Operationalizing the Recent Multisociety Postoperative Pain Guidelines

David M. Dickerson, MD

Assistant Professor, Anesthesiology and Pain Medicine
Director, Acute Pain Service
Department of Anesthesia & Critical Care
University of Chicago Medicine
Chicago, Illinois

Following the guidelines on acute postoperative pain management requires the hard work of institutionalizing and implementing the recommendations.

Updating the 2012 practice advisory of the American Society of Anesthesiologists (ASA) on acute postoperative pain management, the multisociety postoperative pain guidelines offer a blueprint for best practices in postoperative pain care.^1,2 Published last year, the guidelines incorporate 8 years of development and review by the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, the ASA Administrative Council, the ASA Executive Committee, and the ASA Committee on Regional Anesthesiology. The publication presents 32 evidence-based recommendations for the rel ief of acute postsurgical pain. In the current opioid epidemic, the guidelines illustrate the role that pain clinicians, anesthesiologists, and their professional societies have in the public health crisis. This crisis, a national emergency, creates a robust leverage point for garnering institutional support for improvement in the quality of pain care.

To bridge the gaps between science and practice requires a discussion on how to translate research into practice. Practice guidelines are one tool in translational research, but guideline adoption relies on several factors:

• knowledge diffusion and dissemination,
• systematic implementation,
• ongoing utilization analysis, and
• frequent reevaluation of the impact and value created for patients, providers, and health care systems.

The 32 recommendations in the guidelines and the strength of the evidence and level of recommendation for each are presented in the Table. This article discusses key recommendations and a framework for their implementation.

Table. Recommendations From the Multisociety Acute Postoperative Pain Guidelines2
Recommendations		Level of Evidence	Strength of Recommendation
1	Provide patients, their families, and caregivers with education on treatment options; document a plan and treatment goals	Low	Strong
2	Educate parents of pediatric patients on developmentally appropriate methods for pain assessment, educate on analgesics and treatment modalities	Low	Strong
3	Conduct pre-op evaluation assessing for factors that increase risk for uncontrolled pain or affect pain management or patient risk	Low	Strong
4	Frequently adjust pain management plan based on adequacy of pain relief or adverse events	Low	Strong
5	Track treatment response with validated pain assessment tool; adjust treatment accordingly	Low	Strong
6	Offer children and adult patients multimodal analgesia combined with nonpharmacologic interventions	High	Strong
7	Consider TENS as an adjunct to other treatments	Moderate	Weak
8	Acupuncture, massage, cold therapy may or may not have benefit	Not sufficient	No recommendation
9	Consider cognitive-behavioral modalities in adults	Moderate	Weak
10	Oral opioids are preferred to intravenous opioids in patients able to use the oral or enteral route	Moderate	Strong
11	Avoid using the intramuscular route	Moderate	Strong
12	When parenteral route is needed, IV PCA should be used	Moderate	Strong
13	Avoid routine basal infusions with IV PCA in opioid-naive adults	Moderate	Strong
14	Appropriately monitor for sedation, respiratory depression, and other adverse events when systemic opioids are used	Low	Strong
15	Acetaminophen and/or NSAIDs should be used for adults and children without contraindication as part of a multimodal approach	High	Strong
16	Preoperative celecoxib should be given to adults without contraindication	Moderate	Strong
17	Consider use of gabapentin as a component of multimodal analgesia	Moderate	Strong
18	Consider IV ketamine as a component of multimodal analgesia in adults	Moderate	Weak
19	Consider IV lidocaine infusions in adults for open and laparoscopic abdominal surgery	Moderate	Weak
20	Consider surgical site–specific local anesthetic infiltration	Moderate	Weak
21	Use topical local anesthetics in combination with nerve blocks before circumcision	Moderate	Strong
22	Avoid intrapleural analgesia with local anesthetics after thoracic surgery	Moderate	Strong
23	Consider site-specific peripheral regional anesthetic techniques in adults and children for procedures with established efficacy	High	Strong
24	Use continuous, local anesthetic–based peripheral regional analgesic techniques when pain is expected to exceed the duration of a single-shot injection	Moderate	Strong
25	Consider adding clonidine as an adjuvant to prolong single-injection peripheral blocks	Moderate	Weak
26	Offer neuraxial analgesia for major thoracic and abdominal procedures, especially if concerns for ileus, or pulmonary or cardiac complications	High	Strong
27	Avoid neuraxial magnesium, benzodiazepines, neostigmine, tramadol, and ketamine	Moderate	Strong
28	Appropriately monitor patients receiving neuraxial interventions	Low	Strong
29	Surgical facilities should develop an infrastructure to develop policies and processes for safe and effective pain care	Low	Strong
30	Surgical facilities should have pain specialist consultation for challenging care scenarios	Low	Strong
31	Policies and procedures should guide neuraxial and continuous peripheral block procedures	Low	Strong
32	Adults, children, and caregivers should be provided education on post-discharge pain plans and analgesic tapering	Low	Strong
Recommendations in red refer to practices that should be avoided. NSAIDs, nonsteroidal anti-inflammatory drugs; PCA,patient-controlled analgesia; TENS, transcutaneous electrical neural stimulation

Surgical Medicine and the Opioid Epidemic

Modifying postsurgical prescribing can curb the opioid epidemic, especially if patients are receiving more pain medicine than they need.³ Ninety days after surgery, 6% of previously opioid-naive patients continue to take opioids.⁴

The guidelines for opioid prescribing by the Centers for Disease Control and Prevention recommend for acute pain “the lowest effective dose of immediate-release opioids” and “no greater quantity than needed for the expected duration of pain severe enough to require opioids.” The norm is 3 days or less and rarely more than 7 days.⁵ Defining the lowest effective dose depends on several factors: patient expectations; utilization of effective, nonopioid techniques; and prescriber awareness of the amount of medication needed after a specific procedure.

Instituting a Governing Body For Implementation

If surgical care is indeed a gateway to persistent opioid use, excellence in perioperative pain assessment and treatment aims to reduce pain and prolonged opioid use.⁵ As pain specialists and anesthesiologists continue to emphasize their role as experts who can curb the opioid epidemic, institutional support evolves for quality improvement initiatives in perioperative pain care. Coupling expertise and influence with an institutional mandate is necessary as the efforts required and benefits obtained reach far beyond the anesthesia or pain management group.

Implementing a protocol for guideline-based care conserves resources and aligns patient, provider, and institutional goals. Recommendation 29 suggests surgical facilities develop an infrastructure to create policies for safe and effective pain care. With a low level of evidence and a strong recommendation, successful delivery of the recommendations relies on institutional initiatives and a burgeoning consensus.

Clinical effectiveness and quality leadership must prioritize patient satisfaction, safety, and quality metric reporting. Reimbursement, patient outcomes, and market share drive this effort. High-quality pain care is an integral part of institutional expense and patient experience.

Building a task force or committee with membership from pharmacy, nursing, clinical leaders, and administration is one mechanism for influencing ongoing practices in pain management. One of the primary activities of such a working group would be to use the guidelines as a rubric for a gap analysis and a road map for quality improvement. Implementing this recommendation early may enable success across multiple domains, many of which depend on data and institutional buy-in.

A Novel Model for Implementation: Pain Stewardship

A stewardship model is one guide for implementation. In 2016, at the University of Chicago Medicine, a stewardship program was instituted analyzing pain management. The program offered key institutional initiatives:

• patient and provider education,
• provider-level and procedure-specific opioid prescribing reports,
• standardized preoperative nonopioid analgesics,
• electronic health record integration with state-based prescription monitoring, and
• safe opioid medication return via a campus-based Drug Enforcement Administration–approved MedSafe medication collection system with ongoing messaging to patients and providers.

Patient Engagement: Preparation and Education

Recommendations 1, 2, 4, and 32 focus on patient and caregiver engagement. Patients want to be informed participants in decision making and want to feel that the care team is doing everything it can to minimize their pain.^6,7 The panel highly recommends providing patients and caregivers with education on treatment; specifically, how pain will be assessed and treated as well as a plan for post-discharge pain management and analgesic tapering. The panel also recommends documentation of the treatment plan and goals of therapy.

At our institution, standardized materials are a part of a patient-centered booklet for surgical preparation. The booklet explains the role and risks of opioids, the importance of nonopioids and nonpharmacologic interventions, and how pain is assessed. It gives a timeline for discontinuing analgesics postoperatively, and the steps for returning surplus medications to the medical center via MedSafe. Patient literacy experts reviewed and revised the materials for comprehension across various levels of education.

Pain Specialist Availability and Pain Screening

Recommendation 28 from the postoperative pain guidelines suggests that surgical facilities consult with pain specialists for challenging care scenarios. Even with standardized protocols, patients with special pain care needs can be underserved without treatment planning and care coordination. Identifying these patients has been well described in the literature.

The third recommendation is for preoperative evaluation for factors that increase risk for uncontrolled pain or affect pain management.^8,9 Policies and procedures describing treatment planning and triggers for escalation standardize individual treatment planning. Screening can trigger evaluation by a pain specialist.

At our institution, all patients are screened preoperatively for daily preoperative opioid use or daily pain over the preceding month (recommendation 3). This information drives clinical decision making, such as broadening multimodal analgesic exposure (recommendations 15-19), instituting continuous regional anesthesia (recommendation 24), or including the chronic pain clinic or acute pain specialists perioperatively (recommendation 28).

Broadening Multimodal Analgesic Use

Recommendations 15 through 17 suggest using nonsteroidal anti-inflammatory drugs (NSAIDs) such as celecoxib, acetaminophen, and gabapentin as part of multimodal treatment. Creating a standardized pathway ensures adequate medication availability in perioperative areas, streamlines ordering by surgical services, supports timely administration, and permits analysis of ongoing utilization.

As a quality improvement initiative at our institution, a survey of orthopedic surgeons, anesthesiologists, and nurses found that the majority of clinicians and nurses supported using nonopioid analgesics preoperatively for ambulatory orthopedic surgical procedures. Yet a limited number of outpatient orthopedic surgical patients received a dose of acetaminophen, an NSAID, or gabapentin, and less than 1% of patients received all 3 agents. After a didactic session for orthopedic surgical residents and implementation of a standardized preoperative order, concomitant administration of all 3 medications increased by 50-fold.

Eliminating IV Opioids for Some Patients

The guidelines recommend the elimination of some practices. These recommendations appear in red in the Table. Intrapleural catheters should not be used for thoracic surgery, and neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, and ketamine is not recommended. Eliminating intravenous opioids for patients able to take oral medications challenges the current practice of many groups, including ours. Creating initiatives that support oral opioids as a first line of treatment can be challenging.

In one randomized study, oral opioid regimens decreased opioid exposure with similar analgesic efficacy when compared with intravenous regimens.¹⁰ There is a distinct difference in duration of action of oral agents and intravenously administered opioids. Transitioning a patient from a primarily intravenous regimen to an oral regimen is challenging and may be best avoided by using oral opioids as first line. By eliminating parenteral opioids, a potentially prolonged hospital stay and suboptimal satisfaction may be prevented.

Infusion Therapies: Ketamine and Lidocaine

The panel recommended considering intravenous ketamine and lidocaine infusions as a component of multimodal analgesia. Many anesthesia and surgical providers do not utilize these agents in standard practice. At our institution, a pain care subcommittee of the Pharmacy and Therapeutics Committee standardized workflows for ketamine and lidocaine infusions for intraoperative and postoperative analgesia.

With provider education, order sets, evidence-annotated institutional guidelines, pharmacy premixed medication bags, and standardized narrow-range pump library programs, consistent and safe infusion therapy can be readily available for patients. Since implementing these standard pathways at our institution, utilization of these infusions dramatically increased and variation in dosing of ketamine and lidocaine for analgesia has decreased.

Optimizing Use of Regional Anesthesia

Recommendations 23 and 24 indicate site-specific peripheral regional anesthesia for adults and children with a continuous technique when pain is expected to exceed the duration of a single-shot injection. Recommendation 31 suggests that policies guide neuraxial and continuous peripheral blocks to ensure safety and efficacy.

During specific procedures when benefit has been demonstrated relative to general anesthesia, regional anesthesia should be supported by payors and institutions as an evidence-based component of value-based care.

There are many obstacles, however, to the utilization of regional anesthesia, despite its established benefits. From concerns about potentially delaying the start of the case to availabilityof skilled regionalists at every surgical site on the day of surgery, the specific cultural and logistical issues must be identified. Institutions must support:

• development of a skilled regional anesthesia team,
• block rooms and block carts,
• a framework for perioperative communication before the day of surgery,
• standardized anticoagulant and antiplatelet management guidelines, and
• a formal request process for booking regional anesthesia or continuous catheters.

Most important is a method for evaluating utilization, process, and effect on patient care.

At our institution, a perioperative pain care list circulates the day before surgery to perioperative leadership and clinical personnel. The list is compiled from requests entered into a multidisciplinary care section of the electronic health record’s case booking form. An email lists all requests for regional anesthesia, including epidurals and continuous nerve catheters; patients who will need the acute pain service care; and patients with treatment plans for perioperative ketamine or lidocaine infusions.

The anesthesia coordinator making the schedule incorporates the requests into the specific case assignments. This process reduces case delays and improves care coordination by communication through a conserved workflow.

Translating Guidelines Into Practice: Timing, Effort, Support

It has been suggested that it takes 9 years to fully implement practice guidelines.¹¹Understanding factors that impede and those that predict successful implementation of practice guidelines is key to translating the recent multisociety postoperative pain guidelines into practice.

Successful implementation is associated with ample resources, supportive social conditions, presence of a champion for new knowledge, openness to change, no strong political or bureaucratic opposition, incentives to change, leadership by example, and support for a long-term interactive relationship.¹²

Others have suggested 32 barriers to dissemination of evidence-based interventions.¹³ The barriers depend on the characteristics of the interventions; attributes of the innovations and rate of adoption; situation or context of the intended audience; and limitations of the research being promoted such as cost, validation, methodology, or interaction between these factors.

Most groups already practice the recommendations of the postoperative pain guidelines to some extent. The guidelines are not only a blueprint but also a diagnostic tool for anesthesiologists and pain medicine physicians to assess their own practice. The opioid epidemic makes the guidelines timely. They offer support to physicians who seek to improve pain care while reducing opioid exposure as much as possible.

References

1. American Society of Anesthesiologists Task Force on Acute Pain Management: Practice guidelines for acute pain management in the perioperative setting. Anesthesiology. 2012;116(2):248-273.
2. Chou R, Gordon D, De Leon-Casasola O, et al. Guidelines on the management of postoperative pain. J Pain. 2016;17(2):131.
3. Chapman T, Kim N, Maltenfort M, et al. Prospective evaluation of opioid consumption following carpal tunnel release surgery. Hand. 2017;12(1):39-42.
4. Brummett CM, Waljee JF, Goesling J, et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017;152(6):e170504-e170504.
5. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. 2016;65(No. RR-1):1-49.
6. Schwenkglenks M, Gerbershagen HJ, Taylor RS, et al. Correlates of satisfaction with pain treatment in the acute postoperative period: results from the international PAIN OUT registry. Pain. 2014;155(7):1401-1411.
7. Hanna MN. Does patient perception of pain control affect patient satisfaction across surgical units? J Med Qual. 2012;27(5):411-416.
8. Ip HY, Abrishami A, Peng PW, et al. Predictors of postoperative pain and analgesic consumption: a qualitative systematic review. Anesthesiology. 2009;111(3):657-677.
9. Gerbershagen HJ, Pogatzki-Zahn E, Aduckathil S, et al. Procedure-specific risk factor analysis for the development of severe postoperative pain. Anesthesiology. 2014;120(5):1237-1245.
10. Ruetzler K, Blome C, Nabecker S, et al. A randomized trial of oral versus intravenous opioids for treatment of pain after cardiac surgery. J Anesth. 2014;28(4):580-586.
11. Balas EA, Boren SA. Managing clinical knowledge for health care improvement. In: Bemmel J, McCray AT, eds. Yearbook of Medical Informatics 2000: Patient-Centered Systems. Stuttgart, Germany: Schattauer; 2000(1):65-70.
12. Landry R, Lamari M, Amara N. The extent and determinants of the utilization of university research in government agencies. Public Adm Rev.2003;63(2):92-205.
13. Glasgow RE, Emmons KM. How can we increase translation of research into practice? Types of evidence needed. Annu Rev Public Health. 2007;28(4):413-433.