The implementation of a multimodal analgesic protocol may be a simple, effective way to boost the documentation of preoperative pain scores and opioid use in an acute pain service, new research suggests.
Multimodal protocols for nonopioid analgesia using acetaminophen, cyclooxygenase-2 inhibitors, gabapentinoids and peripheral nerve catheters have been shown to decrease opioid use and improve patient analgesia, according to researchers from the University of Florida, in Jacksonville. However, the effect of these protocols on baseline assessment of patient pain and opioid use, which is “key to providing an appropriate level of postoperative analgesia,” has not been investigated, they wrote.
“It is important to know where a patient’s pain is starting from,” said Alberto Ardon, MD, MPH, study author and assistant professor in the Department of Anesthesiology at the University of Florida. “If, on a 0 to 10 scale, a patient has a baseline preoperative pain score of 8 out of 10, a postoperative pain score of 7 presents a dramatically different picture compared to a baseline score of 2 out of 10.”
The researchers conducted a retrospective chart analysis of 98 hip and knee arthroplasty patients (49 before and 49 after protocol implementation) to determine differences in the rate of baseline documentation of pain and opioid use. Secondary measures included rate of adherence to the multimodal protocol, rate of peripheral nerve catheter use, mean postoperative pain scores and mean hospital length of stay.
The nonopioid multimodal protocol used in the study consisted of acetaminophen, celecoxib, gabapentin and peripheral nerve blocks. The faculty and residents at the institution received three educational sessions that emphasized conducting a succinct preoperative review of a patient’s pain history, evaluating baseline pain and opioid use, and explaining the benefits of this protocol to patients.
The researchers reported a sharp increase in documentation after implementing the protocol.
“What we had found before implementation of the multimodal protocol was that our documentation of these parameters was not good. There was less than a 30% documentation of either baseline pain scores or home opioid use for patients undergoing knee or hip arthroplasty,” Dr. Ardon said at the 2016 annual meeting of the American Society of Regional Anesthesia and Pain Medicine (abstract 1407). “After implementation of the protocol, our documentation of baseline pain rose to 60%, and documentation of home opioid use increased to 70%. Both of these changes were statistically significant.”
Baseline pain and opioid use assessment in the control group was 20% and 24%, respectively. Baseline pain and opioid use assessment after implementation of the protocol was 67% and 73%, respectively. Mean baseline pain scores (measured on a 10-point numeric rating scale) for patients who were assessed were 7.7±1.89 in the control group and 7.51±1.54 in the protocol group.
The rate of adherence to nonopioid analgesics in the protocol was 100% for acetaminophen, 88% for celecoxib and 98% for gabapentin. Dr. Ardon said patient baseline characteristics (i.e., age, sex and American Society of Anesthesiologists physical status classification) were similar between the two groups. However, he noted that a higher percentage of patients had revision arthroplasties in the control group (30.61%) compared with the protocol group (12.24%).
The researchers also found that mean and worst postoperative pain scores were significantly lower for the protocol group on post-op days 1 and 2. The findings were similar after controlling for primary surgery and peripheral nerve catheter use (Table).
Table. Patient Pain Scores
|Mean Pain Score||Worst Pain Score|
|Controlling for primary surgery|
|Controlling for when peripheral nerve catheter was used|
POD, postoperative day
Nerve catheter use also increased from 82% to 92% after implementing the protocol. The new protocol did not affect the mean hospital length of stay (4.04±2.8 days, control vs. 3.47±2.5 days, protocol). Dr. Ardon said this might be attributed to a multifactorial process, including variability in physical therapy, which was not assessed.
He said these findings are significant because they suggest that a protocol emphasizing the use of nonopioid analgesics and active documentation of baseline pain characteristics can indeed affect a patient’s postoperative analgesia. Additionally, given the high use of preoperative opioids among patients in this study, these results may be especially significant for the analgesic management of chronic pain patients presenting for surgery.
“The use of opioid analgesics within our state—and I believe nationwide—is a problem. I think that while opioid analgesics are useful in certain situations, the use of nonopioid modalities is still not as widespread as it should be, and we are facing a nationwide epidemic of opioid overuse,” Dr. Ardon said. “Some pain states frankly sometimes do not require opioid analgesia, and this overprescription has contributed to our current problem.”
He noted the challenges that physicians face when prescribing opioids for postoperative pain, and the potential benefits of trying nonopioid analgesics first.
“It truly becomes a double-edged sword, where you want patients to be on an appropriate pain management strategy, and sometimes that does involve postoperative analgesia such as oxycodone. But you also don’t want to promote a clinical atmosphere where that is the routine or go-to analgesic,” he said. “In the future, my hope is that we can emphasize the use of nonopioid analgesics first and then opioid analgesics, such as fast-acting oxycodone or longer-acting MS Contin [morphine sulfate, Purdue], for example, as a second or third stage in that process.”