Ellen M. Soffin, MD, PhD: I am Dr Ellen Soffin, an anesthesiologist and associate director of research for the Department of Anesthesiology at Hospital for Special Surgery (HSS) in New York City.
James D. Beckman, MD: Hi. I am Dr Jim Beckman, an anesthesiologist and the clinical director of the Department of Anesthesiology at HSS.
Dr Soffin: We practice in a unique setting, in that HSS is entirely devoted to the care of patients with musculoskeletal disorders. We specialize in regional anesthesiology and acute pain medicine as they are applied to patients undergoing orthopedic surgery.
In an accompanying segment, we discussed modern multimodal analgesia and how incorporating it into clinical practice can enhance pain control and improve outcomes. Here, we are going to discuss a case that highlights several key points from that discussion. It also illustrates how to apply multimodal concepts in a practical way. I would like to ask Dr Beckman to present our patient.
A Case Study of Opiate Tolerance
Dr Beckman: Our hypothetical patient is a 52-year-old woman presenting for an elective anterior/posterior spine fusion. The anterior is what we call an ALIF—anterior lumbar interbody fusion—that will require a lower abdominal incision. Her symptoms have begun to interfere with her activities of daily living, enjoyment of life, and sleep, which is a real problem. She has pain on most days, which she rates as moderate to severe. Her pain is in her low back and radiates to both legs.
She has tried, and failed, appropriate conservative therapy, including epidural steroid injections and physical therapy. She takes a nonsteroidal anti-inflammatory drug (NSAID). However, recently, given her progressive symptoms over the past 6 months, her primary care physician has prescribed a combination oxycodone/acetaminophen tablet, of which she takes about two tablets on the order of three to four times daily. She also has well-controlled hypertension and hyperlipidemia, and constipation [that is] most likely the result of the opiate medications.
We are seeing her in the presurgical screening location, which has been requested by her surgeon prior to anesthesia, secondary to her opiate consumption.
Dr Soffin: Is the referral for the opioid use significant here?
Dr Beckman: It is significant. The US Food and Drug Administration defines "opiate tolerance" as the equivalent of 60 mg of oral morphine consumed daily for a week. Her consumption is a good bit in excess of that and has been going on for months. We see opiate tolerance not infrequently at HSS, because we are an orthopedic hospital surgery and [opiates are] often indicated to address a painful condition.
Dr Soffin: So tolerance can develop rapidly. What problems does tolerance present in the management of this patient's perioperative pain?
Dr Beckman: Well, a few. First of all, opiate tolerance leads to decreased analgesic effect over time, and that often requires escalation of dose to achieve the same amount of pain control. Connected to this is the concept of opiate-induced hyperalgesia (OIH). OIH is a heightened nociceptive responsive—or paradoxically, because these patients are on narcotics, they seem to sense things with greater pain than someone not taking narcotics. This could really present a challenge for dealing with surgical and postoperative pain management.
Effective Opioid Tapering Before Surgery
Dr Soffin: This is probably where multimodal analgesia can play an important role throughout the perioperative phase. We have several opportunities to exploit multimodal analgesia in this case.
First—and perhaps most important—we have time, because this is an elective procedure. Recent data suggest that careful opioid weaning before surgery can help to minimize the opioid tolerance and OIH. I would start out by recommending an opioid taper for this patient.
Dr Beckman: How can we safely do that, because one might be concerned about opioid withdrawal or exacerbating her pain?
Dr Soffin: Those are the two main concerns with starting an opioid taper. The safest way to do this is in a supervised and controlled fashion, with very explicit instructions for the patient. The goals should be modest. Reductions of even 20% of baseline are associated with improved analgesic outcomes after surgery.
Dr Beckman: Is there anything else you would change leading up to surgery? If we reduce her opiate consumption, how can we control her pain? It seems to be getting worse and is the reason why she is coming to HSS.
Dr Soffin: That is a good question. First, we should see whether her laboratory values are within normal limits, and in particular her liver function tests and renal function tests, given that she has been taking acetaminophen and an NSAID for some time. If that's the case, we can maximize the analgesic benefit of the acetaminophen that she already takes as part of her combination opioid therapy.
One strategy could be to switch her opioid prescription to oxycodone and increase the dose of acetaminophen. Now when we do this, patient selection becomes key, because some of these changes may be too complicated for some patients. It also means that the patient may have to take more tablets over the course of a day. Some may be unwilling or unable to achieve this.
Dr Beckman: She is also taking a NSAID, and unfortunately, this will be need to be held for about 2 weeks in advance of surgery. She seems like a good candidate for a short course of a gabapentinoid, either gabapentin or pregabalin; both have a pretty good evidence base to support their use for analgesia and opiate-sparing capacity in the setting of spine surgery.
Dr Soffin: I agree. I would start gabapentin, wean the opioid as tolerated, maximize her acetaminophen use, and hold the NSAID in the 7-14 days leading up to her surgery.
Day of Surgery
Dr Beckman: That is a reasonable analgesic plan based on the principles of multimodal analgesia.
Now, if we move ahead to the day of surgery, let us suppose our patient is in the holding area, and she did well with our preoperative plan, but did not take any of her analgesics on the day of surgery because she is concerned or confused about her nil by mouth (NPO) status on the day of surgery. What would you advise in this circumstance?
Dr Soffin: This is something that we see fairly commonly. It is easy for patients to become confused about what to take and what to hold. In her case, it is vital that she takes all three of the preoperative analgesics that we have recommended for her: the opioid, the acetaminophen, and the gabapentin. This will help preserve the plasma levels of all three of those agents, help avoid withdrawal, and help facilitate her ongoing analgesia.
Dr Beckman: So far, we have only been using oral agents. As we are moving from the preoperative to the intraoperative phase, we should have the opportunity to add some additional modalities.
Dr Soffin: Yes. There are a few intravenous (IV) infusions that function very well as part of the balanced anesthetic technique and that also have good evidence for postoperative analgesia. We described a few of these in our accompanying segment, but in brief, this patient is a good candidate for both ketamine and lidocaine infusions during the surgery. Both are associated with postoperative improvements in pain scores, lower opioid consumption, and minimization of opioid-induced side effects after major orthopedic surgery is performed under general anesthesia.[3,4]
We should also provide her with some long-acting agents. I would consider either a methadone or a hydromorphone to get her through the surgery and set her up for good pain control when she wakes up after emergence from anesthesia. Depending on the timing, we could also redose her Tylenol® intravenously, and steroids have also been shown to be analgesic.
Dr Beckman: Because multimodal analgesia really advocates for the use of regional anesthesia and analgesia, one would want to consider the anatomy of this particular procedure.
Although we are operating on her spine, the anterior approach will require a lower abdominal incision. I think a transversus abdominis plane (TAP) block would be very useful here. That is a block where under ultrasound guidance, we insert a needle and inject local anesthetics covering the innervation of the anterior abdominal wall, which gets us coverage from about the levels of T6 to L1.
Dr Soffin: Will the TAP block provide complete analgesia?
Dr Beckman: Probably not. The TAP block will help with the abdominal wall pain, which can be significant, and it will really chip away at her discomfort as part of a comprehensive, multimodal approach. However, there will be other postsurgical pain that will require adjuncts, such as systemic medications. We can also add such things as dexamethasone to the TAP block to help it last for a longer period, often days.
Postoperative Pain Management
Dr Soffin: This brings us to the recovery phase. Of course, early in the postoperative period, the patient will be nil by mouth. How can we continue our multimodal plan of care?
Dr Beckman: It is important to stress that opiates, when used judiciously and appropriately, are an essential ingredient of multimodal analgesia, and their early postop[erative] role is essential. This patient will have some pain and may well benefit from IV opioids.
I would probably use an IV patient-controlled analgesia with hydromorphone, but also one can push up their oral consumption of medications. There is no reason they have to be absolutely NPO. The goal for her opiate therapy will be, as quickly as possible, to get her back onto what she was on preoperatively.
Dr Soffin: And I guess in the meantime, the TAP block will be effective and we can maximize all the other nonopioid pharmacologic options that we have discussed. There may be effective nonpharmacologic components as well, including heat or cryotherapy.
Dr Beckman: Absolutely. The final thought I have about this case relates to systems management and ensuring that this patient receives multimodal analgesia. We use these pathways as part of an enhanced recovery after surgery (ERAS) system at HSS to promote multimodal analgesia in our patients. Do you think that matters?
Dr Soffin: I do, and I think these concepts are highly complementary. ERAS guidelines advocate effective pain control and minimizing opioid reliance. Multimodal analgesia is an approach to pain control that allows us to achieve the same goals. When multimodal analgesia is formalized into a pathway of care, ERAS then becomes a mechanism to help ensure that patients receive the best quality of care available based on the best available evidence.
Dr Beckman: This case demonstrates the rather significant change in our overall paradigm for how we manage anesthesia and analgesia in these patients. We know that multimodal analgesia is well-supported in its beneficial outcomes, is integral to ERAS, and is not just limited to medications, but the accessibility of ultrasound has really significantly increased some of the procedures we can use to make people comfortable using regional anesthesia.
Thanks for joining us.
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Cite this: Pain Paradigm Shift: New Multimodal Analgesia Strategies Use Latest Data to Enhance Care - Medscape - Dec 05, 2017.