Acute pain care remains suboptimal and costly

Opioids are traditionally used as the foundational agents in acute pain management protocols1,2

According to patient surveys, postoperative pain continues to be undermanaged3-5

Of patients reporting postoperative pain in multiple independent, random patient surveys published from 1995 to 2014:

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

Results from the survey published in 2014 also demonstrated that, when given a choice between narcotic and non-narcotic pain medications, 57% of patients preferred non-narcotics5

Opioids may also be associated with adverse drug events, including6-10:


  • 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

In a retrospective analysis of a large, national hospital database, opioid-related adverse drug events (ORADEs) significantly increased both length of stay (LOS) and overall cost of surgical procedures.11,a

a Open colectomy, laparoscopic colectomy, laparoscopic cholecystectomy, total abdominal hysterectomy, and hip replacement. 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.12-16 The Joint Commission supports the need for the judicious and safe prescribing and administration of opioids. Its recommendations include combining both non-pharmacologic and non-opioid pharmacologic approaches for effective pain management.17

Multimodal analgesia for balanced acute pain management

Multimodal analgesia (MMA) combines 2 or more analgesic agents or techniques that use different mechanisms to provide better pain relief with less opioids.17,18 By combining different analgesics, MMA can optimize efficacy with a lower dose of each respective agent and may also reduce the risk for dose-related adverse events.19

Intervening at various points along the pain pathway19-22

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 pain18,23,24

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

MMA is believed to contribute to:

  • REDUCEDdoses of opioids19,25-27
  • REDUCEDrisk of ORADEs19,25,28,29
  • SHORTERlength of stay30
  • LESS PAINduring rest and activity31,32
  • IMPROVEDpatient satisfaction33

Multiple organizations recommend an MMA approach to acute pain management17,18,34-43

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. Warfield CA, Kahn CH. Acute pain management: programs in U.S. hospitals and experiences and attitudes among U.S. adults. Anesthesiology. 1995;83(5):1090-1094.
  4. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003;97(2):534-540.
  5. 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.
  6. Kehlet H. Postoperative opioid sparing to hasten recovery: what are the issues? Anesthesiology. 2005;102(6):1083-1085.
  7. 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.
  8. Kumar L, Barker C, Emmanuel A. Opioid-induced constipation: pathophysiology, clinical consequences, and management. Gastroenterol Res Pract. 2014:141737. doi:10.1155/2014/141737.
  9. 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.
  10. 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.
  11. Oderda GM, Gan TJ, Johnson BH, Robinson SB. Effect of opioid-related adverse events on outcomes in selected surgical patients. J Pain Palliat Care Pharmacother. 2013;27(1):62-70.
  12. 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.
  13. 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.
  14. 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.
  15. Arizona Criminal Justice Commission. Prescription drug reduction initiative. ACJC website. Accessed December 6, 2016.
  16. 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.
  17. The Joint Commission. Safe use of opioids in hospitals. Sentinel Event Alert. 2012;49:1-5. Accessed December 6, 2016.
  18. 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.
  19. Kehlet H, Dahl JB. The value of “multimodal” or “balanced analgesia” in postoperative pain treatment. Anesth Analg. 1993;77(5):1048-1056.
  20. Gottschalk A, Smith DS. New concepts in acute pain therapy: preemptive analgesia. Am Fam Physician. 2001;63(10):1979-1984.
  21. Anderson BJ. Paracetamol (acetaminophen): mechanisms of action. Pediatr Anesth. 2008;18(10):915-921.
  22. Joshi GP. Multimodal analgesia techniques and postoperative rehabilitation. Anesthesiol Clin North America. 2005;23(1):185-202.
  23. Crews JC. Multimodal pain management strategies for office-based and ambulatory procedures. JAMA. 2002;288(5):629-632.
  24. Manworren RCB. Multimodal pain management and the future of a personalized medicine approach to pain. AORN J. 2015;101(3):308-314.
  25. White PF. Multimodal analgesia: its role in preventing postoperative pain. Curr Opin Investig Drugs. 2008;9(1):76-82.
  26. Jo CH, Shin JS, Huh J. Multimodal analgesia for arthroscopic rotator cuff repair: a randomized, placebo-controlled, double-blind trial. Eur J Orthop Surg Traumatol. 2014;24(3):315-322.
  27. Mathiesen O, Dahl B, Thomsen BA, et al. A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery. Eur Spine J. 2013;22(9):2089-2096.
  28. Garimella V, Cellini C. Postoperative pain control. Clin Colon Rectal Surg. 2013;26(3):191-196.
  29. Mann C, Pouzeratte Y, Boccara G, et al. Comparison of intravenous or epidural patient-controlled analgesia in the elderly after major abdominal surgery. Anesthesiology. 2000;92(2):433-441.
  30. Michelson JD, Addante RA, Charlson MD. Multimodal analgesia therapy reduces length of hospitalization in patients undergoing fusions of the ankle and hindfoot. Foot Ankle Int. 2013;34(11):1526-1534.
  31. 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.
  32. Sivrikoz N, Koltka K, Güresti E, Büget M, Sentürk M, Özyalçın S. Perioperative dexketoprofen or lornoxicam administration for pain management after major orthopedic surgery: a randomized, controlled study. Ağri. 2014;26(1):23-28.
  33. Skinner HB. Multimodal acute pain management. Am J Orthop. 2004;33(suppl 5):5-9.
  34. 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.
  35. 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.
  36. 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.
  37. 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.
  38. 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.
  39. 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.
  40. American Society of PeriAnesthesia Nurses. ASPAN Pain and Comfort Clinical Guideline. J Perianesth Nurs. 2003;18(4):232-236.
  41. 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.
  42. 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.
  43. 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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