Dismantling Mindfulness-Oriented Recovery Enhancement to Prevent Chronic Opioid Use

Background and Purpose

Knee and hip replacement surgeries are two of the most common inpatient surgeries performed in the U.S., and surgical rates are expected to increase by 401% and 284%, respectively, over the next 20 years. Unfortunately, surgical outcomes can be highly variable and, too often, suboptimal. Despite improved surgical techniques, implants, and perioperative anesthetic management, joint replacement is often severely painful and can result in chronic postoperative health problems. Opioid analgesics remain the primary, postoperative pain management strategy for joint replacement patients despite no relationship between postoperative prescription of opioids and patient satisfaction with pain control. However, persistent postoperative opioid use is associated with infection, psychological distress, greater disability, and higher medical costs. Persistent opioid use also increases risk for progression to misuse or opioid use disorder among patients having a joint replaced. Thus, knee replacement surgery may serve as a significant pathway by which patients transition into chronic opioid use, misuse, and addiction. Mindfulness-Oriented Recovery Enhancement (MORE) has been shown to reduce pain and opioid misuse. Here, we assessed whether the mindfulness technique taught in MORE, mindfulness of pain (MoP) was superior to a standard mindfulness of breathing technique (MoB) or a cognitive-behaviorally based pain psychoeducation intervention (CB).

Methods

The present randomized clinical trial (N=118) compared MoB, MoP, and CB, all delivered in a very brief (i.e., 20 minute) single session format for patients undergoing total joint arthroplasty (TJA) of the knee or hip. Primary outcomes included preoperative pain intensity along with postoperative pain intensity, pain interference, and opioid use. Pain intensity and pain interference were measured with individual items rated on a numeric rating scale (0–10), and opioid use was measured with a single dichotomously scored item. A total of 6 postoperative surveys were administered over the month following surgery, administered on days two and three after surgery and weekly thereafter.

Results

We used an intent-to-treat framework to assess between group differences by fitting generalized linear mixed models for all outcomes, using full information maximum likelihood estimation. With respect to the preoperative outcome, condition (MoB vs. MoP vs. CB) had a significant effect on baseline adjusted pain intensity (p=.007) immediately after the preoperative intervention. With respect to the postoperative outcomes, a significant condition by time (3^rd postoperative day -> 28^th postoperative day) interaction was observed for baseline adjusted pain intensity (p=.003), pain interference (p=.016), and opioid use (p<.001).

Conclusion

Results indicated that by teaching knee and hip replacement patients a mindfulness-based pain management strategy before surgery, patients reported immediate pain relief along with less postoperative pain, pain interference, and opioid use. MoB appears to be the most effective of the three techniques for immediate pain relief, while MoP, the primary mindfulness technique taught in MORE, appears to have the most substantial postoperative impact. The mindfulness techniques used in this study were efficacious even without the full MORE program. Given that these techniques are brief, highly feasible, and able to be delivered by a wide range of practitioners, mindfulness should be embedded in surgical care pathways.