New guidelines list 32 steps for treating post-op pain

Accreditation Insider, March 1, 2016

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This February, a list of 32 recommendations for post-operative (post-op) pain treatment was released, co-authored, and approved by the American Pain Society (APS), the American Society of Anesthesiologists, and the American Society of Regional Anesthesia and Pain Management. The guidelines are evidence-based, multimodal methods of helping the large number post-op patients who don’t receiving sufficient pain care.

In an interview with Medscape Medical News, lead author Roger Chou, MD, said that multimodal strategies help achieve better pain relief while using lower doses of opioids and potentially fewer adverse effects, by affecting pain via different mechanisms of actions and pathways.

"The same strategy is not going to be ideal in all patients,” he said. “For example, in patients who are already on long-term opioid therapy prior to surgery, managing their pain is not going to be the same as someone not on opioids."

Opioids lose their potency with continued use, meaning that patients with a high opioid tolerance are at a greater risk of acute pain after surgery. Another study released this February by the American Academy of Pain Medicine proved that a multimodal, non-opioid approach to pain care can lower readmission rates, lengths of stay, and opioid dosage.

 “Clinicians need to know what they can offer patients other than opioids to treat pain and suffering, especially when the patients arrive on high-dose opioids already,” said lead author David Edwards, MD, PhD, in a press release.

Edwards’ team developed a system called the Targeted Care Pathway treatment protocol, a process involving early patient identification, pharmacist-enhanced services, patient and professional education, early pain specialist consultation, opioid-sparing multimodal therapies, primary care collaboration, and patient engagement.

Using Pathway, hospitals saw their 60-day readmission rate for post-op patients drop from 40% to 28%. Nor were there any adverse events or change in patient satisfaction on the non-opioid system.
"The day has come and gone where solely using opioids to manage pain in noncancer patients is considered appropriate care," Edwards writes.

He said that for many surgical and nonsurgical patients, opioids are still the best and most potent method pain treatment. However, their evidence indicates that the rise of opioid use, particularly when used in isolation, doesn’t correspond to better pain control or patient satisfaction. Instead, it contributes to poor patient outcomes and a societal burden when patients are eventually discharged on higher-than-ever doses.

“Society suffers when patients suffer,” he said. “The cost of risk-managing prolonged opioid therapy for an ever-increasing pool of patients on opioids overextends the medical system.”

The three strongest recommendations for treating post-operative care from Chou’s study was to:

•    Use acetaminophen and/or NSAIDs as part of multimodal analgesia for management of postoperative pain in adults and children without contraindications

•    Consider surgical site–specific peripheral regional anesthetic techniques in adults and children for procedures with evidence indicating efficacy

•    Offer neuraxial analgesia for major thoracic and abdominal procedures, particularly in patients at risk for cardiac complications or prolonged ileus

Other recommendations include:

•    Administering oral over intravenous (IV) opioids in patients who can use the oral route

•    Avoiding the intramuscular route for administration of analgesic

•    Choosing IV patient-controlled analgesia (PCA) when the parenteral route is needed

•    Not using routine basal infusion of opioids with IV PCA in opioid-naive adults

•    Considering a preoperative dose of oral celecoxib in adults without contraindications

•    Considering gabapentin or pregabalin as a component of multimodal analgesia

•    Using topical local analgesics in combination with nerve blocks before circumcision

•    Avoiding intrapleural analgesia with local anesthetics for pain control after thoracic surgery

•    Using continuous, local anesthetic-based peripheral regional analgesic techniques when the need for analgesia is likely to exceed the duration of effect of a single injection

•    Avoiding the neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, and ketamine

Read all 32 recommendations on treating post-op patients here.

And click here to read more about the effects of non-opioid pain care.

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