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Ways to Reduce Opioid Use
A multimodal pain regimen reduces nausea, vomiting and sedation - and keeps patients smiling in PACU.
Lois Pizzi
Publish Date: April 3, 2008   |  Tags:   Anesthesia

Post-operative pain and associated side effects are common reasons for delayed discharge and complicated recovery from surgical procedures. Historically, we've treated post-operative pain by adhering to a pain management model that relies on one class of analgesics: opioids. While such "monomodal" treatment can be effective, it can cause such associated side effects as nausea, vomiting and sedation, and can lead to respiratory depression.1 These side effects can also limit functional activities necessary for recovery and rehabilitation. Here are five ways you can reduce opioid use.

1. Use multimodal analgesia
A combination drug regimen, otherwise known as multimodal or balanced analgesia, can improve efficacy in treating post-op pain by using two or more analgesics with different mechanisms of action. You can reduce analgesic-related side effects with proper drug, route and dose selection in a carefully planned pain treatment protocol. You can achieve sufficient analgesia due to both the additive or synergistic effects between different analgesics and the differences in side effect profiles.2,10 In a meta-analysis of data reported by Elia et al., a regimen of selective COX-2, NSAID, non-selective NSAID or acetaminophen to IV morphine was shown to result in a 15 to 55 percent reduction in morphine consumption.3

The current trend for more complex surgeries to be done in an outpatient setting would benefit from a multimodal or balanced analgesia pain management program that could reduce opioid medication-related side effects. The addition of regional techniques using local anesthetics can add another dimension to a multimodal pain treatment program to further reduce opioid consumption in the ambulatory surgical setting. Ilfeld et al. report a reduction in pain score, fewer sleep disturbances and greater functional endpoints with the addition of local anesthetic infusions into the post-discharge period.4 Consider the addition of local anesthetics as a home infusion. Allowing continued regional blockade post-op enhances the multimodal pain management model to decrease pain, while allowing for greater mobility and the need for opioid medications for breakthrough pain. The multimodal approach is supported by many professional entities and is endorsed by the American Society of Anesthesiologists.5

Combining Analgesics of Different Classes

NSAIDs (selective and non-selective)

• Block the pain signal transmission at site of activation

acetaminophen

• Use with caution in patients at risk of side effects

opioids

• Bind to opioid receptor sites in the CNS to block the pain signal

gabapentin or pregabalin

• Decrease the hyperalgesic response from the CNS6

local anesthetics

• Block conduction of pain signals from the peripheral nervous system
•Can be used as a single-shot block and as a continuous infusion

2. Mix and match different analgesics
The combination of regional analgesic techniques such as nerve blocks with selective NSAIDs and anticonvulsants can reduce the amount of one specific pain medication needed and reduce the side effect profile when increasing doses of one agent alone. Combining analgesics of different classes stops pain transmission by different mechanisms. Pregabalin (Lyricais) is FDA-approved to treat neuropathic pain associated with diabetic peripheral neuropathy and post-herpetic neuralgia, but clinical trials are presently being conducted to investigate its use to reduce pain in surgical patients. It's important to note that pregabalin has greater bioavailability, linear pharmacokinetics (increasing the dose results in a proportional increase in plasma concentration, for example), requires less dose titration and has a shorter time required to determine analgesia efficacy.6 This will require assessment for the side effects of dizziness and ataxia that could inhibit recovery in the post-op period.

3. Consider pre-emptive and post-op regimens
Ideally, the multimodal approach to post-operative pain management begins before, and is continued during and after surgery using non-opioids, opioids, local anesthetics and adjuvant agents.10

Consider the patient's current pain management regimen. You can modify the pre-op regimen so that patients taking non-selective NSAIDs as part of their analgesic regimen could be switched to a selective NSAID before their surgical procedure.8 Also, patients currently taking opioids should continue the regimen so that opioid withdrawal syndrome and severe pain can be avoided. It should be expected that patients who already use opioids for pain management will require higher doses in the post-op period.1

Remember that pre-emptive analgesic techniques enhance prevention of acute pain by minimizing afferent nociceptive input from injured tissue by pre-injury intervention with local anesthetics or opioids.7

4. Put local anesthetic infusions to work
Local anesthetics infused by perineural technique play an important role in reducing opioid consumption during the post-op period. This can be especially effective in orthopedic procedures.

Continuous, perineural local anesthetic infusions are possible in an ambulatory surgical patient population. Many patients suffer from pain at home after discharge despite the use of a multimodal pain treatment plan. However, patients can be treated for longer periods of time with perineural infusions by using infusions of local anesthetic in the home setting.9 It's beneficial to use a disposable, programmable infusion pump with a large drug reservoir that can easily be disposed of in the patient's home.

Infusion devices of this type should also be capable of allowing the patient a bolus dose that can be used for breakthrough pain. This dose can be predetermined and timed at specific intervals. The patient-controlled analgesia principle applies to this delivery of local anesthetic pain medications, allowing the patient control of bolus dosing when needed.10

In addition, the patient and caregiver can be instructed on care and removal of the perineural catheter. The pump can be disposed of in the household trash (if operated by a non-mercury battery) or the patient can bring the pump back during a follow-up visit, whichever is warranted by physician preference.

5. Educate your patients
A multimodal approach to pain management using perineural infusions in the post-op recovery phase of ambulatory surgery includes a number of different medications, making patient education important for its success. Include family or others who'll be involved with the patient after discharge. Include specific instructions about oral medications that are prescribed on an ATC or PRN regimen. In addition, detailed education about medications and dosing is necessary to ensure that the patient follows through with the treatment plan.1 (See "Learning About Post-op Pain Can Help Patients Feel Better" on page 38.)

All smiles in PACU
As we've shown, you can achieve effective pain control in the post-op period by simply combining old and new therapies to decrease the use of opioid pain medications. A pre-emptive regimen that combines various classes of analgesics and adjuvants can be an effective way to control post-operative pain and provide safer, more effective patient outcomes.

Learning About Post-op Pain Can Help Patients Feel Better

Effective pain management can have many benefits, including earlier mobilization, shorter stays and greater patient satisfaction. Education is the key to making this happen. If there is more awareness about this situation, its common problems and the options available, then hopefully caregivers will have fewer reservations about offering treatment and patients will be more willing to ask for it.

Your pharmaceutical options for treating post-operative pain fit into four categories:

  • Non-opioids, including acetaminophen and NSAIDs such as COX-2 inhibitors.
  • Adjuvant analgesics, including local anesthetics such as lidocaine or ropivacaine for nerve blocks. Researchers are currently studying other compounds such as pregabalin for their efficacy as adjuvant agents.
  • Weak opioids, including tramadol, codeine and hydrocodone.
  • Strong opioids, including morphine, fenatyl, methadone, oxycodone and hydromorphone.

Giving the patient large doses of any agent may get rid of their pain, but it could lead to worse problems. Each class also has adverse effects associated with it. The narcotics can lead to respiratory depression, itchiness or constipation, and the non-opioids may cause bleeding, renal trouble or stomach ulcers after prolonged use.

Since the fears surrounding these agents are justified, the physician must work to minimize the risks. One of the best ways to do this is to individualize the dose to the patient by making adjustments for age (younger and healthier patients will need more than older patients) and considering any underlying conditions present. This could mean, for example, avoiding nonsteroidal agents when treating patients with renal dysfunction.

Whether the procedure is performed in an outpatient or inpatient setting is also important. Inpatients often have the luxury of getting patient-controlled analgesia delivered through an on-demand intravenous system. However, outpatients can be discharged from the center with a customized analgesic plan.

Combination therapy is an excellent technique where the practitioner uses two or more analgesic agents in order to maximize pain control and minimize side effects. This also lets you achieve superior pain control because the combined agents work via different mechanisms. For example, combining a local anesthetic with oral analgesics is an effective technique. Another is combining a narcotic with a COX-2 inhibitor. Other new combinations are being investigated.

Patient-controlled regional anesthesia pumps are a new option for outpatient settings. These deliver small doses of local anesthetics through an in-dwelling catheter to provide effective relief, especially after orthopedic cases. But they're not without their problems, including the fact that the patient's home is an unmonitored setting, which could increase the risk of complications such as overdose, leaking or a disconnected catheter.

Since the public may not understand the need and the options available to treat post-operative pain, plan on educating your patients. Patients should be told, in plain language, about the need to report their pain to raise the expectations about what is available to them.

It's important to encourage patients to take their medications around the clock when they go home. They should know that if they only take the medication when they feel they need it, their pain will be out of control by the time the agent starts working.

Patients need to understand that there are options available to control their pain post-operatively, and this should be a part of their discharge planning from an outpatient facility. Ideally, they should ask about combination therapy and if any local anesthetic techniques providing postoperative pain relief would be suitable for their particular procedures.

— Harold Minkowitz, MD

Dr. Minkowitz ([email protected]) is chairman of the Department of Anesthesiology at Memorial Hermann Memorial City Hospital in Houston.

References
1. R.K. Portenoy and M. McCaffery, Overview of the three groups of analgesics, Pain: Clinical Manual (2nd ed.), Mosby, St. Louis (1999), pp. 103-129.
2. H. Kehlet and J. Dahl, The value of "multimodal" or "balanced" analgesia in postoperative pain treatment, Anesthesia Analgesia 77 (1993), pp. 1048-1056.
3. N. Elia, C. Lysakowski and M.R. Tramer, Does multimodal analgesia with acetaminophen, non-steroidal anti-inflammatory drugs, or selective cycoloxygenase-2 inhibitors and patient-controlled analgesia morphine offer advantages of morphine alone? Meta-analysis of randomized trials, Anesthesiology 103, (2005), pp. 1296-1304
4. B.M. Ilfeld, T.E. Morey, T.W. Wright et al., Interscalene perineural ropivacaine infusion: a comparison of two dosing regimens for postoperative analgesia, Regional Anesthesia Pain Medicine 29 (2004), pp. 9-16.
5. American Society of Anesthesiologists Task Force on Acute Pain Management, Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management, Anesthesiology 100 (2004), pp. 1573-1581.
6. J. Golembiewski, Postoperative pain management ??" is there a role for gabapentin or pregabalin?, Journal of Peri-Anesthesia Nursing, 22-2 (2007), pp. 136-138.
7. R. Sukahani K. and Frey, Multimodal analgesia approach to postoperative pain management in ambulatory surgery, Techniques in Regional Anesthesia and Pain Management 1- 2 (1997), pp. 79-87.
8. M. McCaffery and R.K. Portenoy, Non-opioids, Pain: Clinical Manual (2nd ed.), Mosby, St. Louis (1999), pp. 129-160.
9. N. Rawal, Postoperative pain treatment for ambulatory surgery, Best Practice & Research: Clinical Anaesthesiology 21, (March 2007), pp. 129-148.
10. C. Pasero, R.K. Portenoy and M. McCaffery, Opioids, Pain: Clinical Manual (2nd ed.), Mosby, St. Louis (1999), pp. 174-177.

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