Patients With Pain Benefit From a Multimodal Approach

There is no question that the American health care system must take a radically different approach to pain management. Opioids are potent pain relievers, but their misuse has led to an epidemic of abuse and addiction that must be curbed.

At Arctic Spine, a boutique surgical practice, we have developed a multimodal approach to pain management that includes judicious use of opioids as 1 prong in a multifactorial approach to prevention and control of postsurgical pain. In doing so, we have drastically reduced opioid consumption and optimized pain control.

DANGERS OF OPIOID MISUSE

More than 115 individuals in the United States die from opioid overdoses every day, according to the National Institutes of Health.^1,2 Data from 2015 suggest that 2 million people in the United States suffered from substance use disorders related to prescription opioids.^2,3 The CDC estimates that the total economic burden of prescription opioid misuse alone costs $78.5 billion annually in the United States.^2,3

Despite increasing awareness of the opioid epidemic, there is good evidence that these drugs continue to be overprescribed. Prescribing of opioids in the United States peaked and leveled off from 2010 to 2012, but there were 58 prescriptions for opioids filled for every 100 Americans in 2017.⁴

As the media continue to highlight the impact of the opioid crisis, it is important not to lose sight of the fact that pain requires treatment. However, some physicians have become so fearful of inadvertently overprescribing opioid medications that they undertreat pain or refuse to prescribe any opioid medications. This can leave pain untreated, potentially leading to peripheral and central sensitization of pain pathways, as well as mental trauma and post-traumatic stress disorder (PTSD). All these can result in chronic pain and other medical conditions that place patients at increased risk for addiction disorders. Patients with undertreated physical and psychic pain may look to illegal and more dangerous sources of opioids, which is another gateway to addiction.

THE MULTIMODAL DIFFERENCE

In large part, misuse of opioids in the medical profession has been driven by a “one-size-fits-all” model that fails to consider each patient’s comorbidities, medical history, pain relief needs, personality, and previous exposure to narcotics.

Taking a multimodal approach to pain management recognizes the complex psychology and physiology that underlies experiencing pain. Anxiety, fear, uncertainty, and previous injuries and traumas can all contribute to the experience of physical pain. Our multimodal approach considers all these contributors by focusing on 4 key components of pain management and prevention that can also be used by pharmacists:

• Develop strong relationships with patients. We complete a physical examination and take a full medical history with every patient. But then we take it a step further to learn more about their physical and psychological histories. We get to know patients, what their needs are, and how they reward themselves in their everyday lives. We pay close attention to past injuries and traumas, as conditions such as PTSD are known to modulate the experience of pain. A unique aspect of our protocol is that our anesthesiologist meets with every patient at least once before their surgery to discuss approaches to pain management and other issues.
• Take advantage of all opportunities to de-escalate opioid use. This involves determining how pain is affecting each patient’s life. Surveys are used to provide information on how patients interact with family and friends, as well as how they are managing at work and with daily activities. This helps identify sources of pain to work toward addressing root causes, including the management of other conditions and diseases that might be causing or contributing to the pain.
• Target multiple pain receptors at once. Instead of focusing on the opioid receptors as the primary target for pain control, hitting multiple receptors at once before, during, and after surgery minimizes the need for opiate use while still allowing for appropriate and safe use of opioids, as needed. Nonopioid pain management options that pharmacists can discuss with patients include:

• Acetaminophen, which inhibits central cyclooxygenase (COX) transcription
• Alpha-2 adrenergic receptor agonists, such as clonidine and dexmedetomidine, which have hypnotic sedative effects and can be used for pain reeducation
• Anticonvulsants, such as gabapentin and pregabalin, which inhibit neuronal excitability by blocking the alpha- 2 delta subunit of presynaptic, voltage-dependent calcium channels, thus inhibiting central sensitization pathways
• Corticosteroids, such as dexamethasone, that suppress inflam- mation associated with tissue injury, preventing peripheral and central sensitization
• COX-1 (eg, ketorolac) and COX-2 (eg, celecoxib) inhibitors that suppress peripheral and spinal inflammation and can have a similar effect as an opioid without the addictive highs
• Prehydration with carbohydrate loading, such as presurgical Gatorade, which reduces the risks of anxiety, nausea, and vomiting

• Use opioids judiciously. Opioids are effective pain relievers and, as such, can be useful for pain control when used appropriately. When used on a case-by-case basis, we have had good success with methadone, which not only targets the mu opioid receptors, which are crucial to pain control, but also acts as an NMDA receptor agonist and an inhibitor of norepinephrine and serotonin in the brain, which can have a mood-elevating effect. Some of our patients also receive 5 to 10 mg of oxycodone every 4 to 6 hours during thepostoperative period.

WHAT SUCCESS LOOKS LIKE

At Arctic Spine, the definition of success is that patients are able to rapidly return to the same activities they enjoyed before their surgery, without pain. It means that they do not need to return to us or any health care services for pain management. It means achieving these goals with minimal or no use of opioids. We are decreasing the doses of opioids used, as well as the length of time they are prescribed.

With the introduction of methadone into our protocol, we no longer give opioids intraoperatively, resulting in a 50% reduction in postoperative opioid consumption. The overall opioid consumption rate among our patients has dropped by one-third. Despite this minimal use of opioids for pain relief, we have not had a single patient require a hospital admission for pain control.

HOW WE DO IT

We get to know patients well and provide an individualized approach to their care, because we are a small, nimble surgery center. This allows us the freedom to spend time with each patient and customize a pain management plan in less than 24 hours. Our focus on building relationships with patients is a critical and fundamental component of our approach.

Various aspects of our approach have to be modified to accommodate different practices, but one thing is clear: The continuing focus on a high volume of patients at the expense of optimal pain management will only serve to fuel the opioid crisis. We are well past the point at which we need to seriously consider alternatives.

James Price, MD, is an anesthesiologist and perioperative pain specialist at Arctic Spine in Anchorage, Alaska.

REFERENCES

• Opioid overdose: understanding the epidemic. CDC website. cdc.gov/drugoverdose/ epidemic/index.html. Updated December 19, 2018. Accessed August 1, 2019.
• National Institutes of Health. Opioid overdose crisis. National Institute on Drug Abuse website. drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis#two. Up- dated January 2019. Accessed August 1, 2019.
• Schuchat A, Houry D, Guy GP Jr. New data on opioid use and prescribing in the United States. JAMA. 2017;318(5):425-426. doi: 10.1001/jama.2017.8913.
• Prescription opioid data. CDC website. cdc.gov/drugoverdose/data/prescribing.html. Updated December 2019. Accessed August 1, 2019.