Multimodal Analgesia

Overview: 

The opioid epidemic is a major public health crisis in the United States, costing the healthcare system over $1 trillion since 2001 and projected to exceed another $500 billion over the next three years.1 Addressing new persistent opioid use following surgical care is of great import and procedures are considered a gateway to opioid prescriptions.2 It is increasingly recognized that non-opioid analgesia is as effective as some opioid analgesia and that multimodal analgesia is better than exclusive opioid analgesia.   

Undertreatment of pain garnered national attention as an indicator of poor surgical quality and many reports cited physician insensitivity to pain and disparities in pain management related to gender, age and race.3 Ability to participate in and successfully complete rehabilitation and return to the community can be hampered by inadequate pain control.4–6

Multimodal analgesia is readily available, and the evidence is strong to support its efficacy. Surgeons and anesthesiologists should use this effective approach for patients both using and not using the ERAS pathway to reduce opioid consumption.7 A multimodal analgesic regimen can be designed such that the physiologic and pharmacologic benefits are maximized and the adverse effects are minimized to facilitate the patient’s recovery and return to baseline function.7 Please see Table 17 for a list of these benefits. In fact, hospital interventions can change the prescribing culture and increase the use of opioid-sparing medications.8

  • Multimodal analgesia focuses on opioid-sparing medication to avoid the harmful side effects of opioids, both short and long-term 
  • Multimodal analgesia is safe, and can be offered in different routes and doses
Clinical Use: 

Treatment recommendations will vary based on the patient, type of surgery, age and comorbidities. However, there are key considerations for each type of medication included in Table 1 below. 

In general, recommendations include starting with around the clock non-opioids, specifically acetaminophen and ibuprofen. These should be scheduled, not prn. Then the lowest effective dose of an oral opioid can be provided on a prn basis. An IV opioid can be provided if the patient cannot tolerate oral intake. Opioids should then be discontinued as soon as possible. 

Other modalities should be considered such as neuraxial blocks (spinal and epidural anesthesia) and peripheral nerve blocks, when appropriate.  

These recommendations do not apply to patients with allergies or contraindications to these medications. In complex cases, expert advice from the pain team should be obtained. 

 

Special Considerations: 

Patient factors need to be considered in any pain regimen, and this remains true for multimodal analgesia. Age, comorbidities (such as renal function) and medication interactions all need to be carefully considered. 

References: 

Economic Toll of Opioid Crisis in U.S. Exceeded $1 Trillion Since 2001. Altarum. Published September 27, 2018. Accessed March 17, 2021. https://altarum.org/news/economic-toll-opioid-crisis-us-exceeded-1-trillion-2001

Brummett CM, Waljee JF, Goesling J, et al. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg. 2017;152(6):e170504. doi:10.1001/jamasurg.2017.0504

Sobel RM, Todd KH. Risk factors in oligoanalgesia. Am J Emerg Med. 2002;20(2). doi:10.1053/ajem.2002.31143

Capdevila X, Barthelet Y, Biboulet P, Ryckwaert Y, Rubenovitch J, d’Athis F. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology. 1999;91(1):8-15. doi:10.1097/00000542-199907000-00006

Ilfeld BM, Le LT, Meyer RS, et al. Ambulatory continuous femoral nerve blocks decrease time to discharge readiness after tricompartment total knee arthroplasty: a randomized, triple-masked, placebo-controlled study. Anesthesiology. 2008;108(4):703-713. doi:10.1097/ALN.0b013e318167af46

Yang R, Wolfson M, Lewis MC. Unique Aspects of the Elderly Surgical Population. Geriatr Orthop Surg Rehabil. 2011;2(2):56-64. doi:10.1177/2151458510394606

Wick EC, Grant MC, Wu CL. Postoperative Multimodal Analgesia Pain Management With Nonopioid Analgesics and Techniques: A Review. JAMA Surg. 2017;152(7):691. doi:10.1001/jamasurg.2017.0898

Lancaster E, Bongiovanni T, Lin J, Croci R, Wick E, Hirose K. Residents as Key Effectors of Change in Improving Opioid Prescribing Behavior. J Surg Educ. 2019;76(6):e167-e172. doi:10.1016/j.jsurg.2019.05.016

Author: 
Tasce Bongiovanni
Elizabeth Lancaster
Liza Wick