Acute pain care remains suboptimal and costly

Opioids are traditionally used as the foundational agents in acute pain management protocols.1,2

According to patient surveys, postoperative pain continues to be undermanaged.3

44% to 51% reported moderate pain 8% to 22% reported extreme pain

In a survey of 300 patients who underwent surgery within 5 years of survey date, 57% of patients stated a preference for non-narcotic medications over narcotic medications.3

Opioids may also be associated with adverse drug events, including4-8:


  • Constipation
  • Dizziness
  • Nausea
  • Pruritus
  • Sedation
  • Urinary retention


  • Bowel obstruction
  • Confusion
  • Dysphoria
  • Ileus
  • Vomiting


  • Airway obstruction
  • Respiratory arrest
  • Respiratory depression

Impact of ORADEs on length of stay and cost

This was a matched cohort study of opioid-related adverse drug events (ORADEs) in surgical inpatients aged greater than 17 years who had at least one dose of an opioid in a single center between 1990 and 1999. The study demonstrated that ORADEs increase hospital length of stay (LOS) and total hospital costs.9,a

a Major joint and limb reattachment procedures, uterine and adnexa procedure for nonmalignancy without complication or comorbidity, major small and large bowel procedure, uterine and adnexa procedure for nonmalignancy with complication or comorbidity, or procedures for obesity. b P<0.001.

Addressing the challenges

Today, numerous state and federal programs, as well as hospital associations, support efforts to decrease opioid abuse and dependence.10-14 The Joint Commission supports the need for the judicious and safe prescribing and administration of opioids. Its recommendations include combining both nonpharmacologic and non-opioid pharmacologic approaches for effective pain management.14

Multimodal analgesia for balanced acute pain management

Multimodal analgesia combines 2 or more analgesic agents or techniques that use different mechanisms to provide better pain relief with fewer opioids.15,16 By combining different analgesics, multimodal analgesia can optimize efficacy with a lower dose of each respective agent and may also reduce the risk for dose-related adverse events.17

Intervening at various points along the pain pathway17-20

Perception of pain involves both the peripheral and central nervous systems, and different types of analgesics can intervene at different levels of this signal transduction:

  • Cortical level (opioids, α2-agonists, acetaminophen, NMDA antagonists)
  • Spinal cord level (local anesthetics, opioids, α2-agonists, NMDA antagonists)
  • Peripheral level (local anesthetics, NSAIDs, COXIBs)
COXIB, cyclooxygenase-2–specific inhibitor; NMDA, N-methyl-D-aspartate.

Schedule non-opioid analgesics first, adding opioids for moderate to severe pain16,21,22

Schedule non-opioid analgesics first, adding opioids for moderate to severe pain

Multimodal analgesia is believed to contribute to:

  • REDUCEDdoses of opioids23-26
  • REDUCEDrisk of ORADEs27
  • SHORTERlength of stay28
  • LESS PAINduring rest and activity29
  • IMPROVEDpatient satisfaction26,30

Multiple organizations recommend a multimodal analgesia approach to acute pain management15,16,34-40

Explore educational materials and resources for acute pain management
  1. Thorson D, Biewen P, Bonte B, et al; Institute for Clinical Systems Improvement (ICSI). Health care protocol: acute pain assessment and opioid prescribing protocol. Published January 2014. Accessed December 6, 2016.
  2. Singla NK, Hale ME, Davis JC, et al. IV acetaminophen: efficacy of a single dose for postoperative pain after hip arthroplasty: subset data analysis of 2 unpublished randomized clinical trials. Am J Ther. 2015;22(1):2-10.
  3. Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL. Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey. Curr Med Res Opin. 2014;30(1):149-160.
  4. Kehlet H. Postoperative opioid sparing to hasten recovery: what are the issues? Anesthesiology. 2005;102(6):1083-1085.
  5. Wheeler M, Oderda GM, Ashburn MA, Lipman AG. Adverse events associated with postoperative opioid analgesia: a systematic review. J Pain. 2002;3(3):159-180.
  6. Kumar L, Barker C, Emmanuel A. Opioid-induced constipation: pathophysiology, clinical consequences, and management. Gastroenterol Res Pract. 2014:141737. doi:10.1155/2014/141737.
  7. Remy C, Marret E, Bonnet F. Effects of acetaminophen on morphine side-effects and consumption after major surgery: meta-analysis of randomized controlled trials. Br J Anaesth. 2005;94(4):505-513.
  8. Sinatra RS. Opioids and opioid receptors. In: Sinatra RS, Jahr JS, Watkins-Pitchford JM, eds. The Essence of Analgesia and Analgesics. Cambridge, United Kingdom: Cambridge University Press; 2011:chap 13.
  9. Oderda GM, Evans RS, Lloyd J, Cost of opioid-related adverse drug events in surgical patients J Pain Symptom Manage. 2003;25(3):276-283.
  10. Franklin G, Sabel J, Jones CM, et al. A comprehensive approach to address the prescription opioid epidemic in Washington State: milestones and lessons learned. Am J Public Health. 2015;105(3):463-469.
  11. Johnson H, Paulozzi L, Porucznik C, Mack K, Herter B. Decline in drug overdose deaths after state policy changes—Florida, 2010-2012. MMWR Morb Mortal Wkly Rep. 2014;63(26):569-574.
  12. Joint Policy Working Group. Response to the Massachusetts opioid prescription drug epidemic: 2014 report of best practices. Published August 27, 2014. Accessed December 6, 2016.
  13. Arizona Criminal Justice Commission. Prescription drug reduction initiative. ACJC website. Accessed December 6, 2016.
  14. Massachusetts Health & Hospital Association. MHA Task Force launches state’s first opioid prescription recommended guidelines for hospital emergency departments: first of three-phase healthcare provider effort to fight opioid abuse epidemic. MHA website. Published February 5, 2015. Accessed January 17, 2017.
  15. The Joint Commission. Safe use of opioids in hospitals. Sentinel Event Alert. 2012;49:1-5. Accessed December 6, 2016.
  16. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012;116(2):248-273.
  17. Kehlet H, Dahl JB. The value of “multimodal” or “balanced analgesia” in postoperative pain treatment. Anesth Analg. 1993;77(5):1048-1056.
  18. Gottschalk A, Smith DS. New concepts in acute pain therapy: preemptive analgesia. Am Fam Physician. 2001;63(10):1979-1984.
  19. Anderson BJ. Paracetamol (acetaminophen): mechanisms of action. Pediatr Anesth. 2008;18(10):915-921.
  20. Joshi GP. Multimodal analgesia techniques and postoperative rehabilitation. Anesthesiol Clin North America. 2005;23(1):185-202.
  21. Crews JC. Multimodal pain management strategies for office-based and ambulatory procedures. JAMA. 2002;288(5):629-632.
  22. Manworren RCB. Multimodal pain management and the future of a personalized medicine approach to pain. AORN J. 2015;101(3):308-314.
  23. Hah J, Mackey SC, Schmidt P, et al. Effect of perioperative gabapentin on postoperative pain resolution and opioid cessation in a mixed surgical cohort: a randomized clinical trial. JAMA Surg. 2018;153(4):303-311.
  24. Warren JA, Stoddard C, Hunter AL, et al. Effect of multimodal analgesia on opioid use after open ventral hernia repair. J Gastrointest Surg. 2017;21(10):1692-1699.
  25. Feld JM, Laurito CE, Beckerman M, Vincent J, Hoffman WE. Non-opioid analgesia improves pain relief and decreases sedation after gastric bypass surgery. Can J Anaesth. 2003;50(4):336-341.
  26. Buvanendran A, Kroin JS, Tuman KJ, et al. Effects of perioperative administration of a selective cyclooxygenase 2 inhibitor on pain management and recovery of function after knee replacement: a randomized controlled trial. JAMA. 2003;290(18):2411-2418.
  27. Langford RM, Joshi GP, Gan TJ, et al. Reduction in opioid-related adverse events and improvement in function with parecoxib followed by valdecoxib treatment after non-cardiac surgery: a randomized, double-blind, placebo-controlled, parallel-group trial. Clin Drug Investig. 2009;29(9):577-590.
  28. McLaughlin DC, Cheah JW, Aleshi P, Zhang AL, Ma CB, Feeley BT. Multimodal analgesia decreases opioid consumption after shoulder arthroplasty: a prospective cohort study. J Shoulder Elbow Surg. 2018;27(4):686-691.
  29. Fu PL, Xiao J, Zhu YL, et al. Efficacy of a multimodal analgesia protocol in total knee arthroplasty: a randomized, controlled trial. J Int Med Res. 2010;38(4):1404-1412.
  30. Moore A, Costello J, Wieczorek P, Shah V, Taddio A, Carvalho JC. Gabapentin improves postcesarean delivery pain management: a randomized, placebo-controlled trial. Anesth Analg. 2011;112(1):167-173.
  31. Wells N, Pasero C, McCaffery M. Improving the quality of care through pain assessment and management. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008:chap 17.
  32. American Academy of Orthopaedic Surgeons Work Group. Management of hip fractures in the elderly: evidence-based clinical practice guideline. American Academy of Orthopaedic Surgeons website. Published September 5, 2014. Accessed December 6, 2016.
  33. Mohanty S, Rosenthal RA, Russell MM, Neuman MD, Ko CY, Esnaola NF. Optimal perioperative management of the geriatric patient: a best practices guideline from the ACS NSQIP/American Geriatrics Society. American College of Surgeons website. Accessed December 6, 2016.
  34. Shah S, Almenas F, Castillo C, Vaynberg E; The American Geriatrics Society. Pain management in the elderly. The American Geriatrics Society website. Accessed December 12, 2016.
  35. Antman EM, Bennett JS, Daugherty A, Furberg C, Roberts H, Taubert KA. Use of nonsteroidal antiinflammatory drugs: an update for clinicians: a scientific statement from the American Heart Association. Circulation. 2007;115(12):1634-1642.
  36. Jarzyna D, Jungquist CR, Pasero C, et al. American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Manag Nurs. 2011;12(3):118-145.
  37. American Society of PeriAnesthesia Nurses. ASPAN Pain and Comfort Clinical Guideline. J Perianesth Nurs. 2003;18(4):232-236.
  38. Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. World J Surg. 2013;37(2):259-284.
  39. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263-306.
  40. Frederickson TW, Gordon DB, De Pinto M, et al, eds. Reducing Adverse Drug Events Related to Opioids Implementation Guide. Philadelphia, PA: Society of Hospital Medicine; 2015.
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