The Advantages of Multimodal Pain Management over Opioid Monotherapy

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Multimodal pain management improves quality, financial outcomes over opioid monotherapy

At one time, opioids were the standalone method of managing the acute pain following surgery in American hospitals. But for decades, virtually all leading authorities have recommended a multimodal approach in lieu of the traditional opioid monotherapy.

A multimodal approach is one that relies on a combination of therapies including non-opioid analgesics (e.g., NSAIDs, acetaminophen, cyclooxygenase-2 inhibitors, and local or regional agents) as a primary means of pain control. In a multimodal approach, opioids are used only to the extent that non-opioid analgesics are proven inadequate. Some refer to it as a balanced, opioid-sparing, or non-opioid foundation approach.

It’s a fortunate truth that good medicine is good business. This applies to the multimodal approach as compared to opioid monotherapy. It’s good medicine because it improves outcomes and quality scores while reducing the risks of opioid-related adverse events or addiction. Multimodal analgesia reduces costs, length of stay, and liability risks.1,2

Although multimodal analgesia has proven to be both good medicine and good business, many hospitals continue to rely on opioids as the exclusive or near-exclusive method of managing the acute pain of surgery.

It’s Good Medicine

Authorities Recommending a Multimodal Approach

The list of authorities recommending a multimodal approach is compelling, including the American Society of Anesthesiologists, American Society of PeriAnesthesia Nurses, Enhanced Recovery After Surgery Society, The Joint Commission, and the National Center for Biotechnology Information, amongst others.3

Potential Limiting Side Effects, Adverse Events & Complications  

Recommending a multimodal approach is based primarily on recognition of:

  1. the numerous negative side effects of opioids
  2. the high risk and severity of adverse drug events and complications
  3. the substantial proportion of the population falling into the higher-than-normal risk category for opioid-related adverse events

Common side effects that can limit opioid therapy include respiratory depression, dizziness, nausea and vomiting, constipation, sedation, delirium, hallucinations, falls, depression, hypotension, cognitive impairment, and aspiration pneumonia. Opioids affect multiple organ systems. In addition to side effects, opioids are implicated in adverse drug reactions to a greater degree than any other class of drugs with the Joint Commission cautioning that “adverse events can occur with the use of any opioid.”4 A 2014 report by the Advisory Board concluded that “high-opioid approaches contribute to preventable complications.”5 The risk of addiction is well known and even better documented.

The risk is exacerbated by the fact that a substantial proportion of patients fall into the higher-than-normal risk category, which according to The Joint Commission, includes those with sleep apnea; the morbidly obese, very young, very ill, and over age 60; and those on drugs depressing the central nervous or respiratory system.6

Addiction, Chronic Pain

Opioids pose a higher risk of addiction than any other class of drugs.7 Hospital-administered opioids may lead to addiction in either of two ways.  The first is well-known: a person becomes dependent on and addicted to opioids because they relieve pain, produce euphoria or both.

The second is less well-known but real: a clinician relies on opioids to manage a surgical patient’s pain but, concerned with the risks, under-management of the patient’s pain through too low of a dosage. Under-management of acute pain is a proven cause of chronic pain, and chronic pain a proven cause of opioid dependence.8

Recent studies document the frightening transition from reliance on opioids prior to surgery to chronic opioid use in the year following surgery. A recent article in the journal Pain reports that while 5-10% of opioid-naïve patients undergoing total hip or knee arthroplasties continued opioid use after six months, the percentage of opioid-reliant patients continuing opioid use was sharply higher: nearly 54% of total knee patients and 35% of total hip patients. Those taking greater than 60mg oral morphine equivalents prior to surgery had an 80% likelihood of chronic use. 9

Further, a July 2016 JAMA Internal Medicine article found that, beyond specific demographics, certain procedures have shown higher incidences of chronic opioid use. Procedures such as total knee or hip arthroplasties have some of the highest increased risks for chronic opioid use in the year following surgery.10

Physicians can treat pain effectively and train patients to use them safely and responsibly — and physicians and pharmacists can help achieve this through counseling and consultations. Problems occur when people begin taking more tablets than prescribed or taking them more often than recommended. The risk of overdose also increases when people take the drugs for reasons other than pain relief — to help them sleep, for instance, or to self-medicate anxiety or depression.

It’s Good Business

Length of Stay

Studies have repeatedly documented the effects of opioid-related side effects and adverse events on length of stay. A study in Annals of Pharmacotherapy found a 10.3% increase in length of stay for patients experiencing opioid-related adverse events, with such events occurring more frequently as dosages increased.11 An Advisory Board study of over 2.5 million cases showed that patients on a lower-dose opioid regimen had a length of stay 29% shorter than those on a high-dose regimen.12

Patient Satisfaction

Opioids often decrease patient satisfaction in two specific ways:

  1. the associated side effects and adverse events are usually uncomfortable and painful
  2. under-management of pain has been repeatedly documented as a primary cause of patient dissatisfaction

While CMS has proposed removing pain management scores from the payment calculation, pain management would remain a component of the HCAHPS patient satisfaction survey.

Operations and Supplies

A study of total hip and total knee arthroplasty at the Mayo Clinic compared patients on a multimodal regimen with those on the traditional, opioid-reliant regimen. It concluded that the multimodal regimen reduced the following Medicare Part A costs: room and board, medical/surgical supply, operating room, pharmacy, and anesthesia supply. Total costs (Parts A and B) were reduced by 11.77%.13

Liability Costs

It’s difficult to measure the liability costs of over-reliance on opioids, but several factors indicate that the costs are real and likely to grow exponentially. First, over-reliance produces negative side effects, complications, and adverse events, which may be the basis of liability claims. Second, over-reliance departs from the practice standards recommended by recognized authorities, which in itself risks liability.

Third, there is a clear national movement toward holding clinicians liable for the consequences of drug dependence and addiction. Congress recently passed the Comprehensive Addiction and Recovery Act (CARA), a bipartisan act that will allow for more education research, treatment and funding for the opioid addiction. The movement is evidenced by the establishment of state-mandated prescription drug monitoring programs in 49 states,– excluding Missouri, making prescribers responsible for knowing the controlled drug profiles and histories of their patients. Judicial precedents apply as well, such as the West Virginia decision permitting addicted patients to sue prescribers despite admission that they were addicted before seeing the prescribers and that they lied about symptoms and injuries.14

Opportunities to Save

The savings opportunity for any particular hospital depends on a number of factors, headlined by the number and nature of surgical procedures performed. An Advisory Board study found that the average 250-bed facility, by optimal intravenous acetaminophen use and opioid reduction, could reduce complication-driven charges from $1,480,000 to $110,000 and length of stay from 1,209 days to 19 days annually. The study concluded that opioid-related complications cost that 250-bed hospital $1.6 million annually.15

The Issue and the Opportunity

Over-reliance on opioids to manage the acute pain of surgery remains widespread despite the ever-increasing knowledge that it’s outdated medicine, high risk, and costly. One recent study estimates that fully seven out of ten patients who receive intravenous pain treatment for acute pain receive opioids alone.

This continuing over-reliance on opioids can be viewed as a problem or an opportunity.  It’s a problem because of the continued reliance on opioids alone. Despite overwhelming literature supporting alternatives, it is also an unique opportunity because now there is a clear solution: moving to a multimodal approach to acute pain management, hospitals can improve their quality of care and at the same time limit costs, reduce risk and improve quality of care.

References

  1. Kampman, S., et al., “Cost and Quality Impact of Multi-Modal Pain Regimens,” Advisory Bd. R&D and Physician Executive Council (2014).
  2. Kessler, ER., et al., “Cost and Quality Implications of Opioid-Based Postsurgical Pain Control Using Administrative Claims Data from a Large Health System: Opioid-Related Adverse Events and Their Impact on Clinical and Economic Outcomes,” Pharmacotherapy, 33(4):383-391 (Apr. 2013).
  3. “Practice Guidelines for Acute Pain Management in the Perioperative Setting: An Updated Report by the American Society of Anesthesiologists Task Force on Acute Pain Management,” Anesthesiology, 116:248-272, 251 (2012); American Society of PeriAnesthesia Nurses, “Pain and Comfort Clinical Guideline,” Postanesthesia Phase I, Interventions, 2.B;  Gustafsson, U.O., et al., “Enhanced Recovery After Surgery (ERAS): Good News for Now, but What about the Future?” Clinical Nutrition, 31.6: 783-800 (2012); and The Joint Commission, “Clarification of the Pain Management Standard PC.01.02.07, vol. 34, issue 11 (Nov. 2004),” and “Sentinel Alert: Safe Use of Opioids in Hospitals,” issue 49 (Aug. 8, 2012).  See, e.g., Wells, N., et al., “Improving the Quality of Care through Pain Assessment and Management,” Patient Safety and Quality: An Evidence-Based Handbook for Nurses, National Center for Biotechnology Information (2008).
  4. The Joint Commission, “Sentinel Alert: Safe Use of Opioids in Hospitals.”
  5. Kampman, S., et al.,“Cost and Quality Impact of Multi-Modal Pain Regimens,” Advisory Board R&D and Physician Executive Council (2014).
  6. See note 2, supra.
  7. Davies, E.C., et al., “Adverse Drug Reactions in Hospital In-Patients: A Prospective Analysis of 3965 Patient-Episodes,” PLOS ONE, 4(2):e4439 (Feb. 2009).
  8. See, e.g., Wells, N., et al., “Improving the Quality of Care through Pain Assessment and Management,” Patient Safety and Quality: An Evidence-Based Handbook for Nurses, National Center for Biotechnology Information (2008).
  9. http://journals.lww.com/pain/Fulltext/2016/06000/Trends_and_predictors_of_opioid_use_after_total.12.aspx
  10. http://archinte.jamanetwork.com/article.aspx?articleid=2532789
  11. Oderda, G.M., et al., “Opioid-related Adverse Events in Surgical Hospitalizations: Impact on Costs and Lengths of Stay,” Annals of Pharmacotherapy, 41(3):400-6 (Epub Mar. 2007).
  12. See note 2, supra.
  13. Duncan, C.M., et al., “The Economic Implications of a Multimodal Analgesic Regimen for Patients Undergoing Major Orthopedic Surgery: A Comparative Study of Direct Costs,” Regional Anesthesia and Pain Medicine, vol. 34, no. 4 (Jul.-Aug. 2009).
  14. Tug Valley Pharm. v. All Plaintiffs in Mingo County, 2015 BL 148172, W.Va. 14-0144 (W.Va. 2015).
  15. See note 2, supra.
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About Author

Anita Gupta

Dr. Anita Gupta is vice-chair and associate professor at Drexel University College of Medicine in Philadelphia, Pa. She is an anesthesiologist, pain specialist and pharmacist and is currently co-chair of the American Society of Anesthesiology Committee on Opioid Abuse and an advisor to FDA.

Norman G. Tabler, Jr.

Norman G. Tabler, Jr., is an attorney in the health practice group of Faegre Baker Daniels law firm. He was formerly senior vice president and general counsel of Indiana University Health, where in addition to leading the system’s legal department, he chaired a number of affiliated corporations, including the Cayman-based captive insurance company and South Carolina-based risk retention group. He may be reached at Norman.Tabler@FaegreBd.com and 317-569-4856.