Multimodal Analgesia in the Era of the Opioid Epidemic
Introduction
A long introduction exposing the origins of the opioid crisis with its associated dismal mortality and morbidity rate should not be needed to encourage providers to adopt new analgesic strategies with less reliance on opioid medications. Unfortunately, we are in the midst of this crisis due to an overreliance on opioids. The thought that better pain control can be achieved with just adding more opioids was clearly wrong. It should be profoundly evident to all providers that a new paradigm is needed in order to curb this opioid crisis. Achieving good pain control with less or no opioid medications while minimizing complications should be our new goal. Multimodal analgesic regimens can achieve this new goal of reducing opioids while providing improved pain control. These regimens that should incorporate a more holistic approach to pain control are explored and discussed.
Section snippets
Patient evaluation overview
There is no silver bullet for good postoperative pain control. Historically, analgesic regimens focused on the postoperative period. However, contemporary pain control begins as soon as the preoperative period. Using strategies of enhanced recovery after surgery (ERAS) encapsulate the ideas of focusing on the patient’s total perioperative timeline in order to affect positive outcomes for the surgical intervention. ERAS pathways have identified not only improved pain control and opioid reduction1
Patient and family preoperative education
It is helpful to identify patients at risk for poor postoperative pain control so that interventions may be tailored to the patient’s individual needs. Several patient characteristics have been described as contributing to poor postoperative pain control: psychiatric illnesses such as depression, anxiety, catastrophizing,7, 8, 9, 10 younger age,8,11 elevated preoperative pain scores,8, 9, 10, 11 longer operative times,11 sole use of general anesthesia,9 and chronic opioid use.12 Many of these
Standardized anesthesia regimens
The anesthetic care that a patient receives can greatly affect postoperative analgesia. Regular consultation with your anesthesiologist will help ensure that anesthesia therapy is being delivered in a manner that maximizes analgesia and reduces opioid exposure; this can be achieved by developing expectations for optimization of regional anesthesia, minimizing agents such as remifentanil that have been associated with hyperalgesia,15 and increasing the utilization of agents such as ketamine,16
Appropriate use of opioids
Opioids have been used for centuries to treat acute pain, and unfortunately, they still play an important role in the management of acute pain. However, physicians must understand the many caveats that exist with this drug class in order to use opioids in an appropriate manner while being sensitive to the potential pitfalls. Namely, physicians must understand that all opioids are addictive, which is contrary to prior false assumptions contributing to the current opioid epidemic.18 Historically,
Multimodal therapy
“Aggregation of marginal gains in cardiac surgery” was coined by Dr Fleming and colleagues28 in his study, which embodies the intent of multimodal therapy, which is to provide improved outcomes while reducing complications. There is currently no “silver bullet” for postoperative analgesia; therefore, a provider must use therapies that reduce pain but do not cause undue side effects. For instance, prescribing high-dose gabapentin in the hopes of improved analgesia may result in oversedation of
Regional Anesthesia
Regional anesthesia represents 2 distinct categories: peripheral and neuroaxial anesthesia. Both of these techniques can be introduced into a multimodal regimen. Historically, thoracic or lumbar epidural analgesia has been considered the gold-standard regional analgesia. However, this standard is quickly changing with the improvement of technology namely ultrasound technology, and this has allowed the expanded use of peripheral nerve blocks as well as improved the safety of this technique. The
Multidisciplinary approach
Providing a multidisciplinary approach to complex acute pain issues may be necessary in many patients. An evidence-based approach such as ERAS protocols can incorporate a multidisciplinary approach to patient care in the setting of surgery. Similarly, utilization of guidelines such the American College of Critical Care Medicine’s pain, agitation, and delirium guidelines in an intensive care setting may facilitate optimized analgesic care in a critically injured patient.44 These guidelines take
Nonpharmaceutical therapy
These treatment options are often times overlooked due to lack of evidence or reimbursement issues. They can range from simple measures such as warm and cold compresses that require little effort but may safely provide analgesia.46,47 Distraction therapies such as guided imagery, meditation,48 and music49 have also shown benefits in improving analgesia. Nurse education can include training for instituting these types of techniques. Transcutaneous electrical nerve stimulation is another modality
Summary
The opioid crisis has certainly brought attention to the use of opioids to treat pain. This crisis has helped reveal that analgesic regimens should not be heavily relied on opioids to deliver pain control. The potential risk of overutilization of opioids has been self-evident. Unfortunately, until a new class of drug is discovered these medications will still play an important role in analgesia especially in critically injured patients. Even though these medications are still used, they should
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