Mastering the Multimodal Approach

Total joint replacements have long been recognized as one of the more painful surgeries patients undergo. Thanks to the widespread use of multimodal pain management protocols, an increasing number of patients are walking out of facilities on the same day they have their procedures done. These protocols allow you to provide better care that leads to improved outcomes, earlier ambulation and more satisfied patients. Perhaps most importantly, by reducing the need for opioids — and often requiring lower doses and shorter prescriptions when they are used — multimodal pain management is a vital tool at a time when opioid abuse is a national public health crisis.

Multiple approaches to treating pain are superior to any single approach on its own, and facilities that employ this multipronged attack swear by it. “Multimodal pain management has been absolutely crucial to our joint replacement practice,” says Tad L. Gerlinger, MD, director of the adult reconstructive fellowship and an associate professor of surgery at Rush University Medical Center in Chicago. “It has allowed us to perform the procedures on an outpatient basis.”

Multimodal pain management has been absolutely crucial to our joint replacement practice.
— Tad L. Gerlinger, MD

Dr. Gerlinger notes that in the four years since he started doing outpatient total joints, the typical time patients use pain medication post-operatively has dropped from six or more weeks to just three weeks. That outcome alone is a big part of why there’s been a dramatic increase in the demand for outpatient procedures. In fact, when his facility first started offering outpatient total joints, Dr. Gerlinger did 100 or fewer per year. That number is now up to 400 — about half his total joints cases. What’s more, he expects to perform 70% of his joint replacements on an outpatient basis within the next year or two.

Denis Nam, MD, MSc, agrees with his colleague about the many benefits of multimodal pain management. Dr. Nam, an associate professor of orthopaedic surgery in the Division of Hip and Knee Reconstruction and Replacement at Rush, cites two ways this approach is superior to a less comprehensive analgesia strategy: Patients are able to mobilize much more quickly post-surgery, which ultimately improves their joints’ range of motion, and multimodal protocols reduce the risk of complications and decrease the need for narcotics to manage pain. Before employing a multimodal protocol, Dr. Nam says his total joint patients typically stayed in the hospital for six to seven days post-op. Now, around 35% of them go home on the day of surgery. The patients who stay overnight typically do so only because they require observation for prior medical conditions.

The specific recipes of pain relief cocktails vary from facility to facility, but the main ingredients are often the same. The analgesia starts preoperatively with a combination of acetaminophen, non-steroidal anti-inflammatories (NSAIDS) and low-dose gabapentin. This pre-op combination is designed to address nerve and arthritis-related pain, and target the various pain pathways before the procedure, without subjecting patients to potential side effects of an opioid-heavy approach. Intraoperatively, surgeons and anesthesia providers have a variety of potent options they can employ. For the team at Rush, that process includes a combination of regional blocks and local anesthetic injections as well as spinal anesthesia.

Regional blocks and injections of local anesthetics, which come in different formulations and can provide pain relief ranging from 24 hours to several days, allow providers to target very specific anatomical landmarks and nerve endings in a way that provides strong pain relief and allows patients to ambulate quickly after surgery — a fundamental part of any total joints recovery process.

The ability to ambulate quickly and awake from surgery without the many unpleasant side effects of generous opioid dosages generally leads to more satisfied patients. “Multimodal pain management can increase patient satisfaction and their speed of recovery,” says Dr. Nam says. “We want happy patients.”

The decreased use of narcotics also has practical benefits. It reduces the amount of medication prescribed, which translates to fewer phone calls from patients who have questions about their post-op care, Dr. Nam adds. In states where it’s harder to prescribe long-term narcotics, this change alone can significantly reduce the amount of time staff (and patients) spend managing ongoing refills.

Not every patient is a candidate for outpatient total joint surgery, but every joint replacement patient is a candidate for a multimodal pain management regimen. That’s an important distinction. “My experience is with hips and knees, but I can’t think of an orthopedic procedure where you wouldn’t consider multimodal pain management,” says Dr. Nam. “Certain patients may not be optimal candidates due to allergies to the medications. Some procedures, such as spinal fusions, may complicate the use of a regional block. But we try to make some adjustments to the protocol to accommodate every patient.”

Dr. Gerlinger adds that multimodal regimens are extremely effective, so they can be used for patients who can’t be treated as outpatients due to other medical issues. “We still use multimodal principles, but modify them somewhat,” he says. “For example, we might place an epidural that can be re-dosed versus a single-shot spinal as part of their regional anesthesia, or we might go straight to using a general anesthetic to facilitate a longer procedure.” Generally, a multimodal approach to pain management will increase your pool of patients who are good candidates for total joint replacement — or make the procedure safer for those who face higher risks for complications under more traditional pain management protocols. “It widens the spectrum of patients you can get through surgery,” says Dr. Nam. The patients whom you might worry about being able to handle the pain of surgery and complete physical therapy will likely have better outcomes under a comprehensive multimodal pain management regimen, he adds.

However, be sure to find out if a total joints candidate is already on a high dose of narcotics, because that can make it more difficult to achieve successful outcomes. “The number of patients that are on opioids or other medications and not being helped by them is very high,” says Dr. Nam.

He adds that many people are on higher doses of opioids because they don’t metabolize the drugs effectively. These individuals might end up with reactive hyperalgesia and become even more sensitive to pain. “People are different in how they respond to and metabolize different drugs,” says Dr. Nam. “It’s one of the most difficult aspects of pain management to manage.”

In these cases, try to decrease patients’ use of opioids before surgery and transition them to anti-inflammatories. “For patients who are seeing pain management doctors and are on high doses, that can be difficult,” says Dr. Nam. “Most commonly, the patient saw a primary care physician and received pain relievers for a chronic condition. It’s easier to get them to stop once they realize medications such as meloxicam and acetaminophen are effective. It’s all about appropriate patient education.”

Speaking of education, it’s always worthwhile to spend a little extra time helping your patients understand the what and the why of your facility’s multimodal protocols. The “multi” part of multimodal can look like a laundry list of medications, something that can feel overwhelming to patients.

That’s why Dr. Nam says patients in his practice attend a pre-op class 30 days before their surgeries. “I hear the nurses explaining to the patients: ‘This is why you get this medication now. This is what we’re trying to achieve with this medication …’” he says. “Patients get inundated with so much information, and it helps to repeat and reinforce all of it, so they understand.”