Let’s flip the script for a second and look at opioid abuse from the perspective of the patient; more specifically, a patient who has just undergone some sort of operation. First and foremost, that patient is in pain. What will the doctors and nurses administer to numb the pain? Opioids, most likely. What will the doctor prescribe to make sure the patient can adequately manage his pain at home? Opioids, most likely. What will that patient increasingly rely on to get them through the day as pain-free as possible? Opioids, most likely.
Moral of the story: more often than not, patients don’t know any better. All they know is that the opioids make them feel better, and they completely trust their health care professional to give them the adequate means to manage their postoperative pain. To make matters worse, regardless of the degree of opioids being administered to a patient, a recent study showed that “most patients who undergo surgical procedures experience acute postoperative pain, but evidence suggests that less than half report adequate postoperative pain relief” (Chou et al. 2016).
It’s safe to say that clinicians are under a tremendous amount of pressure to both steer patients away from opioid usage as well as provide superior methods of pain relief. To guide this effort in a definitive, sustainable direction, the American Pain Society put together an interdisciplinary expert panel to develop a guideline to support evidence-based, efficient, and safer postoperative pain management.
“The recommendations are based on the underlying premise that optimal management begins in the preoperative period with an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved. The panel found that evidence supports the use of multimodal regimens in many situations, although the exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure” (Chou et al. 2016).
Because these recommendations cover the preoperative, intraoperative and postoperative interventions and management strategies, we know some of these might not apply to you and your role in your patient’s pain relief. However, we recommend you review the full report to get a better idea of the current initiatives in the healthcare industry. How can you support and apply them in your practice?
The following information is featured in The Journal of Pain, the official journal of the American Pain Society. To view a detailed review of the guideline, the details and key indicators for each recommendation and the supporting evidence, read the full report.
Preoperative Education and Perioperative Pain Management Planning Recommendations
- Provide patient and family-centered, individually tailored education to the patient (and/or responsible caregiver), including information on treatment options for management of postoperative pain, and document the plan and goals for postoperative pain management.
- Give the parents (or other adult caregivers) of children who undergo surgery instruction in developmentally-appropriate methods for assessing pain as well as counseling on appropriate administration of analgesics and modalities.
- Conduct a preoperative evaluation including assessment of medical and psychiatric comorbidities, concomitant medications, history of chronic pain, substance abuse, and previous postoperative treatment regimens and responses, to guide the perioperative pain management plan.
- Adjust the pain management plan on the basis of adequacy of pain relief and presence of adverse events.
Methods of Assessment Recommendation
- Use a validated pain assessment tool to track responses to postoperative pain treatments and adjust treatment plans accordingly.
Multimodal Therapies Recommendation
- Offer multimodal analgesia, or the use of a variety of analgesic medications and techniques combined with nonpharmacological interventions, for the treatment of postoperative pain in children and adults.
Physical Modalities Recommendations
- Consider transcutaneous electrical nerve stimulation (TENS) as an adjunct to other postoperative pain treatments.
- The panel can neither recommend nor discourage acupuncture, massage, or cold therapy as adjuncts to other postoperative pain treatments.
Cognitive–Behavioral Modalities Recommendations
- Consider the use of cognitive–behavioral modalities in adults as part of a multimodal approach.
Systemic Pharmacological Therapies Recommendations
- Oral over intravenous (i.v.) administration of opioids are recommended for postoperative analgesia in patients who can use the oral route.
- Avoid using the intramuscular route for the administration of analgesics for management of postoperative pain.
- I.v. patient-controlled analgesia (PCA) is recommended for postoperative systemic analgesia when the parenteral route is needed.
- Avoid routine basal infusion of opioids with i.v. PCA in opioid-naive adults.
- Provide appropriate monitoring of sedation, respiratory status, and other adverse events in patients who receive systemic opioids for postoperative analgesia.
- Provide adults and children with acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) as part of multimodal analgesia for management of postoperative pain in patients without contraindications.
- Consider giving a preoperative dose of oral celecoxib in adult patients without contraindications.
- Consider use of gabapentin or pregabalin as a component of multimodal analgesia.
- Consider i.v. ketamine as a component of multimodal analgesia in adults.
- Consider i.v. lidocaine infusions in adults who undergo open and laparoscopic abdominal surgery who do not have contraindications.
Local and/or Topical Pharmacological Therapies Recommendations
- Consider surgical site–specific local anesthetic infiltration for surgical procedures with evidence indicating efficacy.
- Use topical local anesthetics in combination with nerve blocks before circumcision.
- The panel does not recommend intrapleural analgesia with local anesthetics for pain control after thoracic surgery.
Peripheral Regional Anesthesia Recommendations
- Consider surgical site–specific peripheral regional anesthetic techniques in adults and children for procedures with evidence indicating efficacy.
- Use 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.
- Consider the addition of clonidine as an adjuvant for prolongation of analgesia with a single-injection peripheral neural blockade.
Neuraxial Therapies Recommendations
- Offer neuraxial analgesia for major thoracic and abdominal procedures, particularly in patients at risk for cardiac complications, pulmonary complications, or prolonged ileus.
- Avoid the neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, and ketamine in the treatment of postoperative pain.
- Provide appropriate monitoring of patients who have received neuraxial interventions for perioperative analgesia.
Organizational Structure, Policies, and Procedures Recommendations
- The panel recommends that facilities in which surgery is performed have an organizational structure in place to develop and refine policies and processes for safe and effective delivery of postoperative pain control.
- The panel recommends that facilities in which surgery is performed provide clinicians with access to consultation with a pain specialist for patients with inadequately controlled postoperative pain or at high risk of inadequately controlled postoperative pain (eg, opioid-tolerant, history of substance abuse).
- The panel recommends that facilities in which neuraxial analgesia and continuous peripheral blocks are performed have policies and procedures to support their safe delivery and trained individuals to manage these procedures.
Transitioning to Outpatient Care Recommendation
- Provide education to all patients (adult and children) and primary caregivers on the pain treatment plan including tapering of analgesics after hospital discharge.
Chou et al. 2016. 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. The Journal of Pain, Volume 17 , Issue 2 , 131 – 157