Addressing Pain: Anesthesia Considers Best Practices

SUMMARY: The prevalence of opioid usage among America's patients has generated the need for a set of protocols to be used by those providing acute pain care. A consortium of 15 medical societies has recently provided best-practice recommendations.

The second law of thermodynamics, which is an axiom of accepted science, says that, over time, things tend to break down, to degenerate, to become more chaotic. And, yet, when it comes to humankind, we see continual improvement in living conditions, technology and processes. We're always learning—finding new ways to build a better mouse trap, as it were. We may take a few steps back every now and then (anyone remember the Dark Ages?); but, on the whole, there has been a general upward trajectory in our ability to improve upon the status quo.

Those in the medical field are especially keen on process improvement. Given their background in science and their bent toward excellence, they are particularly fit for the task of investigating better ways to provide care for their patients. This includes those in the anesthesia specialty. Recently, a group of anesthesiologists, along with representatives from 14 other medical societies, generated several recommendations that ostensibly represent new and better methods for addressing the needs of certain types of patients. Care to guess what particular area of care the recommendations addressed? Here's a clue: what do you call a nice-looking kid who's a bit of a brat? A cute pain.

Necessity Leads to Invention

Over the years, the performance of acute pain management has become an increasingly significant part of the anesthesia team's practice. What was once predominantly the purview of the surgeon has gradually shifted, in large measure, as a responsibility of the anesthesiologist. Many anesthesia providers are asked every day to take over the patient's postoperative pain management, though such management is already bundled into the surgeon's global surgical payment package. This is why we ask our clients to be consistent in documenting, on the medical record (e.g., anesthesia record, block note), that the acute pain block was performed "at the surgeon's request." This helps to support the medical necessity of the transfer of pain management to the anesthesia team should it be questioned by the payer.

Interestingly, as the acute pain volume within anesthesia's case load has increased, there has also been a corresponding increase in the incidence of patients with special conditions. These conditions are the result of demographic and other factors beyond the anesthesia department's control. Nevertheless, it is increasingly up to anesthesia providers to take into account these complicating conditions when dealing with today's patients. Specifically, we're talking about patients with opioid or other substance use history and patients with chronic pain issues. We don't have to remind you that America is facing an opioid crisis. It has been coming on for the last several years and is currently crashing down around us. Many of the patients you treat will have used or abused these agents, and the question is: to what extent do you need to adjust your care parameters in light of this reality.

Then there is the phenomenon of America's aging. With the baby boomers hitting the retirement years, there is a growing percentage of patients who will necessarily have chronic pain issues. Many will have been treated with opioids and many of these will ultimately become your patients. Again, you will need to take into consideration their use of these drugs into your care plan. However, is there a guide available that is truly sufficient to assist you in these calculations, especially as it concerns acute pain services?

The Societies Step In

As anesthesiology is increasingly the go-to specialty in understanding and utilizing acute pain services, the American Society of Anesthesiologists (ASA) has partnered with 14 other medical societies to create a set of acute pain management standards, specifically with these special patients in mind. On March 8, the ASA issued a news release entitled, "Seven Principles for Individualized Pain Care of Surgical Patients with Substance Use Disorders, Chronic Pain or on Long-Term Opioid Therapy." These principles or "best practices" were developed to help providers better address the perioperative treatment of acute pain in complex surgical patients.

"Every surgical patient deserves adequate pain relief that aims to prevent opioid reliance, chronic pain and other negative outcomes, but it may be more challenging to achieve this in certain patient populations," said ASA President Randall M. Clark, M.D., FASA. "The new principles were created to build upon an original set established last year during our first pain summit, but specifically address patients undergoing surgery with chronic pain, those taking opioids preoperatively, and those with substance use disorders.

The ASA and other specialties had created a set of guidelines back in February of 2021. These new guiding principles reached by the ASA and its partner organizations this year will act to augment those earlier recommendations. The new recommendations for best practices are as follows:

1. If clinicians identify a positive screen for substance use preoperatively, a more detailed assessment tool should be utilized to risk stratify patients for additional support or referral for treatment when indicated.
2. In conducting a preoperative evaluation, if a patient is identified as having chronic pain, opioid tolerance, or a substance use disorder, clinicians should coordinate with the patient's care team, including consultation with a pain medicine, behavioral health, or addiction medicine specialist.
3. For patients on long-term opioid therapy preoperatively, clinicians should coordinate with the patient's prescribing clinician and continue the baseline opioid dose in the perioperative period with supplemental analgesia as needed for postoperative acute pain.
4. Clinicians should work with patients who have opioid tolerance on an individualized tapering plan for postoperative opioids, coordinating with the long-term opioid-prescribing clinician, with the goal of return to the preoperative dose or lower as soon as possible.
5. For patients prescribed opioids at discharge following surgery, clinicians should inform them and their caregivers about the risks, signs and management of opioid-induced respiratory depression; that they must avoid concurrent use of medicines with sedative effects and alcohol while taking opioids; and when to call for emergency assistance.
6. For patients identified as having significant risk of opioid-related adverse drug events or severe uncontrolled perioperative pain, clinicians should consult a pain specialist or anesthesiologist preoperatively.
7. For patients identified as benefitting from additional consultation with a pain medicine, behavioral health, or addiction medicine specialist, clinicians should utilize telehealth options if in-person consultation is not available.

According to the ASA's president, "The next step for this multi-society consortium and effort is to establish how we can help institutions implement both sets of guiding principles into their practices." As new challenges and changing circumstances arise, we are grateful there are those who see the need and provide new solutions. As your business partner, we are all about finding new and better ways to serve our clients. If you have a need that we can address, please reach out to us at info@anesthesiallc.com.

With best wishes,

Tony Mira
President and CEO