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Multimodal Analgesia in the Surgical Population

Senior Asian Couple Young Female Doctor
Wednesday, November 21, 2018

Multimodal analgesia is defined as using two or more medications and/or techniques to achieve two important patient outcomes—adequate pain control and minimized patient risk. The single biggest benefit to the patient through the use of multimodal analgesia is the ability to limit the patient’s exposure to opioids. Opioid-induced side effects are not only clinically relevant, but more importantly, they are dose-dependent. By limiting opioid exposure to the patient, the risk of opioid-induced side effects is dramatically reduced, including risk of urinary retention, constipation, nausea, sedation, and even respiratory depression.

Approximately four years ago, Covenant Medical Center introduced a multimodal strategy for acute pain management in its surgical population. Covenant Medical Center’s approach was based on two big paradigm shifts in the treatment of acute pain that have taken place in the last few years. The first treatment change is incorporating the non-opioid treatment modalities as the foundation of the approach, such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and others. The second treatment change is administering these non-opioid medications in a scheduled fashion rather than pro re nata (PRN) or “as needed.” This results in decreased opioid exposure, fewer analgesic gaps, improved patient satisfaction, and minimized risk to the patient.

Since its inception, and with some minor tweaks along the way, multimodal analgesia produced two clinically significant benefits for Covenant Medical Center:

  • Its opioid-induced side effect rate has been cut in half over the last year, and is trending downward. Covenant Medical Center currently has a side-effect rate of 0.4/1000 patient days with the national average being 1.2–1.5/1000 patient days.
  • The use of unscheduled naloxone (Narcan) use at its facility for emergent reversal has also been cut in half over the last three years.

As an addition to its multimodal strategy, regional anesthesia blockade and an Enhanced Recovery After Surgery (ERAS) protocol has been put in place. These two practices are also non-opioid based and are incorporated into the multimodal strategy to achieve significant global value for the patient as well as the health system.

For more information, please contact Allen Cunningham, PharmD, Clinical Pharmacy Director, Covenant Medical Center, at