Hi, my name is Mark Pickett, and I'm speaking on Optimizing Acute Pain Care, How to Implement Multimodal Treatment Strategies Across Clinical Settings. This event is part of the Providers Clinical Support System, Medications for Opioid Use Disorder. And the goal here is to increase professionals' knowledge, skills, and confidence in evidence-based practices as we approach prevention, treatment, recovery, and harm reduction for opioid use disorder. Here's some disclosures to note. So for today's talk, our hope is that we'll be spending time to define components and the benefits of multimodal treatment in the context of acute pain care. We'll be talking about steps in terms of implementing multimodal treatment of acute pain in different clinical practice settings. We'll also compare the current state of evidence for various acute pain treatment modalities. And we'll spend some time analyzing how best practices for acute pain treatment would be applied through case examples. So first, let's start by thinking a moment about what acute pain is. There are several features that help to distinguish acute pain from some of its counterparts of chronic pain or subacute pain. Acute pain is one of those things that we've all likely experienced, typically a sudden and onset. And we can imagine situations where we might have injured ourselves, we feel this sharp or intense sensation. In terms of timing, we know it's certainly when it's sudden, it can come on very quickly. And then in terms of how long it lasts, this can range from whether it's several seconds to minutes, days, or even weeks. And this contrasts a bit with how we think about chronic pain, which is where pain is persisting for three months or more, based on most of our definitions, or when pain lingers around for a longer time period than just several weeks, but it doesn't quite become chronic. And we often think of pain in that one to two months as a subacute type of pain. Typically, the most likely cause for acute pain is frank tissue damage that happens. And it's the body's natural and protective response system to help inform the fact that that tissue damage is happening. And then when we think about the consequences of acute pain, if it's not adequately treated, this can lead to worse pain down the road, whether that's transition into subacute and chronic pain or other issues that happen. What are common types of acute pain that individuals can experience? Well, there certainly is a wide gamut. And here are some of the most common conditions that are represented. Back and neck pain certainly impacts a large proportion of the population and is a significant driver of disability. Pain can certainly arrive from issues related to nerve or nerve injury, and neuropathic pain is another category of pain. Pain happens after tissue injury, and sometimes that happens during surgery with surgical incisions. Pain can come about from other chronic conditions, such as sickle cell disease. It can happen with kidney stones. This can happen in the setting of dental procedures or just frank issues with teeth that can cause quite a bit of pain. And then musculoskeletal injuries are another acute pain common condition that happens. When we think about treating acute pain, here we'll discuss what some of the components of multimodal pain treatment consist of. And under the umbrella of all the ways to treat pain, we can divide them up into different categories. And one category system that is sometimes useful is thinking about the different treatments from the perspective of what types they are, and these can include non-pharmacologic treatments. These include medications, and within medications, we often have classes that consist of prescription opioids or non-opioid medications. And so under the umbrella of multimodal treatment of pain, we often think about ways that we can emphasize non-opioid medications and also non-pharmacologic treatments. So using a combination of these different analgesic medications as well as techniques to target multiple pain pathways, this is really the essence of what multimodal treatment of pain is all about. Part of the reason that we would like to approach pain from this way of treating pain is the way that pain pathways in the body have been studied and are known to exist. And so here's a fairly simple view of how a painful stimuli ends up coming into the body and getting processed and eventually registered as pain. Now this process happens in less than a second in our own bodies, but typically there's this painful signal as shown by the fire down by the foot. And that signal gets transduced into important communication signals through the pathways within the body. The signal then gets transmitted in the second step where it travels through peripheral nerves, comes in through the spinal cord, and travels again upwards towards the brain where we have that third step, the perception of pain. And so this is where it registers with our consciousness. And we not only have typically an experience noting that, but often there's an associated emotional response with pain there in our limbic system. And importantly, there is this fourth step in which there can be pathways for pain that actually go back in the opposite direction. And these are shown by that fourth step, the modulation that happens there. So while a more nuanced understanding of this is a little bit beyond the scope of today's talk, these steps in the pain communication pathway really set up our approaches to thinking about multimodal pain treatment and ways that we can modify this process all along the pathway that is outlined here. These medications that we think about often begin with non-opioid medications and ways that we can combine them. And the thought is that by combining them, we have these medication classes, which are shown by some different examples here, and they all have slightly different mechanisms by which they can work to help alleviate pain. One of the most common types of medication classes are non-steroidal anti-inflammatory drugs, commonly referred to as NSAIDs. So we can think of examples of these being ibuprofen or naproxen. And the way these medications work are by inhibition of the cyclooxygenase enzyme that is there. Local anesthetics represent another important medication class when it comes to multimodal analgesia. And so these are numbing medications, commonly referred to as lidocaine, bupivacaine, that end up inhibiting our sodium channels. You can see different medication classes that are listed here, and the important thing is to recognize that, again, the mechanisms, when they are slightly different, these can permit the drugs to be used in combination, and hopefully we'll end up needing to use a little bit of a lower dose of them to help end up resulting in pain relief for individuals who are experiencing pain. In addition to thinking about the medications, when we talked about multimodal pain treatment, we mentioned that there are different techniques that may contribute to helping relieve acute pain. And so what are some examples of those techniques and the benefits and drawbacks that they may have? Well, among several ways to help with pain treatment, these can include neuraxial blocks or a couple different types of racial anesthesia. So to be a little bit more specific, neuraxial blocks often include things like epidural catheters. These can be for people who have surgery or women who are in labor and in need of pain relief. A spinal block or getting a spinal anesthetic is another example of a neuraxial block. And so, like all treatments in medicine, there are certain benefits and drawbacks to these types of multimodal analgesic treatments. Often with neuraxial blocks, these will result in lower pain scores and opioid use, in particular in acute pain settings like surgery. They can have side effects based on the types of medications and the doses that are given with them. And those could include low blood pressure, individuals who may experience a headache after access to the epidural or dural space. And in some instances, if people have challenging anatomy or other situations may occur clinically, sometimes these techniques may not work in all patients, and that's an important thing to be recognized. What's another example of a technique that's important in multimodal analgesia? Peripheral nerve blocks are another important category. And here are a few select nerve blocks that are listed here, though there certainly are many more than we could list. These examples include interscaling blocks, transverse abdominous plane blocks for abdominal surgery, among others. And similar to neuraxial blocks, these often will lead to lower pain scores and opioid use. There are times where the medicine that's given in these blocks, if they're not given through a catheter, may end up wearing off, and then individuals' pain may come back after that. There are also ways in which nearby structures, when the medicine is placed, could be susceptible to having injury. Though with the use of ultrasound guidance in the last few years, these risks have really decreased. Other techniques that are listed here, intravenous infusions of some of these different medications like lidocaine or ketamine, wounded infiltration, again, just to show you different ways that techniques. And while this isn't an exhaustive list, again, we're showing you different examples of ways that we can combine these techniques to then help result in lower pain scores, better recovery, and or an experience while having acute pain. So what are the main goals or benefits of this multimodal treatment in acute pain? Well, one thing that certainly is an overarching goal is to just improve the management of pain itself. And so in terms of lessening any of the suffering that may come along, any of the emotional experiences, as well as the intensity of the pain. One way in which these techniques and medications are thought to help is by lowering doses of other analgesics that are needed. Now these other analgesics or pain medications may be non-opioid medications, but they may also be opioids as well. And typically, when individuals need lower doses of a medicine, they're also going to be less likely to experience side effects from that medicine. As we mentioned before, all medicines that are prescribed or used by patients certainly have benefits as well as risks, and one of those risks ends up being side effects that they experience, which are typically dose-dependent. And so that means that as a dose of that medicine changes, so too does the likelihood that a patient may experience side effects. Overall, the goal here really is to enhance patient outcomes and again help to lessen the suffering that may be occurring with acute pain. So here, just to restate one of the important points about multimodal analgesic treatments, here the goal really is to maximize the benefits and minimize adverse effects for a pain regimen. And typically, this is done by reducing the need for opioids. It's important to understand that there are pros and cons, certainly, to different non-opioid treatments for pain. And that really here, trying to reduce the reliance on opioids is one of the important goals. Now that's not the same as eliminating opioid use entirely. There certainly may be situations where that could be appropriate, but it's not to say that there has to be no opioids involved in someone's pain relief regimen at all. All right, let's think about some examples about multimodal pharmacology that show and illustrate some of the points we've spoken about. Let's spend a moment to dive deeper into our examination of non-steroidal anti-inflammatory drugs and acetaminophen and how these commonly available, whether it's over-the-counter or in prescription-strength drugs, illustrate some of these points. So as one example, ibuprofen 200 mg and acetaminophen 500 mg are available both over-the-counter and via prescription. These medicines have different mechanisms of action, and it turns out that each one of these ends up enhancing the ability of the other to help relieve pain. And so while some individuals may not think acetaminophen may do much on its own and perhaps ibuprofen won't be just by itself able to completely eliminate someone's pain, when these medicines are combined, the pain relief reported by patients ends up exceeding that that's expected when either one is taken alone and we consider how much each one should be relieving pain and just put together. Another way of illustrating this point or driving this point home is to compare the pain relief when we combine medicines like ibuprofen and acetaminophen together and compare them to other medicines like opioids. And so in some studies that have been published, we've seen that more patients were able to experience significant pain relief when they've taken a combination of ibuprofen and acetaminophen, and that pain relief was actually more profound than with a dose of oxycodone that was 10 mg, and when that medicine, oxycodone, was combined with acetaminophen. So certainly, whether it's over the counter or as a prescription strength, this use of NSAIDs and acetaminophen is one of the most powerful ways to help relieve acute pain when patients are able to take both of the medicines together. If we think about our general approach to multimodal pain relief, there exists a fairly broad support across several professional societies to use multimodal strategies to help relieve pain, and so this support really spans across the multidisciplinary spectrum. Several professional groups have weighed in, evaluated evidence about best practices and how patient care should be delivered and recommended for multimodal approaches to be available to patients and kind of tailored to their particular conditions and experiences of pain. In particular, one group is this Pain Management and Best Practices Interagency Task Force report, stating here, you know, a multimodal approach that includes medications, nerve blocks, physical therapy, other modalities, should be considered for acute pain conditions. Fourteen professional societies have signed on to a consistent statement noting that clinicians should offer multimodal analgesia for the treatment of postoperative pain in adults. And groups like the American Nurses Association have come out with statements that multimodal and interprofessional approaches are necessary to achieve pain relief. So we see fairly broad support across various professional groups about the use of multimodal pain relief. That being said, there are certainly challenges that come up with the delivery of acute pain management using multimodal strategies. And so many factors of a patient and even beyond the patient end up influencing the decision for what types of treatment are offered, and that includes multimodal approaches. You know, here we see certainly setting, clinical environment, patient characteristics are important factors that make a difference here. And it has been observed that clinicians may take pain less seriously in some groups of patients. And those groups that have certainly been documented in literature could include women, people with a history of substance misuse, age certainly could play a role here. And so it's important for practitioners to recognize about these situations and certainly consider in their own practices how we may best serve the patients who we care for in ways that really help to individualize our care and meet them best where they're at. Let's shift for a moment as we've thought about multimodal pain treatment regimens to thinking about ways to implement them and help them come into practice. We'd really like to outline some of the steps for making clinical care incorporate multimodal treatment regimens. That can include the assessment, planning, and execution of multimodal treatment strategies. And here we see often these revolve around implementing some standard care pathways where in various clinical settings, we consider some elements that are outlined here. And so these could be condition-specific treatment plans, protocols to enact nerve blocks, the use of epidural analgesia, order sets that emphasize multimodal treatment and non-opioid medication options, and programs or protocols like the enhanced recovery after surgery program. Here we've taken those same types of pathways and then linked them to various care settings where you can see, while certainly these aren't just the only care settings where these may be applicable, there are certainly ones in which they could or have been applied out there. So for the ambulatory clinic, having condition-specific treatment plans such as ones for commonly seen chronic pain conditions like back pain, someone who has acute back pain can help ensure that multimodal treatment for that condition is getting implemented in a way that clinicians can easily use and patients can then more easily receive. In emergency room settings, nerve block protocols, for example, for individuals who have hip fractures or others, may help end up reducing the need for opioids and improving pain management there. Epidural analgesia we mentioned as one option for pain treatment on the labor ward. Acute pain order sets certainly can apply to a variety of settings. And then in perioperative environments, this enhanced recovery after surgery. All right, we'll shift and speak for a moment on interdisciplinary approaches to acute pain management for surgery. And certainly there are various roles that physicians, nurses, physical therapists, psychologists can play when it comes to the multimodal treatment of pain. Here we've outlined a few roles that clinicians in the surgical setting may play. And one example among several for ways in which that particular clinician may contribute to multimodal pain treatment. For the anesthesiologist, regional anesthesia certainly comes to mind about deciding if a nerve block is appropriate and offering that and performing that with the patient. Among the many ways that nurses may help with being involved with multimodal treatment of pain, this includes assessing pain levels and administering non-opioid analgesics in these acute care settings. Pharmacists, importantly, can help educate patients on the proper use of non-opioid analgesics. And surgeons, certainly one small thing would be thinking about the injection of local anesthetics into the surgical field if that is appropriate. Let's turn and dive into two case studies. We're going to start with one case study looking at subacute low back pain that's here. And so we'll describe background about a patient and then dive into a few questions and look at evidence supporting information about the case study. Here we're looking at a patient who we've called Michael, who's a 59-year-old male. He's an electrician and coming to his primary care provider. He has low back pain. It started about five weeks ago after lifting some heavy objects at work. And the pain that he describes, this is a dull, achy pain, rating slightly to his buttocks. He denies muscle spasms. He notes no history of chronic pain. And he also says there's no difficulty with sleep. He does have history of a single vessel coronary artery bypass about six years ago. His examination includes no signs of radiculopathy or neurological deficits, fortunately. And then red flag symptoms were not present. These would be things we would be looking out for like urinary retention, fever, recent trauma, unexplained weight loss, history of cancer, not there. So here with the case with subacute low back pain, the question is, which approach is most likely to have the best benefit to risk ratio for improving acute pain management and enabling return to work? So our four options here are A, a trial of cyclobenzaprine 10 milligrams daily for two weeks. B, an injection of intramuscular catorlac while in clinic, C, the prescription of duloxetine 60 milligrams daily for 30 days, or D, advice to remain active and referral for physical therapy and exercise therapy. All right, for low back pain there are several different treatment guidelines and evidence summaries that exist that review evidence as it relates to the best treatment as well as multimodal treatment for low back pain. And here we would put an emphasis that all of these, when we examine them, typically call out multimodal strategies as one of the best ways to help manage low back pain. Among the different organizations that are out there, the American College of Physicians has non-invasive treatments for acute, subacute, and chronic low back pain. Within the Veterans Affairs and the Department of Defense, there's an evidence summary about the diagnosis and treatment of low back pain. The American Physical Therapy Association has this Interventions for the Management of Acute and Chronic Low Back Pain, and HRQ has Treatments for Chronic Pain, a systematic review collection that dives into evidence for low back pain. All of these agree about pursuing a multimodal strategy for treating pain that's there. And so once we dive into these documents, these guidelines and evidence summaries agree that a layered approach is really preferred for managing low back pain, progressing from less invasive and risky treatments to those that are more so. And so this layered approach certainly applies to acute and subacute low back pain. Here in this case example, the pain's gone on for about five weeks. We're out of that acute pain window and into this subacute window. Really it's this kind of tie between acute and chronic pain that is there. And this multimodal analgesia really builds again on the non-pharmacologic therapies, and these are typically introduced before at the same time as medications that are not opioids. So here we would think about having some shared decision-making with the patient, having some watchful waiting versus using other therapies, thinking about non-pharmacologic therapy, and then non-opioid pharmacologic therapy after that. When we think about pharmacologic considerations for low back pain from a multimodal perspective, we see that there are several different medication classes and examples that pertain to this particular clinical case. For acetaminophen, we see that, you know, one issue here is that there are many other products that can contain acetaminophen. And while it's available over-the-counter, there is this rare but serious risk of skin reactions. There also can sometimes be a general sense that acetaminophen for individuals who are persisting with pain may not be as efficacious as perhaps other treatments. And certainly this has happened in clinical settings when I've seen patients. Non-steroidal anti-inflammatory drugs here, examples we mentioned before, ibuprofen, salicoxib, catoralac, and one of the case study questions asked about getting a shot of catoralac intramuscular dose in clinic. It's important to note that there's a small increase with moderate evidence for increase in cardiovascular events, and in particular in this case, because this patient has had a history of a CABG, that would be a contraindication for the patient's receipt of this treatment. When it comes to antidepressants, duloxetine is one example that's been studied for low back pain. This leads to an improvement in pain intensity, though not function based on moderate evidence from the evidence reviews that are out there. And we do need to be careful about any overlap that may happen with other medicines that end up working on serotonin receptors, so SSRIs come to example there. Gabapentinoids sometimes come up as an example, gabapentin or pregabalin, and these end up sometimes being prescribed off-label for lumbar radiculopathy. Skeletal muscle relaxants also for people who have acute and low back pain, as an example, cyclobenzaprine, often may be employed to address muscle spasm. Now, this patient denied having muscle spasm, and so the utility of prescribing a skeletal muscle relaxant would likely not be as strong as perhaps other treatments that are there. Benzodiazepines and steroids sometimes may be prescribed by clinicians. It's important to note some of the considerations that they have about either their CNS depressant effects, dependency, or abuse potential that can come along with benzodiazepines, as well as the fact that there is a bit of a dose-dependent issue with steroids, as with most medications, but overexposure to steroids certainly in individuals can present some challenges there as well. When it comes to thinking about non-pharmacological considerations for low back pain, here's some evidence from one of the Agency for Healthcare Quality and Research reviews related to different modalities, and then their strength of evidence to help improve individuals' function that is there. And so you can see the modality that really stands out here at the top, the exercise in physical therapy is noted to lead to improvements in functional status, in particular in this one to less than six months after it's initiated, and has a low strength of evidence for improvements in the year, up to one year afterwards. Other therapies have been evaluated, for example, massage, mind, body, and yoga, acupuncture, and spinal manipulation, all with some varying levels of evidence from low to moderate. And then cognitive behavioral therapy is another type of non-pharmacological treatment that has moderate strength of evidence for functional improvement up to one year after having back pain. So when we return to this case study looking at Michael and run through our different approaches that are most likely to have the best benefit-to-risk ratio for improving acute pain management and enabling return to work, we can go through and consider the various options here. The trial of cyclobenzaprine 10mg daily for two weeks seems less ideal given this patient is not endorsing muscle spasm. We mentioned with the injection of intramuscular catortlac while in clinic, this would be contraindicated given the patient's had a history of a single vessel coronary artery bypass. And so the risk with the NSAID would not be appropriate for this patient to be exposed to. Prescription of duloxetine 60mg daily for 30 days. This is a treatment that's appropriate for chronic low back pain. Though at this point in time, advice to remain active in referral for physical therapy and exercise therapy would have a better benefit ratio, both given what we reviewed from the evidence summary as well as the fact that this is a non-pharmacologic therapy. And when we think about layering in the approach, it's appropriate for us to do that prior to thinking about the non-opioid pharmacologic approach in this case study. All right, so what happened with this case? Well, with activity modification, he was able to return to work within a week and his pain intensity gradually diminished over the following one month's time. All right, we'll turn our attention to a second case and dive in about this patient who has post-surgical pain. So to start, we'll call this patient Linda. She's a 57-year-old female who has advanced gynecologic cancer. She has obstructive sleep apnea and then moderate liver dysfunction. She's scheduled to undergo a total abdominal hysterectomy with bilateral salpingo-ophorectomy and lymph node dissection. The surgical approach will be open via longitudinal incision, and she'll be anticipated to be hospitalized for three days after surgery. She has no history of depression, anxiety, or substance use. So here the main question is, which technique of multimodal analgesia is most likely to achieve the largest reduction in opioid requirement and improvement in acute pain management after surgery? And so our options here are infusion of ketamine in the post-operative care unit, injection of Cortorlac into the surgical field, injection of lidocaine via a transversus adverse plane block at the end of surgery, and then preoperative placement of a thoracic epidural catheter with a post-operative infusion. While we're presenting this case study, I think it's important to emphasize that you don't necessarily need to know about which one's most appropriate, as it is to know that there are multiple different options, and really coordination and collaboration with anesthesia colleagues is important in this case. But we also will go through these different techniques to help get everyone up to speed about different levels of evidence that we have at this point in time. Multimodal pain regimens within enhanced recovery after surgery protocols have been examined by various groups, one of which is the Cochrane Review Group, and they published this systematic review looking at preoperative enhanced recovery programs for women with gynecologic cancers in 2022. Here, their objective was to evaluate both benefit and harms of these ERAS programs, and they examined randomized control trials, reaching the conclusion that there was low certainty evidence suggesting that ERAS programs can shorten length of post-operative hospital stay. Now, while they didn't include conclusions there about pain, it's important to note that that would be one of the patient outcomes there that has been enhanced through their use. When we think about these enhanced recovery after surgery protocols, they consist of various components, and so there are some differences based on whether it's the site, institution, or the protocols, and that within these, typically, multimodal analgesia is one of the most common, if not the kind of universal component that stands out in enhanced recovery after surgery protocols. These are offered in addition to other components of the ERAS pathway, and that can sometimes make it challenging to isolate their specific impact in the studies that are out there. We'll turn for a moment and think about ketamine infusions for acute pain management. Ketamine is a compound that acts on N-methyl-D-aspartate, or NMDA, receptors as an antagonist, and has dose-dependent effects, and this can range from providing just simple analgesia at low doses to sedation or even anesthesia if given at much higher doses. Typically, ketamine is showing an opioid-sparing effect, one of the reasons it's often thought of in multimodal pathways, though it does have a side effect profile that can commonly include hallucinations, individuals feeling poorly. This can lead to elevations in blood pressure. For example, systolic blood pressure is greater than 160, elevations in heart rate, whether that's more than 100, more than 120, or more than 130 out there, and some of these risks that come along with these common side effects really depend on the patient's condition and certainly are one other way in which we speak about tailoring multimodal therapies to patients, but the considerations for risk here should be tailored to patients as well. Part of the reason we bring up ketamine infusions are there have been some recent consensus guidelines on their use for acute pain management that are published by a few different pain societies. And so on the question of which patients and acute pain conditions should be considered for ketamine treatment, this consensus statement mentioned that some anesthetic ketamine infusion should be considered for patients undergoing painful surgery with a grade of evidence of B and a level of certainty that was moderate. And so ketamine in particular may also be considered for opioid-dependent or opioid-tolerant patients undergoing surgery with a similar grade of evidence and a low level of certainty. They also have some other recommendations here as well when it comes to other conditions as well, but these top two speak to individuals who are undergoing surgical procedures. On the question of what are contraindications to ketamine infusions in the setting of acute pain management, these same consensus guidelines noted that ketamine infusion should be avoided in individuals who have poor control of cardiovascular disease, pregnancy, or access to pregnancy or active psychosis, severe hepatic disease like cirrhosis or elevated intracranial pressure and elevated intraocular pressure. And then also that ketamine should be used in caution in individuals with moderate hepatic disease. So you can see the various grades of evidence here and levels of certainty that range from low to moderate. Obviously a consensus statement doesn't mean that there's no way for patients who have these conditions to receive it, but that the general guidance is the suggestion. And in our case, we would likely adhere to the statement that we would only think about this being used with caution in our case example here, given the patient demonstrates some hepatic disease. And that would factor into our case in that way. All right, wound infiltration was one example we had mentioned earlier in the lecture of a multimodal technique to use. This is where there's injection of a local anesthetic or other analgesics into the incision at the conclusion of the surgery, typically by the surgeon. The pros are that this is quick and relatively straightforward to perform. And the benefit or drawback is about the duration of action, that it often is dependent on the local anesthetic medication that's injected. And so the duration really is dependent on the type of medication, as you can see here with results lasting up to several hours after surgery. This technique is unlikely to address pain at locations other than just the incision. So someone has a deeper abdominal surgery, there may be pain that's not addressed there. Or if there are multiple surgical sites, it could be difficult to address each one of those. As one example of regional anesthesia techniques, the transversus abdominis plane or TAP block is one approach to address pain with abdominal incisions. Here we are placing local anesthetic medications between the internal oblique and the transversus abdominis muscle, which is shown and depicted by a cartoon diagram over here, where the purple arrow is leading to the purple circle. This targets the lower thoracic and upper lumbar nerves that supply the abdominal wall and is typically administered through a single application, we call that a single shot, or a one-time placement of the medication. And this duration, again, is contingent on the local anesthetic, typically lasts for several hours. Complications certainly could include this not working or issues with surrounding structures that are there as well. And then to explore one other regional anesthetic technique, that of the thoracic epidural catheter. So this is where an infusion of a local anesthetic with or without opioids happens into the epidural space. And here we're targeting, along the pain pathways that we reviewed a bit earlier, the spinal nerves of the thoracic and perhaps the lower lumbar region, depending on displacement. This is really to reduce the need for systemic opioids. And sometimes challenges, as we alluded to earlier, could come up if individuals have anatomical variations through spinal deformities or scoliosis that leads to difficult placement. And then there certainly are ways in which someone's coagulation or infection status may make placement of an epidural inappropriate. And then here we think about challenges that can come up, potential complications about one-sided blocks, low blood pressure, if these end up blocking motor nerves, urinary retention, things like that. When it comes to recommendations on multimodal analgesia for abdominal surgery, we have guidelines from 2019 from the Enhanced Recovery After Surgery Society. And here they've issued a few statements. One is about the combination of acetaminophen and non-steroidal anti-inflammatory drugs. We have high quality of evidence and a strong level of certainty. One of the topics we alluded to earlier directly on one of our slides. And when it comes to thoracic epidural analgesia, moderate quality of evidence and a strong level of certainty for that use. And then for transversus abdominus plane blocks, low quality of evidence with a strong level of certainty. So if we return to our patient Linda, the 57-year-old female who advanced gynecologic cancer, who is having abdominal surgery and thinking about techniques of multimodal analgesia, most likely to achieve the largest reduction in opioid requirement and help improve her pain recovery after surgery. We spoke about these different options in terms of infusion of ketamine, where this moderate liver dysfunction makes us a bit more cautious about using that technique. Injection of Catorlac into the surgical field certainly would have a briefer duration of action than perhaps other options. Lidocaine from a tap block at the end of surgery has a lower basis of evidence compared to placement of a thoracic epidural with post-operative infusion there. So before surgery, epidural catheter was placed via a loss of resistance technique at a lower thoracic level. And then after leaving the operating room, an infusion of bupivacaine, 0.125%, was started with a continuous infusion of 6 mLs per hour and then a patient-controlled demand dose of 2 mLs with a one-hour lockout. Now, this patient also received acetaminophen and ibuprofen scheduled around the clock. And then the epidural was removed on post-operative day two, and the patient was discharged home with 5 milligrams of oxycodone, 5 milligrams, sorry, 5 pills of oxycodone, 5 milligrams for breakthrough pain. All right, when it comes to thinking about best practices in acute pain management, we've emphasized the administration of acetaminophen and NSAID analgesics together and on a scheduled basis as one important point. And we would do that instead of doing this on an as-needed basis, meaning patients have to request it. In particular, if acute pain has just started, they're immediately after surgery, taking them around the clock and on a scheduled basis certainly is one way to help promote their most effective use. We do need to be cautious about thinking about sedating analgesic agents in patients older than 65 years of age. That's a statement that applies not just to certainly one particular clinical setting. So whether surgery, the emergency room, the outpatient pain clinic, analgesic agents that we initiate certainly may have different impacts as individuals age, and in particular for those who are at the extremes of age. We do want to make sure and adapt protocols that emphasize non-opioid analgesics and various techniques such as non-pharmacologic techniques to help treat acute pain and manage it, and then ensure that these can be tailored to the needs of patients. And one way to do that is to make sure that patients do have at least a few options to choose from based on what techniques may make sense based on the acute pain condition that they're having. All right, so just to summarize and review our key takeaways here, today we spent time talking about how multimodal analgesia relies on combining different analgesic medications and techniques to target the multiple pain pathways. We saw the cartoon diagram and outlined the different steps that pain takes as it comes up to be perceived, and then ways in which we can impact that along the way through different treatments. We mentioned that acetaminophen and NSAIDs are key non-opioid analgesics. There are several medications that have different mechanisms, and they exist really to help us with multimodal treatments and impact how pain is transmitted, how it's modulated, and how those signals end up leading to someone's acute pain experience. Techniques for multimodal analgesia, these include certainly interaxial and peripheral nerve blocks, catheters, intravenous infusions, wound infiltration, among others that are out there. And so here we've kind of opened up a few items among the many on the menu of multimodal treatments. We've mentioned that by reducing the use of opioids, one of the goals of multimodal analgesia is to lead to better patient outcomes, improvements in pain, and also the reduction in adverse effects or side effects that patients experience. And one of the kind of final key takeaways to emphasize is about multimodal treatment that really is here to treat pain more effectively and prevent the progression to more severe and longer lasting types of pain. There's decent evidence that by treating acute pain effectively, we are helping to prevent and ward off chronic pain that may arise in the future. Here are relevant references for the talk. And final slides.

acute pain management

multimodal treatment

evidence-based practices

non-opioid medications

non-pharmacologic interventions

interdisciplinary approaches

chronic pain prevention

pain management strategies