Multimodal Postsurgical Pain Management Minimizes Opioids Reliance

James Price, MD

An opioid crisis is raging across the United States. According to the National Institutes of Health, more than 115 individuals die every day from an opioid overdose. The Centers for Disease Control and Prevention estimates that the economic burden of opioid misuse exceeds $78 billion annually.

One of the most common uses of opioid analgesics in the clinical setting is for the management of postsurgical pain. More than 100 million people in the United States undergo surgical procedures every year, with approximately 53 million performed in the ambulatory setting.[1] Research suggests that nearly all these patients will receive a postoperative opioid prescription. Can such prescriptions—given for an appropriate medical indication—serve as a gateway to misuse? One recent study suggests it might, revealing continued opioid use in 7.7% of opioid naïve patients 1 year after surgery.¹

On the other hand, adequate pain control following surgical procedures is essential for optimal recovery. In this light, it is imperative that surgical practices provide an approach to postsurgical pain management that minimizes reliance on opioid medications.

Our Multimodal Approach

The manifestation of pain can be driven by several underlying pathophysiological processes and can have physical, psychosocial, and even spiritual components. An effective multimodal approach to pain management, therefore, addresses several of these underlying processes at once, leading to more effective pain control.[2]At Arctic Surgical Group, we have adopted a protocol known as enhanced recovery after surgery (ERAS). This approach emphasizes use of multimodal analgesia combined with a focus on early mobilization and resumption of oral intake. Research published in 2015 has revealed that implementation of ERAS reduced care time by 30% and postsurgical complications by up to 50%.[3]

To optimize the patient experience and outcome, which includes effective postsurgical pain control, we recognize the importance of developing a partnership and a bond based on mutual trust between patient and anesthesiologist. To foster this, we have a minimum of 5 points of contact between patients and their anesthesia provider before, during, and after undergoing a diagnostic nerve block. At least 3 of these occur in person, with follow-up postoperative telephone calls making up the bulk of contact.

Our Tips for Success

These multiple points of contact allow us to tailor anesthesia plans and increase the comfort and trust levels in our patients. What success looks like in terms of patient outcomes is that in over 2 years and over 300 cases, we have not had a single admission to the hospital for pain, nausea, or vomiting control. Patient satisfaction scores run approximately 95%. The patient's perception is that Arctic Surgical Group is a family unit superseding a medical group. Patients typically meet discharge criteria 2 hours after admission to the post-anesthesia care unit (PACU).Several factors are essential to the successful implementation of a multimodal program such as ours. These include:

1. Universal commitment: Our program requires 100% buy-in from our entire clinical staff as well as our patients. The administrative team must also be invested in education and in increasing staff, as needed, to accommodate this approach. A dedicated anesthesiologist in the PACU setting is particularly important.
2. Appropriate equipment: It is essential to have procurement of multiple pumps for each operating room for standardization of total intravenous (TIVA) therapies.
3. Pharmacy support: Pharmacists must ensure that medications are easily available to the anesthesia provider in the operating theater.

Our Approach

We have developed a comprehensive multimodal analgesia protocol for use in the preoperative, intraoperative, maintenance, and postoperative settings, as well as for use after discharge. While this protocol can involve use of opioids, including a prescription for oxycodone after discharge, the opioid forms only one component of a synergistic pain relief approach that addresses pain from many pathophysiological angles.

We use anti-inflammatory drugs in the form of cyclooxygenase (COX)-1 and COX-2 inhibitor non-steroidal anti-inflammatories (NSAIDS) to inhibit spinal and peripheral COX enzymes. We combine these with acetaminophen to inhibit central COX transcription.^[4] Corticosteroids are also employed to suppress inflammation associated with tissue injury, thus preventing peripheral and central sensitization.

NMDA receptor antagonists, including methadone and ketamine, are used to reduce central pain sensitization produced by injury through their NMDA receptor blockade[5]. Methadone actually covers multiple fronts, as it is also a potent mu-receptor agonist and decreases the reuptake of serotonin and norepinephrine in the brain, which may contribute a mood elevating effect.[6]

We use anticonvulsants such as gabapentin and pregabalin because they produce an inhibitory modulation of neuronal excitability by blocking the alpha 2 delta subunit of presynaptic, voltage dependent calcium channels, which are upregulated in the central sensitization processes.⁵

Finally, Alpha-2 adrenergic receptor agonists, such as clonidine and detomidine, have sedative effects through both peripheral and central mechanisms of action.

We have found that our protocol, which addresses multiple potential routes to the development of acute and chronic pain at once, is an effective means of keeping patients comfortable before, during, and after surgery.

[1] Jianx X, Orton, .Feng R, et al. Chronic opioid usage in surgical patients in a large academic center. Ann Surg. 2017;265(4):722-727. doi: 10.1097/SLA.0000000000001780.

[2] Faisal W, Jacques J. Role of ketamine and methadone as adjunctive therapy in complex pain management: a case report and literature review. Indian J Palliat Care. 2017;23(1):100-103. doi: 10.4103/0973-1075.197956.

[3] Lyass S, Link D, Grace B, Verbukh I. Enhanced recovery after surgery (ERAS) protocol for outpatient laparoscopic sleeve gastrectomy in ambulatory surgery -safe and effective. Surg Obes Relat Dis 2015;11(6):S198. doi: 10.1016/j.soard.2015.08.316.

[4] Botting RM. Inhibitors of cyclooxygenases: Mechanisms, selectivity and uses. J Physiol Pharmacology 2006; 57(suppl 5):113-24.

[5] Richebé P, Capdevila, Rivat C. Persistent postsurgical pain: Pathophysiology and preventative pharmacologic considerations. Anesthesiology. 2018;129(3):590-607. doi: 10.1097/ALN.0000000000002238.

[6] Murphy G, Szokol J. Use of Methadone in the Perioperative Period. Anesthesia Patient Safety Foundation Newsletter 2018;32(3):81-82.

James Price, MD, is a board-certified Anesthesiologist and Perioperative Pain Specialist with the Arctic Surgical Group in Anchorage, AK. He is a diplomat of the American Board of Anesthesiology and a delegate to the American Society of Anesthesiologists. The piece reflects his views, not necessarily those of the publication.Healthcare professionals and researchers interested in responding to this piece or contributing to MD Magazine® can reach the editorial staff here.