1. Multimodal Analgesia in the Acute Care Setting
Daniela Fernandez, PharmD
PGY1 Pharmacy Resident
Morton Plant Hospital
March 26, 2019

2. Disclosures
The speaker has no disclosures to report.

3. Objectives Define the types of pain and their sources
Define and describe multimodal pain management with brief review of medication classes
Review current literature on benefit of multimodal pain management
Identify current practices within Morton Plant Hospital utilizing multimodal pain management

4. Classification of Pain

5. PAIN
“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”
In 1994, the International Association for the Study of Pain (IASP) defined pain as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”
This definition persists to this day
Pain management in general is a vital criteria and outcome measure for healthcare institutions.
It’s important to remember that pain is always subjective, although we use various tools to try to quantify this pain and aid in patient assessment.
Most relevant to our discussion today, pain can be categorized in a variety of ways - by its basic type (nociceptive vs neuropathic), intensity, location, and most commonly duration (which involves the discussion of acute vs chronic)

6. Classification of Pain
Adaptive vs. Pathophysiologic
Nociceptive
Somatic, Visceral
Neuropathic
Diabetic neuropathy, postherpetic neuralgia
Centralized
Fibromyalgia, IBS
Classification of pain helps to guide assessment and treatment in patients:
At its core, pain can be considered adaptive or pathophysiologic
Adaptive pain serves to sense and/or avoid actual or potential tissue damage
Pathophysiologic pain is more ongoing and chronic, and serves no protective purpose.
Under that umbrella, we have three major types of pain: nociceptive, neuropathic, and centralized pain.
Nociceptive pain – represents normal physiologic response to tissue injury
Somatic – muscle pain, cutaneous pain, well localized pain
Visceral – organs and smooth muscle pain; usually referred pain
Neuropathic
Caused by ongoing peripheral nerve injury or in the CNS (as in a patient with MS or post ischemic stroke)
IASP definition: “Pain arising as a direct consequence of a lesion or disease affecting the somatosensory system”
Sensory abnormalities can range from tingling, numbness, to burning
Examples include diabetic neuropathy, postherpetic neuralgia, spinal cord injury pain, phantom limb (post-amputation) pain
Centralized
No nerve injury or inflammation exists but a centrally mediated disturbance in pain processing within the CNS leads to pain hypersensitivity and subsequently spontaneous pain
Classic examples are fibromyalgia, irritable bowel syndrome, temporomandibular joint disorder and chronic tension headaches

7. Types of Pain Pain Type Definition Sources Acute Pain
Usually nociceptive
Useful physiologic process
Short in duration (< 3-6 months)
Acute illness
Surgery and other medical procedures
Trauma
Chronic Pain
Persistent
Disruptive to daily life
Usually combination of nociceptive, neuropathic, centralized
Injury
Chronic conditions (e.g. arthritis, fibromyalgia, neuropathy)
From here, we can broaden our classification of pain to include its duration.

8. Types of Pain Pain Type Definition Sources Cancer Pain
Caused by malignancy (e.g. tumor invasion) and/or by procedures and treatments
Malignancy
Chronic Noncancer Pain
Pain is the “disease”
Respond poorly to standard treatment
May last for years
Idiopathic
Chronic Noncancer Pain – pain levels usually only weakly correlate with any present pathology

9. Statistics Those with pain are more likely to
Have a worse health status
Use more health care
Suffer from more disability
Knowing all the different ways pain can present and be classified, we need to be aware of how it impacts the general population in the US
It is said that in 1 year, over 25 million adults will experience acute pain due to injury or surgery
⅓ of them progressing to chronic pain
Those with pain were also likely to have a worse health status, use more health care, suffer from more disability
This requires a better understanding of pain and takes us right to problem that has arisen from it

10. Opioid Epidemic
Of the 11.4 million adults misusing prescription opioids, % stated the reason for misuse was to “relieve physical pain”
In 2015, a study by the US Department of HHS found that over 90 million adults used prescription pain medications
Of those, over 11 million reported misusing these medications, where misuse is defined as taking the pain medication at a higher dose or more often than prescribed
Of those 11 million, 63.4% reported that their reason for misuse was to “relieve physical pain”
On the flipside, 2016 saw over 47,000 people die of opioid overdoses, making it one of the most common causes for accidental deaths in the US
Of those deaths, an estimated 40% involved the use of prescription opioids, which had probably been prescribed to the person for a legitimate reason at one point
All of these statistics about pain and opioid abuse bring us to the core of our topic: multimodal analgesia

11. Uncontrolled Postoperative Pain
Associated with:
Increased morbidity
Delayed recovery time
Functional and quality-of-life impairment
Longer duration of opioid use
Higher healthcare costs
Predictive of development of chronic pain
Where is the source of patient’s pain in the hospital? Most commonly, it is due to surgery and other medical procedures
Uncontrolled postoperative pain itself is associated with a number of complications that leave patients vulnerable to long term complications
It is well studied that there are many negative side effects associated with uncontrolled postop pain
All of this culminates in longer hospital LOS and re-admissions, as well as higher healthcare costs
How can we target and adequately control postop pain without relying on the very opioids that have results in such terrible outcomes for our patient population?
The answer brings us to the core of the presentation: Multimodal analgesia.

12. Multimodal Analgesia
Multimodal analgesia is a pain management concept that first made its way into the literature in 1993 but has recently seen an explosion in popularity as healthcare systems face the stark reality of the statistics I’ve just shared with you.
Given the concern that abuse sometimes starts with opioids prescribed in the course of medical care, health care systems throughout the world have adopted a multimodal approach to acute to reduce opioid use.

13. Multimodal Analgesia Acetaminophen NSAIDs Neuromodulatory agents
NMDA antagonists
Muscle relaxants
Local anesthetics
Opioids
Multimodal Analgesia
Multimodal analgesia involves the administration of two or more drugs that provide analgesia through different mechanisms of action
In abandoning the old opioid-centric model, multimodal analgesia provides an alternative pain management strategy through the use of:
NSAIDs, local anesthetics such as lidocaine, muscle relaxants, ketamine, gabapentinoids, etc.
This strategy does not exclude opioids entirely, as they still play an integral role, especially postoperatively
However, there are numerous reasons to implement multimodal analgesia in the acute care setting

14. Rationale for Multimodal Analgesia
Decrease use of opioids
Decrease side effects associated with opioids (e.g. nausea/vomiting, sedation)
Provide a more effective pain control strategy
Prevent complications associated with untreated pain
Prevent progression to chronic pain
Improve patient quality of life postoperatively
This is exactly why the implementation of a multimodal pain management strategy is the key to better patient care.
Poor pain control impedes postoperative rehabilitation, reduces patients’ health-related quality of life, causes significant personal burden, and adds to national health care expenditure
The rationale behind it is multi-layered but essentially it results in the decreased opioid use and decrease of opioid-related side effects, such as nausea/vomiting and over-sedation, which can impact a patient’s ability to participate in physical therapy for postop recovery.
Goals of multimodal analgesia include:
Decreasing opioid use and reducing incidence of opioid-related side effects, such as N/V and sedation which can impact a patient’s ability to participate in physical therapy for postop recovery
Prevent inadequate pain relief postoperatively, which can be a major deterrent to a patient’s recovery
Complications associated w/ untreated pain include:
Adequate pain control postop can lead to include earlier oral intake, ambulation, and hospital discharge for postoperative patients as well as higher levels of participation in activities necessary for recovery

15. ERAS Pathways ERAS = Enhanced Recovery After Surgery
Strategy to improve quality of surgical care
Goal is to optimize patient outcomes
Essential component is a standardized multimodal pain regimen
Image:
This endeavor to incorporate multimodal analgesia into pre- and post-op patient care has given rise to ERAS pathways, which stands for Enhanced Recovery After Surgery.
Enhanced Recovery after Surgery (ERAS) refers to patient-centered, evidence-based, multidisciplinary team developed pathways for a surgical specialty and facility culture to reduce the patient’s surgical stress response, optimize their physiologic function, and facilitate recovery

16. Pharmacologic Agents
This brings us to our next question: what are the alternatives to opioids that make up the core of multimodal analgesia?
As you saw on a few slides ago, the options are varied and the goal is to target pain management from different angles using a spectrum of mechanisms of action, which I’ll review briefly now.

17. Nonopioid Analgesics Examples include: Mechanism of action:
Acetaminophen
Nonsteroidal anti-inflammatory drugs (NSAIDs) [e.g. aspirin, celecoxib]
Mechanism of action:
Acetaminophen centrally inhibits cyclooxygenase (COX) pathway
Mechanism not fully understood
NSAIDs inhibit COX enzyme, preventing prostaglandin synthesis
First, we have our basic non-opioid analgesics, an umbrella term that encompasses acetaminophen and the NSAID class of drugs.

18. Selective vs. Non-Selective NSAIDs
COX-1 vs. COX-2 enzymes
COX-1: platelets, renal hemodynamics, and gastric cytoprotection
COX-2: inflammation
Selective NSAIDs block COX-2
Advantages include lower incidence of GI side effects
Useful in higher risk patients (e.g. previous ulcers)
Black Box Warning
Increased risk of cardiovascular events and GI bleeds
Required by FDA on all NSAIDs
Our nonselective NSAIDs (such as aspirin, naproxen, ketorolac) inhibit both COX1 and COX2,
In contrast to celecoxib, which only inhibits COX2 and is the only selective NSAID available in the US
Theoretically, selective inhibition of COX-2 would provide anti-inflammatory effects without disrupting gastric cytoprotection and platelet function
This provides an advantage of selective NSAIDs which might include a lower incidence of GI side effects and may be useful in higher risk patients, such as those with a history of previous ulcers.
Ultimately, NSAIDs as a class have an FDA black box warning for increased risk of cardiovascular events (e.g. MI, stroke) and GI bleeds, which is something to keep in mind when assessing their appropriateness in patients.
Their use is often limited by their potential impact on renal function, platelet dysfunction, bleeding or GI ulcers.
Reference: Chaiamnuay S, Allison JJ, Curtis JR. Risks versus benefits of cyclooxygenase-2 selective nonsteroidal anti-inflammatory drugs. Am J Health Syst Pharm. 2006;63(19):

19. Nonopioid Analgesics Medication Dosing Clinical Pearls
Acetaminophen (Tylenol)
325 – 650 mg PO q4-6h
Max: 4g daily
Ibuprofen (Advil, Motrin)
1200 – 3200 mg PO in 3-4 divided doses
Max: 3.2g daily
Naproxen (Aleve)
500 mg PO q12h OR
250 mg PO q6-8h
Contraindicated for post-op pain in CABG
Ketorolac (Toradol)
30 mg IM/IV q6h
Age > 65 or CrCl < 30 mL/min:
30 mg IM/IV x 1 OR 15 mg IV q6h
Indicated for ≤ 5 days in acute pain
Contraindicated in renal impairment
Risk of bleeding due to platelet inhibition
Celecoxib (Celebrex)
50 – 200 mg PO q12h
Selective COX-2 inhibitor
With that said, NSAIDs and acetaminophen are are often preferred first-line therapies in the treatment of mild-to-moderate pain, and as adjunct to other pain medications.
One is not more efficacious than the other, although NSAIDs provide a degree of anti-inflammatory effects that acetaminophen does not.
This slide provides an overview of our commonly used non-opioid analgesics, their dosing, and some clinical pearls such as max daily doses or limits on length of therapy, as seen with Toradol.
I want to draw special attention to Toradol as it is our only NSAID available IV or IM, which is especially useful in the postop period when patients may be unable to take PO medications. It has a 5 day limit on its use due to an increase risk of bleeding after this period, but studies have found that it can provide equivalent or even superior pain relief in comparison to opioids.
NSAIDs are not without risks
Renal failure, platelet dysfunction, and gastric ulcers or bleeding are associated with the nonspecific inhibition of the COX-1 enzyme and are the primary adverse events that limit the use of NSAIDs
A Cochrane review examining 23 trials (comprising 1459patients) noted that NSAIDs caused a clinically unimportant transient reduction in renal function in the early postoperative period in patients with normal preoperative renal function and should not be withheld from adults with normal preoperative renal function because of concerns about postoperative renal impairment
Toradol is limited to 5 days due to increased risk of side effects such as GI bleeding with a longer duration of therapy

20. Clinical Pearls on NSAIDs
Ketorolac and platelet function inhibition
Reversible binding and shorter duration of inhibition
No increase in postoperative bleeding at normal doses
Superior postoperative pain control equivalent to opioids
History of GI bleed or ulcers
Contraindication to NSAID use
Alternatives: Steroids (e.g. dexamethasone)
There has been a concern for its impact on platelet function and risk of bleeding in the postop period specifically, as well as its impact on bone healing.
However, it’s important to recall that Toradol provides reversible platelet inhibition, which lasts for the duration of the dosing interval essentially.
A major systematic analysis found that Toradol is not associated with an increased risk of bleeding in the postoperative period at normal doses or impact bone healing negatively.
This was of particular concern in spinal fusion surgeries due to worries over pseudarthrosis or nonunion, but the risks with Toradol were increased at high doses defined as >120 mg/d while patients traditionally receive low doses of 30 or 15 mg q6h for a limited time period postoperatively.
Therefore it remains a strong option for postop pain control.
Another important note to keep in mind, there are patients that may have contraindications to NSAID use such as those with a history of GI bleed or NSAID-induced ulcers. While this remove NSAIDs from their multimodal analgesic strategy, a possible alternative is steroids such as dexamethasone, in conjunction with other pain medications.
STEROIDS
Dexamethasone is a potent glucocorticoid that decreases inflammation by decreasing neutrophil migration and reducing capillary permeability
Long term treatment is discouraged 2/2 adverse effects such as immunosuppression
Immunosuppressive GC doses (40 mg/day of prednisolone [or equivalent] for > 7 days)
Image:

21. Neuromodulatory Agents
Mechanism of action:
Inhibition of alpha-2-delta subunits of voltage-gated calcium channels on neuronal cells
Decrease neuronal excitability
May help decrease central sensitization to pain
Medication
Dosing
Clinical Pearls
Gabapentin (Neurontin)
300 – 1200 mg PO q8h
Off-label use
Common adverse effects: Sedation, dizziness, peripheral edema
Pregabalin (Lyrica)
150 – 600 mg PO in 2-3 divided doses
Another option is our neuromodulatory agents, which encompasses gabapentin and pregabalin
This medications inhibit the alpha-2-delta subunits of voltage-gated calcium channels on neurons, decreasing their excitability.
Theoretically, this mechanism should help decrease central sensitization to pain.
The American Pain Society guidelines actually recommend the use of gabapentin or pregabalin pre-op as well as post-op
various studies have found that they reduce opioid requirements and produce lower post-op pain scores when used in combination with other pain medications.
The main concern with these medications are the side effects of sedation, dizziness, and peripheral edema.

22. NMDA Antagonist Mechanism of action:
Inhibition of N-methyl-D-aspartate (NMDA)-gated calcium channel
Nonbarbiturate, dissociative anesthetic
Medication
Dosing
Clinical Pearls
Ketamine
0.3 – 0.5 mg/kg IV bolus, then
0.1 – 0.2 mg/kg/h initial rate of infusion
Adverse effects:
Increased sympathetic activity, salivation, nystagmus, hallucinations
Caution in coronary artery disease, intracranial pathology, psychiatric comorbidities
One unique class is the NMDA antagonist KETAMINE, which is an up-and-coming medication that is seeing more use for pain control.
It is a nonbarbiturate dissociative anesthetic that inhibits the NMDA-gated calcium channels on neurons.
Normally it is given as an IV bolus followed by an infusion.
Its adverse effects include increased sympathetic activity, salivation, nystagmus, and hallucinations.
It comes with precautions for use in patients with coronary artery disease due to its CV effects and ability to cause tachycardia, intracranial pathologies, and psychiatric comorbidities due to risk of hallucinations.

23. Muscle Relaxants Mechanism of action: Varies by medication
Can be classified as antispastic (e.g. baclofen) vs. antispasmodic (e.g. tizanidine, methocarbamol)
Antispasmodic agents preferred for musculoskeletal conditions
Medication
Dosing
Clinical Pearls
Methocarbamol (Robaxin)
1500 mg PO QID for 2-3 days, then 750mg PO q4h OR 1500 mg PO TID
Adjunctive therapy to analgesics
Effective for acute nonspecific lower back pain
Adverse effects: Dizziness, drowsiness, anticholinergic effects (w/ Flexeril)
Cyclobenzaprine (Flexeril)
5 mg PO TID
Diazepam (Valium)
2-10 mg PO TID-QID
Muscle relaxants are another familiar class to pain management.
Their MOA vary by medication as the class includes a variety of structurally unrelated compounds
Can be classified by their roles as antispastic medications vs. antispasmodics
Antispasticity agents work on the spinal cord or directly on the skeletal muscles to improve muscle hypertonicity and involuntary spasms  particularly useful for spinal cord injuries, multiple sclerosis
Antispasmodics decrease muscle spasms through alterations of CNS conduction  subdivided into benzos and nonbenzos
Listed in the table below are only three out of many, but some of the most commonly used here nonetheless.
Ultimately, these are adjuncts to analgesics not monotherapy for pain, and have been found to be effective specifically for acute nonspecific lower back pain.
Some adverse effects include dizziness, drowsiness, and anticholinergic effects with muscle relaxants like Flexeril

24. Local Anesthetics Mechanism of action:
Inhibit voltage-gated sodium channels and prevent depolarization of sensory nerves
Useful for peripheral nerve blocks
Medication
Pharmacokinetics
Clinical Pearls
Lidocaine
Onset: <2 min
Duration: 1-2 h
Low risk yet highly effective
Associated with earlier mobilization and decreased hospital length of stay
Adverse effects: Hematoma formation, systemic toxicity, nerve and vessel damage, transient muscle weakness and associated patient falls
Lidocaine also available as transdermal patch for local pain control; not associated with same side effects
Bupivacaine
Onset: 5 min
Duration: 2-4 h
A different approach to pain control involves the use of local anesthetics like lidocaine and bupivacaine, which work to inhibit voltage-gated sodium channels and prevent the depolarization of sensory nerves,
providing numbness which is particularly useful in peripheral nerve blocks.
They can be injected into nerve roots or a nerve plexus, as well as into joint spaces, and can effectively relieve pain locally.
Sometimes, commonly in orthopedic joint surgeries, they are used near the end of the procedure in tissues expected to cause the most pain postoperatively.
They are low risk yet highly effective, and associated with earlier mobilization and decrease hospital LOS.
Some adverse effects include hematoma formation at site of injective, systemic toxicity, nerve and vessel damage, and some transient muscle weakness.
Some advantages include lidocaine’s availability as a transdermal patch for local, long-term pain control which is not associated with the same risk of side effects.

25. Opioids Mechanism of action: Role in multimodal analgesia protocols:
Bind to mu-, delta-, and kappa- opioid receptors
Causes inhibition of ascending pain pathways
Role in multimodal analgesia protocols:
Around-the-clock immediate-release opioids for 48 h after surgery
Additional opioids as needed for breakthrough pain
Used in addition to nonopioid analgesia
Finally, we come to our opioids, which remain an integral part of multimodal analgesia for their effectiveness in pain control when used at the lowest possible dose for the shortest amount of time.
They bind to mu-delta, and kappa- opioid receptors causing inhibition of ascending pain pathways.
Most multimodal analgesia protocols actually advocate for the use of around-the-clock immediate release opioids for 48 h after surgery on a fixed scheduled.
Afterward, additional opioids may be available on a PRN basis for breakthrough pain in addition to nonopioid analgesia.
Most multimodal analgesia protocols advocate for the use of immediate-release opioids for 48 hours after surgery, with around-the-clock dosing at a fixed schedule (Halawi MJ, Grant SA, Bolognesi MP. Multimodal analgesia for total joint arthroplasty. Orthopedics. 2015;38(7):e616-25)

26. Opioids Medication Dosing Clinical Pearls Oxycodone IR
5 – 20 mg PO q4-6h
Adverse effects: Nausea/vomiting, constipation, sedation, dizziness, respiratory depression
Ideally prn or scheduled for short period of time at lowest dose to achieve adequate analgesia
Hydromorphone is 5x more potent than morphine w/ more rapid onset
Oxycodone ER (Oxycontin)
10 mg PO q12h (if opioid naïve)
Acetaminophen/Oxycodone (Percocet)
Based on oxycodone content:
5 – 10/325 mg PO q4-6h
Acetaminophen/Hydrocodone (Norco)
Based on hydrocodone content:
Morphine
2 – 4 mg IV q4-6h PRN
Hydromorphone (Dilaudid)
0.5 – 1 mg IV q4-6h PRN
Tramadol
50 mg PO q4-6h
It’s important to note that PO administration of opioids may provide equally adequate analgesia when compared with IV, and is associated with fewer side effects. Some of these adverse effects to watch out for are nausea/vomiting, sedation, constipation, and respiratory depression - many of which can impede a patient’s recovery
Dose more frequently in their immediate release forms for breakthrough pain

27. Chronic Opioid Use
Patients that are on chronic opioids are the exception to the multimodal analgesia model
Discontinuing or drastically reducing their opioid use could induce withdrawal
Continue patient’s baseline opioid use
Manage breakthrough pain using multimodal analgesia protocols
Now in our endeavor to cut down on opioid use, it’s also important to remember that not all our patients will be opioid-naive prior to surgery.
Patients that chronically take opioids are a unique exception to the multimodal analgesia model.
You can put them at risk of withdrawal if you dramatically reduce or discontinue their opioid use prior to or after surgery.
Studies recommend to continue their baseline use and manage their breakthrough pain using multimodal analgesia protocols.

28. Non-Pharmacologic Options
Of course, there are also non-pharmacologic options for managing a patient’s pain.

29. Non-Pharmacologic Options
Should supplement but not replace analgesics
Physical Methods
Psychological Methods
Physical therapy or immobilization (as appropriate)
Patient education
Massage
Relaxation
Application of heat or cold
Guided imagery
Transcutaneous electrical nerve stimulation (TENS)
Distraction
The various modalities listed in the table should supplement but not replace analgesics entirely.
The main takeaway for surgical pain is patient education, particularly prior to the surgery.
Working to give the patient realistic expectations for their pain management after surgery is key.
In fact, it’s believed that psychological preparation for pain may help control or minimize the biological stress response that the patient may experience, as well as emotional distress and suffering.
The other options on here vary by appropriateness for patients, such as physical therapy to mobilize and encourage healing, and relaxation or distraction to decrease a patient’s focus on their pain.
Educate the patient about pain assessment (e.g., methods, frequency) and pharmacologic and nonpharmacologic management strategies
Develop a postop pain management strategy for the patient
Set realistic pain management goals
PSYCOLOGICAL
EDUCATION:
When pain is acute, psychological preparation (such as preparation for surgery or for an invasive procedure) or psychological intervention such as relaxation may help to control the affective dimension of pain
This, in turn, helps minimize the biological stress response that the patient experiences, as well as emotional distress and suffering
Relaxation: Decreases patient’s focus on their pain, tension
Distraction: Goal is for patient to actively occupy their attention with an activity or topic other than their pain

30. Current Literature

31. Postoperative Multimodal Analgesia
Study
Study Design
Results/Conclusions
Wick et al
Meta analysis (27 RCTs)
No difference in postoperative bleeding between the groups taking ketorolac (33/1304 [2.5%]) and the control groups (21/1010 [2.1%]) (P = .72)
Sufficient evidence to support efficacy of multimodal analgesia
Chou et al.
APS/ASA guidelines 2016.
Systematic review
Recommends multimodal analgesia for treatment of postoperative pain (strong recommendation, high-quality evidence)
Gritsenko et al
Literature review
Provides overview of multimodal analgesia in various surgical specialties (e.g. general, orthopedic, gynecologic/urologic)
Emphasizes against a “one-size-fits-all” approach
On a general scale, we have these two articles and the most recent update to the American Pain Society pain management clinical guidelines.
Altogether, they provide evidence that speaks to the efficacy of multimodal analgesia and recommend its implementation to treat postoperative pain across a variety of surgical specialties, from general to orthopedic to urologic procedures.
The biggest takeaway point from here is that they also acknowledge that multimodal analgesia is not a “one size fits all” approach and must be tailored to the specialty and, most importantly, to the patient.
On a more specific scale, multimodal analgesia has been extensively studied for orthopedic surgery and is seeing a rise in spinal surgery. The next few slides will focus on these two specialties as they are the areas within Morton Plant that have implemented, or will implement, multimodal analgesia.

32. Multimodal Analgesia in Orthopedic Surgery
Study
Study Design
Results/Conclusions
Memtsoudis et al
Population-based study
N = 1,318,165 total hip/knee arthroplasties
85.6% of patients received multimodal analgesia
THA patients receiving > 2 modes of pain control vs. opioids only (all P <0.05):
19% and 26% fewer respiratory and GI complications
18.5% decrease in opioid use
12.1% decrease in length of stay
Halawai et al
Literature review
Multimodal analgesia provides superior pain relief, speeds up functional recovery, minimizes adverse effects of opioid-based analgesia, increases patient satisfaction, and reduces length of hospital stay
Here we can see that the Memtsoudis et al study found that over 85% of almost 1.4 million patients undergoing a hip or knee arthroplasty received multimodal analgesia post=op.
In comparison to patients receiving only opioids, these patients had fewer respiratory and GI complications, a 20% decrease in opioid use, and as a 12% decrease in hospital length of stay.
A literature review conducted by Halawai et al in orthopedic surgeries specifically found that its was beneficial and effective overall in managing patient’s pain and speeding up their recovery.

33. Multimodal Analgesia in Orthopedic Surgery
Study
Study Design
Results/Conclusions
Gaffney et al
Literature review
Preemptive use of a multimodal pain management approach is now standard of care after hip and knee arthroplasty
Russo et al. 2017
Adherence to multimodal pain protocol minimizes adverse effects of opioids
Allows for rapid recovery post-joint replacement
Increases mobilization, decrease VTE risk

34. Multimodal Analgesia in Spine Surgery
Study
Study Design
Results/Conclusions
Kurd et al
Literature review
A growing body of evidence supports use of preemptive and multimodal analgesia for patients undergoing spine surgery
Bohl et al
Retrospective cohort study (N = 239)
Patients who received multimodal analgesia had a lower rate of inpatient opioid use, less nausea/vomiting, and shorter length of stay vs those using patient-controlled analgesia (P < 0.01)
No difference between groups in rate of narcotic dependence postoperatively
Devin et al
Identified good (Grade A) evidence gabapentinoids, acetaminophen, neuraxial blockade and local anesthetics reduce postoperative pain and narcotic requirements
Now in spine surgery, there is a growing body of evidence to support to use of multimodal analgesia.
Bohl et all specifically found that spine patients receiving multimodal pain control had decreased opioid use, less nausea/vomiting, and a shorter length of stay in contrast to those using a PCA.

35. Summary of Literature
Multimodal analgesia approach remains variable but beneficial
No standardized model for multimodal analgesia
Research needed:
Optimal methods for patients on opioids prior to surgery
Effectiveness of multimodal regimens
Evidence-based interventions for postoperative pain
In summary, while there is no standardized approach to multimodal analgesia, there is a growing body of literature that supports its implementation across multiple surgical specialties.
Gaps in research remain for chronic opioid users, the objective effectiveness of these regimens, and the creation of evidence-based interventions for postop pain.

36. Current Practices
Here at Morton Plant and across the rest of the Morton Plant Mease hospitals, multimodal analgesia has been implemented in a variety of ways.

37. BayCare Multimodal Pain Management Algorithm
A core of the current practices at MPH is the multimodal pain management algorithm, of which I’m only displaying a portion of on the slide
It is a multidisciplinary approach to pain management while patients are hospitalized, including using your resources such as pharmacy to make sure these medications are being used appropriately
Provides assessment, documentation, patient education, and strategies to address a patient’s pain before escalating their pain therapy
Of course, it hinges on the patient having analgesic medications on their profile for use
This is where our post-op power plans provide a huge advantage in our move toward incorporation multimodal pain management into our patient care

38. Examples of Multimodal Analgesia Protocols
Total Hip Arthroplasty Power Plans
Preop
Pregabalin 75 mg PO OR Gabapentin 600mg PO
Celebrex 400 mg PO or Acetaminophen 650 mg PO
If allergic to sulfonamides: Etodolac 300 mg PO or Meloxicam 15 mg PO
Dexamethasone 10 mg IV
PACU
Ketorolac 15 mg IV x 1
Oxycodone ER 10 mg PO x 1
On the following slides, I have taken a representative sample of the existing power plans for both total hip arthroplasty and craniotomy to showcase the pain medications available for providers to pre-check for their patients. In the THA power plan, the patient has a pre-op, PACUS, and post-op power plan for pain management using, for example, gabapentin, celebrex, dexamethasone, Toradol, and oxycodone.

39. Examples of Multimodal Analgesia Protocols
Total Hip Arthroplasty Power Plans
Postop
Ketorolac 15 mg IV q8hr x 3 doses
Celecoxib 200 mg PO q12hr x 24hrs (starts 6 hours after ketorolac is complete)
If allergic to sulfonamides: Etodolac 300 mg PO q8h or Meloxicam 15mg daily x 24 hour
Scheduled hydrocodone/oxycodone product:
Acetaminophen/hydrocodone 5-10 mg PO q4h x 48h
Acetaminophen/oxycodone 5-10 mg PO q4h x 48hr
Oxycodone ER 10 mg q12h x 48h
PRN therapy (starts after initial 48h of scheduled medications):
Acetaminophen/hydrocodone 5-10 mg PO q4h PRN
Acetaminophen/oxycodone 5-10 mg PO q4h PRN
Hydromorphone 0.5 mg IV q2h PRN
Tramadol 50 mg PO q6h PRN
You can see that this power plan includes 3 scheduled doses of Toradol post-op then a Celebrex that starts 6 hours after and lasts for 24 hours with a simultaneous opioid that is scheduled for 48 hours. The goal is to optimize pain management in the first 48 hours after surgery, after which a patient will be scaled back to PRN medications.
We’re still keeping patient specific parameters in mind, such as patient allergies and appropriateness in renal function

40. Examples of Multimodal Analgesia Protocols
Craniotomy Power Plans
Postop
Acetaminophen/oxycodone 5-10 mg PO 1-2 tabs q4h PRN
Acetaminophen 650 mg PO or rectal q4h PRN
Dexamethasone 4 mg IV q6h
Methocarbamol 750 mg PO QID prn muscle spasm
Methocarbamol 1000 mg IV q6h x 4 doses
Hydromorphone 0.5 mg IV q4h PRN x 3 days
Morphine 1-2 mg IV q1hr PRN
The craniotomy power plan showcases a similar theory

41. Spinal Surgery ERAS Pathway
Currently in progress under multidisciplinary team
Goal is to create a multimodal approach to caring for patients undergoing spinal surgery at MPH
Will result in implementation of new power plans
Image:
Currently, a spinal surgery ERAS pathway is in development here at MPH under a multidisciplinary team that has evaluated the literature and are working to create evidenced-based power plans that include multimodal analgesia with the goal of improving patient outcomes after spinal surgery.

42. Conclusion
Multimodal analgesia is an optimal approach to postsurgical pain management
Associated with decreased opioid use and side effects
Targets quicker postoperative recovery and increased patient satisfaction
In conclusion, I hope that you’ve come away from this presentation with a better understanding of how multimodal analgesia can provide a better approach to pain management in the acute care setting, particularly in our post-op patients primarily due to decreased opioid use associated with its implementation as well as faster recovery and better quality-of-life for our patients.

43. Questions?

44. References
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National Institute of Health. NIH Analysis Shows Americans Are In Pain. Published August Accessed March
U.S. Department of Health and Human Services. What is the U.S. Opioid Epidemic? Updated January Accessed March
Libari RN, Williams M, and Van Horn SL. Why do adults misuse prescription drugs? Published July Accessed March
The Joint Commission on Accreditation of Healthcare Organizations; The National Pharmaceutical Council. Pain: Current Understanding of Assessment, Management, and Treatments. National Pharmaceutical Council; December 2001.
Graff V, Grosh T. Multimodal Analgesia and Alternatives to Opioids for Postoperative Analgesia. Anesthesia Patient Sagety Foundation Newsletter. alternatives-to-opioids-for-postoperative-analgesia/. Accessed March
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