Multimodal pain management: 4 questions with pain medicine expert Dr. Asokumar Buvanendran

In recent years, multimodal pain management has become a routine part of surgical care, as pain management specialists incorporate regional nerve blocks, oral medications and intraoperative methods to safely produce effective analgesia.

Asokumar Buvanendran, MD, professor of anesthesiology at Rush University Medical Center in Chicago and chair of the American Society of Anesthesiologists' committee on pain medicine, spoke with Becker's ASC Review about how a multimodal approach can improve pain management while also reducing risk of opioid dependence.

Question: How can multimodal pain management help to optimize pain relief, beyond other analgesia techniques?buvanendran1 (3)

Dr. Asokumar Buvanendran: The concept of multimodal analgesia, by definition, is the principle of utilizing different classes of drugs that act at different receptors in the pain pathway.

To explain it simplistically, in a kind of 'cartoon' fashion, if you need 10 milligrams of morphine, for example, instead of using those 10 milligrams you may be able to use drug A with 2 milligrams, drug B with 2 milligrams, drug C with 2 milligrams, drug D with 2 milligrams and thereby use only 2 milligrams of morphine, instead of the original 10 milligrams, to achieve the same pain control. In fact, there is sometimes better pain control, because you're attacking the pain pathway at different receptors and with different mechanisms, rather than only utilizing one drug.

Q: How can a multimodal pain management approach help to decrease opioid dependence?

AB: Traditionally, opioids have been utilized for pain management; but by utilizing different types of drugs, you can minimize the utilization of opioids for achieving a certain level of pain control.

The biggest factor is that you're decreasing the utilization of opioids, which will decrease a patient's opioid-related side effects. Cutting down on the number of pills prescribed would be of significant benefit to cutting down the opioid epidemic, too; I think it's critical that these patients be discharged home with a smaller quantity of opioids, because the secondary use of opioids is what led to the opioid crisis, the opioid epidemic, in our country.

There has to be a paradigm shift in the quantity of opioids being prescribed to patients being discharged home. There are recent publications that have shown that of the number of tablets prescribed to patients after their surgery, only about 10 percent of them are consumed — maybe 90 percent is left in the cabinets, which can be used by a secondary user.

Q: How can multimodal pain management benefit those in the outpatient setting?

AB: In the outpatient world, you not only want these patients to be discharged home the same day, but also to be comfortable in their situation, and the perioperative physicians in the ambulatory surgery center play a pivotal role in formulating an appropriate medical strategy to decrease the readmissions of the patients once they're at home.

You don't want this patient coming back to a hospital to be readmitted for pain and postoperative nausea and vomiting — these are the top two reasons patients come back to a healthcare facility after they have been discharged from a surgery center. There are measures that can be tailored, specifically, to prevent nausea and vomiting and to control the pain in the immediate postoperative period.

Q: How can a physician identify the best pain management technique for each patient?

AB: The perioperative physician who takes care of the patient is the best suited to determine the type of multimodal routine that is appropriate for pain management, by the mere fact that we understand the physiological changes that happen during surgery, along with the patient's stress response. As a perioperative physician, we are best suited to understand what, in the surgery, produces pain.

This physician should also partake in the discharge of the patient, in a multimodal fashion. We can appropriately not only utilize traditional nerve blocks, or regional analgesic techniques, to prevent some of the pain conduction pathways prior to surgery — but we can also take care of the stress response that happens during the surgery by administering perioperative drugs, which can reduce the need for postoperative opioid prescription at discharge.

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