Designing the ideal perioperative pain management plan starts with multimodal analgesia

Abstract

Multimodal analgesia is defined as the use of more than one pharmacological class of analgesic medication targeting different receptors along the pain pathway with the goal of improving analgesia while reducing individual class-related side effects. Evidence today supports the routine use of multimodal analgesia in the perioperative period to eliminate the over-reliance on opioids for pain control and to reduce opioid-related adverse events. A multimodal analgesic protocol should be surgery-specific, functioning more like a checklist than a recipe, with options to tailor to the individual patient. Elements of this protocol may include opioids, non-opioid systemic analgesics like acetaminophen, non-steroidal anti-inflammatory drugs, gabapentinoids, ketamine, and local anesthetics administered by infiltration, regional block, or the intravenous route. While implementation of multimodal analgesic protocols perioperatively is recommended as an intervention to decrease the prevalence of long-term opioid use following surgery, the concurrent crisis of drug shortages presents an additional challenge. Anesthesiologists and acute pain medicine specialists will need to advocate locally and nationally to ensure a steady supply of analgesic medications and in-class alternatives for their patients’ perioperative pain management.

<p>A Commonsense Patient-Centered Approach to Multimodal Analgesia Within Surgical Enhanced Recovery Protocols</p>

“…When this duration matches the expected trajectory of pain resolution after surgery, there may be little need for additional systemic analgesics. For TKA, regional analgesia is well-established as part of the multimodal regimen, 4,11 but the trajectory of pain resolution may commonly extend beyond the 3-day duration of most regional analgesic techniques. 12 Another important consideration for patients undergoing major surgery is central sensitization.…”

“…While the regimen includes multiple interventions and medications, it may be adapted to meet the needs of the individual patients. 4 Some patients who are opioidnaïve may not need any scheduled opioid after surgery and will respond to as-need administration only. For all TKA patients, spinal anesthesia is strongly preferred for intraoperative anesthesia 25 and will eliminate the need for systemic analgesics during surgery.…”

“…23 However, the integration of non-pharmacologic interventions and non-opioid analgesic modalities including regional anesthesia techniques effectively decreases opioid consumption and should be considered routine. 4,11,23 In order to be successful, ERPs must be accepted by both healthcare practitioners and patients. Ethical concerns have been raised about the "weaponization" of ERPs with the goal of eliminating all postoperative opioids even in patients on long-term opioids.…”

“…Because the objective of achieving analgesia does not exist in a vacuum and must be balanced with the goal of early mobility, today's standard for pain management in the perioperative period is multimodal analgesia or using more than one analgesic agent with different mechanisms of action. 4 While a single analgesic agent has the potential to provide complete postoperative pain management alone, it often comes at a significant cost. Consider these two extremes: continuous spinal anesthesia and opioid-only analgesia.…”

<p>Dorsal and ventral thoracic 12 vertebra body height is associated with incident lumbar vertebral fracture in postmenopausal osteoporotic women</p>

“…[1][2][3][4][5] The ability to predict risk factors for LVF is crucial because of the negative consequences of LVF that include chronic back pain, related functional disability, kyphosis, and height loss, all of which have major impacts on a patient's quality-of-life; as well as the associated increases in morbidity and mortalitiy. [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] Analysis of bone mineral density (BMD) using dual-energy X-ray absorptiometry (DEXA) is the most commonly used index of bone power, and a low BMD is the most important risk factor for LVF prediction. [21][22][23][24] But, almost 50% of LVF occurs in patients with BMD above the World Health Organization (WHO) diagnosis threshold of osteoporosis (T-score#2.5).…”