Integrating Nonpharmacological Options Into Perioperative Pain Care: A Cluster Randomized Clinical Trial

Postoperative pain is commonly treated with opioids, which may contribute to unnecessary opioid-related harms. Scalable approaches to integrate recommended nonpharmacologic pain care could reduce opioid exposure while improving or at least preserving functional recovery outcomes.

To evaluate whether an electronic health record (EHR)-embedded intervention promoting nonpharmacologic pain care improves postoperative pain interference and physical function while reducing opioid exposure.

This cluster randomized clinical trial was conducted from October 16, 2020, through April 30, 2024. Participants included patients undergoing surgery at 22 surgical practices in 6 surgical centers in Minnesota, Wisconsin, Florida, and Arizona.

A multicomponent EHR-based intervention including a patient-facing Healing After Surgery educational guide, clinical decision support, and nonpharmacologic pain care support materials integrated into routine perioperative touchpoints and workflows.

Co-primary outcomes were Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference and Physical Function T scores measured preoperatively and at 1, 2, and 3 months after surgery. Secondary outcomes included opioid prescribing and administration (morphine milligram equivalents [MMEs]), PROMIS Anxiety scores, and health care utilization for 3 months after surgery. Mixed-effects models were used to account for correlation of outcomes within surgery, patient, and cluster, as appropriate for each model.

Among 68 141 included surgical procedures (40 892 male patients [60.0%]; mean [SD] age, 59.27 [16.26] years), 43 053 occurred during the intervention period, and 25 088 occurred during the usual care period. The intervention did not change PROMIS pain interference (adjusted mean difference, 0.09; 95% CI, -0.18 to 0.36; P = .51) or PROMIS physical function (adjusted mean difference, 0.15; 95% CI, -0.11 to 0.41; P = .27) in the intervention compared with control surgical procedures. However, total postoperative opioid exposure was lower during intervention periods (rate ratio, 0.90; 95% CI, 0.82 to 0.99; P = .03), corresponding to an approximately 10% relative reduction and an adjusted mean difference of approximately 260 MMEs per patient, with no changes in anxiety, adverse events, or health care utilization. This reduction was driven primarily by lower opioid administration during hospitalization (adjusted rate ratio, 0.94; 95% CI, 0.90 to 0.97; P = .001), with an adjusted mean difference of approximately 85 MMEs.

In this cluster randomized clinical trial of patients undergoing surgery, an EHR-embedded perioperative pain management intervention promoting nonpharmacologic pain care reduced opioid exposure without changes in patient-reported outcomes, suggesting potential for scalable EHR-based strategies to support safer postoperative pain management.

ClinicalTrials.gov Identifier: NCT04570371.