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Winning the Pain Game
No single drug is capable of targeting all types of pain, so a multimodal approach is vital.
Jaime Baratta
Publish Date: June 4, 2015   |  Tags:   Anesthesia
multimodal pain approach MAKE IT STOP Pain is multifactorial in nature. Using a multimodal approach focused on non-opioids will provide better pain control, decreased unwanted side effects and better outcomes.

As clinicians, we've been taught to assess patient pain with numbers. On a scale of 1 to 10, how much does it hurt? But if we rely solely on that approach, we're in danger of failing to ask a vital question when it comes to treating pain: What type of pain is the patient having — sharp, throbbing, stabbing, burning or spasm-like?

Surveys show that many, if not most, patients still suffer with moderate to severe post-operative pain. Uncontrolled pain may have significant clinical, psychological and socioeconomic consequences, including increased morbidity and mortality, delayed recovery, unanticipated readmissions, decreased patient satisfaction and even chronic postsurgical pain.

But the fact is that pain, along with being one of the greatest concerns of patients facing surgery, is multifactorial in nature. As such, there isn't just one single drug we can use to adequately treat it. That's something we need to come to grips with as we navigate the new world of health care. With reimbursements being tied to both outcomes and patient satisfaction, we must understand and use multimodal techniques. We can't afford to neglect the best and most appropriate ways to treat post-surgical pain.

patient education CLEAR DIRECTIONS Patient education is key with pain pumps. Provide both oral and written instructions to the patient and caretaker, as well as a 24-hour contact number.

Bad habits
The first step may be to break old habits. Traditionally, many have turned to opioids to help manage all types of postsurgical pain. While it's true that opioids are well suited to treat nociceptive pain, postsurgical pain is often a combination of different types of pain, including nociceptive, neuropathic and inflammatory. Opioids aren't just less effective for treating other types of pain, they can also be accompanied by a number of unwanted side effects, including sedation, respiratory depression, pruritus, urinary retention and constipation. Tolerance and addiction are also risks. (Very early research in animal models suggests there may be even be a link between opioids and cancer recurrence, although much more research is needed in this area.)

What's the alternative? The best approach is to focus your pain regimen on non-opioid analgesics. But since there's no single wonder drug capable of targeting pain at all angles, the multimodal approach is vital. In fact, the most recent guidelines for acute pain management from the American Society of Anesthesiologists advocate a multimodal approach that includes around-the-clock non-opioid analgesics — including acetaminophen and non-steroidal anti-inflammatory agents (NSAIDs) or cyclooxygenase-2 (COX-2) selective inhibitors — as well as local anesthetic techniques, whenever possible. With this approach, opioids become adjunctive agents instead of mainstays.

A large arsenal
Depending on the kind of pain you're dealing with, you have numerous weapons at your disposal. However, it's important to devise an analgesic plan for each patient before he enters the operating room. Remember, never let post-surgical pain get out of control. Developing clinical pathways aimed at pain management for different types of surgeries can be an effective approach. Studies suggest that treating pain with preemptive analgesia may decrease the severity of pain post-operatively. Even when treating acute pain, don't reach for the opioids first. Use a multimodal approach focusing on non-opioids, and you'll see better pain control, decreased unwanted side effects and better outcomes.

Some other points to keep in mind:

  • Acetaminophen acts both centrally and peripherally to relieve pain and reduce fever.
  • NSAIDs are potent anti-inflammatory agents that act by stopping production of cyclooxygenase.
  • Pregabalin and gabapentin are anticonvulsants that have proven very effective in treating neuropathic pain — the kind that results when nerve endings are damaged by surgery.
  • Ketamine, an NMDA antagonist, is proven to be effective in combating acute postsurgical pain in one of the most challenging groups of patients — those with chronic pain maintained on opioid therapy. In fact, one of the biggest risk factors for developing chronic pain after surgery is uncontrolled acute pain, making it that much more important that you use an effective multimodal approach.

Local anesthetics, whether through wound infiltration or via a peripheral nerve block, are also important components of pain management. Long-acting local anesthetics, such as ropivacaine or bupivacaine, may provide significant relief when given via wound infiltration. Early studies suggest that Exparel, a liposomal bupivacaine formulation that uses DepoFoam to enable time-release delivery, may provide analgesia for up to 72 hours. So far, Exparel is only approved for use in wound infiltration and not for peripheral nerve blockade.

Do Opioids Add as Much as They Subtract?

medication ONLY IF NEEDED The multimodal approach reduces opioids to an adjunct instead of a mainstay.

We know that opioids help reduce nociceptive pain, but at what cost? The list of undesirable side effects is long and troublesome.

In a review (osmag.net/UgtK7X) of 6 studies involving 1,342 participants who'd undergone various procedures, we found that patients given a combination of ibuprofen plus high-dose codeine experienced significantly higher rates of pain relief than patients given a placebo. Not surprising. But interestingly, we also found that patients who were given 400 mg of ibuprofen plus codeine fared only slightly better in pain relief than patients who were given the same dose of ibuprofen alone. In fact, the difference was just barely statistically significant.

It's all the more reason to consider whether the benefits of opioids are likely to be commensurate with the disadvantages. For example, we know that patient satisfaction depends on more than pain control. Those who experience PONV, a common side effect associated with opioids, may be just as dissatisfied as those who experience pain. Patients given opioids may also experience respiratory depression, urinary retention and constipation. Misuse and abuse are also profound concerns.

Taken together, these facts and findings appear to further underscore the need to reduce traditional reliance on opioid analgesics, and to shift their role to that of rescue agents instead.

— Jaime Baratta, MD

ultrasound use\ ON TARGET Dr. Baratta uses ultrasound to place a peripheral nerve blockade. Blocks eliminate the need for opioids for many patients.

Block time
Upper and lower extremity surgery is particularly amenable to peripheral nerve blockade, and many patients don't require opioids if they have effective blocks. With continuous catheters and pain pumps, blocks can be extended for an additional 48 to 72 hours. Many disposable elastomeric pumps are commercially available, and easy and safe to use in both ambulatory and inpatient settings.

Establishing an ambulatory peripheral nerve catheter service may sound daunting, but it may actually be easier than you think. Patient selection is the key. You need to ensure that the patient understands English and has a working phone at home. Provide both oral and written instructions to the patient and care-taker before discharge, as well as a 24-hour contact number they can use if they have questions. Explain how to use the pump, what to expect when the primary block resolves, the importance of limb protection, how to treat breakthrough pain and how to handle catheter-site leakage. Also, discuss a catheter-removal plan and be sure patients with lower extremity blocks understand the risk of falls. Make sure an anesthesiologist contacts the patient daily while the catheter is still in use. Numerous studies have shown that under the right circumstances, continuous peripheral catheters are very safe and effective for outpatients, with high reported patient-satisfaction scores.

Attack pain on all fronts
Although pain after surgery is a challenge, we have numerous effective therapies in our arsenal. Again, the keys are to start treating pain with preemptive analgesia early and to not reach for opioids first. Using a multimodal approach focused on non-opioids will provide better pain control, decreased unwanted side effects and better outcomes.