Multimodal Analgesia: Ways to Take Away the Pain
Submitted by Kimberly Heister
Every year more than 90 million surgeries take place in the United States (Massaro, 2012). Of these 90 million surgeries, approximately 80% of the patients report moderate to severe pain within the first two weeks post operatively (Massaro, 2012). “It is said that the fear of pain is ranked second only after the fear of death” ("Contemporary postoperative analgesia," 2011, p. 11). Pain is defined by the Taxonomy Committee of International Association for the Study of Pain (IASP) as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (Chaturvedi & Chaturvedi, 2007, p. 204). Pain is a subjective feeling and is whatever the sufferer perceives, and is therefore, one of the main causes of unplanned hospital stays or increased hospital stays. Since pain effects patient outcomes ways to reduce it are essential. One method used to combat this pain is multimodal analgesia. Multimodal analgesia is the use of multiple medications and multiple techniques and refers to the combination of any two or more modalities that work at different pathways to control pain and decrease adverse effects (Polomano, Rathmell, Krenzischek, & Dunwoody, 2008). This can include using an opioid, also called narcotics, or non-opioid with a different technique or using an opioid and non-opioid together using the same or different route or a combination of any of these. Research has shown reducing narcotic use in the surgical patient reduces potential negative side effects that increase the patient’s mortality and morbidity rate (Savoia, Gravino, Loreto, & Erman, 2005). Multimodal analgesia not only reduces the negative side effects but it also controls the patient’s pain. When pain management is increased, the patient will participate more willingly in their rehabilitation and be more compliant in their treatment. Due to the patient’s compliance with rehabilitation, movement, deep breathing, etc., they begin to heal quicker because the body no longer has to try to heal from multiple and painful complications of surgery. Given these reasons, research shows that the administration of multimodal analgesia prior to, during and after surgery is beneficial to the patient by reducing narcotic use, increasing pain management and thereby allowing the patient to begin healing.
Multimodal analgesia reduces narcotic use in the surgery patient. Doctors and nurses achieve this in numerous ways using different medications and different techniques. Research has proven through randomized placebo-controlled trials that the use of non-selective and selective non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, ketorolac, or naproxen, cox-2 inhibitors such as celecoxib, rofecoxib, or valdecoxib and acetaminophen along with opioids such as fentanyl, hydromorphone, meperidine, morphine, sufentanil, hydrocodone or oxycodone have an opioid-sparing effect (Maund et al., 2011). In another study of these same medications the use of morphine decreased by 15% to 55% (Polomano et al., 2008). Simply put these non-opioid medications decrease the amount of narcotic needed to reduce the patient’s pain. These medications also decrease the side effects often seen with an increased use of opioids such as respiratory depression, weakness, nausea and vomiting, etc.
Another way to reduce narcotic use is through pre-emptive medication such as gabapentin or pregabalin (Polomano et al., 2008). These medications work on the premise of blocking the pain signals prior to an incision and therefore the site of tissue damage will not be sensitized (Polomano et al., 2008). If the tissue is not sensitized the pain felt post-surgery will be decreased therefore decreasing the amount of opioid needed. Although patients are to be NPO starting at midnight the night before the surgery, these medications are safe to take the morning of the surgery.
Multimodal analgesia is comprised of many techniques as well. Infiltration of the surgical area with local anesthetics has been shown to have an opioid sparing effect as well (Pasero & McCaffery, 2007). Research in patients undergoing soft-tissue surgery that were treated with infiltration showed they did not ask for an opioid until approximately 14 hours post-surgery (Massaro, 2012). This technique decreased inflammation in the surgical area therefore decreasing the amount of opioid needed for adequate pain management (Pasero & McCaffery, 2007).
In addition to decreasing narcotic use, multimodal analgesia also increases pain management in the surgical patient. As previously stated medications such as NSAIDs, cox-2 inhibitors and acetaminophen decrease the use of opioids (Maund et al., 2011). This is due to blocking nociceptors (also called pain receptors) from releasing substances that carry pain signals that sensitize the damaged tissue ("Contemporary postoperative analgesia," 2011). As one can see, the effect of one, increasing pain management, has a direct effect on the other, decreasing narcotic use. Another non-opioid medication that has shown to increase pain management is liposomal bupivacaine, which is an infiltration medication. After a single dose patients were found to have pain relief up to 72 hours post-surgery (Massaro, 2012). Now that it has been shown how multiple uses of non-opioid medications can interrupt pain along its pathway, look at how multiple techniques can help.
Regional anesthesia is one technique for increasing pain management in the surgical patient. Regional anesthesia encompasses nerve blocks and epidurals. Nerve blocks are beneficial in the orthopedic surgical patient by blocking pain pathways and reducing the inflammatory response thereby increasing pain management (Pasero & McCaffery, 2007). Nerve blocks provide localized pain management and decrease the need for medications that work at the systemic level (Polomano et al., 2008). Not only can nerve blocks be a one-time dose but can also be administered as a continuous dose. In this manner, they constantly bathe specific nerve bundles to allow for pain management over a longer period of time. Whether a nerve block medication is given as a one-time dose or a continuous dose both methods can be performed prior to or after surgery. Numerous blockade combinations are synergistic in blocking pain and increasing pain management (Argoff, Albrecht, Irving, & Rice, 2009). This synergy results in complementary therapy, where one will generally increase the effectiveness of the other. Another regional anesthetic to consider is the epidural. An epidural consists of placing a catheter outside the spinal dura and injecting medications to achieve numbness. It is most often used to anesthetize the lower half of the body at and below the navel. A thoracic epidural is also used which will provide numbness to a ring around the chest, generally starting below the nipples and extending to the navel. The use of the epidural does not come without its own set of concerns and possible complications, such as infection and sensory and movement loss higher than anticipated. With this said, research has shown that extended-release epidural morphine (EREM) can provide up to 48 hours of pain management (Polomano et al., 2008). This reduces the need for an indwelling catheter in the patient’s back, reducing the incidence of infection and higher than anticipated loss of sensation and movement.
Increasing pain management in the surgical patient has many benefits but perhaps none as important as healing. Research has shown that multimodal analgesia allows the surgical patient to begin healing faster. Since multimodal analgesia allows for decreased narcotic use lending to decreased side effects such as postoperative ileus (POI), this allows an earlier introduction of a balanced diet, which the body needs to begin healing (Maxson, Lovely, Wrobleski, & Isaacson, 2011). POI is of greatest concern for patients undergoing colorectal surgery, but can be a concern for any postoperative patient taking increased doses of opioids for pain management (Maxson et al., 2011). POI is the decrease or absence of movement in the bowel. The patient’s ability to begin taking oral sustenance is dependent upon the return of bowel sounds, the passing of gas and eventually the passing of fecal material. Unfortunately, opioids slow down this process and therefore delay the introduction of food. With the decrease in the use of opioids due to multimodal analgesia, the body’s normal digestive process can resume quicker and thus the patient can begin eating sooner. Another obstacle that may decrease the patient’s desire to eat is post-operative nausea and vomiting, which is one of the most common side effects of opioids. Being able to decrease the use of opioids decreases nausea and vomiting in the patient allowing them to be able to begin eating a balanced diet. Eating a balanced diet will increase the patient’s strength and prepare them for getting up and being mobile.
The increased energy and decreased pain due to multimodal analgesia allows the patient to begin earlier mobilization and avoid issues which can increase their convalescence including pneumonia, deep vein thrombosis etc. (Bonnet & Marret, 2005). Ambulation, or walking, as with any movement, can cause the patient increased pain. This increased pan can lead to the patient remaining in bed for longer periods of time and declining to participate in their care or rehabilitation (Chaturvedi & Chaturvedi, 2007). Patients may become susceptible to muscle wasting, atelectasis (a reduction in the filling of the lungs with oxygen-rich air), deep vein thrombosis and urinary retention (Chaturvedi & Chaturvedi, 2007). The usage of multimodal analgesia as described earlier keeps the patient at a manageable pain level so they can get out of bed and begin moving around. The patient can begin to turn, cough and deep breathe to prevent atelectasis and pneumonia. Walking helps to prevent deep vein thrombosis caused by blood forming a clot in the deep veins of the legs. Early ambulation avoids this by allowing normal circulation to resume in the legs. In summation, the earlier ambulation occurs, the better the outcome (Polomano et al., 2008).
In conclusion, one can clearly see how multimodal analgesia intertwines with the reduction of narcotic use, the increase in pain management and allowing the patient to begin healing. The reduction of narcotic use with the combination of non-opioid medications and different techniques such as nerve blocks, epidurals and infiltration of the surgical site benefits the patient in that it decreases side effects caused by an increased use of opioids. Side effects can and do cause increased convalescence that is avoidable in most cases with the use of multimodal analgesia.
The increased pain management through these same procedures improves not only the patient’s outcome but also the way a patient views recovery and their participation in their recovery. Under-treatment of pain is the main cause of increased hospital stay and unplanned hospital admissions in the surgery patient ("Contemporary postoperative analgesia," 2011). When possible, multiple combinations of opioid and non-opioid medications should be combined with multiple techniques as a standard practice.
In today’s healthcare environment, the sooner the patient can begin a diet and start ambulating, the less time they will spend in the hospital. Multimodal analgesia accomplishes this by decreasing the adverse side effects of opioids, therefore enabling the patient to begin eating sooner. The increase in pain management from multimodal analgesia encourages the patient to begin moving sooner. All these things combined decrease the risk of POI, pulmonary atelectasis, urinary retention and deep vein thrombosis.
“Multimodal analgesia is the best practice to address pain” ("Contemporary postoperative analgesia," 2011, p. 8) and should be considered for every patient having surgery. Research shows that the administration of multimodal analgesia prior to, during and after surgery is beneficial to the patient by reducing narcotic use, increasing pain management and thereby allowing the patient to begin healing.
Argoff, C. E., Albrecht, P., Irving, G., & Rice, F. (2009, August, 20, 2009). Multimodal analgesia for chronic pain: rationale and future directions. Pain Medicine, 10, S53-66.
Bonnet, F., & Marret, E. (2005, July 2005). Influence of anaesthetic and analgesic techniques on outcome after surgery. British Journal of Anaesthesia, 95(1), 52-58.
Chaturvedi, S., & Chaturvedi, A. (2007, October-December). Postoperative pain and its management. Indian Journal of Critical Care Medicine, 11(4). Retrieved from
Contemporary postoperative analgesia: the experience for day surgery patients- what more can we do? [Entire issue]. (2011). Day Surgery Australia, 10(3). Retrieved from
Massaro, F. (2012, June). Liposomal bupivacaine: a long-acting local anesthetic for postsurgical analgesia. Formulary, 47(6), 212-226. Retrieved from FormularyJournal.com
Maund, E., McDaid, C., Rice, S., Wriht, K., Jenkins, B., & Woolacott, N. (2011, March 2011). Paracetamol and selective and non-selective no-steroidal anti-inflammatory drugs for the reduction in morphine-related side-effects after major surgery: a systematic review. The British Journal of Anaesthesia, 106(3), 292-297.
Maxson, P. M., Lovely, J. K., Wrobleski, D. M., & Isaacson, E. C. (2011, May). Using evidence to enhance the recovery of patients undergoing colorectal surgery: part 2. Journal of Continuing Education in Nursing, 42(5), 197-198.
Pasero, C., & McCaffery, M. (2007, June 2007). Orthopaedic postoperative pain management. Journal of PeriAnesthesia Nursing, 22, 160-174.
Polomano, R. C., Rathmell, J. P., Krenzischek, D. A., & Dunwoody, C. J. (2008, February). Emerging trends and new approaches to acute pain management. Journal of PeriAnesthesia Nursing, 23, S43-S53.
Savoia, G., Gravino, E., Loreto, M., & Erman, A. (2005, November). Analgesia in PACU: indications, monitoring, complications. Current Drug Targets, 6(7), 755-765.