By Joseph F. Answine, MD
Pain medications, especially opioids, have understandably undergone intense scrutiny due to recent public concern over prescription drug abuse, as well as the known side effects of opioids limiting enhanced recovery programs (e.g., somnolence impeding early ambulation and feeding, increased postoperative nausea and vomiting, higher incidence of ileus after colorectal surgery and significant respiratory depression).
The problem with eliminating opioid use is that major surgery comes with major pain, and opioids are effective at treating major pain. Furthermore, when opioids are finally introduced after attempting to avoid their use, it is usually done “emergently”—only after the patient is in extreme, inconsolable pain that disrupts recovery. This will likely lead to giving patients larger doses and increasing the risk for adverse events that we are all trying to avoid.
Note that severe acute pain is a risk factor for the development of chronic pain, sleep disturbances, changes in mood and behavior (especially in children), poor wound healing and delayed recovery. This avoidance of opioids in the face of intense pain due to their potential short- and long-term negative effects has created, what I call, the “perioperative pain paradox.”
Confusion Over Multimodal Pain Management
In my opinion, there seems to be a misinterpretation of the thought process and goals behind multimodal pain management. The intention of this style of management, based on extensive literature, is to utilize multiple medications involving multiple receptors, multiple routes of administration, non–medication-based methods, and patient and provider education and preparedness to maximize pain control while minimizing unwanted side effects. It is not designed to eliminate a major contributor to successful acute pain management. Understandably, acute pain management has historically been based on opioids and fraught with many unwanted side effects and risk for abuse. However, a complete removal of opioids has been and will continue to be extremely difficult to achieve, and likely lead to short- and long-term disabilities.
Multimodal pain management is an individualized program that is procedure– and patient population-specific and designed in part, as stated above, to limit unwanted side effects. This is an important statement because opioids are not the only medications with side effects. The risk for unwanted or even life-threatening side effects increases with higher drug dosages, regardless of the medication’s mechanisms of action. For example, local anesthetic use can lead to central nervous system and cardiac toxicities; acetaminophen can lead to hepatic toxicity; and nonsteroidal anti-inflammatory drugs can lead to hematologic and renal toxicities. There is also an overemphasis on neuraxial and regional techniques causing muscle weakness and hemodynamic instability leading to delayed recovery.
Guidelines and publications from influential organizations such as the American Society of Anesthesiologists (Anesthesiology 2012;116:248-273) and the American Pain Society (J Pain 2016;17:131-157) advocate the utilization of opioids for perioperative pain management in a multimodal, patient- and procedure-directed manner—not a complete elimination.
It seems reasonable then to move away from an opioid-based pain management program to one that utilizes them as part of a coordinated protocol with nonopioid medications, physical modalities and education in order to provide optimal pain control and reduce opioid-induced adverse events.
How, then, should opioids be delivered since routes of administration are numerous?
The most common route in the immediate postoperative period is IV. It is most consistent from patient to patient in terms of blood levels achieved, speed of delivery to the site of action and duration of action; the onset of pain reduction is relatively rapid. It also allows for more coordinated and efficient patient monitoring. Intravenous patient-controlled analgesia optimizes delivery by minimizing the pharmacokinetic and pharmacodynamic variability among patients and patient populations, and provides “on-demand” dosing based on the level of perceived pain and the cognitive ability of the patient. This “immediate” delivery gives patients a sense of control and helps to improve their satisfaction.
A transition to oral opioids in a time-limited manner while continuing multimodal pain control can then occur while emphasizing the use of nonopioid modalities throughout the post-op period. Other routes of administration such as epidural, intra-articular and transdermal can also be considered depending on the procedure performed and the patient’s comfort level.
Therefore, a multimodal pain management program that includes opioids as one of many arms used to control surgical pain should be employed to avoid the “perioperative pain paradox.”
Dr. Answine is a clinical associate professor in the Department of Anesthesiology and Perioperative Medicine at Penn State College of Medicine, in Hershey, Pa. He is also a partner at Riverside Anesthesia Associates, and staff anesthesiologist at Pinnacle Health Hospitals, in Harrisburg, Pa.