MULTIPLE PAIN PATHWAYS Multimodal anesthesia lets you target each component as needed.

Embracing non-opioid techniques for anesthesia and post-op pain control may take a little getting used to, but the enhanced patient safety, minimized pain and faster turnover times that can result are well worth it. Here's a look at why you need to start combining IV and PO analgesics, regional blocks and other tools, and how to move toward a nearly opioid-free facility.

Deciphering pain at the source
The end goal of post-op pain management isn't merely "no pain" — it's really a set of goals, including minimizing pain, thwarting potential side effects and complications, and avoiding long-term chronic pain (which can be triggered by an episode of acute pain).

Pain is multifactorial, so treatment should target all components. No single drug can adequately treat each of these components, including opioids, which come with a lot of potentially serious side effects, ranging from nausea, vomiting and constipation to respiratory depression, sedation and confusion. Because pain is complex, appropriate management requires a balanced therapeutic approach. Multimodal anesthesia offers this balance, letting you target each component as needed. It also lets you reduce doses of each analgesic; improve pain relief secondary to synergistic or additive effects of particular agents; potentially reduce side effects of individual medications; and improve acute pain outcomes.

Applying multiple modalities
The American Society of Anesthesiologists' 2012 Guidelines for Perioperative Pain Management offer 4 steps for multimodal pain management:

1. Whenever possible, employ a multimodal analgesic approach.
2. A non-opioid treatment plan should include local/regional anesthetic techniques, acetaminophen and NSAIDs.
3. Restrict opioid use to supplemental treatment.
4. Use around-the-clock acetaminophen and selective or non-selective NSAIDs routinely when possible.

NON-OPIOID IV ANALGESIA Plastic surgeon Richard A. Baxter, MD, FACS, administers Exparel infiltration for breast augmentation.

YOUR ARSENAL

Analgesic Adjuncts That Make a Difference

A wide variety of options is at your disposal when using multimodal.

• acetaminophen
• NSAIDs, COX-2 inhibitors
• NMDA receptor antagonists
  • - ketamine
  • - dextromethorphan
  • - magnesium
  • - amantadine
  • - memantine
• alpha-2 agonists
  • - clonidine
  • - dexmedetomidine
• anticonvulsants (alpha-2-delta)
  • - gabapentin
  • - pregabalin
• opioid antagonists
• corticosteroids

— Eugene R. Viscusi, MD

To be considered true multimodal analgesia, the regimen should include at least 2 non-opioid agents, and opioids should be used as adjunctive agents, after the non-opioids have been introduced. You can combine a number of agents to develop a multimodal regimen. Your key options:

• Acetaminophen. Works on multiple peripheral and central sites to change the way the body senses pain and to cool the body (which reduces fever). Using the IV version effectively reduces mild to moderate pain while avoiding the side effects of opioids, and can also be used in combination with a variety of opiates.

• Pregabalin/gabapentin. Relieves neuropathic pain caused by damage to the nerves during surgery by decreasing the number of pain signals sent out by these damaged nerves. Studies have shown that these anticonvulsants not only decrease sensitization in the immediate post-op period, but also subsequent persistent pain. Administration before and 12 hours after surgery significantly reduces opioid consumption and the use of additional pain rescue for 48 hours after surgery without significant side effects.

• Nonsteroidal anti-inflammatory drugs. Works by stopping the body's production of COX-1 or COX-2, substances that cause pain, inflammation and fever. The new IV versions can manage mild to moderate pain — or severe pain, when used with opioids. NSAIDs don't have a negative effect on soft tissue healing or osteointegration, making them an option for multiple specialties, including orthopedics.

• Peripheral nerve blocks with liposomal drug delivery. Improves the efficacy of local anesthetics by increasing drug circulation time. The sustained release may improve tolerability/reduce side effects. In addition, the liposomal formulations themselves are generally well tolerated, as they're made from naturally occurring lipids. Using PNBs wherever possible reduces the doses needed to ease pain post-op.

• Ketamine. Use in opioid-tolerant patients who are experiencing new, acute pain. Ketamine reduces opioid requirements and improves pain control. Use 0.5mg/kg at induction and 10mcg/kg/min intraoperatively to combat post-op pain without an increase in opioid-related side effects.

Multimodal's benefits
These are suggestive treatment options and must be individualized to the patient, surgery and setting. Multimodal anesthesia and post-op pain control minimizes opioid use, closes analgesic gaps, and im-proves long-term outcomes. It's the new pathway for acute pain. OSM