent pain problem, addiction, tolerance, or another medical issue that should be addressed. Shah et al. documented that the probability of long-term opioid use increases significantly at the second prescription for opioids and in patients on their 5th to 31st day of opioid therapy.The role of the pharmacist at the time of filling the postdischarge prescription is important. Pharmacists should discuss opioid equivalents  and interactions with other medications .119 The Current Opioid Misuse Measure may also be helpful, as may be urine screens to check that the patient is actually using the medication and not diverting. Studies are still ongoing to refine tools to assist with risk assessment, especially in the acute care setting.120At present, opioid risk assessment tools such as the Pain Medication Questionnaire and the Screener and Opioid Assessment for Patients with Pain are used mainly in the setting of chronic pain but may still be used to give an idea of a patient’s propensity for misuse.122 Alarming statistics such as these are congruent with Theisen et al.’s report of anywhere between 53% and 91% of patients being found to have kept leftover opioids postrecovery.88 In 2016, Kim et al. also reported a rate of only 5.3% of patients being instructed on what to do with unused opioids after orthopedic surgery,123 and Bartels et al. found that 77% of post–C-section patients and 73% of post–thoracic surgery patients in their study stored unused opioids in an unlocked location.914.2. If patients require a refill prior to their scheduled follow-up visit, a maximum of 14 days (maximum 60 opioid-containing tablets) should be prescribed. Dated part fills for 7-day intervals should be given.Unused opioids should never be kept by patients. Unused opioids should be returned to the dispensing pharmacy. In addition to the possibility of entering public circulation, contamination of soil and water due to poor disposal techniques is becoming an environmental issue. Pediatric exposure is also a possibility with unfortunate consequences. From 2000 through 2015, 188,468 pediatric opioid exposures were reported to U.S. poison control centers, and thousands of opioid-related deaths among minors have been recorded.124 Chronic pain in this context is defined as pain lasting for 12 or more weeks following surgery and is mediated by neural rearrangement and dysfunction. The incidence of opioid misuse disorders among chronic pain sufferers is debatable, with a wide range from 0.5% to 81%.125 Longstanding pain is still described as a potential115 predictor of future opioid misuse.126–128In a subset of patients, acute pain evolves into a chronic pain condition. It is estimated that the 1-year incidence of moderate to severe chronic postsurgical pain is between 5% and 10%.33 Factors predicting it have been well defined and include preoperative pain and opioid use, the extent of trauma surrounding the perioperative course, and a background of psychiatric mood or anxiety disorders.4.4. If there is a suspicion that a patient is misusing opioids, the patient should be referred to a transitional/chronic pain clinic.4.3. If pain persists beyond 3 months, patients should be referred to a transitional/chronic pain clinic.In patients with chronic postsurgical pain, the incidence of opioid misuse is up to 10% 1 year following surgery.33 Factors predicting it have been well defined through research and include preoperative pain and opioid use, the extent of trauma surrounding the perioperative course, and a background of psychiatric mood or anxiety disorders.Chronic postsurgical pain has an incidence of up to 10% 1 year following surgery.The role of the transitional pain clinic is to essentially change the trajectory of acute pain in order to avert the development of chronic pain syndromes and their associated negative entourage, including opioid use disorders. Patients identified as “high risk” can be referred preoperatively and then followed postoperatively. Patients who did not appear to be at high risk but seem to have persisting pain beyond the expected postoperative period should also be referred.A biopsychosocial approach is the core strategy of this clinic. The Toronto General Hospital’s model incorporates an anesthesiologist with specialized training in pain medicine, advanced practice nurses, psychologists, a pharmacist, a physiotherapist, and a yoga practitioner.33 Surgeons should make full use of such services not only as part of good clinical practice but also as part of exercising social responsibility in an era of prescription drug abuse. Institutions that provide major surgical interventions should mandate programs that provide support to patients with complex postsurgical.In addition to improving patient coping and functioning, the primary focus of this clinic is responsible surveillance of opioid use and opioid weaning postoperatively. Preliminary data show rates of up to 46% and 26% complete weaning in opioid-naïve and opioid-experienced patients, respectively, 6 months postsurgery through The Toronto General Hospital’s Transitional Pain Clinic.Limited evidence is currently available on the subject of perioperative opioid harm reduction strategies and their effectiveness. The impact of implementation on workers’ time and institution funds is also unknown. Undertaking analysis of the effects postimplementation of this consensus statement will be necessary to validate these statements and their impact on perioperative care.This document does not outline exactly which professionals should hold which responsibilities. Education, for example, may be the responsibility of the primary surgery team in some institutions, whereas it may be that of the pharmacists, preoperative education teams, and/or nurse practitioners in others. Each institution will need to designate roles according to their local custom and resources.The extent to which institutions apply these recommendations will vary according to resources.Postimplementation metrics will focus on how well this information was disseminated and whether an overall reduction in opioids prescribed at discharge was implemented with a concomitant measure of patient satisfaction and global functioning.As other groups create similar statements and academic material accrues on strategies for postoperative opioid prescribing and pain management, these documents should be graded to lead to the creation of a postoperative opioid prescribing guideline that would be acceptable to a wide audience.This consensus statement is not intended to apply to certain populations; for example, pregnant women, children, patients with chronic pain, or patients already on opioids preoperatively. It is therefore limited in its application. Ideally, future versions of this document will incorporate guidance for the excluded populations, particularly patients with chronic pain on opioid medications preoperatively and the pediatric population.The effect of this consensus statement on postoperative pain and long-term functioning is not known. Prospective cohort studies are required to assess these long-term outcomes.


In recent years, there has been an increasing interest in local infiltration analgesia (LIA) as a technique to control postoperative pain. We compared this technique to the gold standard the 3 in 1 femoral nerve block (FNB) in postoperative pain management after total knee arthroplasty (TKA) in a large patient population. This trial analyzes in the early postoperative phase the pain, range of motion, and consumption of pain medications after TKA.We conducted a retrospective trial that included all patients who were undergoing primary TKA by one single surgeon in a high-volume arthroplasty center in 2015. Patients who have secondary osteoarthritis due to rheumatoid arthritis or previous knee arthrotomy, as well as revision cases, were excluded. The included patients were divided into 2 groups according to the applied pain management . Concerning the LIA group, a modified form of composition compared to the first describer without the use of adrenaline was carried out. Post-operative additional pain medications were given on a fixed scheme to the patient. The primary outcome was pain at rest over 7 days after surgery labeled by the numeric pain rating scale (NRS). The secondary outcome measures were the total amount of opioid consumption over the hospital stay and the additional need for non-opioid medication. The conversion of the opiate medications on the morphine preparation was carried out according to the conversion data from the literature. For functional recovery, we compared the range of motion in both groups, which was recorded from the second postoperative day by the attending physiotherapist.p < 0.05). Secondary outcome measurements: The total volume of morphine consumption for the first six postoperative days was significantly lower in the LIA group than the FNB group (FNB 159.8 vs. LIA 96.07). There is also a significant difference between the total morphine consumption of both groups in the direct postoperative course with respect to time and group  On the day of the operation and on the first postoperative day, the intake of additional non-opioids in the LIA group was also significantly reduced compared to the FNB group. No significant difference was observed on the second to sixth postoperative day concerning an additional consumption of non-opioid medications. In terms of range of motion, the LIA group showed a higher active range of motion at the operated extremity than the FNB group during the hospital stay.In total, 202 patients were assessed for eligibility and included in this clinical trial. Hundred patients were allocated to the continuous FNB group (group 1) and 102 patients to the LIA group (group 2). No statistical difference was found between the two groups regarding demographic data. Primary outcome measurements: The LIA group had a significantly lower NRS score than the continuous FNB group for the measurement in the morning on days 1, 2, and 3 after surgery  is a sufficient alternative to regional anesthesia avoiding the known risks of regional procedures. The results of this study reflect the efficiency of this pain management with a lower consumption of analgesics, identical to reduced postoperative pain ratings and an improved ROM in the first postoperative days.Retrospective trial Effective postoperative pain therapy and early mobilization has a significant influence on patient’s satisfaction and the spectrum of complications after implantation of a knee arthroplasty (TKA). A proven and effective principle is to perform regional anesthesia using an isolated and combined femoral and/or sciatic nerve block (FNB or SNB) with or without a permanent catheter , 15, 18.Kerr et al. initiated an alternative procedure in 2005 by introducing a local intraarticular infiltration therapy (LIA) with a combination of ropivacaine, ketorolac, and adrenaline, avoiding the mentioned risks of regional procedures , 3, 12. The aim of our study was to show that the use of a modified local intraarticular infiltration is an adequate alternative to standardized postoperative pain management, assuming the indicated advantages, in a large patient population. On the other hand, we want to prove that earlier postoperative mobilization with increased progress of range of motion as well as reduced additive use of painkillers within the first postoperative week is possible by performing LIA. We retrospectively compare two patient populations with LIA or a three-in-one femoral nerve block as selected pain management.The study was approved by the regional ethics committee on 15 March 2012 (ref: 12/NW/0153). It was registered with controlledtrials.com, identifier: ISRCTN42045594. We conducted a non-randomized, non-blinded retrospective trial that included all patients that were scheduled to undergo primary unilateral TKA (TKA model Nex Gen LPS Flex Zimmer ®) by one single surgeon (R.H.) in a high-volume arthroplasty center between January 2015 and November 2015. The inclusion criteria were any patient undergoing a primary TKA for primary or secondary knee osteoarthritis without previous knee arthrotomy. Exclusion criteria were based on patients that lacked capacity to consent to the study or patients who were unwilling to consent and patients with known allergy to any of the drugs being administered. Patients who have secondary osteoarthritis due to rheumatoid arthritis or previous knee arthrotomy, as well as revision cases, were also excluded.All surgeries were performed without a tourniquet with the medial parapatellar approach. The postoperative rehabilitation regimens were the same for both groups and started the day after surgery. Transfer to wheelchair and quadriceps setting exercise were started 1 or 2 days after surgery. Ambulatory training with weight bearing as tolerated and active-assisted range of motion exercise were started 1 day after surgery. Gait training using a walker was started at 2 days after surgery and using a cane at 3 days after surgery. Staircase climbing exercise and walking outside were started 3 days after surgery.Demographic data as age, sex, height, weight and the resulting body mass index, operated side, and ASA Score were protocolled.The included patients were divided into 2 groups according to the certain pain management, which was performed. Group 1 was treated as described in Table Group 2 was treated according to the protocol of Table In both groups, additional pain medication according to the WHO pain ladder was prescribed on patient’s requirements .The two protocols are slightly different from each other due to the fact that when switching to the LIA scheme, we applied changes to the pain protocol based on recent literature. Giving pain medication already before the surgery allowed us to reduce the standard doses after the surgery. Being a retrospective trial and comparing our modifications to our previous pain protocol, we are aware of this study limitation.The primary outcome was pain at rest over 7 days after surgery. For the objective measurement of pain intensity, the numeric pain rating scale (NRS) was used. Patients were asked to quantify their pain on a scale of 0 to 10, while 0 means no pain and 10 the strongest imaginable pain. Immediately after the operation in the intermediate ward, the nurse asked the patient to quantify his pain intensity. Since the operations were performed at different times of the day, the measurement of pain intensity was not related to a particular daytime. On the regular ward, the pain was measured in the morning and evening throughout the hospital stay. The measurement refers to the intensity of resting pain. The postoperative pain scores were taken from the patient’s personal file, and the mean values were adopted for a comparison between the two groups.The secondary outcome measures were the total amount of opioid consumption over the hospital stay and the additional need for non-opioid medication, evaluated by the patient’s file. The conversion of the opiate medications on the morphine preparation was carried out according to the conversion data from the literature Table For functional recovery, we compared the range of motion, which was recorded from the second postoperative day by the attending physiotherapist using a goniometer. The total extent was measured according to the extension and flexion.t test was used to compare continuous variables after determining the distribution was appropriate for parametric testing. As the data from this study were not to be normally distributed, the Mann–Whitney U test was used for analysis. P values < 0.05 were considered significant.Statistical analysis was carried out using the SPSS software . The control of the variance equality was performed according to the Levine test. The chi-square independence test was performed to compare categorical variables. The independent In total, 202 patients were assessed for eligibility and included in this clinical trial. Hundred patients were allocated to the continuous FNB group (group 1) and 102 patients to the LIA group (group 2). Table The NRA scores at rest are shown in Fig. p < 0.05) for the measurement in the morning . From the fourth to the sixth postoperative day, no significant difference in pain intensity was shown for the morning measurements. On the seventh postoperative day, there was again a significant difference between the two groups . Figure The LIA group had a significantly lower NRS score 1 day after surgery than the continuous FNB group ). Relative to the comparison between the two groups on the respective postoperative day, the day of the operation shows a decent higher, not significant consumption (21.52 mg ± 5.98 (LIA) vs 15.67 ± 3.46 mg (FNB)). In the following postoperative days 1–6, there is a higher but non-significant use of opiates in the FNB group  . Similar results could be shown on the 1st postoperative day, where 50% in the FNB group received no additional non-opioid medication, 36% an additional, and 14% two more non-opioid medications. In contrast, in the LIA group, 67% did not need any additional medication, 32% received one, and only 1% two more non-opioid medications. The difference between both groups was likewise significant (p < 0.05). No significant difference was observed between the two groups on the second, third, fourth, sixth and seventh postoperative day concerning an additional consumption of non-opioid medications (p > 0.05).Additionally Fig. In terms of range of motion on each postoperative day, a significant difference in movement between the two groups was observed. The LIA group showed a higher active range of motion at the operated extremity than the FNB group. Although there is a significant difference over the entire included observation period, the largest numerical difference is in the first 3 days and the movement rates approach until the 4th postoperative day Table .Table 6Effective pain therapy, especially for direct postoperative pain reduction, has a significant influence on patient satisfaction and the spectrum of complications after implantation of a knee arthroplasty (TKA). A proven and effective principle is to perform regional anesthesia using an isolated and combined femoral and/or sciatic nerve block (FNB or SNB) with or without a permanent catheter. As an alternative procedure, we investigated the local intraarticular infiltration therapy (LIA) avoiding the known risks of regional procedures in this study with a modified drug mixture. At present, the most effective pain management continues to be the subject of controversy.The results of this work reflect the efficiency of this pain management with a lower consumption of analgesics, identical to reduced postoperative pain ratings and an improved ROM in the first postoperative days.Further recent works has demonstrated a possible equivalent pain management using the LIA method, whereby the individual composition of substances such as adrenaline or different cortisone preparations still varied. Since LIA affects only the surgical area with moderate analgesia, there is limited interference to muscle strength of the lower limb and safety in short-time follow-up . BesidesIn our study, we compared this 2 routinely used methods that are both effective for postoperative pain relief in TKA. The large number of procedures for each pain management performed at one hospital by one high volume surgeon (LIA = 102 vs. FNB = 102) is methodologically advantageous. Concerning the outcome parameter pain intensity, pain killer consumption, and postoperative range of motion, a slight superiority of the local infiltration method over the singular femoral catheter is shown. Up to 72 h after surgery, there was a significant reduction of the NRS score in the recorded values from the 1st–7th postoperative day with advantage to the patient group with regional nerve blocks. With regard to opiate consumption, there is an increased consumption of painkillers in the patient group with FNB compared to the LIA patient population. The functional outcome parameter range of motion (ROM) also shows significantly better results for the 1st to 7th postoperative day after surgery, although a rapid approximation of the movement amounts is seen.The present publication even tends to show an apparent superiority; however, this can only be expressed with reservations in the case of existing limitations of the study. These include the retrospective, non-randomized study design with consecutive influence on outcome parameters such as pain anamnesis, opiate consumption, and functional postoperative rehabilitation. The two patient groups (LIA vs. FNB) received different additive pain medications pre- and postoperatively, so that a direct comparison of drug consumption can only be carried out to a limited extent. Previous studies also showed a positive effect on pain reduction by addressing the posterior capsule with a combined procedure of FNB and SNB, which could lead to a renewed reduction of pain medication. For regional reasons, only FNB was used. The preoperative consumption of painkillers could no longer be determined retrospectively as an influencing factor on the later consumption. Missing outcome parameters such as length of hospital stay, side effects, and patient’s satisfaction with pain control are not documented and not subsequently evaluated.Despite two current meta-analyses, the heterogeneity of the various, existing study designs makes it difficult to accurately assess the effectiveness of the intraarticular infiltration method. The definition of the outcome parameters differs in object and observed time span. Both the application of painkillers by catheter or single shot or in combination with additive regional procedures and the composition of the intra-articular pain medications are various.In their meta-analysis, Zhang et al. evaluate the results of 10 publications (RCT) that compare the efficacy of LIA with peripheral nerve blocks, primarily FNB . The outFan et al. already showed similar results in a further meta-analysis (8 RCT), whereby 4 included publications were included in both meta-analyses . Again, On the other hand, Fan et al, in its previous meta-analysis, could show that NRS values for pain on rest were lower in the LIA group than in the group of regional methods applied. As to the NRS score with activity, there was no significant difference between the two groups.Toftdahl et al. could not detect any significant difference directly postoperatively between LIA and FNB analgesic patients at rest until the 2nd postoperative day (pod), but there was a better pain reduction in the first 24 h postoperatively after LIA, if the patient has already been treated in physiotherapy . Carli eThe outcome parameter of morphine consumption is influenced by the fact that different opiates have been applied pre- and postoperatively. A comparison of the publications was approximated by the conversion into equivalent doses. Zhang et al. showed no difference between the two groups, whereby no time scheduling is shown. In contrast, Fan et al. describes lower morphine consumption in the LIA group compared to the patient group of the regional procedures on the 1st postoperative day with a low heterogeneity factor in its pooled data. In most studies, including our own, there is reduced opiate demand in the first 24 h , 16, 20.The comparison of both treatment strategies on the basis of the outcome parameter of postoperative functionality is again made difficult by the decisive differential definition of an acceptable function. Zhang et al. evaluated the passive ROM in 4 studies in 308 patients. There was no significant difference between the FNB and LIA group with regard to the knee ROM. Fan et al. also with reference to a high heterogeneity factor, also could not detect any significant difference in the range of motion after 3 months postoperatively. However, the study indicates earlier mobility and shorter hospital stays in the group of LIA patients , 20.Our data indicate that the 2 analgesic regimens gave similar quality of pain relief and time of functional recovery during the directly postoperative time. Both FNB and LIA resulted in low average pain intensity. A femoral nerve block is commonly administered to reduce the side effects and complications related to self-administered analgesia in patients who have had a TKA. Nevertheless diminished muscle control, nerve damage, and local infection are recognized complications, ranging from 0.1 to 2.5%, and 15% of femoral nerve blocks are unsuccessful. LIA offers the benefits of blocking pain influx at its origin and maximizing muscle control.Both procedures are methods of analgesia that have an excellent effect for pain management after TKA, but the types, doses, and methods of administration of the agents used have yet to be established. Despite existing meta-analyses including high-quality studies , the sample size of all included studies is very small. With 101 patients per treatment branch for pain management, our study confirms the efficacy of intra-articular infiltration therapy as an attractive alternative treatment method without the risks of regional procedures.The LIA group showed in this study a significantly lower consumption dose of opioid and a quicker recovery of range of motion than the FNB group. Furthermore additional pain killer medicine could be reduced during the hospital stay. The LIA group proved to be as effective as the FNB group.


Patellofemoral pain is a prevalent condition in the general population, especially in women, and produces functional impairment in patients. Therapeutic exercise is considered an essential part of the conservative management. The use of vibration platforms may help improve strength and function and reduce pain in patients with knee disorders. The aim of this investigation was to determine the effects of adding whole body vibration  to an exercise protocol for pain and disability in adults with patellofemoral pain.2). Significant level was set al P < 0.05.A randomised clinical trial was designed, where 50 subjects were randomly distributed into either an exercise group plus whole body vibration or a control group. Pain, knee function (self-reported questionnaire) and range of motion and lower limb functionality were assessed at baseline and at 4 weeks. The experimental group performed 12 supervised sessions of hip, knee and core strengthening exercises on a vibration platform 3 times per week during 4 weeks. The control group followed the same protocol but without vibration stimuli. Differences in outcome measures were explored using an analysis of the variance of 2 repeated measures. Effect sizes were estimated using Square Eta  and function outcomes scores .Statistically significant differences were found after intervention in favour of the experimental group in the between-groups comparison and in the interaction of the experimental group before and after treatment in terms of pain perception . This study was prospectively registered on the 24th July, 2019.ClinicalTrials.gov ( Knee pain is a common condition with a high prevalence in the general population, with patellofemoral pain (PFP) being one of the most common forms of knee pain . PatelloThere is no specific cause of pain in these patients and the aetiology of PFP is considered multifactorial. For this reason, the diagnosis is complex and essentially based on the clinical history, always ruling out lesions of adjacent structures such as ligaments or menisci . This syPain around or behind the patella, weakened knee extensor muscles and associated symptoms usually reduce knee functionality and entail a limitation in daily and occupational activities, negatively impacting a patient’s quality of life and social aspects .Exercise therapy is an evidenced-based non-pharmacological intervention often prescribed for this condition . There iWhole body vibration (WBV) training has demonstrated improvements in muscle strength, power, balance, flexibility, proprioception or human gait in healthy adults, the elderly –15. In tIn clinical settings, there is growing evidence about the positive effects of WBV training on reducing pain intensity and increasing lower limb functionality in patients with several musculoskeletal painful conditions , 20. ZafTo our knowledge, only one study using WBV training has been developed in patients with PFP . The impThis study was a single-blind prospective randomised-controlled clinical trial, conducted between September and December 2019 at the AY360° Health and Sport Clinic .clinicaltrials.gov, Identifier NCT04031248). The Consolidated Standards of Reporting Trials (CONSORT) guidelines were followed. All participants provided written informed consent prior to being included in the study.The study was approved by the Ethical Research Committee of Jaen Province  and prospectively registered ; knee joint effusion; concomitant injury or pain from the hip, lumbar spine, or other knee structures ; traumatic lesions of soft tissues or previous orthopaedic surgery in lower limbs; having received knee injections of corticosteroids or hyaluronic acid; cognition or impaired communication; being involved in an ongoing medical-legal dispute.In addition, the exclusion criteria included having any contraindication for using whole body vibration, such pacemakers, arrhythmias, cardiac valve dysfunction, pregnancy, epilepsy, recent acute thrombosis, infection and recent inflammation, malignant tumours, recent implants, recent fractures, acute disc pathology, acute tendinopathy, renal lithiasis or biliary and an acute episode in rheumatic pathology.Patients were advised not to take analgesic medication from the beginning of the study, as well as not to receive other treatments, such as physiotherapy or injection therapy. Patients in both groups were required to participate in at least 80% of the programmed sessions (10 sessions) for the analysis.http://www.randomization.com, and considering a 1:1 ratio distribution of participants in the study groups).Those participants who met the inclusion criteria were randomly assigned by a member of the research team to the experimental or control group following simple randomization procedures  using standardised instruments and cross-culturally validated patient-reported outcome measures.For the assessment of pain intensity during activity, VAS of 10 cm was used, where 0 corresponds to ‘no pain’ and 100 represents the ‘worst pain imaginable’ . PatientIn addition, to assess neuropathic pain (NP), the Spanish version of the Douleur Neuropathique-4 items (DN4) was used . This quFor the knee flexion assessment, subjects lay in a supine position with 90 degrees of hip flexion. Hip positioning was guaranteed by the use of a thigh device that aided in the maintenance of the pre-set position. A universal goniometer was placed next to the femoral lateral epicondyle. The static handle of the goniometer was aligned with the thigh, using the femoral major trochanter as a reference, while the mobile handle aligned with the leg referencing the fibula lateral malleolus . For theShort Form Health Survey (SF-36), especially with the physical function and pain subscales ). This model has a Class IIA certificate (MDD 553319/0086), which classifies it as having a medium low risk, ensuring that the device offers a therapeutic benefit under correct use .In the present study, an axial  vibration platform was used . This device is annually reviewed by the technical unit of the company and complies with the international Medical Devices regulations  was set at 2 mm in the first two weeks, and 4 mm during the following two . The accEach session was structured following scheduled phases of warm-up, main active part and, finally, cool-down and stretching, as recommended by the American College of Sports Medicine . The warThe treatment protocol comprised 12 sessions conducted over 4 consecutive weeks (3 sessions per week) and each session was supervised by an experienced clinical physiotherapist. The aim was to avoid pain during all exercises and also to avoid unusual physical activity or other additional exercises [The control group participants were instructed to do the same supervised exercise protocol but on a vibration platform while the system was off and did not transmit any vibration to the patient’s feet.The statistical data processing was carried out using the PASW Advanced Statistics Package , version 24.0. The data were reported as mean (standard deviation) and confidence intervals (95% CI). First, the normal distribution of the variables was verified by the Shapiro-Wilk test, following a descriptive analysis. The homogeneity of the variations was observed using the Levene test. Linearity was evaluated by bivariate scatter plots of residual values observed against expected values. Comparisons between the baseline demographic and clinical data of the groups were made using the Student’s t-test for continuous data and the chi-square test for categorical data.2) was used to calculate the effect size . The statistical significance was set at a value of p < 0.05.Separate 2 × (2) mixed-model analysis of variance (ANOVA) was used to evaluate interaction time × groups, including the time effects  and group effects (supervised exercise group vs WBV+ supervised exercise group) for each outcome measure. All analyses followed the intention-to-treat principle and groups were analyzed as randomized. Effect sizes were calculated using Square Eta  a 15% change in the intensity of self-reported pain  and 2) aA sample of 55 subjects, between 19 and 67 years of age, were selected for the study. A participant flow-diagram is shown in Fig. n = 27) and the left for 46% (n = 23). The participants’ level of education was: 40% primary studies (n = 20), 30% secondary (n = 15) and 30% university degree (n = 15). With respect to pharmacology treatment, 28 subjects used to take nonsteroidal anti-inflammatory drugs and analgesics before the study and 22 did not take any medication. Around 58% of the sample had an occupation in the service sector, 20% in the construction field and 22% in industry.The right lower limb side was affected for 54% of the participants . The average change on self-reported instruments obtained by the subjects in the experimental group  reached the respective thresholds of minimal clinically important difference. Therefore, the combination of exercise and vibration may be considered to have a high short-term value in clinical practice for pain relief and improve lower limb functionality.Pain intensity reduction after WBV training has been reported in previous studies but the mechanism for this effect remains unclear . SeveralRespect to the pain quality in PFP syndrome, Jensen et al. hypothesised that the observed sensory aberrations in these patients may cause neuropathic-like knee pain . Using tWe suggest that the present findings about the WBV training on pain level reduction effect in short-term could help patients with PFP to overcome the negative emotional impact of this injury, which include confusion and low expectations for improvement as well as low perceived self-efficacy . It is kIn most studies, exercise programs that reported positive effects on pain intensity and muscle strength for patients with PFP were 8 weeks in duration . TherefoIn our study, a statistically significant improvement in the knee flexion range of motion after completing the protocol was observed. Osawa & Oguma, in their meta-analysis, showed that vibration interventions had significant effects on flexibility . These oIn this study, the exercise programme was carried out by decentralising the focus of attention on the patellofemoral joint and trying to improve the strength and function of the full lower limb and core , 10. PreThe results of this study should be considered with caution due to some methodological limitations. First, the main outcomes were obtained using self-reported measures of pain and knee functionality without any other neuromuscular objective parameters. A longer follow-up period is most likely needed in order to objectively register neuromuscular adaptations. Second, only acute effects on clinical outcomes were assessed during the post-intervention period and, therefore, we do not know how long the registered benefits can be maintained. Studies with longer follow-up periods are necessary. Third, we did not stratify our sample into subgroups of patients with homogeneous clinical statuses as has been suggested . Due to In conclusion, the realisation of a training protocol of hip, knee and core exercises on a vibratory platform produces positive effects on the pain level and functional capacity of patients with PFP and is more effective than exercise alone in improving pain and function in patients with PFP in the short term.


P = 0.001) and lower cost of pain control . Baseline data, clinical characteristics, pain score, additional non-opioid consumption, side effects, and patient subjective satisfaction score were similar between the two groups. The MMA seems to be a good alternative to the PCA after one or two-level PLF.A multimodal analgesic method was known to avoid the high-dose requirements and dose-dependent adverse events of opioids, and to achieve synergistic effects. The purpose of this study was to compare the efficacy of our multimodal analgesia (MMA) regimen with that of the patient-controlled analgesia (PCA) method for acute postoperative pain management. Patients who underwent one or two-level posterior lumbar fusion (PLF) followed by either MMA or PCA administration at our hospital were compared for pain score, additional opioid and non-opioid consumption, side effects, length of hospital stay, cost of pain control, and patient satisfaction. From 2016 through 2017, a total 146 of patients were screened. After propensity score matching, 66 remained in the PCA and 34 in the MMA group. Compared with the PCA group, the MMA group had a shorter length of hospital stay (median (interquartile range): 7 days (5–8) vs. 8 (7–11);  Effective postoperative pain control allows for faster recovery, reduced complications, and improved patient satisfaction. This is common knowledge among clinicians. However, approximately more than 80% of patients who undergo surgical procedures experience acute postoperative pain, and 75% of those with postoperative pain report moderate, high, or extreme pain severity ,2,3. InaSpinal surgeries are generally associated with intense pain in the postoperative period, especially for the initial few days . TraditiOne common technique to address pain after surgery is patient-controlled analgesia (PCA) ,14. PCA A retrospective review of a prospective collected spine registry at our institution was conducted to compare the effectiveness of our MMA protocol and the conventional PCA protocol for postoperative pain management. The study was approved by the Soonchunhyang University of Institutional Review Board . Patients were included if they underwent a one-level or two-level posterior lumbar fusion (PLF) surgery with PCA and MMA between June 2016 and July 2017. The exclusion criteria were: any history of prior lumbar spine surgery, hepatic dysfunction, renal insufficiency, depressive disorder, an emergency surgery, a history of drug/alcohol abuse, or prior adverse or allergic reactions to any of the analgesic medications to be administered . In our institution, the postoperative pain control method switched from a PCA-based to MMA-based regimen from January 2017. One hundred and nine PCA patients were collected in 2016 and 37 consecutive patients enrolled in 2017.All patients who had a history of more than three months of conservative pain control underwent one or two-level posterior lumbar fusion (PLF) with degenerative spinal disorder. The two protocols are described in detail in For each patient, baseline data and clinical characteristics were investigated. Baseline data included age, sex, current smoking status, and body mass index (BMI). Clinical characteristics included preoperative pain on the 10-point numeric rating scale (NRS), Oswestry Disability Index (ODI), preoperative pain medication, American Society of Anesthesiologist (ASA) physical class, autologous iliac bone graft, suction drain use, intraoperative complications, and operation time. The pain position was classified into an axial, radiating to a leg, and a combined. When NRS was more than 4 points, it was regarded as significant. The preoperative pain medication was defined from one month before surgery and assorted into five groups: none, acetaminophen/nonsteroidal anti-inflammatory drug (NSAID), weak-opioids, strong-opioids, combination method. The combination is a complex method such as a steroidal injection plus oral medication and/or other type of pain medication used together. The ASA physical class was estimated by an anesthesiologist before the preoperative evaluation. Postoperative NRS scores were recorded during assessments at 1, 4, 8 h after surgery on postoperative day (POD) 0 and every 8 h on POD 1, 2. The patients were asked by one of the authors to rate their average pain on the NRS (0–10). An average NRS was then recorded for each postoperative day. Additional opioid consumption during the inpatient stay was calculated for each patient and expressed in oral morphine equivalents (ME) per day. For statistical comparisons, the oral morphine equivalent dose was calculated based on the following oral ratio: pethidine (1:3). Additional non-opioid analgesia consumption using IV tramadol during the inpatient stay was calculated for each patient and expressed in mg/day. Patients were interviewed about nausea/vomiting and abdominal discomfort at 1, 4, 8 h after surgery on postoperative day (POD) 0 and every 8 h on POD 1, 2. Additional antiemetic drug, IV ramosetron (0.3 mg) was administered if needed. Length of hospital stay and the cost of the pain control  were documented. The cost of the PCA group consisted of setup costs, which consisted of machine rental costs and installation costs, maintenance costs per used day, medicine costs, which mixed in the PCA pump and costs of the rescue regimen. Additionally, the cost of the MMA group consisted of costs of the regimen prescribed by the MMA protocol and costs of the rescue regimen. The patient’s satisfaction with their pain control method was assessed on POD 3 using a 5-point categorical scale .P-value less than 0.05 denoted statistical significance and the tests performed were two-tailed. Because this study was not a randomized trial, the propensity score matching (PSM) method was used to reduce selection bias between two groups . In Statistical analyses were conducted using SPSS version 26.0 . Continuous variables were compared using the student t-test or Mann–Whitney test. Nominal variables were compared using Pearson’s chi-squared test or Fisher’s exact test. A Thirty-seven patients in the MMA group received our multimodal pain management regimen and 109 patients in the PCA group received conventional pain management. Twelve patients were withdrawn from the study. Three patients in the MMA group wanted to change to PCA due to severe pain. Nine patients in the PCA group discontinued their PCA due to uncontrolled severe nausea/vomiting. Then, the patients were matched on the basis of age and BMI in a 1:2 ratio to reduce selection bias between two groups by using the propensity score matching (PSM) method. One hundred patients were analyzed in this study. Of these, 34 (34%) received MMA and 66 (66%) received PCA . The basP = 0.137) and at POD 1 . However, these trends did not reach statistical significance. At POD 2, the MMA group had lower opioid use than the PCA group  (The mean NRS was not significantly different between the groups . Additio= 0.014) . Additio= 0.014) .The use of medication for postoperative nausea and vomiting (PONV) was similar between the MMA and PCA groups . There wP = 0.001) (P < 0.001)  . The cos< 0.001) . The sub< 0.001) .The NRS, additional opioid and non-opioid rescue medication were not different between the groups on POD 0 and 1. Moreover, there was less consumption of additional opioids in the MMA group compared to the PCA group on POD 2. These results mean that the pain control effect of our MMA protocol is not inferior to that of the convention PCA protocol. In the 1970s, the development of PCA was expected to achieve rapid and complete pain control after surgery. However, there is a possibility that patients will self-administer the pain medication to get high, and therefore, use large amounts of opioids. In addition, opioids have been reported to have a high frequency of side effects such as nausea and vomiting .A multimodal approach to postoperative pain is attractive for a number of reasons . First, The use of MMA regimens after joint arthroplasty has gained acceptance ,30, but In the present study, our MMA regimen was focused on preemptive analgesia, which is administered before pain onset and based on central sensitization. It composed of MMA medication  and long-acting local analgesic (bupivacaine) injection before pain stimuli. Celecoxib, which is a selective inhibitor of cyclooxygenase (COX)-2, inhibits prostaglandin synthesis in the spinal cord and in the periphery so it diminishes the hyperalgesic state after surgical trauma . It is aThese data show that additional opioid use was less in the MMA group compared to the PCA group on POD 2. This may be related to PCA  that terminated on POD 2 in the PCA group. A relatively regular infused painkiller in the PCA was abruptly stopped, and it seemed that the rescue medication may be necessary. Some literature reported pain is one of the most common causes of delayed discharge . In the This study had several limitations. First, our study was not randomized. So, there may have been selection bias with respect to which patients were assigned to each pain control method. However, we used the PSM method to reduce selection bias between the two groups. Ultimately, the patients in the MMA group did not differ in most demographic variables from those in the PCA group. Second, our study was a small sample size. Although rescue opioid usage tended to be lower in the MMA group, the difference did not reach statistical significance. In addition, although the regimen for each MMA protocol is different, the side effects with MMA are typically less common than with PCA ,16,19. WIn this study, multimodal analgesia, which uses a combination of selective COX-2 inhibitors, pregabalin, long-acting opioids, and acetaminophen appears to be a safe and effective analgesic regimen after one or two-level posterior lumbar fusion surgery. Additional opioid use was lower in the MMA group compared to the PCA group on POD 2. Moreover, patients who received MMA did not report any increase in their pain compared to those patients receiving PCA. Moreover, the MMA group discharged more quickly and at a lower total cost than the PCA group.The present study demonstrated that our MMA protocol was not inferior to the conventional PCA method for postoperative pain control after a one-level or two-level posterior lumbar fusion surgery. MMA was beneficial in terms of cost and length of hospital stay. MMA seems to be a good alternative to PCA after short level posterior lumbar fusion.