Reducing opioid dependence — The multimodal approach to pain management


At the North American Spine Society's 30th Annual Meeting held in Chicago, experts discussed the benefits of utilizing a multimodal model in pain management in a symposium titled "Recent Advances in Managing Postoperative Pain Without Opioids."

Sheeraz Quereshi, MD, MBA, began the symposium quoting Tom Frieden, the director of the CDC. Tom Frieden said, "Prescription drug overdose is an epidemic in the United States. All too common, in far too many communities, the treatment is becoming the problem."


Dr. Quereshi explained the face of the opioid epidemic is changing. Those patients affected by opioid abuse are surgeons' every day patients and the problem is rapidly expanding. In the United States, 70 million patients are prescribed opioids for postsurgical pain each year. Of those patients, one in 15 will go on to experience long-term use or abuse.


"The numbers are quite staggering," Dr. Quereshi said. "If we specifically look into spine, there have been studies that have shown a year after elective spine surgery, one-third of all patients are still using opioids and 18 percent of those people were not previously taking narcotic medications. This is happening across the board, in elderly patients and in young patients."


Patients often have a fear of addiction, and many providers tell their patients it is acceptable to take the opioids, thus adding to the growing opioid epidemic. Many organizations, including The Joint Commission, Centers for Disease Control and Prevention and American Society of Anesthesiologists, are urging physicians to shift toward prescribing a non-opioid treatment plan. The ASA advises, "a multimodal approach to pain management — often beginning with a local anesthetic where appropriate."


The multimodal model of care is a necessary strategy in reducing opioid abuse, at a time when our nation is losing the battle to the pain medication. The first part of this approach entails preventing adverse drug events. "It is really about screening that patient who could be at risk for adverse events," Dr. Quereshi said.


As the rate of spine surgery procedures increases, more healthcare professionals are analyzing the costs associated with spine surgery. "The current trends in spine surgery are to reduce length of stay and costs," Dr. Quereshi said. "Minimally invasive techniques are becoming more important." Surgeons are also looking at complications in spinal surgery such as readmission, which is often due to inadequate pain relief.


"When we think about pain, there is increasing evidence that we aren't doing a very good job of managing pain following spine surgery," Dr. Quereshi said. "Some of the highest pain scores of all procedures across the board occur after spine surgery." Many factors driving up costs are linked to the deficiencies evident in pain management.

The United States rates as the world's greatest consumer of opioid medications, with orthopedic surgeons being the third highest opioids prescribers in the nation. Opioid use also has its fair share of side effects, which may be devastating for a patient. Side effects include respiratory depression, nausea, constipation and vomiting. These adverse drug events often result in a longer length of stay and higher costs of care. In patients undergoing spinal fusions, surgeons often overlook the effect opioids have on bone remodeling and fracture healing.


"We have to understand that a unimodal approach to pain treatment can't be expected to provide efficient pain relief," Dr. Quereshi said. There are several areas that can generate pain, and surgeons need to utilize a multimodal approach to attach these different areas causing the pain. In this model, it is imperative to attack pain during the pre- and perioperative period. Certain non-opioid medications including NSAIDs should be considered either instead of or in combination with opioids.


"The take home point here is that perioperative pain is all too often inadequately managed after spine surgery," says Dr. Quereshi. "As physicians, we are relying primarily on narcotic pain management." Thus, medical professionals should seriously consider a multimodal pain management model as it has shown to improve pain control and reduce reliance on opioids.


Choll Kim, MD, presented on the use of NSAIDs following spine surgery. The benefits of NSAIDs include non-habit form, non-mind altering, no respiratory depression, no nausea, no vomiting and no constipation. "Here's what's interesting about this list," Dr. Kim said. "It's basically a list of what a narcotic is not."


However, there are a set of disadvantages to NSAIDs. For one, it is "not nearly as potent as a narcotic," explained Dr. Kim. Additionally, there is an issue with gastric acid as well as an increased bleeding risk. Most importantly for spine surgeons, NSAIDs inhibits fusion. 


Dr. Kim discussed a key paper, "The Effect of Postoperative Nonsteroidal Anti-inflammatory Drug Administration of Spinal Fusion." The paper serves as map for spine surgeons on the best way to manage pain. In the study, led by Steven Glassman, MD, researchers determined  surgeons should not prescribe NSAIDs for three months after fusion surgery.


However, Dr. Kim stated these findings do not go far enough. "We need to ask more detailed questions about this problem," said Dr. Kim. He cited another study that "goes to the farthest end of the spectrum in terms of NSAID use after surgery." The meta-analysis, titled "High-Dose Ketorolac Affect Spinal Fusion: A Meta-Analysis of the Effect of Perioperative Nonsterodial Anti-Inflammatory Drugs on Spinal Fusion," concluded surgeons could prescribe NSAIDs within the first two weeks following spinal fusion surgery. Researchers found if surgeons used a normal dose of NSAIDs, there was no effect on non-union rates. However, if a surgeon used a high dose, that relative risk goes up almost three-fold.


Essentially, researchers of both studies found the dose matters when it comes to spine fusion. A third study also found that not only dose matters, but duration of NSAID use matters as well. Dr. Kim suggested surgeons use NSAIDs at a normal dose for only a few days.


"In an effort to decrease our reliance on powerful narcotics, we don't have a single drug that can replace them," Dr. Kim said. "Therefore, we are replacing them with multimodality therapy strategies. One of those components includes NSAIDs, and those can be used safely in certain doses and for certain time periods."

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