Multimodal pain control is a technique designed to reduce the amount of opioids patients need for their pain control. Multimodal techniques combine 2 or more non-opioid pain control medications or procedures to reduce pain. Multimodal pain control is quickly becoming the standard for treating patient’s pain because it works so well and does not require opioids and all the associated side effects. In fact, multimodal approaches are recommended by many top organizations including the American Society of Anesthesiologists, The Joint Commission, and the American Academy of Orthopedic Surgeons.
Pain is transmitted from the area of injury or surgery to the brain. Patient’s pain can be reduced by preventing the transmission of the pain signal. Different medications and interventions work at different sites along the transmission route. So by combining different medications and techniques (like nerve blocks) we can attack the pain signal at different sites along the transmission route. Nerve blocks can provide excellent non-opioid pain control when used effectively and as part of a multimodal approach.
The transmission of pain is quite complex and there is still much to be discovered. There are different modes of transmission for pain, and also inhibitory pathways which can naturally block pain signals.
Controlling pain without opioids frequently requires multiple therapies that when combined, result in excellent pain control without all the harmful side effects of opioids. Opioids carry a long list of dangerous side effects including addiction.
Let’s discuss some of the many medications used for non-opioid (non-narcotic) pain relief:
NSAID medications like Ibuprofen, Celecoxib (Celebrex) and Ketorolac (Toradol) can all help reduce the amount of pain. They are all non-addictive and are not opioids. They work by decreasing the amount of inflammatory mediators that are activated. With less of these inflammatory mediators circulating, patients will have less pain. NSAID’s effects are mainly at the injury site, and are thus classified as peripheral agents.
Acetaminophen (Tylenol) also works to control pain. It is commonly sold over the counter and has a central effect on the pain control. This means it reduces the pain transmission at a brain level. Acetaminophen’s effects can be synergistic with other medications, thus enhancing its effects.
Gabapentin (Neurontin) is a medication that was originally developed to prevent seizures. However, we have found that it can help reduce pain in patients especially when taken before the surgery or painful event. It is well studied and has a low side effect profile.
Additional medications include NMDA antagonists (Ketamine) and alpha-2 agonists (Dexmedetomidine) can also be used to reduce pain perception. Ketamine is an older medication, but we have found that when used in small doses it can provide excellent pain control.
One major non-opioid, non-medication intervention for pain control is nerve blocks. Nerve blocks involve injecting numbing medicine around the peripheral nerves that innervate certain portions of your body. We perform these procedures so patients will not feel pain during or after the procedure. Depending on the specific numbing medicine (local anesthetic) used, the “nerve block” can last even longer, ranging from hours to days. Some anesthesiologists have specialty training (fellowships) in nerve blocks.
Overall, there is no “magic bullet” to control pain without using opioids. However, it is possible through a team approach i.e. a multimodal approach to pain control. By combining different non-opioid medications and nerve blocks we can control patients’ pain after surgery without using opioids! Patients planning for future surgeries should discuss with their anesthesiologist options for reducing opioids with a multimodal approach to pain control.