Multimodal Analgesia in the Acute Care Setting

1. Multimodal Analgesia in the Acute Care Setting Daniela Fernandez, PharmD PGY1 Pharmacy Resident Morton Plant Hospital March 26, 2019

2. Disclosures • The speaker has no disclosures to report.

3. Objectives • Define the types of pain and their sources • Define and describe multimodal pain management with brief review of medication classes • Review current literature on benefit of multimodal pain management • Identify current practices within Morton Plant Hospital utilizing multimodal pain management

4. Classification of Pain

5. PAIN “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”

6. Classification of Pain

7. Types of Pain

8. Types of Pain

9. Statistics • Those with pain are more likely to • Have a worse health status • Use more health care • Suffer from more disability

10. Opioid Epidemic • Of the 11.4 million adults misusing prescription opioids, 63.4% stated the reason for misuse was to “relieve physical pain”

11. Uncontrolled Postoperative Pain • Associated with: • Increased morbidity • Delayed recovery time • Functional and quality-of-life impairment • Longer duration of opioid use • Higher healthcare costs • Predictive of development of chronic pain

12. Multimodal Analgesia

13. Multimodal Analgesia

14. Rationale for Multimodal Analgesia • Decrease use of opioids • Decrease side effects associated with opioids (e.g. nausea/vomiting, sedation) • Provide a more effective pain control strategy • Prevent complications associated with untreated pain • Prevent progression to chronic pain • Improve patient quality of life postoperatively

15. ERAS Pathways • ERAS = Enhanced Recovery After Surgery • Strategy to improve quality of surgical care • Goal is to optimize patient outcomes • Essential component is a standardized multimodal pain regimen

16. Pharmacologic Agents

17. Nonopioid Analgesics • Examples include: • Acetaminophen • Nonsteroidal anti-inflammatory drugs (NSAIDs) [e.g. aspirin, celecoxib] • Mechanism of action: • Acetaminophen centrally inhibits cyclooxygenase (COX) pathway • Mechanism not fully understood • NSAIDs inhibit COX enzyme, preventing prostaglandin synthesis

18. Selective vs. Non-Selective NSAIDs • COX-1 vs. COX-2 enzymes • COX-1: platelets, renal hemodynamics, and gastric cytoprotection • COX-2: inflammation • Selective NSAIDs block COX-2 • Advantages include lower incidence of GI side effects • Useful in higher risk patients (e.g. previous ulcers) • Black Box Warning • Increased risk of cardiovascular events and GI bleeds • Required by FDA on all NSAIDs

19. Nonopioid Analgesics

20. Clinical Pearls on NSAIDs • Ketorolac and platelet function inhibition • Reversible binding and shorter duration of inhibition • No increase in postoperative bleeding at normal doses • Superior postoperative pain control equivalent to opioids • History of GI bleed or ulcers • Contraindication to NSAID use • Alternatives: Steroids (e.g. dexamethasone)

21. Neuromodulatory Agents • Mechanism of action: • Inhibition of alpha-2-delta subunits of voltage-gated calcium channels on neuronal cells • Decrease neuronal excitability • May help decrease central sensitization to pain

22. NMDA Antagonist • Mechanism of action: • Inhibition of N-methyl-D-aspartate (NMDA)-gated calcium channel • Nonbarbiturate, dissociative anesthetic

23. Muscle Relaxants • Mechanism of action: • Varies by medication • Can be classified as antispastic (e.g. baclofen) vs. antispasmodic (e.g. tizanidine, methocarbamol) • Antispasmodic agents preferred for musculoskeletal conditions

24. Local Anesthetics • Mechanism of action: • Inhibit voltage-gated sodium channels and prevent depolarization of sensory nerves • Useful for peripheral nerve blocks

25. Opioids • Mechanism of action: • Bind to mu-, delta-, and kappa- opioid receptors • Causes inhibition of ascending pain pathways • Role in multimodal analgesia protocols: • Around-the-clock immediate-release opioids for 48 h after surgery • Additional opioids as needed for breakthrough pain • Used in addition to nonopioid analgesia

26. Opioids

27. Chronic Opioid Use • Patients that are on chronic opioids are the exception to the multimodal analgesia model • Discontinuing or drastically reducing their opioid use could induce withdrawal • Continue patient’s baseline opioid use • Manage breakthrough pain using multimodal analgesia protocols

28. Non-Pharmacologic Options

29. Non-Pharmacologic Options • Should supplement but not replace analgesics

30. Current Literature

31. Postoperative Multimodal Analgesia

32. Multimodal Analgesia in Orthopedic Surgery

33. Multimodal Analgesia in Orthopedic Surgery

34. Multimodal Analgesia in Spine Surgery

35. Summary of Literature • Multimodal analgesia approach remains variable but beneficial • No standardized model for multimodal analgesia • Research needed: • Optimal methods for patients on opioids prior to surgery • Effectiveness of multimodal regimens • Evidence-based interventions for postoperative pain

36. Current Practices

37. BayCare Multimodal Pain Management Algorithm

38. Examples of Multimodal Analgesia Protocols Total Hip Arthroplasty Power Plans • Preop • Pregabalin 75 mg PO OR Gabapentin 600mg PO • Celebrex 400 mg PO or Acetaminophen 650 mg PO • If allergic to sulfonamides: Etodolac 300 mg PO or Meloxicam 15 mg PO • Dexamethasone 10 mg IV • PACU • Ketorolac 15 mg IV x 1 • Oxycodone ER 10 mg PO x 1

39. Examples of Multimodal Analgesia Protocols Total Hip Arthroplasty Power Plans • Postop • Ketorolac 15 mg IV q8hr x 3 doses • Celecoxib 200 mg PO q12hr x 24hrs (starts 6 hours after ketorolac is complete) • If allergic to sulfonamides: Etodolac 300 mg PO q8h or Meloxicam 15mg daily x 24 hour • Scheduled hydrocodone/oxycodone product: • Acetaminophen/hydrocodone 5-10 mg PO q4h x 48h • Acetaminophen/oxycodone 5-10 mg PO q4h x 48hr • Oxycodone ER 10 mg q12h x 48h • PRN therapy (starts after initial 48h of scheduled medications): • Acetaminophen/hydrocodone 5-10 mg PO q4h PRN • Acetaminophen/oxycodone 5-10 mg PO q4h PRN • Hydromorphone 0.5 mg IV q2h PRN • Tramadol 50 mg PO q6h PRN

40. Examples of Multimodal Analgesia Protocols Craniotomy Power Plans • Postop • Acetaminophen/oxycodone 5-10 mg PO 1-2 tabs q4h PRN • Acetaminophen 650 mg PO or rectal q4h PRN • Dexamethasone 4 mg IV q6h • Methocarbamol 750 mg PO QID prn muscle spasm • Methocarbamol 1000 mg IV q6h x 4 doses • Hydromorphone 0.5 mg IV q4h PRN x 3 days • Morphine 1-2 mg IV q1hr PRN

41. Spinal Surgery ERAS Pathway • Currently in progress under multidisciplinary team • Goal is to create a multimodal approach to caring for patients undergoing spinal surgery at MPH • Will result in implementation of new power plans

42. Conclusion • Multimodal analgesia is an optimal approach to postsurgical pain management • Associated with decreased opioid use and side effects • Targets quicker postoperative recovery and increased patient satisfaction

43. Questions?

44. References • International Association for the Study of Pain. IASP Terminology. https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698. Updated December 14 2017. Accessed March 18 2019. • National Institute of Health. NIH Analysis Shows Americans Are In Pain. https://nccih.nih.gov/news/press/08112015. Published August 11 2015. Accessed March 18 2019. • U.S. Department of Health and Human Services. What is the U.S. Opioid Epidemic? https://www.hhs.gov/opioids/about-the-epidemic/index.html. Updated January 22 2019. Accessed March 18 2019. • Libari RN, Williams M, and Van Horn SL. Why do adults misuse prescription drugs? https://www.samhsa.gov/data/sites/default/files/report_3210/ShortReport-3210.html. Published July 27 2017. Accessed March 18 2019. • The Joint Commission on Accreditation of Healthcare Organizations; The National Pharmaceutical Council. Pain: Current Understanding of Assessment, Management, and Treatments. National Pharmaceutical Council; December 2001. • Graff V, Grosh T. Multimodal Analgesia and Alternatives to Opioids for Postoperative Analgesia. Anesthesia Patient Sagety Foundation Newsletter. https://www.apsf.org/article/multimodal-analgesia-and-alternatives-to-opioids-for-postoperative-analgesia/. Accessed March 18 2019. • 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 Feb;17(2):131-57. • Herndon CM, Strickland JM, Ray JB. Pain management. In: DiPiro JT, Talbert RL, Yee GC, et al. Pharmacotherapy: A Pathophysiologic Approach, 10e. New York, NY: McGraw-Hill; . http://accesspharmacy.mhmedical.com.ezproxylocal.library.nova.edu/content.aspx?bookid=1861&sectionid=146063604. Accessed March 18, 2019. • Kaye AD, Cornett EM, Helander E, et al. An Update on Nonopioids: Intravenous or Oral Analgesics for Perioperative Pain Management. Anesthesiol Clin. 2017 Jun;35(2):e55-e71. • Chaiamnuay S, Allison JJ, Curtis JR. Risks versus benefits of cyclooxygenase-2 selective nonsteroidal anti-inflammatory drugs. Am J Health Syst Pharm. 2006;63(19):1837-1851. • Maslin B, Lipana L, Roth B, et al. Safety Considerations in the Use of Ketorolac for Postoperative Pain. Curr Drug Saf. 2017;12(1):67-73.

45. References • Witenko C, Moorman-Li R, Motycka C, et al. Considerations for the Appropriate Use of Skeletal Muscle Relaxants for the Management Of Acute Low Back Pain. P T. 2014 Jun; 39(6): 427-435. • Tan M, Law LS, Gan TJ. Optimizing pain management to facilitate Enhanced Recovery After Surgery pathways. Can J Anaesth. 2015 Feb;62(2):203-18. • Gan TJ. Poorly controlled postoperative pain: prevalence, consequences, and prevention. J Pain Res. 2017; 10: 2287–2298. • Codding JL, Getz CL. Pain Management Strategies in Shoulder Arthroplasty. Orthop Clin North Am. 2018 Jan;49(1):81-91. • Gritsenko K, Khelemsky Y, Kaye AD, et al. Multimodal therapy in perioperative analgesia. Best Pract Res Clin Anaesthesiol. 2014 Mar;28(1):59-79.  ADD TO POWERPOINT • Wick EC, Grant MC, Wu CL. Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques: a review. JAMA Surg. 2017;152(7):691-697. • Memtsoudis SG, Poeran J, Zubizarreta N, et al. Association of Multimodal Pain Management Strategies with Perioperative Outcomes and Resource Utilization: A Population-based Study. Anesthesiology 5 2018, Vol.128, 891-902. • Halawi MJ, Grant SA, Bolognesi MP. Multimodal analgesia for total joint arthroplasty. Orthopedics. 2015;38(7):e616-25 • Gaffney CJ, Pelt CE, Gililland J1, Peters CL. Perioperative Pain Management in Hip and Knee Arthroplasty. Orthop Clin North Am. 2017 Oct;48(4):407-419. • Russo MW, Parks NL, Hamilton WG. Perioperative Pain Management and Anesthesia: A Critical Component to Rapid Recovery Total Joint Arthroplasty. Orthop Clin North Am. 2017 Oct;48(4):401-405. • Kurd MF, Kreitz T, Schroeder G, Vaccaro AR. The role of multimodal analgesia in spine surgery. J Am AcadOrthop Surg. 2017;25(4):260-268. • Bohl DD, Louie PK, Shah N, et al. Multimodal Versus Patient-Controlled Analgesia After an Anterior Cervical Decompression and Fusion. Spine (Phila Pa 1976). 2016 Jun;41(12):994-8. • Devin CJ, McGirt MJ. Best evidence in multimodal pain management in spine surgery and means of assessing postoperative pain and functional outcomes. J Clin Neurosci. 2015;22(6):930-938.