A multisociety organizational consensus process to define guiding principles for acute perioperative pain management

Abstract

The US Health and Human Services Pain Management Best Practices Inter-Agency Task Force initiated a public–private partnership which led to the publication of its report in 2019. The report emphasized the need for individualized, multimodal, and multidisciplinary approaches to pain management that decrease the over-reliance on opioids, increase access to care, and promote widespread education on pain and substance use disorders. The Task Force specifically called on specialty organizations to work together to develop evidence-based guidelines. In response to this report’s recommendations, a consortium of 14 professional healthcare societies committed to a 2-year project to advance pain management for the surgical patient and improve opioid safety. The modified Delphi process included two rounds of electronic voting and culminated in a live virtual event in February 2021, during which seven common guiding principles were established for acute perioperative pain management. These principles should help to inform local action and future development of clinical practice recommendations.

Research priorities for the surgical care of patients taking opioids preoperatively

“…The impact of opioid exposure on the efficacy and risk profile of different non-opioid modalities is also not known. Lastly, while multiple societies have recently published recommendations regarding strategies for postdischarge analgesia, follow-up, and tapering plans, this is an important next step that has not yet been enacted 8. The exclusion of opioid-exposed patients from these efforts is likely in part because of the general consensus that these patients are likely physiologically different, yet a standardized definition of exposure that allows these patients to be categorized and studied does not exist.…”

Regional anesthesia and enhanced recovery after colorectal surgery: are we asking the right questions?

“…Use of multimodal analgesia for providing effective postoperative pain management and decreasing opioid-related side effects is evidence-based12 and incorporated into every enhanced recovery protocol 10. Multimodal analgesia has also been promoted as one of the key principles of acute perioperative pain management endorsed by 14 medical and surgical organizations 13. Although the present study may be criticized for combining all local anesthetic techniques (eg, neuraxial blocks, fascial plane blocks, wound infiltration) into one cohort, it is true that all of these interventions represent various approaches of delivering one class of medications—one class out of many that may comprise a multimodal analgesic regimen 13 14.…”

“…Multimodal analgesia has also been promoted as one of the key principles of acute perioperative pain management endorsed by 14 medical and surgical organizations 13. Although the present study may be criticized for combining all local anesthetic techniques (eg, neuraxial blocks, fascial plane blocks, wound infiltration) into one cohort, it is true that all of these interventions represent various approaches of delivering one class of medications—one class out of many that may comprise a multimodal analgesic regimen 13 14. Given the multiple components of multimodal analgesia nested within the many more elements of an enhanced recovery protocol, it is nearly impossible in our opinion to tease out the individual importance of one intervention, regional analgesia, especially if there is overall high adherence to all bundle elements.…”

“…In truth, while many may assume that multimodal analgesia is universally practiced in modern surgery since many guidelines have recommended it,13 15 16 there is still much room for improvement. The practical application of multimodal analgesia may be challenging at times as certain categories of analgesic modalities may be used more often in some surgeries and avoided in others 17.…”

“…However, we now have evidence that patient factors may influence postoperative pain trajectories,21 and we cannot reliably predict in advance which patients will have greater than expected postoperative pain and benefit most from regional analgesia. It is common to exclude patients with chronic pain and long-term opioid use from randomized clinical trials of postoperative pain management and even clinical practice recommendations,13 so we do not know which multimodal analgesic regimen within an enhanced recovery protocol will work best for these patients. Further, as clinicians, we cannot make the decision as to whether or not regional analgesia is in the best interest of patients without measuring outcomes that matter to them and involving them in the decision-making process.…”