Mitigating the Opioid Crisis for Wound Care Providers Using Opioid Stewardship

Robert George Smith, DPM, MSc, RPh


Wounds. 2020;32(6):146-151. 

In This Article

M: Multimodal Analgesic Strategies

"M" stands for multimodal analgesic strategies. A multimodal analgesic approach is likely to produce superior analgesia over the use of an opioid-based approach because multimodal analgesic agents target a variety of pain pathways.[5–7] Published clinical-based evidence has described the effects of employing local anesthetic products to mitigate postoperative pain and reduce the need for opioid analgesics. Kohring and Orgain[11] declared that local anesthesia techniques provide excellent pain relief without adverse events. Multimodal analgesia for pain management is now widely applied to reduce opioids and opioid-related side effects.

The foundation of a wound care clinician belief system is that wound healing occurs in distinct and overlapping phases, which include hemostasis, inflammation, proliferation, and maturation. Wang et al[12] examined the contribution of mu-opioid receptors in mediating the healing of full-thickness ischemic wounds using mu-opioid, delta-opioid, and kappa-opioid receptor knockout mice. Endorphins and analgesic opioids, including morphine, have been demonstrated to stimulate endothelial proliferation, survival, and angiogenesis in wounds and tumors via mu-opioid receptors mediating phospho-mitogen-activated protein kinase/extracellular signal-regulated kinase signaling.[13–16] Wang et al[12] found the expression of mu-opioid receptors is significantly higher in wounds compared with intact skin and co-localized with vasculature and the epidermal layer. Keratinocytes play a critical role in skin homeostasis and epithelialization phases via delta-opioid receptors.[12] Their conclusions suggest that opioids offer a unique advantage in treating wounds because of their ability to concurrently stimulate revascularization and reduce neuroinflammation.[12]

The analgesic ladder proposed by the World Health Organization[17] (WHO) is a useful reference in applying and accentuating an opioid stewardship approach when treating acute and chronic pain, starting with non-steroidal anti-inflammatory agents and ending with opioid medication. The use of a non-opioid analgesic with or without an analgesic adjunctive agent is the first step or rung in the WHO ladder.[1,17] Many non-opioid multimodal agents are inexpensive and benefit patients by resulting in a lower consumption of opioids. Examples of drugs with differing mechanisms of actions that target pain pathways in additive and/or synergistic effects include acetaminophen, alpha-2 agonists, dexamethasone, duloxetine, gabapentinoids, N-methyl-D-aspartate receptor antagonist, non-steroidal anti-inflammatory agents, selective cyclooxygenase inhibitors, and topically applied medications.[11,18–21]

Topical pain relief medication can be prescription-based, over-the-counter, or homemade. Topical pain relievers should always be tested on a small area of the skin since some can cause irritation.[21] Transdermal and topical routes of opioid administration also are associated with a lower risk of addiction compared with oral and parenteral routes of opioid analgesics administration.[22] Pain resulting from certain conditions such as osteoarthritis, peripheral neuropathy, and fibromyalgia can be reduced with capsaicin,[21] which is available in both cream and gel forms. Capsaicin is prepared from chili peppers and delivers a hot sensation to the region where applied. After exposure to capsaicin, nociceptors in the skin become less sensitive to different stimuli; therefore, the late action of capsaicin is depicted as anesthesia.[22] Lidocaine is a local anesthetic cream that causes temporary numbness, thereby minimizing pain in the treated area.[21] A secondary mechanism of lidocaine is associated with an inhibition of the release of nociception process mediators by keratinocytes.[22] Topical lidocaine is generally used for arthritis and other musculoskeletal conditions. Trolamine salicylate cream is often recommended for arthritis pain.[21] Trolamine salicylate is chemically similar to aspirin and provides a slight anti-inflammatory effect. Ingredients such as menthol, wintergreen, and eucalyptus in counterirritant topical agents create a hot or cold feeling.[21] Counterirritant topical agents are often used for treating sore muscles; they can typically be used with other forms of pain relief. Lidocaine and capsaicin in patches, capsaicin in cream, EMLA cream (Astra Pharmaceutical Production), and creams containing antidepressants (eg, doxepin, amitriptyline) act mainly locally in tissues through receptors and/or ion channels.[22] Non-steroidal anti-inflammatory drugs (NSAIDs) performing the basic action of blocking prostaglandin formation are an important component in the treatment of this type of pain.[22] Topically administered NSAIDs are normally used for a period of 1 to 2 weeks and are effective in the following types of pain: musculoskeletal, mainly suffered after injuries; soft tissue pain; and rheumatic diseases.[22]

Shanmugam et al,[23] building on previously published literature, emphasized the importance of using an opioid stewardship approach when treating chronic wounds and thereby adding to the body of knowledge, which proposes that the use of opioids may attenuate the healing of chronic wounds. These investigators have suggested that opioid use may negatively impact wound healing by reducing immune activation, impacting tissue oxygenation and angiogenesis,[24,25] and altering myofibroblast recruitment as well as impacting keratinocyte cytokine production and endothelial proliferation.[25,26] The investigation by Shanmugam et al[23] used data collected through the Wound Etiology and Healing (WE-HEAL) study to investigate the relationship between patient-reported pain, opioid exposure, and wound outcome in the clinical care of a longitudinal cohort of patients with chronic wounds. Three major conclusions presented at the end of their investigation[23] are summarized as follows: (1) patients who never received opioids in the WE-HEAL study healed faster than those who received opioids; (2) opioid exposure was a strong predictor of wound size; and (3) patients who received opioids at doses above 10 mg per day had slower rates of healing than those with no exposure or dosages less than 10 mg per day.