with novel mechanisms of action and formulations," adds Dr.
Memtsoudis, "but there is little clinical evidence showing they work
any better than established medications."
Coping in comfort
The stakes have never been higher for widespread implementation of
multimodal anesthesia as more complex procedures causing signifi-
cant pain are being performed in the outpatient setting. Dr.
Memtsoudis says a basic approach is often best.
He says patients will often respond well to peripheral nerve blocks,
NSAIDs and COX-2 inhibitors. After discharge, patients who receive
those treatments might report their pain scores as 3 out of 10. "Why
should we give them opioids, with known and serious side effects, to
reduce their pain scores even more?" he asks. "Is the risk worth such
a small gain?"
Instead of requesting patients to attach a number to their pain, ask
if they can cope with the discomfort they're feeling. "That's the ques-
tion we need to be asking," says Dr. Memtsoudis. "Work on patient
education and setting proper expectations about surgical pain, and
explain pain is part of the healing process."
Dr. Schwenk points to the importance of attacking pain on many
levels and at different points along the pain arc, and reserving opioids
for treating severe breakthrough pain.
"Opioids were never intended to be used as the cornerstone of
post-op pain management practices," he says. "During the rise of the
crisis, they became relied upon too heavily. By taking steps to alter
the trajectory of pain in the perioperative period, we can reduce post-
op acute pain that turns into chronic pain and continues the vicious
cycle of the epidemic."
OSM
2 4 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • J A N U A R Y 2 0 2 0
