Publish Date: March 25, 2020
In an effort to reduce perioperative opioid use, ASCs are increasingly migrating toward the use of multimodal analgesia for postoperative pain management. When leveraged effectively, multimodal analgesia can be an integral part of improving the surgical patient experience, improving pain control and solving the opioid crisis.
"Almost every surgery can benefit from multimodal postoperative pain management," says Mauricio Mejia, MD, anesthesiology medical director at Porter Adventist Hospital in Denver. "Whereas opioids are often a beneficial and necessary part of anesthesia and the early recovery period from surgery, for many types of surgeries, they are rarely needed once patients return home. The consistent delivery of multimodal analgesia remains an area of opportunity for reducing patient exposure to the increased risks and side effects of opioids."
Here are six things Mejia says ASCs should know about multimodal postoperative pain management.
Opioid risks and dangers necessitated alternative solutions.While opioids often play a critical role in surgery, their potential for severe side effects has made it necessary for providers to find better ways to manage postoperative pain and to significantly reduce the number of opioids being prescribed, Mejia says. "Opioids after surgery are often overprescribed, which is problematic when you consider that serious side effects of opioid use include addiction, respiratory depression, cardiac abnormalities, inhibition of cellular immunity, hormonal disruptions, sudden respiratory arrest and sudden cardiac death."
Statistics further support the need for diligence when prescribing opioids Persistent opioid use after surgery is a widespread, under-recognized complication, Mejia says. As the Institute for Healthcare Improvement notes, "Fifty million Americans have surgery each year. Approximately 2 million of these surgical patients will develop persistent opioid use— meaning they continue to use opioids 90–180 days after surgery." A JAMA Surgery article states that an estimated 5.9% of patients who undergo minor procedures and 6.5% who undergo major surgeries become new persistent opioid users.
"Interestingly, the fact that these rates are similar despite the extent of the surgical procedure suggests that patient factors play an important role. Careful screening of patients for an elevated risk of developing opioid use disorder may help protect patients," says Mejia. "It is important to keep in mind that opioids are highly addictive drugs; and virtually anyone who is exposed to them — particularly at higher doses and longer duration — is at risk for addiction."
Recent developments have spurred multimodal adoption. Historically, Mejia says, medicine has overemphasized pain control. "It did so by making pain the 'fifth vital sign.' While a patient was recovering from surgery, caregivers felt pressured to achieve a pain score of zero. Patients would frequently be overmedicated with opioids and experience a range of side effects — some mild, some severe."
To help discourage overuse of opioids, the American Medical Association removed pain as a vital sign in 2016. That same year, the Centers for Medicare & Medicaid Services announced it was removing pain management questions from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.
"Medicine has moved towards deemphasizing a numerical pain scale rating to incorporating functional assessments in recovery pathways," Mejia says. "We want patients to have tolerable pain that would allow them to be awake and functional, receive the sleep and rest needed, take in the appropriate amount of fluids and nutrition that are important for healing and perform any recommended physical therapy exercises. Having some pain is helpful in guiding patients so that they do not overexert themselves."
The goal, he adds, is to move away from over-narcotized, sleepy and nauseous patients to more awake, functional and motivated-to-recover patients.
Multimodal pain management can work for most ASC patients. Multimodal pain management is the use of medications and regional anesthesia that work in different mechanisms to control pain, Mejia says. "For many types of ambulatory surgeries, the addition of several nonopioid multimodal analgesic therapies reduces or eliminates the amount of perioperative opioids used and improves patient outcomes."
Examples of multimodal analgesic options to consider include: acetaminophen, blocks (neuraxial, regional or plane), celecoxib, dexamethasone, dexmedetomidine, dextromethorphan, diazepam, esmolol, gabapentinoids, ketamine, lidocaine (drip or patch), local infiltration of surgical site, magnesium, muscle relaxants and nonsteroidal anti-inflammatory drugs. "For surgical procedures, physicians should consider two or more such multimodal analgesic options, preferably administered within the time frame of four hours before the start of surgery through four hours following completion of surgery," Mejia says. "For less invasive surgeries, physicians should use fewer/safer options."
Multimodal approach carries its own risks. Whereas multimodal pain management has been proven safe and effective, clinicians should understand the potential risks and consequences of polypharmacy, Mejia says. "Several medications and blocks, when administered together or in combination with anesthetic drugs or opioids, can contribute to a wide range of side effects, which include bradycardia, dysrhythmias, hypotension, local anesthetic systemic toxicity, renal disease and respiratory depression."
The risk of these side effects can be decreased or eliminated by avoiding certain drugs and/or drug combinations; avoiding multiple or high dosages of a drug; and timing the administration of certain drugs so that they do not reach peak levels simultaneously (for example by timing some drugs to be given preoperatively or early during surgery and other drugs to be given near the end of surgery or in the recovery room. "It is important that clinicians understand the administration instructions, benefits, dosages, interactions and risks of each medication and block," Mejia says.
Simple solutions are often effective. Regional anesthesia is one of the most effective ways to control postoperative pain, Mejia says. This is where local anesthetics drugs — with or without local anesthetic adjuvant drugs to increase the quality and duration of the block — are used to numb areas of the surgery often for 12 to 36 hours.
"Much healing occurs in the first 24 hours, and when regional anesthetic blocks wear off, the pain is often not as intense," Mejia says. "In addition, studies have shown that controlling pain early can result in better long-term pain control. Regional anesthesia blocks can inhibit the chance of the wind-up phenomenon, which is an increase in pain intensity over time when a repeated stimulus is delivered."
When at home from many types of surgeries, pain can be well controlled by patients taking scheduled nonopioids alone, such as acetaminophen and ibuprofen. Mejia says. "Several studies have also shown that drinking, eating and mobilizing as soon as possible after surgery frequently results in enhanced recovery and better outcomes."
ASCs with standardized multimodal pain management protocols for various types of surgeries have seen the benefit it provides their patients, Mejia says. "They are more satisfied, recover better and have better pain control with less opioids." He advises ASC clinical leaders to work with their local anesthesia and surgeon partners to establish these protocols at their facilities.
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