By Annette M. Boyle
WASHINGTON—Since the rollout of the VA’s Opioid Safety Initiative in 2014, the department has aggressively focused on developing non-narcotic alternatives to reduce opioid use for chronic pain. Now, attention is turning to options that delay or reduce the need for opioids for pain related to diseases, such as cancer or following trauma or surgery.
A multimodal approach to treating pain has gained traction in the VA and DoD as the preferred approach to management of acute as well as chronic pain. Multimodal pain management combines several agents from different pharmacologic analgesic classes that affect different mechanisms in the pain pathway to achieve more-effective pain control with fewer adverse side effects. This technique can combine regional anesthesia or nerve blocks, nonopioid medications and complementary integrative health services.
Multimodal pain management techniques can help delay and reduce opioid use following a procedure or injury by harnessing the synergistic action of multiple agents. The approach might also enable patients to avoid the complications of opioid-based analgesia, which include delayed recovery, hypoventilation, atelectasis, nausea, vomiting, urinary retention, pruritus, prolonged ileus, dizziness and confusion, according to Leopoldo Rodriguez, MD, a director of the Society for Ambulatory Anesthesia.
Anticonvulsants and nonsteroidal anti-inflammatories and other drugs can be effectively combined with reduced dosages of opioids to control pain in this context. “There is evidence that certain non-opioid medication given perioperatively (including gabapentin, pregabalin, ketamine, and acetaminophen) may reduce opioid requirements postoperatively,” explained Friedhelm Sandbrink, MD, deputy national director of pain management at the VA.
Other options include use of a single agent with dual mechanisms of action such as tramadol or tapentadol. Both medications act as mu-opioid receptor agonists and inhibit reuptake of serotonin and norepinephrine, respectively, according to Kevin Galloway, BSN, MHA; Chester Buckenmaier III, MD; Rollin M. Gallagher, MD, MPH; and Rosemary Polomano, PhD, RN, the authors of “War on Pain,” which outlines multimodal and multidisciplinary therapies for pain management in the VA and DoD.1
Other agents that might be used for multimodal analgesia include lidocaine, bupivacaine, COX-2 inhibitors, dexamethasone, clonidine and dexmedetomidine. A study of liposomal bupivacaine during major colorectal surgery found that the multimodal approach provided better pain control, reduced opioid use significantly up to 72 hours post-surgery, shortened hospital stays from nine days to 7.2 days and was associated with fewer adverse events compared with those receiving conventional pain management with intravenous opioids.2
Nonsteroidal anti-inflammatories such as naproxen, ibuprofen, diclofenac and ketorolac also are used to reduce the need for opioids. IV ibuprofen, for instance, was associated with a 31% reduction in morphine use in the 28-hour, post-surgery period in one study. Patients emerged from surgery with less pain and reported lower pain levels throughout their recovery.3
“For acute pain management after surgery or injury with localized tissue injury, especially as it relates to the extremities, regional anesthesia is also a very effective way to provide pain management temporarily. This is used at selected VA facilities that have anesthesiologists with such expertise on staff,” Sandbrink told U.S. Medicine.
Regional anesthesia essentially “blocks” pain in a portion of the body and, generally, “single shot” nerve blocks last between four and 24 hours. In a continuous peripheral nerve block (CPNB), a catheter can be inserted in the proximity of a target nerve to extend the duration of pain relief by providing continuous local anesthetic infusion with marcaine, ropivacaine or similar drugs. This method offers advantages in pain relief, outcomes and patient satisfaction, according to Galloway and co-authors, and is particularly useful for servicemembers who have experienced polytrauma and require multiple procedures, dressing changes and debridements.
One option is to combine regional anesthesia with general anesthesia during a procedure, which might reduce the amount of general anesthesia needed during surgery, as well as the amount of pain medication required afterward, according to the American Society of Regional Anesthesia and Pain Medicine. CPNB analgesia reduces the time to discharge and can be continued outside of the hospital setting, notes the society.
In addition, CPNB can be used instead of patient-controlled analgesia for postoperative pain. In one study, patients using patient-controlled analgesia required 30 times more opioids, compared to those with a nerve block on the first day following surgery.4
Alternatives for Cancer Pain
Options to opioids also exist for some types of cancer-associated pain. For example, when combined with prednisone, the androgen biosynthesis inhibitor abiraterone acetate delays the progression of pain and associated decline in quality of life for chemotherapy-naïve men with metastatic castration-resistant prostate cancer. A study in Lancet Oncology found that the combination extended the median time to progression of mean pain intensity by eight months (26.7 months vs. 18.4 months) and extended time to pain interference in daily life, and time to initiation of cytotoxic chemotherapy compared to those receiving prednisone alone.5 A study in the New England Journal of Medicine found that the abiraterone acetate/prednisone combination significantly delayed the time to opioid use (not-reached vs. reaching opioid use within 23.7 months).6
In addition to multimodal pain management and nonopioid pharmacological interventions to reduce opioid use, the VA has also increased access to and use of nonpharmacological interventions and integrative medicine modalities such as acupuncture, yoga, mindfulness and cognitive behavioral therapy for both acute and chronic pain. Medication, psychotherapy and other modalities also are employed in comprehensive pain rehabilitation programs. “VA has specifically articulated the goal to have at least one fully accredited pain rehabilitation program within each VISN,” Sandbrink said.
The intensified focus on developing new options for pain management and educating both prescribers and patients about the risks posed by opioids appears to be having the desired effect. “Overall evidence from the opioid safety initiative is that the volume of opioids prescribed within VA has decreased,” said Alison Whitehead, health system specialist with the VA’s Office of Patient Centered Care & Culture Transformation.
The VA reported recently that, from July 2012 to June 2015, 115,575 fewer VA patients were receiving opioids and 100,074 fewer veterans were on long-term opioid therapy. In addition, 13,731 fewer patients were receiving greater than or equal to 100 morphine equivalent daily dosing.
To gather more specifics about various nonopioid pain management alternatives, the VA’s Office of Health Services Research & Development has more than 80 research projects in process. Those will help the VA determine the efficacy of various integrative health services to treat and address a variety of conditions and effectively relieve acute and chronic pain.
Whitehead told U.S. Medicine that HSR&D also is planning a state-of-the-art meeting in November to “evaluate the evidence on the effectiveness of nonopioid therapies for pain, identify promising practices and operational barriers, and set the research agenda on nonopioid therapies for pain.”
1 Galloway Kt, Buckenmaier CC, Gallagher RM, Polomano RC. Special Report—War on Pain: Multimodal and multidisciplinary therapy for pain management. American Nurse Today. 2011 Sept;6(9).
2 Beck DE, Margolin DA, Babin SF, Russo CT. Benefits of a Multimodal Regimen for Postsurgical Pain Management in Colorectal Surgery. Ochsner J. 2015 Winter;15(4):408-12.
3 Scott L, Intravenous ibuprofen: in adults for pain and fever. Drugs. 2012 May 28; 72(8):1099-109.
4 Luiten WE, Schepers T, Luitse JS, Goslings JC, Hermanides J, Stevens MF, Hollmann MW, van Samkar G. Comparison of continuous nerve block versus patient-controlled analgesia for postoperative pain and outcome after talar and calcaneal fractures. Foot Ankle Int. 2014 Nov;35(11):1116-21.
5 Basch E, Autio K, Ryan CJ, et al. Abiraterone acetate plus prednisone versus prednisone alone in chemotherapy-naive men with metastatic castration-resistant prostate cancer: patient-reported outcome results of a randomised phase 3 trial Lancet Oncol. 2013 Nov;14(12):1193-9.
6 Ryan CJ, Smith MR, de Bono JS, Molina A, Logothetis CJ, et al; COU-AA-302 Investigators. Abiraterone in metastatic prostate cancer without previous chemotherapy. N Engl J Med. 2013 Jan 10;368(2):138-48.
A facility-specific survey found that 138 of 140 VA facilities reported shortages of medical officers, with psychiatry and primary care positions being the most frequently listed.
When Terrence O’Neil, MD, retired as chief of nephrology at the James H. Quillen VAMC in Johnson City in December 2016, he left in his wake decades of work treating kidney disease—nearly 35 years in the Air Force and DoD, plus 11 more at VA.