March 7, 2016

The American Pain Society (APS) last month released its first-ever Clinical Practice Guidelines on the Management of Postoperative Pain.  The American Society of Anesthesiologists, which published its own Practice Guidelines for Acute Pain Management in the Perioperative Setting in Anesthesiology in 2012, provided input, and the American Society for Regional Anesthesia endorsed the APS Guidelines.

"The intent of the guideline is to provide evidence-based recommendations for better management of postoperative pain, and the target audience is all clinicians who manage pain resulting from surgery," said principal author Roger Chou, MD of the Departments of Medicine and Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Pacific Northwest Evidence Based Practice Center.  (APS News Release, February 17, 2016.)  Studies have shown again and again that the majority of surgical patients receive inadequate pain control, which can increase the risks of persistent postoperative pain and of post-surgical complications, function and functional recovery, and quality of life.

The key recommendation in the Guidelines is for greater use of multimodal pain management strategies.  Multimodal techniques, according to Dr. Chou, help achieve better pain relief while lowering doses of opioids and potentially avoiding certain adverse effects, by affecting pain through different pathways and mechanisms of action.  Dr. Chou further explained that using a multimodal approach “means using different medications, for example opioids and nonopioid therapies such as non-steroidal anti-inflammatories (NSAIDs), gabapentin/pregabalin, ketamine, lidocaine, administered in different ways, for example, systemically or via neuraxial/peripheral regional anesthetic techniques, as well as medications and nonpharmacological therapies."

The Guidelines contain 32 recommendations developed by a panel of 23 experts in anesthesia, pain medicine, surgery, obstetrics and gynecology, pediatrics, hospital medicine, nursing, primary care, physical therapy and psychology who reviewed nearly 1,000 primary studies and systematic reviews.  Although the process required only a two-thirds majority for a recommendation to be approved, unanimity or a near-unanimous consensus was achieved in each case. 

Each recommendation received a separate grade for the strength of the recommendation (strong or weak) and for the quality of evidence (high, moderate, or low).  Four recommendations received the highest ratings in both domains (strong recommendation, high-quality evidence):

• Clinicians should offer multimodal analgesia, or the use of a variety of analgesic medications and techniques combined with nonpharmacological interventions, for the treatment of postoperative pain in children and adults.
• Adults and children can be given acetaminophen and/or non-steroidal anti-inflammatory drugs as part of multimodal analgesia for management of postoperative pain.
• Clinicians should consider surgical site-specific peripheral regional anesthetic techniques with proven efficacy in adults and children for certain procedures.
• Spinal analgesia is appropriate for major thoracic and abdominal procedures, particularly in patients at risk for cardiac and pulmonary complications or prolonged intestinal distress.

The following recommendations are among those also rated “strong” albeit based on “moderate” quality evidence:

• Oral administration of opioids is preferred to intravenous administration for post-operative analgesia.
• Intravenous patient-controlled analgesia (PCA) can be used when parenteral administration of analgesics is required.
• Clinicians should consider giving preoperative doses of celecoxib in adult patients without contraindications.
• Gabapentin and pregabalin can be considered for multimodal postoperative analgesia. The medications are associated with lower opioid requirements after surgery.
• Do not use routine basal infusion of opioids with IV PCA in opioid-naive adults.
• Avoid intrapleural analgesia with local anesthetics for pain control after thoracic surgery.
• Use continuous, local anesthetic-based peripheral regional analgesic techniques when the need for analgesia is likely to exceed the duration of effect of a single injection.
• Avoid the neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, and ketamine.
• Avoid using the intramuscular route for the administration of analgesics for the management of postoperative pain.

The panel issued a third group of strong recommendations despite “low” quality evidence, including:

• Clinicians should provide patient and family-centered, individually tailored education to patients and caregivers about treatment options for postoperative pain.
• Every surgical patient should receive a preoperative evaluation, including assessment of medical and psychiatric comorbidities, concomitant medications, history of chronic pain, and substance abuse.
• The pain management plan should be adjusted according to the adequacy of pain relief and the presence of adverse events.
• Use a validated pain assessment tool to track response to postoperative pain treatments and adjust treatment plans accordingly.
• Monitor sedation, respiratory status, and other adverse events in patients who receive systemic opioids.
• Provide appropriate monitoring of patients who have received neuraxial interventions for perioperative analgesia.
• Facilities in which surgery is performed provide clinicians with access to consultation with a pain specialist for patients with inadequately controlled postoperative pain or at high risk of inadequately controlled postoperative pain (e.g., opioid-tolerant, history of substance abuse).

Some of the recommendations were “weak” even if supported by moderate evidence.  Among these recommendations were:

• “The panel does not recommend routine use of local anesthetic infiltration.  Rather, use of local anesthetic infiltration should be on the basis of evidence showing benefit for the surgical procedure in question.”
• Clinicians should consider transcutaneous electrical nerve stimulation (TENS) as an adjunct to other postoperative pain treatments.
• Clinicians should consider the use of cognitive-behavioral modalities in adults as part of a multimodal approach, e.g., guided imagery and other relaxation methods, hypnosis and intraoperative suggestions “(which involve positive suggestions to patients, usually under anesthesia, about the patient’s ability to manage and cope with postoperative pain and recovery from surgery)” and music. 

Finally, the panel found itself unable either to recommend or to discourage acupuncture, massage, or cold therapy as adjuncts to other postoperative pain treatments because of insufficient evidence.  The panel concluded by noting that there remain numerous research gaps.  Of 32 recommendations, the panel rated only four as supported by high-quality evidence, and 11 recommendations were based on low-quality evidence

What impact will the new Guidelines have?  They are intended, as noted above, to help physicians and other clinicians achieve optimal pain management following surgery.  Given the intense health policy emphasis on the management of pain in general, hospitals may actively promote adherence to the Guidelines, which affirm the 2012 ASA Practice Guidelines’ recommendation that:

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.

Any changes in clinical practice that the APS Guidelines may bring about are likely to occur over time.  Any changes in payment policies, such as requiring documented consideration of oral pain medications and relaxation therapy before administration of neural blockade, will come about slowly if at all—but anesthesiologists should certainly recognize that changes are possible and begin to update their own practices as appropriate.

With best wishes,

Tony Mira
President and CEO