By Maureen F. Cooney, DNP, FNP-BC, Pain Management Nurse Practitioner, Westchester Medical Center, Valhalla, N.Y.
For patients preparing for surgery, their biggest worry often has nothing to do with typically noted complications. What patients fear most is pain.1 And for good reason: More than 80% of surgical patients report acute postoperative pain,2 yet less than half report adequate pain relief.3
Postsurgical acute pain management is more than a matter of providing comfort. Failure to adequately control patients’ pain—whether it follows wisdom tooth removal, orthopedic surgery or major cardiothoracic surgery—not only can affect quality of life but also can delay recovery,4 increase the risk for complications5 and evolve into chronic pain.6
Limited attention has been paid to pain management education for registered nurses (RNs), nurse practitioners (NPs), physician assistants (PAs) and other bedside practitioners. As a result, these front-line clinicians may not be optimizing the use of effective and safe postsurgical pain management in the inpatient setting.
In recent years, aggressive pain management with large doses of opioids has been commonplace at hospitals across the United States.7 Too often, the use of opioids is seen as the most humane solution, as this class of drugs is the most powerful tool available. But what we need to consider is this: What are the medical, physical, financial and emotional costs?
As an NP, my thinking about pain management had always been in the context of the patients I cared for each day—until I became a patient myself, forcing me to consider pain management from a new perspective. I underwent surgery for injuries sustained in a bicycling accident and expressed concerns because I did not wish to be overmedicated. I dislike the drowsiness that comes with the typical opioid pain relief regimen. The dose of opioids I was given in the operating room left me so groggy that I was able to stay awake for only seconds at a time and, as I learned later, couldn’t even recall that my family had visited me in the PACU. Making matters worse, during those seconds when I was awake, I experienced severe nausea. My release from the PACU was delayed, as my respiratory rate and heart rate were depressed—common side effects of opioid medications.
I chose to forgo additional opioids after leaving the PACU, and instead opted for ice applied to the affected areas and IV nonopioid analgesics for pain reduction. It got me thinking: Can we—as RNs, NPs and PAs—have a stronger role in improving postsurgical pain management for our patients?
The Challenges of Opioid Monotherapy Perioperatively
Although highly effective in treating pain, overreliance on opioid monotherapy significantly increases patient risk for adverse drug events.8-10 Unintended and serious adverse events include respiratory depression, death, falls, sedation, delirium and bowel obstructions.10-12 Opioid-related adverse effects have been associated with increased hospital length of stay (LOS) and increased risk for readmission.12,13 All patients are at risk for these adverse effects, but the elderly, obese, smokers, individuals with obstructive sleep apnea, patients with no recent opioid use and postsurgical patients have exhibited greater vulnerability.14
Opioid monotherapy also has financial implications. The drugs’ overuse for acute pain treatment contributes to millions of dollars of additional health care spending each year.15 A typical 50-bed hospital incurs $1.6 million in costs annually on average as a result of opioid-related complications.16 In addition, opioid monotherapy can be seen by some health care providers and facilities as an increased legal risk, as opioid analgesics are the drugs most often linked to malpractice adverse event claims.17
Multimodal Analgesia: An Alternative Approach
There is a critical need for hospitals to address acute pain management.
Given the significant risks of opioid monotherapy, how can patients’ postsurgical pain be adequately controlled while reducing the risks associated with use of opioids? It’s a delicate balance.
Pain management must be more effective for patients, while minimizing the use of opioids. Therefore, the best approach can be two or more analgesic agents or nonpharmacologic treatments that act by different mechanisms to provide pain relief. Such an approach is known as multimodal analgesia (MMA).14,18
The rationale for MMA is twofold. First, the combination of an opioid and other analgesics can work on different points along the pain pathway, or act additively or synergistically to potentially achieve better pain relief.14,18 Second, MMA harnesses the beneficial effects of opioids when they are most needed, while limiting their use to stave off the potentially harmful effects.19,20 Some agents that can be used together with lower doses of opioids to manage moderate to severe acute pain include acetaminophen and nonsteroidal anti-inflammatory drugs (both available in IV and oral formulations), local anesthetics and anticonvulsants. Nonpharmacologic approaches and regional anesthetic techniques also are components of an MMA plan.16,19-21
Research shows that MMA confers advantages for patient recovery. For example, it can reduce opioid-related adverse events,22,23 improve functional outcomes and hasten functionality,20,24-26 and reduce hospital LOS.27 MMA also has been demonstrated to reduce the cost of care.16,28
MMA is steadily being embraced as a pain management best practice in the hospital setting. The American Pain Society, supported by other professional associations, has published guidelines for the management of acute postoperative pain that call for the use of an MMA approach.5 Many other medical professional organizations and health care associations recommend a nonopioid agent as the foundation for treatment of postsurgical pain and advocate for the use of MMA (Table). To effectively implement these recommendations, prescribers must recognize that pain must be managed on an individual basis, considering factors such as age, comorbidities, organ function, gastrointestinal function and absorption, and efficacy of the medications. Whenever possible, nonopioids are prescribed on an around-the-clock schedule. Their guidelines are based not only on the benefits noted above but also on research linking MMA with shorter hospital LOS27 and reduced cost of care.16,28
Agency for Healthcare Research and Quality Wells N, Pasero C, McCaffery M. Improving the quality of care through pain assessment and management. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008.
American Geriatrics Society Shah S, Almenas F, Castillo C, et al; The American Geriatrics Society. Pain management in the elderly. The American Geriatrics Society website.
American Pain Society, American Society of Anesthesiologists, American Society of Regional Anesthesia and Pain Medicine Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17:131-157.
American Society for Pain Management Nursing Jarzyna D, Jungquist CR, Pasero C, et al. American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Manag Nurs. 2011;12:118-145.
American Society of PeriAnesthesia Nurses American Society of PeriAnesthesia Nurses. ASPAN pain and comfort clinical guidelines. J Perianesth Nurs. 2003;18:232-236.
Enhanced Recovery After Surgery Society Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. World J Surg. 2013;37:259-284.
The Joint Commission on Accreditation of Healthcare Organizations The Joint Commission. Safe use of opioids in hospitals. ?Sentinel Event Alert. 2012;49:1-5.
Society of Critical Care Medicine Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41:263-306.
Overall, MMA is a practical pain management solution with many benefits and a lower risk profile than opioid monotherapy. Bedside practitioners in collaboration with the multidisciplinary team should consider MMA as a viable, and indeed recommended, approach for postsurgical pain management.
Savage SR, Kirsh KL, Passik SD. Challenges in using opioids to treat pain in persons with substance use disorders. Addict Sci Clin Pract. 2008;4:4-25.
Gan TJ, Habib AS, Miller TE, et al. Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey. Curr Med Res Opin. 2014;30:149-160.
Apfelbaum JL, Chen C, Mehta SS, et al. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003;97:534-540.
Pavlin DJ, Chen C, Penaloza DA, et al. A survey of pain and other symptoms that affect the recovery process after discharge from an ambulatory surgery unit. J Clin Anesth. 2004;16:200-206.
Chou R, Gordon DB, de Leon-Casasola, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17:131-157.
White P, Kehlet H. Improving postoperative pain management: what are the unresolved issues? Anesthesiology. 2010;112:220-225.
Pasero C. The perianesthesia nurse’s role in the prevention of opioid-related sentinel events. J Perianesth Nurs. 2013;28:31-37.
Remy C, Marret E, Bonnet F. Effects of acetaminophen on morphine side-effects and consumption after major surgery: meta-analysis of randomized controlled trials. Br J Anaesth. 2005;94:505-513.
Apfel CC, Korttila K, Abdalla M, et al. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med. 2004;350:2441-2451.
Wheeler M, Oderda GM, Ashburn MA, et al. Adverse events associated with postoperative opioid analgesia: a systematic review. J Pain. 2002;3:159-180.
Jarzyna D, Jungquist CR, Pasero C, et al. American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Manag Nurs. 2011;12:118-145.
Pizzi LT, Toner R, Foley K, et al. Relationship between potential opioid-related adverse effects and hospital length of stay in patients receiving opioids after orthopedic surgery. Pharmacotherapy. 2012;32:502-514.
Oderda GM, Gan TJ, Johnson BH, et al. Effect of opioid-related adverse events on outcomes in selected surgical patients. J Pain Palliat Care Pharmacother. 2013;27:62-70.
The Joint Commission. Safe use of opioids in hospitals. Sentinel Event Alert. 2012;49:1-5.
The Advisory Board Company. Cost and quality impacts of multi-modal pain regimens: an observational study of over 2.5 million cases from 400 acute care hospitals. Washington, D.C.: the Advisory Board Company; November 24, 2014.
Kane-Gill SL, Rubin EC, Smithburger PL, et al. The cost of opioid-related adverse drug events. J Pain Palliat Care Pharmacother. 2014;28:282-293.
Marcus H. An ounce of prevention: the rising tide: perils of opioid use. The Doctor’s Advocate. Third Quarter 2013. www.thedoctors.com/?advocate. Accessed May 15, 2017.
American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012;116:248-273.
Morphine sulfate [package insert]. Lake Forest, IL: Hospira Inc.; 2011.
Kehlet H, Dahl JB. The value of “multimodal” or “balanced analgesia” in postoperative pain treatment. Anesth Analg. 1993;77:1048-1056.
Crews JC. Multimodal pain management strategies for office-based and ambulatory procedures. JAMA. 2002;288:629-632.
Dirkmann D, Groeben H, Farhan H, et al. Effects of parecoxib on analgesia benefit and blood loss following open prostatectomy: a multicentre randomized trial. BMC Anesthesiol. 2015;15:31.
Elvir-Lazo OL, White PF. The role of multimodal analgesia in pain management after ambulatory surgery. Curr Opin Anaesthesiol. 2010;23:697-703.
White PF. Multimodal analgesia: its role in preventing postoperative pain. Curr Opin Investig Drugs. 2008;9:76-82.
Garcia RM, Cassinelli EH, Messerschmitt PJ, et al. A multimodal approach for postoperative pain management after lumbar decompression surgery: a prospective, randomized study. J Spinal Disord Tech. 2013;26:291-297.
Ender J, Borger MA, Scholz M, et al. Cardiac surgery fast-track treatment in a postanesthetic care unit: six-month results of the Leipzig fast-track concept. Anesthesiology. 2008;109:61-66.
Michelson JD, Addante RA, Charlson MD. Multimodal analgesia therapy reduces length of hospitalization in patients undergoing fusions of the ankle and hindfoot. Foot Ankle Int. 2013;34:1526-1534.
Duncan CM, Long KH, Warner DO, et al. The economic implications of a multimodal analgesic regimen for patients undergoing major orthopedic surgery: a comparative study of direct costs. Reg Anesth Pain Med. 2009;34:301-307.