In October 2017, the Department of Health and Human Services officially declared that the opioid crisis constituted a nationwide public health emergency1. The recent recognition of ubiquitous over-prescription of opioids from physicians and policy-makers concurs with this statement. Opioid monotherapy may be considered the standard of care at multiple healthcare institutions given its high magnitude analgesic qualities. However, as noted in the public health emergency declaration, opioid monotherapy is associated with several adverse effects, from respiratory depression to delirium, that may impede post-operative recovery. In response to this scenario, it is introduced that multi-modal pain regimens may affect post-operative pain control for patients, serving as an alternative solution.
Multi-modal pain regimens, also known as multi-modal analgesia, are comprised of two or more pain relief treatments administered simultaneously. The treatments may be pharmacologic agents, such as opioids, anticonvulsants, and benzodiazepines, or non-pharmacologic treatments such as applied heat or ice, massage, or electroanalgesia2. In a broad sense, the appropriate multi-modal pain regimen is decided by anesthesiologists, surgeons and other perioperative physicians. It may vary depending on the patient’s health history and the specific surgical operation’s outcomes. Furthermore, a multi-modal approach is endorsed by leaders in anesthesia and pain management. The American Pain Society published a set of guidelines for post-surgical pain management, including dedicated algorithms for a multi-modal approach3. The Society specifically determined that acetaminophen and/or non-steroidal anti-inflammatory drugs should be included as part of a multi-modal approach. This set of guidelines was further endorsed by the American Society for Regional Anesthesia, a professional society for clinicians and researchers. Multi-modal treatments will range in terms of the combinations of treatments, and effective algorithms continue to be studied.
Recently, research has suggested that a multi-modal analgesia approach delivered to women undergoing Cesarean section (C-section) has a significant effect on patient post-operative opioid use, as well as length of stay. Maternal and pregnant populations are oft understudied in academic medical research, particularly in cases of sensitive anesthesia and pain management services. To respond to this gap in the literature, researchers from the University of Illinois Hospital and Health Sciences System developed a multi-modal approach for C-section mothers4. In the intervention cohort, mothers were administered a combination of ketorolac, gabapentin, and/or acetaminophen medications depending on the patient’s pain designation score. A small subset of patients who reported significantly higher pain scores were treated with an opioid in combination with other drugs. The control was conventional care opioid prescriptions. In the study, the intervention cohort reported a greater than 50% decrease in number of opioid tablets prescribed at discharge. For reference, 89% of control patients were prescribed opioids at discharge, compared to 32.5% of intervention cohort patients. In addition, the intervention cohort reported a decrease in length of stay, which implies positive connotations towards the patient’s recovery. Long-term effects of the patients in this study will continue to be studied, yet the current results point to a promising future of non-opioid or minimized opioid multi-modal regimens for post-C-section patients.
Developing research-supported, modern regimens to treat patients remains a high priority for clinicians and scientists in anesthesia and pain management. Multi-modal analgesia represents a significant opportunity to improve post-operative acute care in sensitive populations, further contributing to clinical efficacy as well as public health.
1.U.S. Department of Health and Human Services. “HHS Acting Secretary Declares Public Health Emergency to Address National Opioid Crisis.” HHS.gov, US Department of Health and Human Services, 23 May 2018, www.hhs.gov/about/news/2017/10/26/hhs-acting-secretary-declares-public-health-emergency-address-national-opioid-crisis.html.
2. Helander, Erik M., et al. “Multi-modal Analgesia, Current Concepts, and Acute Pain Considerations.” Current Pain and Headache Reports, vol. 21, no. 1, 2017, doi:10.1007/s11916-017-0607-y.
3.Chou R, Gordon DB, de Leon-Casasola, et al. 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. J Pain. 2016;17:131-157.
4. Khudeira, Zahra. “Use of Multi-modal Analgesia in Women Post-Cesarean Section: From Innovation to Bedside.” ICHP: Journal of the Illinois Council of Health-System , vol. 44, no. 08, 2018.