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Perioperative Multimodal Pain Relief

Perioperative Multimodal Pain Relief
Author Information (click to view)

Edward R. Mariano, MD, MAS

Chief, Anesthesiology and Perioperative Care Service and
Associate Chief of Staff for Inpatient Surgical Services
VA Palo Alto Health Care System
Associate Professor of Anesthesiology, Perioperative and Pain Medicine
Stanford University School of Medicine

Edward R. Mariano, MD, MAS, has indicated to Physician’s Weekly that he has worked as a consultant for Miramar Labs and has received grants/research aid from Halyard Health (educational funding), B Braun (educational funding), the Foundation for Anesthesia Education and Research (research grant), and the United States Department of Defense (research grant).

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Edward R. Mariano, MD, MAS (click to view)

Edward R. Mariano, MD, MAS

Chief, Anesthesiology and Perioperative Care Service and
Associate Chief of Staff for Inpatient Surgical Services
VA Palo Alto Health Care System
Associate Professor of Anesthesiology, Perioperative and Pain Medicine
Stanford University School of Medicine

Edward R. Mariano, MD, MAS, has indicated to Physician’s Weekly that he has worked as a consultant for Miramar Labs and has received grants/research aid from Halyard Health (educational funding), B Braun (educational funding), the Foundation for Anesthesia Education and Research (research grant), and the United States Department of Defense (research grant).

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According to recent reports, about 2.1 million people in the United States suffer from substance use disorders relating to prescription opioids, and the number of unintentional overdose deaths from prescription pain relievers has more than quadrupled since 1999. It’s important for policymakers and the medical community to respond with compassion and concern to this issue in order to provide pain relief while minimizing risks of opioid misuse, abuse, and addiction.

 

Reconsidering Approaches

For surgical patients, clinicians must reconsider their approach to pain management. Many routine procedures are now performed on an outpatient basis. In such cases, patients are discharged and sent home the same day before we have a full grasp of their pain tolerance and the need for drugs to address pain and discomfort.

Anesthesiologists now use different avenues to treat pain, including approaches that complement opioids, under “multimodal analgesia.” In this approach, the transmission of pain along peripheral nerves is targeted and blocked with local anesthetic drugs to interrupt the signal. This is particularly helpful for surgery in the extremities like the arms or legs and in a selective region, such as the breast. Patients can be given an infusion of numbing medication to reduce pain for days following surgery. Anticonvulsants can also be administered in lower doses than what’s used for seizures to help dull the transmission of pain. Furthermore, inflammation should be treated.

 

Personalizing Care

With the development of new, highly effective drugs and sophisticated anesthesia equipment and techniques, anesthesiologists have the opportunity to personalize medicine in the perioperative period. With transparent physician-patient communication, anesthesiologists can tailor plans based on each patient’s unique history. This includes medications that have worked or were ineffective in the past as well as side effects relating to drugs that were previously used.

Of special note is the use of opioids or illicit drugs prior to surgery. A 2012 study published in Anesthesia & Analgesia found that preoperative substance abuse predicted more prolonged opioid use after surgery. There is a pressing need to get patients on a multimodal approach as early as possible before surgery to shorten the time that opioids are needed after surgery. As prescribers, physicians are gatekeepers in reducing reliance on opioids. The role requires a more conscious, less reflexive decision to rely on opioids for pain management. It also requires more appropriate utilization of prescription drug monitoring databases.

As the principal physician who assesses each surgical patient’s pain control needs, initiates treatment, and administers the first line of pain medications, anesthesiologists have an important role. We need to effectively coordinate perioperative care and create a holistic, personalized multimodal approach that balances risk and relief.

Readings & Resources (click to view)

Merritt CK, Mariano ER, Kaye AD, et al. Peripheral nerve catheters and local anesthetic infiltration in perioperative analgesia. Best Pract Res Clin Anaesthesiol. 2014;28:41-57.

Webb CA, Mariano ER. Best multimodal analgesic protocol for total knee arthroplasty. Pain Manag. 2015;5:185-196.

Mariano ER, Marshall ZJ, Urman RD, Kaye AD. Ultrasound and its evolution in perioperative regional anesthesia and analgesia. Best Pract Res Clin Anaesthesiol. 2014;28:29-39.

1 Comment

  1. Excellent overview of a complex topic! Better pain management by anesthesiologists saves lives.

    Reply

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