
Are your docs overprescribing opioids? It's more common than you'd think. Despite increased awareness of the adverse effects and the potential for widespread abuse and addiction, a new study from the University of Pennsylvania found that physicians are prescribing more opioid painkillers for patients who are undergoing common surgeries than ever before (osmag.net/A9fXFj).
In the study, researchers analyzed insurance claims from 2004 through 2012 for 4 common outpatient procedures — carpal tunnel repair, laparoscopic gall bladder removal, knee arthroscopy and hernia repair — and found that 4 out of 5 patients filled a prescription for an opioid pain medication within 7 days of surgery. The amount of opioids prescribed during the study period also increased.
This comes after the announcement of new CDC guidelines on prescribing opioids, which suggest providers limit the drugs' duration for patients suffering from acute pain to 3 days or less in most situations. Under the guidelines, taking opioids to treat acute pain for more than 7 days should 'rarely' occur.
In light of these developments, providers need new approaches to combat post-op pain, says Kara Settles, MD, assistant professor of anesthesiology at the UMKC School of Medicine in Kansas City, Mo. Her solution? "Two words: multimodal approach." Here are 5 trends that could boost your post-op pain management plan. In a multimodal approach, the emphasis is centered on "achieving optimal pain relief with minimum toxicity" and combining drugs that have different mechanisms of action to produce a more synergistic effect.
1. Ultrasound-guided nerve blocks
Gregory Hickman, MD, medical director and director of anesthesia at the Andrews Institute Ambulatory Surgery Center in Gulf Breeze, Fla., says regional anesthesia is becoming the go-to treatment for post-op pain in more and more facilities. "In the last 10 years, that's really the cornerstone of what has been growing and what's continuing to grow in popularity," he says. "There are a lot of places that are just now getting on board."

Placing nerve blocks, whether single-shot or continuous, is an effective way to handle painful extremity procedures like knee replacements and shoulder surgery, says Dr. Settles. "Using a nerve stimulator or, more and more frequently, ultrasound, you can get near the nerve where the surgery is going to take place, inject a local anesthetic and quiet the pain signals before they even start imprinting on the patient's brain," she says. "Being ahead of it provides a big impact for lessening the pain post-operatively."
Part of what is driving the trend is improved equipment, says Dr. Hickman. Innovations like easy-to-use catheters and echogenic needles — which are better visualized under ultrasound — make it simpler for your anesthesia providers to place the blocks. But, by far, the biggest factor driving the increase of regional blocks is the use of ultrasound, says Dr. Hickman. The latest ultrasound devices are smaller and contain features like high-definition imaging and touchscreen interfaces. They're also becoming more affordable. And the technology is only going to improve in the future. Dr. Hickman notes that manufacturers are currently working on adding features like wireless probes and software that could transform your mobile phone or tablet into an ultrasound device, an ideal option for small facilities who want to boost their regional programs.
2. Improved pain pumps
For especially painful procedures — outpatient total joint replacements are a prime example — the use of continuous peripheral nerve blocks is a way to extend pain relief for patients recovering at home. "We have started to, depending on the case, send patients home with a continuous nerve block catheter," says Dr. Settles. "You can continue to infuse the local anesthetic for 2 to 5 days post-op, depending on the infusion rate, and then the patient can remove it at home, like a Band-Aid."
While the basic functions of pumps have stayed the same over the years, Dr. Hickman notes that manufacturers are touting new features that give patients better control over their pain. Both elastomeric and electronic pumps now offer options like bolus delivery for breakthrough pain and patient-controlled infusion rates. Providers can even program some electronic pumps to begin delivering the local anesthetic up to 24 hours after surgery, allowing you to take advantage of the initial block in place for surgery and extend relief.
The pumps are pretty easy to use, though they can require some additional communication with patients pre- and post-operatively, says Dr. Settles. "You have to do a lot of education with them on what to expect," she says. "We also call every day post-operatively to see if there are any problems or questions." To take some of this burden off the facility, some manufacturers now offer services that call patients daily while they use the pumps, or have 24/7 hotlines to answer any patient questions and concerns.
3. New uses for local anesthesia
While regional anesthesia is the cornerstone of a multimodal program, injecting local anesthesia into the surgical wound and surrounding soft tissue is being used more in orthopedic surgery, says Dr. Settles.
In particular, there's been a growing use of pericapsular injections for total knee replacement. In one recent study, researchers looked at whether pericapsular injections of a mixture of bupivacaine, epinephrine, ketoprofen and morphine, along with placing a 4-day intra-articular catheter, offered any benefits over continuous femoral and single-shot sciatic nerve blocks for total knee replacement patients. They found that the injections and catheter provided good pain control without the complications typically associated with nerve block motor weakness (osmag.net/NDsSs2).
In another study, researchers found that using a mixture of ropivacaine, ketorolac, epinephrine and clonidine injected into 4 areas around the knee — the posterior capsule, the medial periosteum and medial capsule, the lateral periosteum and lateral capsule, and the surrounding soft tissue — gave patients immediate pain relief after a total knee replacement (osmag.net/Yq8KTb).
While soft tissue injections of local anesthesia can be a good adjunct to regional blocks, they still don't provide the same lasting relief of continuous nerve blocks, says Dr. Hickman. However, more manufacturers are attempting to create stronger formulas that could change that in the future, he says.

4. Non-opioid analgesics
One thing that has really driven the multimodal approach in recent years is the growing list of non-opioid analgesics, says Dr. Settles. More providers are using combinations of these medications before, during and after surgery in an effort to keep patients comfortable without the side effects of opioids.
Acetaminophen delivered intravenously can be a powerful addition to your multimodal plan. "You get much higher blood levels and CNS (central nervous system) levels with the IV acetaminophen over its PO version," says Dr. Hickman. "The CNS levels are very important for acetaminophen because its main effect occurs in the brain."
You have plenty of options in IV NSAIDs, including a new diclofenac sodium injection that can be delivered in a small-volume IV bolus much more quickly than its alternative, ketorolac. However, Dr. Hickman notes that ketorolac offers the same analgesic effect at a lower cost. "The new option has the same complications and issues as ketorolac, but it's much more expensive," he says.
IV acetaminophen offers similar advantages over oral versions of the drug, but an uptick in its cost has limited its use in some facilities. "The cost doubled a year or so ago for IV acetaminophen," adds Dr. Hickman. "We used to use it a lot more, but now we tend to give it more orally and use the IV version in certain cases or as a rescue in PACU."
More providers are also combining drugs traditionally used to treat seizures, like gabapentin or pregabalin, with an NSAID to provide pre-emptive analgesia, says Dr. Settles. "Especially in orthopedics, you'll see that the night before or the day of surgery, providers will have the patient take a little water and a combination of the 2, like gabapentin and celecoxib," she says.
Steroids also play a role in these cocktails. Dr. Hickman notes that there's a growing movement to inject the corticosteroid dexamethasone pre-operatively to ward off post-op inflammation and PONV.
5. Abuse-deterrent opioids
While opioids have received a bad rep lately, they still can play a role in your treatment of surgical pain, says Dr. Settles. "[Opioids] still have a place in multimodal pain management," she says. New options — including Xartemis XR, an oxycodone and acetaminophen formula designed to release the opioid slowly — have been specifically formulated to reduce abuse, according to the drugs' manufacturers. The key is finding the right balance, which often means limiting their use to treating breakthrough pain. "But you have to individualize the approach," says Dr. Settles. "Every surgery and patient is different. People try to make medicine an algorithm, but you have to understand the patient and any comorbidities, and tailor the medications to create the optimal plan." OSM