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Multimodal Pain Management

Postoperative pain control

Discover the benefits of multimodal analgesia for postoperative pain management.

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Multimodal pain management for post-operative pain comprises the comprehensive concept of combining multiple analgesics to relieve acute pain after surgery as much as possible, while reducing the potential side effects by reducing the individual dose. This may help to manage occurring pain better and tailor the pain therapy to the individual sensation of pain and the health condition of the individual patient. The basic principle is to use as much as needed but as little as possible with the least likelihood of side effects.

We as B. Braun work with health care professionals to offer choices across the different pain managing medicines to create a patient-centered pain management.

“Managing postoperative acute pain is a challenge, as we need to treat acute pain as soon as possible to avoid chronic pain while minimizing opioid related risks.”

Dr. Rosalia Navarro-Perez, Consultant Anesthetist at University Hospital Clinico San Carlos, Madrid, Spain

Recommendation for treatment of acute pain ^1,2

Therapy step 1

Non-Opioids ±
Adjuvants

Therapy step 2

Opioids from mild to moderate pain
+ Non-Opioids ± Adjuvants

Therapy step 3

Opioids from moderate to severe pain ±
Non-Opioids ± Adjuvants

Therapy step 4

Invasive and minimally invasive treatments

Multimodal pain therapy is a patient-centered approach, which combines therapies based on experiences as well as scientific research. Established key guidelines like PROSPECT Guideline (ESRA)³, ASA Guideline⁴, N1 Guideline (NICE UK)⁵ and S3 Guideline (Germany)⁶ recommend a multimodal approach to combine therapies for an effective pain relief and a reduction of side effects. Multimodal pain management can help to reduce the use of opioids and their associated risks.

Multimodal pain management can be used in chronic as well as in acute pain (e.g. after surgery). However, approaches differ.

In acute pain after surgery, the goal is to get to a tolerable pain level in order to reduce the risk of chronic pain and enable mobilization, while climbing down the pain ladder of medication as quickly as possible.

Multimodal pain management can include a variety of therapies, such as:

Pharmacological therapies: This may include non-opioid pain relievers, antidepressants, anticonvulsants, and topical pain relievers.

Non-pharmacological therapies: This may include physical therapy, occupational therapy, acupuncture, massage therapy, and cognitive-behavioral therapy.

The specific therapies used in multimodal pain management should be selected depending on the individual patient’s needs and condition. However, all multimodal pain management plans should be designed to provide effective pain relief while reducing the risk of side effects.

0%

of anesthesiologists use opioids as part of their post-operative IV pain medication.⁸

Often pain after surgery is not managed well.⁷ Multimodal pain management can help to provide a more effective pain relief while reducing side effects of medication. In case of a single approach treatment often very high doses or very strong analgesics are needed to manage pain effectively, which are often associated with more significant risks of side effects. Multimodal pain management can offer a number of benefits for both patients and hospitals.

Patient benefits:

More effective pain relief ⁹
Reduced risk of side effects¹⁰
Improved patient satisfaction^11,12
Less risk for chronic pain¹³

Hospital benefits:

Less opioids needed
Reduced length of stay
Reduced costs: multimodal pain management can help to reduce the overall costs of care for patients. This is because it can help to reduce the use of expensive opioids and other medications, as well as the need for extended hospital stays.
Increased efficiency: multimodal pain management can help to improve the efficiency of hospitals by reducing the amount of time that health care professionals need to spend managing pain. This is because it is a more comprehensive and proactive approach to pain management than opioid-only therapy.

However, multimodal pain management means more than just treating postoperative pain. The multimodal approach also has advantages during the operation. For a long time, perioperative pain treatment was dominated by opioids. Recently, awareness of the risk of developing addiction has grown.^{14, 15} In addition, these drugs have many undesirable side effects. Studies show that it is possible to effectively manage pain by combining different agents.¹⁶These include opioids, but also NSAIDs and other analgesics. Multimodal pain treatment makes it possible to tailor therapy to the risk profile of your patients.

National and international guidelines can help to identify scientifically evaluated pain management approaches for multimodal pain management tailored to your patient in a surgery-specific way.

Even though there is no one-size-fits-all approach to manage pain, most guidelines have in common, that they try to provide a good pain relief and reduced opioid consumption after surgery by combining different measures such as non-opioid systemic treatment options, peripheral nerve blocks, pain catheters and local infiltration techniques.

Find out more about our solutions that can help you manage the pain of your patients in an efficient way.

A blonde woman lies in a hospital bed. She is connected to an infusion, a Spaceplus pump can be seen in the background. A dark-haired doctor in a green surgical gown stands next to the bed. He is regulating the administration of the pain medication by infusion and talking to the woman.

Pain management in pediatrics

A dark-haired girl and a dark-haired doctor are standing opposite each other in a hospital corridor, both smiling. The doctor has crouched down to be at eye level with the little patient. They high-five each other with both hands.

Relieve children's pain

The smaller the patient, the bigger the challenge – also in anesthesia. It is estimated that up to 82 % of all hospitalized pediatric patients suffer from moderate to severe pain.¹⁷ With serious effects: Studies show, that inadequate analgesia may delay recovery,^{18, 19} and cause morbidity or even mortality after surgical trauma.²⁰ Vice versa effective pain management may improve the patient outcome detectably.^{18, 21, 22}

The growing awareness of the risks of opioids is drawing increasing attention to multimodal pain therapy for children. It may decrease the use of opioids and the associated side effects while it can be more effective in pain control.²³

To effectively relieve the pain of these vulnerable patients – without the need for off-label use – B. Braun offers various products: NSAIDs as well as other non-opioids specifically intended for pediatric use.

> 0%

of drugs used in children have not been tested in or approved for children.^{24, 25}

Play it safe

A mother lies in the operating room after a caesarean section and looks at her newborn baby, which a nurse is showing her. She looks exhausted, but also relieved. She is wearing a surgical cap over her dark hair, the newborn is wrapped in a white cloth and is wearing a light blue cap.

Pain relief for C-section patients

Patients undergoing a caesarean section are particularly vulnerable, as all medications can affect the mother and child. International guidelines give helpful recommendations for pain management.

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NSAIDs and other non-opioid safety profiles

Multimodal pain management:

Play it safe.

Enhancing safety is the most urgent demand we all share. Many studies give rise to scrutinize the all too frequent and long-term administration of opioids. All the more since there are effective and less risky alternatives like NSAIDs and other non-opioids, which feature safer molecules. Less opioids may mean less side effects, less risk of opioid addiction, and less complications with a potential medication change when it comes to home care.

Read more about how your patients benefit.

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References

1. https://www.ncbi.nlm.nih.gov/books/NBK554435/

2. https://www.cfp.ca/content/56/6/514

4. https://esraeurope.org/prospect/

Chou, R., Gordon, D. B., de Leon-Casasola, O. A., Rosenberg, J. M., Bickler, S., Brennan, T., Carter, T., Cassidy, C. L., Chittenden, E. H., Degenhardt, E., Griffith,

S., Manworren, R., McCarberg, B., Montgomery, R., Murphy, J., Perkal, M. F., Suresh, S., Sluka, K., Strassels, S., Thirlby, R., Viscusi, E., Walco, G. A., Warner,

L., Weisman, S. J., and Wu, C. L. 2016. ‚Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council’, J Pain, 17: 131-57.

5. https://www.nice.org.uk/guidance/ng180/evidence/n1-managing-acute-postoperative-pain-pdf-317993437913

6. https://register.awmf.org/assets/guidelines/001-025l_S3_Behandlung-akuter-perioperativer-posttraumatischer-Schmerzen_2022-03.pdf

7. Meißner, W, et al: The Quality of Postoperative Pain Therapy in German Hospital. Dtsch Arztebl Int 2017; 114: 161–7.

8. Survey among 100 anesthesiologists in Germany, Spain, Italy, UK and France, conducted in 2022.

9. https://www.scirp.org/html/1-1920609_98236.html

10. https://jamanetwork.com/journals/jamasurgery/article-abstract/2629299

11. Berend ME, Berend KR, Lombardi AV., Jr Advances in pain management game changers in knee arthroplasty. Bone Joint J. 2014;96(Suppl):7–9.

12. Maher DP, Woo P, Wong W, Zhang X, Yumul R, Louy C. Perioperative factors associated with Hospital Consumer Assessment of Healthcare Providers and Systems responses of total hip arthroplasty patients. J Clin Anesth. 2016;34:232–238.

13. https://www.painphysicianjournal.com/current/pdf article=NjUwNA%3D%3D&journal=122

14. Volkow ND, Jones EB, Einstein EB, Wargo EM. Prevention and Treatment of Opioid Misuse and Addiction: A Review. JAMA Psychiatry. 2019 Feb 1;76(2):208-216. doi: 10.1001/jamapsychiatry.2018.3126. PMID: 30516809.

15. Dydyk AM, Jain NK, Gupta M. Opioid Use Disorder. 2024 Jan 17. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–.PMID: 31985959.

16. Wick EC, Grant MC, Wu CL. Postoperative Multimodal Analgesia Pain Management With Nonopioid Analgesics and Techniques: A Review. JAMA Surg. 2017;152(7): 691–97.

17. O’Donnell FT, Rosen KR. Pediatric Pain Management: A review. Mo Med. 2014 May-Jun; 111(3): 231–237.

18. D’Amours RH et al., JOSPT 1996; 24(4): 227 - 36

19. Pavlin DJ et al., Anesth Analg 2002;95: 627 - 35

20. Verghese ST & Hannallah RS. Acute pain management in children. J Pain Res. 2010; 3: 105–123.

21. Khelet H, Br J Anaesth 1997;78: 606-17

22. Jayr C, In Les Aspects Economiques de l’Anesthésie. JEPU 2000: 131-8

23. Graff V, Grosh T. Multimodal Analgesia and Alternatives to Opioids for Postoperative Analgesia. The official journal of the anesthesia patient safety foundation 2018 Oct; 33(2): 33–68.

24. Boston Children’s Hospital. Division of General Pediatrics. What to consider when considering “off-label” drug prescriptions for children. https://www.childrenshospital.org/centers-and-services/departments/general-pediatrics/clinician-resources/off-label-drug-prescriptions (last access 6.5.21).

25. European Commission. Better Medicines for Children From Concept to Reality. Progress Report on the Pediatric Regulation (EC) No. 1901/2003. 2013.

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Postoperative pain control

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Medical professional

We as B. Braun work with health care professionals to offer choices across the different pain managing medicines to create a patient-centered pain management.