From Stephen M. Robinson, MD:
This presentation, “Mutltimodal Analgesia… May be Key in Reducing Opioid Use” contains not even a mention of incorporating cannabinoids into the pain management regimen. Perhaps this is one beachhead SCC should attempt to land on.
Retro Message: A quick search just turned up another Multimodal Analgesia study supposedly reviewing all the “Current Concepts.” Keywords: “Acetaminophen; Alpha 2 agonists; Clonidine; Dexamethasone; Dexmedetomidine; Duloxetine; Ketamine; Magnesium; Multimodal analgesia; NSAIDs; Opioids.” And, of course, “Indexed for Medline.” —FG
Multimodal Analgesia, Current Concepts, and Acute Pain Considerations.Helander EM1, Menard BL1, Harmon CM1, Homra BK2, Allain AV1, Bordelon GJ1, Wyche MQ1, Padnos IW1, Lavrova A1, Kaye AD3,4.
Management of acute pain following surgery using a multimodal approach is recommended by the American Society of Anesthesiologists whenever possible. In addition to opioids, drugs with differing mechanisms of actions target pain pathways resulting in additive and/or synergistic effects. Some of these agents include alpha 2 agonists, NMDA receptor antagonists, gabapentinoids, dexamethasone, NSAIDs, acetaminophen, and duloxetine.
Alpha 2 agonists have been shown to have opioid-sparing effects, but can cause hypotension and bradycardia and must be taken into consideration when administered. Acetaminophen is commonly used in a multimodal approach, with recent evidence lacking for the use of IV over oral formulations in patients able to take medications by mouth. Studies involving gabapentinoids have been mixed with some showing benefit; however, future large randomized controlled trials are needed. Ketamine is known to have powerful analgesic effects and, when combined with magnesium and other agents, may have a synergistic effect. Dexamethasone reduces postoperative nausea and vomiting and has been demonstrated to be an effective adjunct in multimodal analgesia. The serotonin-norepinephrine reuptake inhibitor, duloxetine, is a novel agent, but studies are limited and further evidence is needed. Overall, a multimodal analgesic approach should be used when treating postoperative pain, as it can potentially reduce side effects and provide the benefit of treating pain through different cellular pathways.