Shoulder surgery is notoriously painful, but it's not uncommon for post-op shoulder patients at the Andrews Institute for Orthopaedic & Sports Medicine in Gulf Breeze, Fla., to never have to take a pain pill, says Gregory Hickman, MD, medical director and director of anesthesia. Like a growing number of surgical facilities, the famed Andrews Institute has tapped into the magic of a multimodal approach to pain management.
The traditional pyramid of pain management involves giving more and more narcotics, depending on whether pain is mild, moderate or severe. Dr. Hickman has turned that pyramid on its head. Less than 10% of his patients get narcotics in the recovery room.
"My pyramid is totally different," he says. "The primary thing we do is regional anesthesia. If we can do a regional anesthesia, we're going to do it, unless it's something really simple like a carpal tunnel or a trigger finger."
When you add up all the elements of strategically executed multimodal pain management, something remarkable happens. The whole turns out to be greater than the sum of the parts.
"You always want to use multimodal therapy, because you get a lot more bang for your buck," says John Dombrowski, MD, a specialist in pain medicine at the Center for Pain Medicine in Washington, D.C. "People say, we just use this and that alone. Well, that's good, but it could be so much better."
Mixing the right cocktail
The key is to use a cocktail of drugs that work on different sites, target different receptors and have different effects. The goal is to effectively reduce post-operative pain, opioid consumption and opioid-related adverse effects after surgery.
Dr. Hickman augments his blocks with continuous catheters, running a dilute solution of local anesthetic for 3 or 4 days. If he doesn't do a nerve block, pre-operatively he gives patients 200mg of pregabalin, useful for treating neuropathic pain. In the operating room, right after induction but before the surgery starts, he'll give IV acetaminophen, which works centrally in the brain. He also gives small does of ketamine, an NMDA receptor antagonist that works in the spinal cord and "really helps a lot with analgesia." He can also give patients the anti-inflammatory ketorolac.
"We're doing a multimodal approach hitting different sites with the different drugs," he says.
Multimodal Approaches Catching On
The multimodal approach appears to catching on. When we surveyed readers 3 years ago, only 12% said they used more than 2 non-opioid analgesics in their multimodal regimens. That number was up to 35% in a survey conducted last month. Meanwhile, 50% say they now use 2 non-opioids, compared with 45% in our previous survey. The percentage using only 1 non-opioid alternative has declined from 43% to 15%.
Also on the rise is the percentage of readers who administer non-opioids pre-operatively. Three years ago, only 35% said they do so at least 50% of the time. In our more recent survey, that number stood at 55%.
The percentage of respondents who say they administer non-opioids post-operatively at least 50% of the time declined from 51% to 41%, possibly because the added pre-operative steps help reduce the need.
The time for opioids
The time to use opioids in small doses, says Dr. Hickman, is before the pain ratchets up, not after. He gives select patients a small dose of fentanyl (100 mics), which works on the mu receptors in the spinal cord and the brain.
"I'm a big believer in preemptive analgesia. You want to prevent spinal wind-up," says Dr. Hickman, whose facility is well known for repairing some of the biggest names in sports. "That's where nerve fibers send a message to the spinal cord and the spinal cord sends it up to the brain. Pain gets the spinal cord wound up. If you prevent that from getting going, that keeps it from getting bad."
Or as Dr. Dombrowski puts it, why not control the horses before they get out of the barn?
"Doing everything you can beforehand is really important," he says. "It's a lot better to give people pre-medications before surgery, like pregabalin or gabapentin. You can even start people 24 hours beforehand on these medications, or with a non-steroidal or Cox-2 inhibitor. There's some concern about how that's going to affect bleeding, but it's at least worth considering. An anesthesiologist can also give a patient IV acetaminophen, which has no risk of any bleeding issues."
Drs. Hickman and Dombrowski both tout the benefits of the steroid dexamethasone as a post-op medication.
"Steroids like dexamethasone do several different things for patients," says Dr. Dombrowski. "They're anti-inflammatories, and inflammation and pain are synonymous. They also tend to prevent nausea, which is great, and they make you feel better. You get a bit of a steroid high. That's a lot of benefit from a very cheap medication."
Single-shot injections at the surgical site can also play a major role in multimodal therapies. "In abdominal surgery, the bulk of the pain is somatic, not visceral," says Ashish Sinha, MD, PhD, vice chair of anesthesiology and perioperative medicine at Drexel University College of Medicine in Philadelphia. "A shot of local at the site can provide several hours of pain relief, which decreases the need for narcotics." Administering fewer narcotics lessens the risk of respiratory depression, limits PONV and lets patients ambulate sooner after surgery.
One of the cheapest therapies is also one that's often overlooked: ice. "That's something people don't even think about," says Dr. Dombrowski. "It's simple, it's easy and it has no side effects. Ice the heck out of the area and people tend to have a lot better recovery. A lot of people don't do that."
While eliminating opioids, and the numerous problems attached to them, remains a lofty some would say unattainable goal, one of the strengths of multimodal therapy is that it's designed to minimize that need for narcotics, and in so doing, it benefits virtually everyone involved patients, surgeons, nurses and administrators.
"If you use a multimodal approach and do it preemptively," says Dr. Hickman, "you'll at least decrease the need for narcotics. It's really pretty simple. If people read the literature and know these drugs, they're all good for analgesia. I just put them together."
"We're trying to block or lessen each of the many different chemicals that cause the transmission of pain," echoes Dr. Dombrowski.
After all, the ability to manage pain without leaning heavily on opioids has benefits far beyond reducing PONV, says Dr. Dombrowski. "Not only will you have faster throughput, because patients are more awake and more comfortable, and with fewer side effects, but good pain management increases your market share," he says. "When you have happy patients, they tend to tell friends and go on social media and recommend you.
"And surgeons are going to love you, because when you have bad pain control, that makes them look bad, or they have patients calling them because they're uncomfortable. And surgeons don't like phone calls. It's very competitive out there, so it's valuable to be able to say to surgeons, 'You want to do your case in my facility because you'll never get a phone call about pain.'"