2026 Southeastern Residency Conference

Impact of Opioid-Sparing Multimodal Pain Management Order Set on Opioid Use and Clinical Outcomes in Thoracic Surgery Patients

Authors: Kylie Michot, Michael Ezebuenyi, Monica Campbell, Jennifer Jones, Greggory Davis

Background: Multimodal analgesia optimizes postoperative pain management while reducing opioid use and associated risks. Pain management is achieved by optimizing the synergistic effects of non-opioid medications with complementary mechanisms of action. The Enhanced Recovery After Surgery (ERAS) Society recommends multimodal analgesia over scheduled opioid therapy for thoracic surgery postoperative pain management. While current evidence highlights the benefits of multimodal strategies, further research is needed to evaluate opioid-sparing effects and clinical impact after thoracotomy. This study evaluates whether implementation of a postoperative multimodal analgesia regimen within an ERAS protocol reduces opioid utilization among thoracic surgery patients undergoing thoracotomy compared to traditional opioid-based postoperative pain management.
Methods: This single-center, retrospective chart review evaluated patients admitted to FMOL Health – Our Lady of the Lake between March 2017 and September 2025 who underwent thoracotomy and received postoperative analgesics from a standardized order set. Patients were excluded if they were younger than 18 years or older than 80 years of age, receiving renal replacement therapy, pregnant, receiving comfort care, or had a documented allergy to a medication included in the order set.
The primary outcome was three-way comparison of opioid utilization, measured in morphine milligram equivalents (MMEs), in patients receiving a multimodal pain management protocol versus usual care with opioids for pain management after a thoracotomy on post-operative day (POD) 0, POD 1-3, and total postoperative length of stay (LOS). Secondary endpoints included chest tube duration, post-operative ventilator duration, intensive care unit (ICU) LOS, hospital LOS, average pain control score on POD 1 and POD 3, time to first dose of opioids after surgery, and opioid prescriptions upon discharge.
Results: A total of 156 patients were included in this study with 78 patients in each group. Regarding baseline characteristics, the majority of the multimodal group had a higher American Society of Anesthesiologists (ASA) Physical Status Score (ASA score >3, 17% vs. 46%; P < 0.001), an overall lower number of female patients (67% vs. 44%, P = 0.004), and patients over the age of 60 (median age, 60 vs. 66; P = 0.005). No difference in inpatient opioid consumption was seen between groups on POD 0 (17 vs. 20; ratio, 1.2; 95% CI 0.68 to 2.05; P = 0.78). There was a statistically significant reduction in inpatient opioid consumption between groups on POD 1-3 (83 vs. 20; ratio, 0.19; 95% CI, 0.11 to 0.34; P < 0.001) and total postoperative LOS (130 vs. 55; ratio, 0.38; 95% CI, 0.24 to 0.62; P < 0.001). Multimodal analgesia reduced pain score on POD 1 (median pain score, 4.6 vs. 3.5; P = 0.003) but had no difference in pain score on POD 3 (median pain score, 3.8 vs. 3.0; P = 0.07). Additionally, multimodal analgesia was associated with decreased chest tube duration (median chest tube days, 3.1 vs. 2.2; P = 0.003), and decreased hospital LOS (median LOS, 4 vs. 3; P = 0.010). There was no difference in discharge opioid prescription MMEs (median discharge MMEs, 225 vs. 300; P = 0.89).
Conclusion: Among patients undergoing thoracotomy, a multimodal analgesia regimen with an ERAS protocol was associated with significant reductions in opioid utilization during POD 1-3 and total postoperative hospitalization but did not demonstrate a difference on POD 0. Limitations include the retrospective nature of this single site study and the inability to access opioid usage data from patient-controlled analgesia (PCA) pumps.
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