Impact of modified-release opioid use on clinical outcomes following total hip and knee arthroplasty: a propensity score-matched cohort study

Modified-release opioids are often prescribed for the management of moderate to severe acute pain following total hip and knee arthroplasty, despite recommendations against their use due to increasing concerns regarding harm. The primary objective of this multicentre study was to examine the impact of modified-release opioid use on the incidence of opioid-related adverse events compared with immediate-release opioid use, among adult inpatients following total hip or knee arthroplasty. Data for total hip and knee arthroplasty inpatients receiving an opioid analgesic for postoperative analgesia during hospitalisation were collected from electronic medical records of three tertiary metropolitan hospitals in Australia. The primary outcome was the incidence of opioid-related adverse events during hospital admission. Patients who received modified with or without immediate-release opioids were matched to those receiving immediate-release opioids only (1:1) using nearest neighbour propensity score matching with patient and clinical characteristics as covariates. This included total opioid dose received. In the matched cohorts, patients given modified-release opioids (n = 347) experienced a higher incidence of opioid-related adverse events overall, compared with those given immediate-release opioids only (20.5%, 71/347 vs. 12.7%, 44/347; difference in proportions 7.8% [95%CI 2.3–13.3%]). Modified-release opioid use was associated with an increased risk of harm when used for acute pain during hospitalisation after total hip or knee arthroplasty.     

A randomised trial of oral versus intravenous opioids for treatment of pain after cardiac surgery

Background

Cardiac surgery and sternotomy are procedures accompanied by substantial postoperative pain which is challenging to treat. In general, intravenous (IV) opioids are used in the immediate postoperative phase, followed by oral opioids. Oral opioids are easier to use and generally less expensive. Our goal was thus to determine whether a new opioid preparation provides adequate analgesia after sternotomy. In particular, we tested the primary hypothesis that total opioid use (in morphine equivalents) is not greater with oral opioid compared with patient-controlled IV morphine. Our secondary hypothesis was that analgesic efficacy is similar with oral and IV opioids.

Methods

A total of 51 patients having elective cardiac surgery were enrolled in this study. After rapid postoperative respiratory weaning, the patients were randomised into one of two groups receiving different types of analgesia: oral Targin (a combination of oxycodone–hydrochloride and the opioid antagonist naloxone hydrochloride-dihydrate) or patient-controlled IV morphine. Pain score (visual analogue scale), sedation (Ramsey score), respiratory rate and side effects were assessed at 3, 5, 7, 9 and 11 h after surgery, and every 6 h throughout the third postoperative evening.

Results

The total opioid dose in morphine equivalent doses was significantly lower with oral opioid than with IV morphine (adjusted geometric means [95 % confidence interval]: 34 [29; 38] vs. 69 [61; 78] mg, respectively). Pain scores were similar in each group.

Conclusions

Analgesic quality was comparable with oral and IV opioids, suggesting that postoperative pain even after very painful procedures can be sufficiently managed with oral opioids.     

Analgesic efficacy of the Pecs II block: a systematic review and meta-analysis

Surgery is the primary therapeutic intervention for breast cancer and can result in significant postoperative pain. We searched the current literature and performed a meta-analysis in order to compare the analgesic efficacy of the pectoral type-2 (Pecs II) block with systemic analgesia alone and with a thoracic paravertebral block for breast cancer surgery. Primary outcome was postoperative opioid consumption in the first 24 h after surgery. Secondary outcomes were pain scores at 0, 3, 6, 9 and 24 h after surgery, intra-operative opioid consumption, time to first analgesic request and incidence of postoperative nausea and vomiting. We identified 13 randomised controlled trials that included 815 patients. The Pecs II block significantly reduced postoperative opioid consumption (standardised difference in means: −13.64 mg oral morphine equivalents; 95%CI: −21.22 to −6.05; p < 0.01) and acute postoperative pain at all intervals in the first 24 h after surgery compared with systemic analgesia alone. Compared with the thoracic paravertebral block, the Pecs II block resulted in similar postoperative opioid consumption (standardised difference in means: −8.73 mg oral morphine equivalents; 95%CI: −18.16 to 0.69; p = 0.07) and postoperative pain scores after first measurement. In conclusion, the Pecs II block offers improved analgesic efficacy compared with systemic analgesia alone and comparable analgesic efficacy to a thoracic paravertebral block for breast cancer surgery.     

Intra-articular infiltration analgesia for arthroscopic shoulder surgery: a systematic review and meta-analysis

Phrenic-sparing analgesic techniques for shoulder surgery are desirable. Intra-articular infiltration analgesia is one promising phrenic-sparing modality, but its role remains unclear because of conflicting evidence of analgesic efficacy and theoretical concerns regarding chondrotoxicity. This systematic review and meta-analysis evaluated the benefits and risks of intra-articular infiltration in arthroscopic shoulder surgery compared with systemic analgesia or interscalene brachial plexus block. We sought randomised controlled trials comparing intra-articular infiltration with interscalene brachial plexus block or systemic analgesia (control). Cumulative 24-h postoperative oral morphine equivalent consumption was designated as the primary outcome. Secondary outcomes included visual analogue scale pain scores during the first 24 h postoperatively; time-to-first analgesic request; patient satisfaction; opioid-related side-effects; block-related adverse events; and any indicators of chondrotoxicity. Fifteen trials (863 patients) were included. Compared with control, intra-articular infiltration reduced 24-h postoperative analgesic consumption by a weighted mean difference (95%CI) of −30.9 ([−38.9 to −22.9]; p < 0.001). Intra-articular infiltration also reduced the weighted mean difference (95%CI) pain scores up to 12 h postoperatively, with the greatest reduction at 4 h (−2.2 cm [(−4.4 to −0.04]); p < 0.05). Compared with interscalene brachial plexus block, there was no difference in opioid consumption, but patients receiving interscalene brachial plexus block had better pain scores at 2, 4 and 24 h postoperatively. There was no difference in opioid- or block-related adverse events, and none of the trials reported chondrotoxic effects. Compared with systemic analgesia, intra-articular infiltration provides superior pain control, reduces opioid consumption and enhances patient satisfaction, but it may be inferior to interscalene brachial plexus block patients having arthroscopic shoulder surgery.     

Erector spinae plane block vs. peri-articular injection for pain control after arthroscopic shoulder surgery: a randomised controlled trial

Interscalene brachial plexus block is the standard regional analgesic technique for shoulder surgery. Given its adverse effects, alternative techniques have been explored. Reports suggest that the erector spinae plane block may potentially provide effective analgesia following shoulder surgery. However, its analgesic efficacy for shoulder surgery compared with placebo or local anaesthetic infiltration has never been established. We conducted a randomised controlled trial to compare the analgesic efficacy of pre-operative T2 erector spinae plane block with peri-articular infiltration at the end of surgery. Sixty-two patients undergoing arthroscopic shoulder repair were randomly assigned to receive active erector spinae plane block with saline peri-articular injection (n = 31) or active peri-articular injection with saline erector spinae plane block (n = 31) in a blinded double-dummy design. Primary outcome was resting pain score in recovery. Secondary outcomes included pain scores with movement; opioid use; patient satisfaction; adverse effects in hospital; and outcomes at 24 h and 1 month. There was no difference in pain scores in recovery, with a median difference (95%CI) of 0.6 (−1.9–3.1), p = 0.65. Median postoperative oral morphine equivalent utilisation was significantly higher in the erector spinae plane group (21 mg vs. 12 mg; p = 0.028). Itching was observed in 10% of patients who received erector spinae plane block and there was no difference in the incidence of significant nausea and vomiting. Patient satisfaction scores, and pain scores and opioid use at 24 h were similar. At 1 month, six (peri-articular injection) and eight (erector spinae plane block) patients reported persistent pain. Erector spinae plane block was not superior to peri-articular injection for arthroscopic shoulder surgery.     

Peri-articular infiltration analgesia for shoulder surgery: a systematic review and meta-analysis

Effective analgesic alternatives to interscalene brachial plexus block are sought for shoulder surgery. Peri-articular infiltration analgesia is a novel, less invasive technique, but evidence surrounding its use is unclear. This systematic review and meta-analysis aims to evaluate the utility of peri-articular infiltration analgesia in shoulder surgery. We searched literature for trials comparing peri-articular infiltration analgesia with control or with interscalene brachial plexus block. Control groups received no intervention, placebo or systemic opioids. The primary outcome was cumulative oral morphine equivalent consumption during the first 24 h postoperatively. Secondary outcomes included: rest pain scores up to 48 h; risk of side-effects; and durations of post-anaesthetic care unit and hospital stay. Data were pooled with random-effects modelling. Seven trials (383 patients) were included. Compared with control, peri-articular infiltration analgesia reduced 24-h oral morphine consumption by a mean difference (95%CI) of −38.0 mg (−65.5 to −10.5; p = 0.007). It also improved pain scores up to 6 h, 36 h and 48 h, with the greatest improvement observed at 0 h (−2.4 (−2.7 to −1.6); p < 0.001). Peri-articular infiltration analgesia decreased postoperative nausea and vomiting by an odds ratio (95%CI) of 0.3 (0.1–0.7; p = 0.006). In contrast, peri-articular infiltration analgesia was not different from interscalene brachial plexus block for analgesic consumption, pain scores or side-effects. This review provides moderate evidence supporting peri-articular infiltration for postoperative analgesia following shoulder surgery. The absence of difference between peri-articular infiltration analgesia and interscalene brachial plexus block for analgesic outcomes suggests that these interventions are comparable, but further trials are needed to support this conclusion and identify the optimal peri-articular infiltration technique.     

Patient-controlled epidural analgesia (PCEA) for postoperative pain control after lumbar spine surgery

Spine surgery remains one of the most common procedures for patients with a wide variety of spine disorders. Postoperative pain after major spine surgery is moderate to severe. We retrospectively reviewed 245 medical records of adult patients undergoing major spine surgery who received either patient-controlled epidural analgesia based on local anesthetics and opioids or patient-controlled intravenous analgesia as postoperative pain management. Several outcomes were analyzed including pain intensity, opioid consumption, time to endotracheal extubation, the incidence of deep venous thrombosis, and length of stay in the hospital. We found that the use of patient-controlled epidural analgesia provided better postoperative analgesia [median (quartiles) verbal analog scale score of 4 (3, 5) vs. 5 (3, 6)] and decreased the amount of opioid consumption postoperatively [median of 0 mg (0, 3) vs. 35 mg (0, 150)] compared with patient-controlled intravenous analgesia. Also, a substantially higher number of patients in the patient-controlled intravenous group required opioids as rescue analgesia. Incidences of deep venous thrombosis, operating room extubation, and length of stay in the hospital were not associated with the analgesic technique. The results of this study suggest that the use of neuroaxial analgesia for the management of postoperative pain associated with major spine surgery may have some beneficial properties over intravenous analgesia. The use of a reduced amount of opioids by patients with epidural analgesia may be relevant because of potential fewer side effects mainly in elderly patients. Several limitations related to the retrospective nature of the study are described. Prospective randomized-controlled trials are needed to understand and elucidate the optimum regimen of postoperative pain management after major spine surgery.     

Prospective analysis of a novel long-acting oral opioid analgesic regimen for pain control after total hip and knee arthroplasty

Parenteral opioid use after total knee (TKA) and hip (THA) arthroplasty often results in substantial functional interference and side effects. This prospective study compared use of traditional intravenous patient-controlled analgesia (IV PCA) with a novel oral regimen after TKA and THA. Sixty-two patients received IV PCA and 62 received scheduled long-acting and, as needed, short-acting oral opioids postoperatively. Surveys and chart audits documented functional interference, pain scores, opioid-related side effects, and opioid consumption. Patients who received the oral regimen had significantly less opioid consumption (P < .05) and experienced less functional interference (P < .05) than the IV PCA group. Both groups had similar pain scores and incidence of opioid side effects. This study demonstrates some significant advantages of an oral analgesic regimen compared with IV PCA after TKA and THA.     

Lack of efficacy of intra-articular opioids for analgesia after day-case arthroscopy

A randomised double-blind placebo-controlled trial was undertaken to assess the analgesic efficacy of intra-articular opioids following arthroscopy of the knee. At the completion of surgery, patients received an intra-articular injection of: morphine 1 mg, buprenorphine 30 μg or 0.9% saline. There were no differences in pain scores among groups for the first 24 h postoperatively. We have found no clinical evidence for a peripherally-mediated opioid analgesic effect.     

Oxycodone and ketobemidone for oral premedication

In a prospective, randomised and double-blinded study the preoperative sedative effect and the postoperative use of analgesics were compared in 90 patients undergoing inguinal hernia repair under general anaesthesia, premedicated orally with ketobemidone 10 mg, sustained-release oxycodone 10 mg or placebo. All patients had a local infiltration with bupivacaine after wound closure. Oral paracetamol 1 g×4 and dextropropoyphene 100 mg×4 were given postoperatively and iv ketobemidone was added if the pain score was >3 on a visual analogue scale from 0 to 10. Oxycodone, ketobemidone and placebo had a similar sedative effect before surgery. The use of ketobemidone after surgery was reduced by 40% in the oxycodone group compared to placebo (P<0.05). No reduction was noted in the ketobemidone group. Conclusion: Sustained-release oxycodone—but not ketobemidone—for oral premedication reduced the postoperative use of opioids after surgery.     

Oxycodone and ketobemidone for oral premedication

In a prospective, randomised and double-blinded study the preoperative sedative effect and the postoperative use of analgesics were compared in 90 patients undergoing inguinal hernia repair under general anaesthesia, premedicated orally with ketobemidone 10 mg, sustained-release oxycodone 10 mg or placebo. All patients had a local infiltration with bupivacaine after wound closure. Oral paracetamol 1 g×4 and dextropropoyphene 100 mg×4 were given postoperatively and iv ketobemidone was added if the pain score was >3 on a visual analogue scale from 0 to 10. Oxycodone, ketobemidone and placebo had a similar sedative effect before surgery. The use of ketobemidone after surgery was reduced by 40% in the oxycodone group compared to placebo (P<0.05). No reduction was noted in the ketobemidone group. Conclusion: Sustained-release oxycodone—but not ketobemidone—for oral premedication reduced the postoperative use of opioids after surgery.     

Opioid versus non-opioid analgesia for spine surgery: a systematic review and meta-analysis of randomized controlled trials

Purpose

Opioids are the primary analgesics used in patients undergoing spine surgery. Postoperative pain is common despite their liberal use and so are opioid-associated side effects. Non-opioid analgesics are gaining popularity as alternative to opioids in spine surgery.

Methods

This systematic review evaluated current evidence regarding opioid and non-opioid intraoperative analgesia and their influence on immediate postoperative pain and adverse events in spine surgery.

Results

A total of 10,459 records were obtained by searching Medline, EMBASE and Web of Science databases and six randomized controlled trials were included. Differences in postoperative pain scores between opioid and non-opioid groups were not significant at 1 h: 4 studies, mean difference (MD) = 0.65 units, 95% confidence intervals (CI) [−0.12 to 1.41], p = 0.10, but favored non-opioid at 24 h after surgery: 3 studies, MD = 0.75 units, 95%CI [0.03 to 1.46], p = 0.04. The time for first postoperative analgesic requirement was shorter (MD = −45.06 min, 95%CI [−72.50 to −17.62], p = 0.001), and morphine consumption during first 24 h after surgery was higher in opioid compared to non-opioid group (MD = 4.54 mg, 95%CI [3.26 to 5.82], p < 0.00001). Adverse effects of postoperative nausea and vomiting (Relative risk (RR) = 2.15, 95%CI [1.37 to 3.38], p = 0.0009) and shivering (RR = 2.52, 95%CI [1.08 to 5.89], p = 0.03) were higher and bradycardia was lower (RR = 0.35, 95%CI [0.17 to 0.71], p = 0.004) with opioid analgesia.

Conclusion

The certainty of evidence on GRADE assessment is low for studied outcomes. Available evidence supports intraoperative non-opioid analgesia for overall postoperative pain outcomes in spine surgery. More research is needed to find the best drug combination and dosing regimen.

Prospero Registration: CRD42020209042.

     

Early oral analgesia after fast-track cardiac anesthesia

PURPOSE: Oral analgesia after "fast-track" cardiac anesthesia has not been explored. The aim of this study was to compare two oral oxycodone analgesic regimens. METHODS: One hundred-twenty patients scheduled for coronary artery bypass grafting were randomly assigned postoperatively to receive immediate-release oxycodone 5 mg and acetaminophen 325 mg (Percocet-5) (group I) per os four times daily, or controlled-release oxycodone 10 mg (OxyContin) (group II) per os every 12 hr and placebo twice daily. Acetaminophen 500 mg per os was used as first-line rescue medication, and immediate-release oxycodone (syrup form) 5 mg per os as second-line rescue medication. Pain intensity was assessed with a visual analogue scale on the first postoperative day, the morning after extubation, and thereafter four times daily for four days. Use of rescue medication and adverse events were recorded. RESULTS: Baseline demographic and operation-related characteristics were similar in both groups. While pain control was good in both groups, the immediate-release group experienced less pain on all postoperative days (P = 0.003), required significantly less rescue medication, and had fewer adverse effects such as somnolence and nausea. CONCLUSION: Peroral oxycodone is effective for early pain control after fast-track cardiac anesthesia. Immediate-release oxycodone/ acetaminophen appears to provide better analgesia and fewer side effects compared to controlled-release oxycodone.     

Efficacy of liposomal bupivacaine in spine surgery: a systematic review

BACKGROUND CONTEXTSpine surgery with posterior approaches may involve extensive manipulation of native structures, resulting in significant postoperative pain. Liposomal bupivacaine (LB) is an injectable analgesic that has demonstrated efficacy in decreasing postoperative pain and opioid requirements in patients across multiple surgical subspecialties.PURPOSETo consolidate and analyze the findings of retrospective cohort-matched studies and prospective randomized controlled trials investigating the use of LB in spine surgery.STUDY DESIGNA systematic review.STUDY SAMPLERetrospective cohort-matched studies and randomized controlled trials (RCTs) investigating the efficacy of injected LB in spinal surgery compared with a control/no treatment group.METHODSMEDLINE, Cochrane controlled trials register, and Google Scholar were searched to identify all studies that examined the effect of LB use on outcomes in spine surgery. Our search identified 10 articles that independently evaluated the effect of LB on reduction of postoperative opioid use, pain scores, hospital length of stay, cost, and incidence of adverse effects. The principles of GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) were applied to assess the quality of evidence from each study.RESULTSTen studies were analyzed (1,112 total patients). LB was associated with significantly lower millimolar morphine equivalents (MME) of postoperative opioids, especially in opiate-tolerant patients, visual analog scale (VAS) scores, area under the curve (AUC) of cumulative pain scores, numeric pain scale scores, and hospital length of stay (LOS), with comparable or lower odds of adverse effects relative to controls.CONCLUSIONSLow-quality evidence suggests that liposomal bupivacaine may safely decrease postoperative opioid requirements, pain scores, and length of stay in patients undergoing spine surgery, whereas moderate-quality evidence does not support its use at this time. Therefore, additional standardized well-powered prospective studies are necessary to more clearly assess the efficacy of LB in spine surgery.     

Subacute pain and function after fast-track hip and knee arthroplasty

In a well-defined fast-track setup for total hip and knee arthroplasty, with a multimodal analgesic regimen consisting of intra-operative local anaesthetic infiltration and oral celecoxib, gabapentin and paracetamol for 6 days postoperatively, we conducted a prospective, consecutive, observational study. The purpose was to describe the prevalence and intensity of subacute postoperative pain and opioid related side effects, use of analgesics and functional ability 1–10 and 30 days postoperatively. Fast-track total hip and knee arthroplasty with early discharge (< 3 days) resulted in acceptable levels of pain and postoperative nausea and vomiting with concomitant low use of opioids in > 95% of patients after discharge before day 10 after total hip arthroplasty. However, after total knee arthroplasty 52% patients reported moderate pain (VAS 30–59 mm), and 16% severe pain (VAS ≥ 60 mm) when walking 1 month after surgery with a concomitant increase in the use of strong opioids. These results emphasise the need for improvement in analgesia after discharge following total knee arthroplasty, to facilitate rehabilitation.     

PROSPECT guideline for oncological breast surgery: a systematic review and procedure-specific postoperative pain management recommendations

Analgesic protocols used to treat pain after breast surgery vary significantly. The aim of this systematic review was to evaluate the available literature on this topic and develop recommendations for optimal pain management after oncological breast surgery. A systematic review using preferred reporting items for systematic reviews and meta-analysis guidance with procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials assessing postoperative pain using analgesic, anaesthetic or surgical interventions were identified. Seven hundred and forty-nine studies were found, of which 53 randomised controlled trials and nine meta-analyses met the inclusion criteria and were included in this review. Quantitative analysis suggests that dexamethasone and gabapentin reduced postoperative pain. The use of paravertebral blocks also reduced postoperative pain scores, analgesia consumption and the incidence of postoperative nausea and vomiting. Intra-operative opioid requirements were documented to be lower when a pectoral nerves block was performed, which also reduced postoperative pain scores and opioid consumption. We recommend basic analgesics (i.e. paracetamol and non-steroidal anti-inflammatory drugs) administered pre-operatively or intra-operatively and continued postoperatively. In addition, pre-operative gabapentin and dexamethasone are also recommended. In major breast surgery, a regional anaesthetic technique such as paravertebral block or pectoral nerves block and/or local anaesthetic wound infiltration may be considered for additional pain relief. Paravertebral block may be continued postoperatively using catheter techniques. Opioids should be reserved as rescue analgesics in the postoperative period. Research is needed to evaluate the role of novel regional analgesic techniques such as erector spinae plane or retrolaminar plane blocks combined with basic analgesics in an enhanced recovery setting.     

Opioid sparing effects of intravenous and oral acetaminophen in hip fracture patients: A population-based study

Study objectiveAcetaminophen (APAP) and intravenous acetaminophen (IVAPAP) has been proposed as a part of many opioid-sparing multimodal analgesic pathways. The aim of this analysis was to compare the effectiveness of IVAPAP with oral APAP on opioid utilization and opioid-related adverse effects.DesignRetrospective study of population-based database.PatientsThe Premier Healthcare database was queried patients undergoing surgery for a primary diagnosis of hip fracture from 2011 to 2019 yielding 245,976 patients. Primary exposure was use of IVAPAP or oral APAP on the day of surgery.InterventionsNone.MeasurementsThe primary outcome of interest was opioid utilization over the hospital stay, secondary outcomes included opioid-related adverse effects, length, and costs of hospital stay. Mixed effect models measured the association of IVPAP and APAP and outcomes.Main resultsIn the study population 30.67% (75,445) received at least 1 dose of IVAPAP on the day of surgery. Upon adjusting for relevant covariates, patients who received IVPAP on the day of surgery had slightly higher opioid use standardized by length of hospital stay (2.8% CI: 2%, 3.6%; p < .001), higher hospital cost (2.7% CI: 2.1%, 3.4%), and higher odds of naloxone use (1.18, CI: 1.1, 1.27; p < .001) when compared with patients who received oral APAP.ConclusionsIn this population, IVAPAP use on the day of surgery failed to reduce opioid use or associated opioid related adverse effects when compared with oral APAP. IVAPAP was associated with increased overall costs, opioid requirements, and naloxone use. These results do not support the use of IV over oral APAP routinely for hip fracture surgery patients.     

Preoperative oral rofecoxib reduces postoperative pain and tramadol consumption in patients after abdominal hysterectomy

We designed this study to determine whether the administration of a preoperative dose of rofecoxib to patients undergoing abdominal hysterectomy would decrease patient-controlled analgesia (PCA) tramadol use or enhance analgesia. Sixty patients were randomized to receive either oral placebo or rofecoxib 50 mg 1 h before surgery. All patients received a standard anesthetic protocol. Intraoperative blood loss was determined. At the end of surgery, all patients received tramadol IV via a PCA-device. Pain scores, sedation scores, mean arterial blood pressure, heart rate, and peripheral oxygen saturation were assessed at 1, 2, 4, 6, 8, 12, and 24 h after surgery. Total and incremental tramadol consumption at the same times was recorded from the PCA-device. Antiemetic requirements and adverse effects were noted during the first postoperative 24 h. Duration of hospital stay was also recorded. The pain scores were significantly lower in the rofecoxib group compared with the placebo group at 6 times during the first 12 postoperative h (P < 0.05). The total consumption of tramadol (627 +/- 69 mg versus 535 +/- 45 mg; P < 0.05) and the incremental doses at 1, 2, 4, 6, 8, and 12 h after surgery were significantly more in the placebo group than in the rofecoxib group. There were no differences between groups in intraoperative blood loss, sedation scores, hemodynamic variables, peripheral oxygen saturation, antiemetic requirements, or adverse effects after surgery. The length of hospital stay was also similar in the groups. We conclude that the preoperative administration of oral rofecoxib provided a significant analgesic benefit and decreased the opioid requirements in patients undergoing abdominal hysterectomy. IMPLICATIONS: This study was designed to determine whether the administration of a preoperative dose of rofecoxib to patients undergoing abdominal hysterectomy would decrease patient-controlled analgesia tramadol use or enhance analgesia. We conclude that the preoperative administration of oral rofecoxib provided a significant analgesic benefit and decreased the opioid requirements in patients undergoing abdominal hysterectomy.