Study Suggests Multimodal Pain Care Leads to Shorter Hospital Stays, Lower Opioid Doses After Surgery

Feb. 18, 2016, PALM SPRINGS, Calif. –- Pain care for patients already taking opioids can be improved by bringing together multiple non-opioid treatment modalities during hospitalization, a prospective pilot study showed. Patients so treated were less likely to be readmitted to the hospital within 60 days, according to results reported in a scientific poster at the 32nd Annual Meeting of the American Academy of Pain Medicine.

A chief concern of the researchers was the high hospital readmission rates historically seen in opioid-tolerant patients due to continued pain symptoms (Gulur et al Pain Physician 2014;17:E503-7). Opioid-tolerant patients who arrive for surgeries or procedures are at heightened risk of suffering acute pain and in particular need of an alternative treatment plan, said the study’s lead author, David A. Edwards, MD, PhD, clinical chief of Pain at Vanderbilt University Medical Center in Nashville, Tenn.
“The transition from in-hospital to out-of-hospital is where the problem lies,” Dr. Edwards said. “Clinicians need to know what they can offer patients other than opioids to treat pain and suffering, especially when the patients arrive on high-dose opioids already.”
For many surgical and nonsurgical patients, opioids are still the best and most potent way to treat pain, he said. However, evidence indicates that the rise of opioid use, particularly when used in isolation, does not correspond to better pain control or patient satisfaction but rather contributes to poor patient outcomes and a societal burden when patients are eventually discharged on higher-than-ever doses (Apfelbaum et al Anesth Analg 2003;97:534 40, Herzig et al J Hosp Med 2014;9:73-81).
“Society suffers when patients suffer,” Dr. Edwards said. “The cost of risk-managing prolonged opioid therapy for an ever-increasing pool of patients on opioids overextends the medical system.” 
The Targeted Care Pathway treatment protocol involved grouping together evidence-based features, found by a literature search and multidiscipline expert review. Components of the Pathway included early patient identification, pharmacist-enhanced services, patient and professional education, early pain specialist consultation, opioid-sparing multimodal therapies, primary care collaboration and patient engagement. Investigators looked primarily at 60-day hospital/emergency room return rate along with opioid consumption, use of adjunctive analgesics, functional recovery satisfaction and cost of care.
Results showed that readmission rate, length of stay and opioid dose dropped as the use of multimodal medical analgesia grew. The return rate was 28 percent for the 18 opioid-tolerant patients who received Pathway care compared with 40 percent for usual care, representing a 30 percent effect size. No adverse events or change in patient satisfaction were reported.
The next step is to complete a randomized controlled trial at the study’s three medical centers: Vanderbilt University Medical Center, Massachusetts General Hospital and Brigham and Women’s Hospital. The ultimate aim is to change the standard of care for treatment of this group of patients. This would include practitioner education in multimodal pain management strategies to prevent opioid escalation and to help patients taper off of high-risk medications after surgery.

Said Dr. Edwards, “The day has come and gone where solely using opioids to manage pain in noncancer patients is considered appropriate care.”

Poster 172 – A Targeted Care Pathway to Improve Outcomes for Opioid-Tolerant Patients: A Pilot Study 

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American Academy of Pain Medicine