Review of nonopioid multimodal analgesia for surgical and trauma patients

Abstract

Purpose Pain is a frequent finding in surgical and trauma patients, and effective pain control remains a common challenge in the hospital setting. Opioids have traditionally been the foundation of pain management; however, these agents are associated with various adverse effects and risks of dependence and diversion. Summary In response to the rising national opioid epidemic and the various risks associated with opioid use, multimodal pain management through use of nonopioid analgesics such as acetaminophen, nonsteroidal anti-inflammatory drugs, α 2 agonists, N-methyl-d-aspartate (NMDA) receptor antagonists, skeletal muscle relaxants, sodium channel blockers, and local anesthetics has gained popularity recently. Multimodal analgesia has synergistic therapeutic effects and can decrease adverse effects by enabling use of lower doses of each agent in the multimodal regimen. This review discusses properties of the various nonopioid analgesics and encourages pharmacists to play an active role in the selection, initiation, and dose-titration of multimodal analgesia. The choice of nonopioid agents should be based on patient comorbidities, hemodynamic stability, and the agents’ respective adverse effect profiles. A multidisciplinary plan for management of pain should be formulated during transitions of care and is an area of opportunity for pharmacists to improve patient care. Conclusion Multimodal analgesia effectively treats pain while decreasing adverse effects. There is mounting evidence to support use of this strategy to decrease opioid use. As medication experts, pharmacists can play a key role in the selection, initiation, and dose-titration of analgesic agents based on patient-specific factors.

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

“…Many of the strategies discussed herein for inpatient postoperative patients may also be applied to various special populations, including trauma/emergent surgical patients, the elderly, the obese, obstetric populations, and pediatrics, as discussed in more detail elsewhere [293,300,[365][366][367][368][369][370][371][372][373][374][375][376][377].…”

Impact of the 2018 Society of Critical Care Medicine Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Guidelines on Nonopioid Analgesic Use and Related Outcomes in Critically Ill Adults After Major Surgery

“…However, the average proportion of ICU days acetaminophen (either IV or oral) was administered was similar between the 2 years. Given higher doses of IV (vs oral) acetaminophen doses are usually administered ( 1 , 6 ), the average daily acetaminophen dose was significantly greater in 2019. For the other nonopioid analgesic, neither the average daily dose nor the proportion of SICU days it was administered over the total SICU days differed between the two groups.…”

“…While opioids remain the mainstay analgesic in critically ill adults after major surgery, multiple concerns exist with their use including respiratory depression, ileus/constipation, coma, delirium, hyperalgesia, and post-ICU continuation ( 1 – 4 , 6 ). Multimodal analgesia, as recommended in the PADIS guidelines, is an important strategy to improve pain control and reduce opioid use ( 6 ).…”

“…acetaminophen, ketamine, neuropathic medication, and nerve blocks) agents to improve pain and reduce opioid use are key components of Enhanced Recovery After Surgery (ERAS) protocols ( 5 ). While multimodal analgesia use is well established after major surgery, its use remains poorly characterized in postsurgical critically ill adults who require continuous opioid infusions and multiple days of mechanical ventilation ( 1 ). The 2018 Society of Critical Care Medicine Pain, Agitation/Sedation, Delirium, Immobility, and Sleep (PADIS) guidelines recommend the use of a multimodal analgesic approach (with acetaminophen, ketamine, and neuropathic agents [e.g., gabapentin or pregabalin]) for post-surgical ICU (SICU) pain control ( 6 ).…”

“…The evidence supporting PADIS nonopioid analgesic use is based on the evaluation of single nonopioid analgesic agents (vs combined analgesics using a multimodal approach) and in postoperative patients, most of who transitioned through the ICU quickly. Little current data exists on multimodal analgesia prescribing practices in postsurgical adults admitted to the ICU with critical illness, whether publication of the 2018 PADIS guidelines has influenced these practices ( 6 ), and how multimodal nonopioid analgesia use affects clinical outcomes ( 1 , 6 ). We compared ICU nonopioid analgesic use (in the context of PADIS recommendations), daily opioid use, daily pain scores, and common clinical sequelae associated with ICU opioid use in critically ill surgical adults before and after publication of the PADIS guidelines.…”