Effective Multimodal Pain Protocols

The right combination at the right time gives patients maximum relief while simultaneously reducing the need for and amount of problematic opioids.

Multimodal pain management is one of those ubiquitous terms that is used so often that it’s easy for providers to lose sight of exactly what it means. This becomes problematic when you’re trying to explain to patients how you are tackling their pain control throughout the perioperative journey.

That’s why Michael A. MacKinnon, DNP, FNP-C, CRNA, owner of MacKinnon Anesthesia in Show Low, Ariz., keeps it as simple as possible when speaking with patients. “I like to tell patients that with our approach to pain control, with multimodal regimens, we’re hitting our target with multiple arrows instead of walloping it with just a single shot.” The arrow analogy is as clear as explanation as we’ve heard to describe an approach to pain management that research continues to show is a superior strategy.

Different agents, different receptors

Multimodal analgesia, which is often combined with regional or local anesthesia, generally refers to techniques that incorporate simultaneous administration of two or more analgesic agents that target pain pathways at different levels. These agents tend to include nonsteroidal anti-inflammatory medications, steroids, acetaminophen and opioids, although the analgesic protocol itself is geared toward reducing the latter. “With multimodal, you have multiple options taking care of the pain and hitting different receptors,” says Dr. MacKinnon. “It’s a little bit of everything.”

By using a multimodal approach, you’re able to ‘cover multiple bases’ and treat potential causes of pain.
Robert W. Simon, DNP, MS, CRNA, CHSE, CNE

The ability to hit multiple receptors is critical when you consider variability among patients. Robert W. Simon, DNP, MS, CRNA, CHSE, CNE, chief CRNA at Huntington Valley (Pa.) Anesthesia Associates, says the fact that one treatment may work on one type of pain but not another is a perfect example of why multimodal analgesia is a universally sound approach. “Everyone experiences pain differently,” he says. “By using a multimodal approach, you’re able to ‘cover multiple bases,’ treat potential causes of pain and hopefully provide a better outcome for the patient.”

Opioid-reducing capabilities

Another benefit of effective multimodal regimens cited by both Dr. MacKinnon and Dr. Simon is the ability to potentially decrease the amount of opioids patients are given.

“This approach is especially helpful when you’re working with patients with chronic pain who have built up a high tolerance for narcotics, and could be susceptible to tachyphylaxis,” says Dr. MacKinnon.

Dr. Simon says the majority of multimodal approaches are aimed at using less narcotics to minimize opioids’ negative side effects such as respiratory depression, nausea and constipation, not to mention the risk of addiction.

Misconceptions and misunderstandings

Setting the right expectations and making sure patients understand that by its very nature surgery will always result in some pain is of paramount importance for providers.

This also tends to be an area where misconceptions about what multimodal entails come up. “Some people think that a multimodal regimen might cure their pain, and that pain is inherently a bad thing,” says Dr. Simon. This, of course, isn’t true or accurate, and it’s a problematic mindset that providers should waste no time correcting. “Pain is a symptom and a warning sign of sorts to not push yourself too hard,” adds Dr. Simon. “This is why it’s always best to set realistic expectations prior to employing a multimodal approach.” This can done by assessing the patient’s current pain level and asking them what they consider an acceptable level. “For example, if the patient’s current pain level on a scale of 1-10 is a 7-8, getting that number down to a 4-5 might be a more realistic goal for providers,” adds Dr. Simon.

Dr. McKinnon points out that patients can sometimes have the opposite reaction to multimodal regimens and assume that because they are getting smaller doses of multiple medications, it will result in more pain. “Effectiveness isn’t about volume,” he says. “Multimodal actually does a better job, and patients do better overall, but it’s important to manage any concerns early in the process.”

Results we can all get behind

Whichever approach your facility takes to multimodal analgesia, it’s important to recognize the benefits of a technique that’s fast becoming the standard in outpatient care.

“Minimizing the need for narcotics and using other medications like PO Tylenol and gabapentin can help patients recover more quickly, spend less time in PACU and ultimately go home sooner than traditional means of paint control,” says Dr. Simon.

Those are the type of results patients should be able to get behind. OSM

Note: This three-part article series is supported by Hikma Pharmaceuticals.