Pain Medication for Postoperative Pain

(CARES Trial)

Recruiting at 4 trial locations

Overseen By Sarah Clark, BA

Age: 18+

Sex: Any

Trial Phase: Phase 4

Sponsor: University of Michigan

Must not be taking: Opioids, NSAIDs

Disqualifiers: Other surgery, Life expectancy, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Prior Safety Data This treatment has passed at least one previous human trial

Compensation: Varies

Number of Visits: 1

Duration: 7 days

900 Participants Needed

Trial Summary

Will I have to stop taking my current medications?

The trial requires that you have not used significant pain medications like opioids or NSAIDs recently. If you've used these medications frequently in the past 30 days, you may not be eligible to participate.

What data supports the effectiveness of the drugs used for postoperative pain management?

Research shows that non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are effective for managing postoperative pain, often reducing the need for opioids, which can have more side effects. Combining these drugs with opioids can improve pain relief and reduce opioid-related side effects like nausea and sedation. ^{1 2 3 4 5}

Is ketorolac safe for managing postoperative pain?

Ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), is generally considered safe for short-term use in managing postoperative pain, with minimal risk of serious side effects like kidney issues, bleeding, or stomach problems when used appropriately. ^{6 7 8 9 10}

How is the drug combination of NSAIDs and opioids unique for postoperative pain management?

This drug combination is unique because it uses both NSAIDs and opioids to manage postoperative pain, aiming to reduce the amount of opioids needed while still providing effective pain relief. This approach helps minimize the risk of opioid-related side effects and the potential for chronic pain development. ^{1 5 11 12 13}

What is the purpose of this trial?

This trial is being completed to compare two commonly used options to treat pain after surgery. Participants that undergo gallbladder removal, hernia repair, and breast lump removal will be eligible to enroll. Eligible participants will be randomized to 1 of 2 groups of medications (Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) plus acetaminophen or low dose opioids plus acetaminophen). It is anticipated that the NSAID group will have superior clinical outcomes and fewer side effects when compared to the opioid group.

Research Team

Mark Bicket, MD

Principal Investigator

University of Michigan

Eligibility Criteria

The CARES trial is for patients having low-risk surgeries like gallbladder removal, hernia repair, or breast lump removal. They must not have used significant pain medication recently and should be free from other surgeries or life-threatening conditions in the next 6 months. Those with specific allergies to NSAIDs, opioids, or acetaminophen can't join.

Inclusion Criteria

I haven't used strong painkillers or NSAIDs much before surgery.

I am having a low-risk surgery like gallbladder removal, hernia repair, or breast lumpectomy.

Exclusion Criteria

I do not expect to have any surgeries in the next 6 months and believe I will live longer than 6 months.

I am not allergic or unable to take NSAIDs, opioids, or acetaminophen.

Timeline

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Treatment

Participants receive either NSAIDs plus acetaminophen or low dose opioids plus acetaminophen for pain management post-surgery

7 days

1 visit (in-person)

Follow-up

Participants are monitored for safety and effectiveness after treatment, including assessments of pain intensity and adverse events

6 months

Multiple visits (in-person and virtual)

Long-term follow-up

Participants are monitored for chronic pain and healthcare utilization related to pain

180 days post surgery

Treatment Details

Interventions

• Acetaminophen
• NSAID
• Opioid

Trial Overview This study compares two pain management strategies after surgery: one group will receive NSAIDs plus acetaminophen while the other gets low-dose opioids plus acetaminophen. Patients are randomly assigned to these groups to see which has better outcomes and fewer side effects.

Participant Groups

Group I: Opioid regimen Experimental Treatment 2 Interventions

Group II: NSAID regimen Experimental Treatment 2 Interventions

Surgical teams will elect for one of the medications within the treatment arm to which the patient is randomized.

NSAID is already approved in European Union, United States, Canada, Japan, China, Switzerland for the following indications:

Approved in European Union as NSAIDs for:

• Pain relief
• Inflammation
• Fever reduction
• Postoperative pain management

Approved in United States as NSAIDs for:

• Pain relief
• Inflammation
• Fever reduction
• Postoperative pain management
• Arthritis
• Menstrual cramps

Approved in Canada as NSAIDs for:

• Pain relief
• Inflammation
• Fever reduction
• Postoperative pain management

Approved in Japan as NSAIDs for:

• Pain relief
• Inflammation
• Fever reduction

Approved in China as NSAIDs for:

• Pain relief
• Inflammation
• Fever reduction

Approved in Switzerland as NSAIDs for:

• Pain relief
• Inflammation
• Fever reduction
• Postoperative pain management

Who Is Running the Clinical Trial?

University of Michigan

Lead Sponsor

Trials

1,891

Recruited

6,458,000+

Patient-Centered Outcomes Research Institute

Collaborator

Trials

592

Recruited

27,110,000+

Findings from Research

Postoperative pain is common and can lead to chronic pain if not treated effectively; multimodal analgesia, including NSAIDs and opioids, is recommended to manage this pain safely.

The combination of dexketoprofen and tramadol is highlighted as a particularly effective and safe option for postoperative pain control, helping to minimize opioid use and reduce the risk of persistent pain.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

New Insights Into the Pharmacological Management of Postoperative Pain: A Narrative Review. Mayoral Rojals, V., Charaja, M., De Leon Casasola, O., et al.[2022]

Postoperative therapy with NSAIDs after tonsillectomy may lead to a higher rate of reoperations, suggesting that their use should be approached with caution.

COX-2 inhibitors combined with intravenous opioids enhance recovery and functional outcomes after knee replacement surgery, indicating a beneficial approach for pain management in this context.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

[New insights in postoperative pain therapy]. Brack, A., Böttiger, BW., Schäfer, M.[2006]

A multimodal approach to pain control after orthopedic surgery, which includes nonopioid agents like intravenous acetaminophen and intranasal ketorolac, offers better pain relief with fewer side effects compared to using opioids alone.

This review highlights the importance of incorporating newer nonopioid medications alongside established treatments like ketamine and gabapentinoids to enhance analgesia, especially in the context of the ongoing opioid epidemic.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Updates on Multimodal Analgesia for Orthopedic Surgery. Pitchon, DN., Dayan, AC., Schwenk, ES., et al.[2018]

Nonsteroidal anti-inflammatory drugs (NSAIDs) are highly effective for managing acute postoperative pain and can enhance pain relief when combined with opioids and local anesthetics, leading to reduced narcotic use and improved overall analgesia.

Combining NSAIDs with opioids not only improves pain management but also offers benefits like better respiratory function and reduced nausea, suggesting that NSAIDs may contribute to faster and higher-quality recovery after surgery.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Efficacy of nonsteroidal anti-inflammatory drugs in the management of postoperative pain. Moote, C.[2022]

Non-opioid analgesics like paracetamol, NSAIDs, and gabapentinoids significantly reduce post-operative morphine requirements, with gabapentinoids showing the highest reduction of ≥13 mg morphine per 24 hours when used alone.

The evidence for the effectiveness of glucocorticoids in reducing opioid use is less convincing, and there is a need for more research on the benefits of combination regimens of these non-opioid drugs.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Post-operative analgesic effects of paracetamol, NSAIDs, glucocorticoids, gabapentinoids and their combinations: a topical review. Dahl, JB., Nielsen, RV., Wetterslev, J., et al.[2022]

A single dose of systemic ketorolac (60 mg) significantly reduces early postoperative pain and opioid consumption, making it an effective adjunct for pain management in surgical patients, based on a systematic review of 13 trials involving 782 subjects.

The 60 mg dose of ketorolac also decreases the incidence of postoperative nausea and vomiting, enhancing its safety profile compared to lower doses, which did not show significant benefits.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Perioperative single dose ketorolac to prevent postoperative pain: a meta-analysis of randomized trials. De Oliveira, GS., Agarwal, D., Benzon, HT.[2022]

A systematic review of 13 studies involving 920 children found that the efficacy and safety of ketorolac for postoperative pain management remain uncertain due to very low-quality evidence and significant variability in study designs.

While some studies reported a reduction in pain intensity with ketorolac compared to placebo, the overall data were insufficient to draw definitive conclusions about its effectiveness or safety, particularly regarding adverse events like bleeding.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Ketorolac for postoperative pain in children. McNicol, ED., Rowe, E., Cooper, TE.[2022]

Ketorolac can significantly reduce the required dose of opioids by an average of 36% in postoperative patients, improving pain management when used alongside opioids.

While ketorolac enhances analgesia, it does not significantly decrease opioid-related side effects, and its use should be cautious, especially in vulnerable populations, due to increased risks of adverse events with higher doses or prolonged use.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Ketorolac in the era of cyclo-oxygenase-2 selective nonsteroidal anti-inflammatory drugs: a systematic review of efficacy, side effects, and regulatory issues. Macario, A., Lipman, AG.[2022]

Short-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) for managing acute postoperative pain does not significantly increase the risk of serious adverse effects such as renal dysfunction, bleeding, or gastric complications when used appropriately.

Given the ongoing opioid epidemic, NSAIDs present a safer alternative for postoperative pain management, highlighting the need to consider them as viable options in pain control strategies.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Are NSAIDs Safe? Assessing the Risk-Benefit Profile of Nonsteroidal Anti-inflammatory Drug Use in Postoperative Pain Management. Chang, RW., Tompkins, DM., Cohn, SM.[2021]

A single study involving 201 participants indicated that intravenous (IV) ibuprofen provided at least 50% pain relief in 32% of patients compared to 22% in the placebo group, suggesting a potential benefit, although the evidence is of very low certainty.

The study found no serious adverse events associated with IV ibuprofen, and the rate of any adverse events was similar between ibuprofen and placebo, indicating that it may be a safe option for postoperative pain management, but further research is needed.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Single-dose intravenous ibuprofen for acute postoperative pain in adults. Ferguson, MC., Schumann, R., Gallagher, S., et al.[2023]

In a study involving 157 patients undergoing shoulder surgery, those who received celecoxib experienced a significant reduction in opioid use, taking fewer morphine-equivalent doses (MEDs) at both 3 weeks (-168 MEDs) and 6 weeks (-199 MEDs) post-surgery compared to those on placebo.

Celecoxib was particularly effective in reducing opioid consumption in patients undergoing total shoulder replacement, while no significant difference was observed in those undergoing rotator cuff repair, highlighting the importance of multimodal pain management strategies in orthopedic surgery.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Celecoxib significantly reduces opioid use after shoulder arthroplasty. Burns, KA., Robbins, LM., LeMarr, AR., et al.[2021]

New analgesic medications and techniques, including preoperative nonsteroidal anti-inflammatory drugs and intraoperative neuraxial analgesia, can improve the management of acute postoperative pain, reducing risks associated with both undertreatment and overtreatment.

These innovative approaches may offer enhanced safety and efficacy compared to traditional pain management methods, such as postoperative oral analgesics, potentially leading to better patient outcomes and shorter hospital stays.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Recent management advances in acute postoperative pain. Argoff, CE.[2022]

Low doses of ketoprofen (0.5-5 mg/kg) effectively reduced guarding behavior in rats after surgical incision, indicating its potential as a targeted analgesic for postoperative pain.

Both locally applied sustained-release microparticles and intrathecal ketoprofen showed similar effects, specifically inhibiting guarding without affecting responses to heat or mechanical stimuli, suggesting a modality-specific action of ketoprofen.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Ketoprofen produces modality-specific inhibition of pain behaviors in rats after plantar incision. Spofford, CM., Ashmawi, H., Subieta, A., et al.[2022]

References

1. United States pubmed.ncbi.nlm.nih.gov

New Insights Into the Pharmacological Management of Postoperative Pain: A Narrative Review. [2022]

2. Germany pubmed.ncbi.nlm.nih.gov

[New insights in postoperative pain therapy]. [2006]

3. United States pubmed.ncbi.nlm.nih.gov

Updates on Multimodal Analgesia for Orthopedic Surgery. [2018]

4. New Zealand pubmed.ncbi.nlm.nih.gov

Efficacy of nonsteroidal anti-inflammatory drugs in the management of postoperative pain. [2022]

5. England pubmed.ncbi.nlm.nih.gov

Post-operative analgesic effects of paracetamol, NSAIDs, glucocorticoids, gabapentinoids and their combinations: a topical review. [2022]

6. United States pubmed.ncbi.nlm.nih.gov

Perioperative single dose ketorolac to prevent postoperative pain: a meta-analysis of randomized trials. [2022]

7. England pubmed.ncbi.nlm.nih.gov

Ketorolac for postoperative pain in children. [2022]

8. England pubmed.ncbi.nlm.nih.gov

Ketorolac in the era of cyclo-oxygenase-2 selective nonsteroidal anti-inflammatory drugs: a systematic review of efficacy, side effects, and regulatory issues. [2022]

9. United States pubmed.ncbi.nlm.nih.gov

Are NSAIDs Safe? Assessing the Risk-Benefit Profile of Nonsteroidal Anti-inflammatory Drug Use in Postoperative Pain Management. [2021]

10. England pubmed.ncbi.nlm.nih.gov

Single-dose intravenous ibuprofen for acute postoperative pain in adults. [2023]

11. United States pubmed.ncbi.nlm.nih.gov

Celecoxib significantly reduces opioid use after shoulder arthroplasty. [2021]

12. United States pubmed.ncbi.nlm.nih.gov

Recent management advances in acute postoperative pain. [2022]

13. United States pubmed.ncbi.nlm.nih.gov

Ketoprofen produces modality-specific inhibition of pain behaviors in rats after plantar incision. [2022]