Multimodal Pain Management

Measure Specification

Besides providing anesthesia care in the operating room, anesthesiologists are dedicated to providing the best perioperative pain management in order to improve patients’ function and facilitate rehabilitation after surgery. In the past, pain management was limited to the use of opioids (also called narcotics). Opioids provide analgesia primarily through a unitary mechanism, and just adding more opioids does not usually lead to better pain control or improve outcomes.

In fact, opioids are responsible for a host of side effects that can be a threat to life, and increasing rates of complications after surgery can be attributed to the overuse and abuse of opioids. In 2012, the American Society of Anesthesiologists (ASA) published its guidelines for acute pain management in the perioperative setting (1), and ASA along with the American Society of Regional Anesthesia and Pain Medicine (ASRA) and American Pain Society collaborated on the 2016 clinical practice guidelines for the management of postoperative pain (2).

These documents endorse the routine use of “multimodal analgesia” which means employing multiple classes of pain medications or therapies, working with different mechanisms of action, in the treatment of acute pain instead of relying on opioids alone. While opioids may continue to be important pain medications, they must be combined with other classes of medications known to prevent and help relieve postoperative pain unless contraindicated.

The list includes but is not limited to: • Non-steroidal anti-inflammatory drugs (NSAIDs): Examples include ibuprofen, diclofenac, ketorolac, celecoxib, nabumetone. NSAIDs act on the prostaglandin system peripherally and work to decrease inflammation. • NMDA antagonists: When administered in low dose, ketamine, magnesium, and other NMDA antagonists act on the N-methyl-D-aspartate receptors in the central nerve system to decrease acute pain and hyperalgesia.

• Acetaminophen: Acetaminophen acts on central prostaglandin synthesis and provides pain relief through multiple mechanisms. • Gabapentinoids: Examples include gabapentin and pregabalin. These medications are membrane stabilizers that essentially decrease nerve firing. Physicians should consider recent literature and applicable guidelines on judicious use of gabapentinoids, including those related to patients who are currently taking gabapentinoids.

• Regional block: The ASA and ASRA also strongly recommend the use of target-specific local anesthetic applications in the form of regional analgesic techniques as part of the multimodal analgesic protocol whenever indicated. • Steroids: Dexamethasone during surgery has been shown to decrease pain and opioid requirements. • Local infiltration analgesia: Injection of local anesthetic in or around the surgical site by the surgeon is an example.

• Systemic lidocaine infusion: Lidocaine administered by intravenous infusion represents an example of multimodal analgesia.

2012 ASA Practice Guidelines for Acute Pain Management in the Perioperative Setting “Multimodal techniques for pain management include the administration of two or more drugs that act by different mechanisms for providing analgesia. These drugs may be administered via the same route or by different routes.” “Whenever possible, anesthesiologists should use multimodal pain management therapy.

Central regional blockade with local anesthetics should be considered. Unless contraindicated, patients should receive an around- the-clock regimen of COXIBs, NSAIDs, or acetaminophen. Dosing regimens should be administered to optimize efficacy while minimizing the risk of adverse events. The choice of medication, dose, route, and duration of therapy should be individualized.

” 2016 ASRA Guidelines on the Management of Postoperative Pain “The panel recommends that clinicians offer multi-modal analgesia, or the use of a variety of analgesic medications and techniques combined with non-pharmacological interventions, for the treatment of postoperative pain in children and adults (strong recommendation, high-quality evidence).

” 2022 A multisociety organizational consensus process to define guiding principles for acute perioperative pain management Principle 3: Clinicians should offer multimodal analgesia, or the use of a variety of analgesic medications and techniques combined with non-pharmacological interventions, for the treatment of postoperative pain in adults.

This measure contains one strata defined by a single submission criteria. This measure produces a single performance rate. For the purposes of MIPS implementation, this procedure measure is submitted each time a procedure is performed during the performance period.