JSES - 2026-05-19 - Journal Article
A Non-Opioid Multimodal Pain Protocol Achieves Equivalent Pain Control After Total Shoulder Arthroplasty: A Randomized-Controlled Trial.
Evans H, Castle JP, Kasto J, Nerys-Fugeroa J, Movassaghi A, Jurayj A, Obinero CV, Zhu K, Wines W, Mahylis JM, Muh SJ
Topics
Key Takeaway
A non-opioid multimodal protocol achieved equivalent 10-day pain scores (VAS 2.4 vs. 2.3, p=0.52) while reducing morphine milligram equivalent consumption by 89% (0.4 vs. 3.7 MME, p<0.001) compared to an opioid-based regimen after TSA.
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Summary
This single-blinded RCT compared a non-opioid multimodal postoperative protocol to a standard opioid protocol (28 tablets oxycodone 5 mg plus multimodal regimen) in 78 patients undergoing primary anatomic or reverse TSA without regional nerve block. At 10 days, VAS pain scores were equivalent (2.4 vs. 2.3, p=0.52) and PROMIS Pain Interference scores were equivalent (61.5 vs. 62.0, p=0.90). The non-opioid group consumed 89% fewer MMEs (0.4 vs. 3.7, p<0.001) with no difference in side effect profiles.
Key Limitation
Follow-up limited to 10 days precludes assessment of opioid refill rates, subacute pain trajectories, or whether the multimodal group sought opioids from outside providers, leaving the full opioid-sparing effect unquantified.
Original Abstract
BACKGROUND
Amid efforts to reduce opioid use, identifying effective non-opioid pain protocols for orthopedic procedures is a priority. Shoulder arthroplasty is associated with significant postoperative pain and has traditionally relied on opioids, despite their side effects. This study evaluated the efficacy of a postoperative non-opioid, multimodal pain protocol compared to an opioid protocol for patients undergoing shoulder arthroplasty.
METHODS
We performed a prospective, single blinded, randomized controlled trial including patients undergoing primary anatomic or reverse total shoulder arthroplasty. Patients were excluded if they underwent revision surgery, surgery for fracture, or received opioids within 3 months of surgery. All patients received standardized preoperative analgesics, general anesthesia, and an intraoperative periarticular injection without a regional block. Patients were randomly assigned to a postoperative non-opioid multimodal pain protocol or a standard opioid protocol containing 28 tablets of 5 mg oxycodone in addition to the multimodal regimen. Patients completed visual analog scale (VAS) and PROMIS Pain Interference (PI) surveys and reported opioid use and side effects over 10 post-operative days. An intention-to-treat analysis was performed.
RESULTS
78 patients were enrolled and included in the analysis with 38 in the multimodal and 40 in the opioid cohort. Demographics (age, sex, race, and body mass index) were comparable between both groups. Pain scores at 10 days postoperatively were comparable between groups with no significant differences in mean VAS pain (2.4 ± 1.7 in the multimodal group vs. 2.3 ± 1.6 in the opioid group; P = 0.52) or median PROMIS-PI scores (61.5, interquartile range 58.5-67.0 in the multimodal vs. 62.0, interquartile range 56.5-64.0 in the opioid; P = 0.90. However, the opioid group consumed significantly more morphine milligram equivalents (3.7 ± 5.07 compared to 0.4 ± 1.35 for the multimodal group; P < 0.001). There were no significant differences in side effects between treatment groups.
CONCLUSION
In patients undergoing shoulder arthroplasty, a non-opioid, multimodal pain protocol provided non-inferior pain relief compared to an opioid-based regimen. These findings support the shift toward opioid-sparing strategies in orthopedic surgery to minimize postoperative dependence without compromising patient care.