Opioid-minimizing, multimodal pain regimen decreased opioid exposure at UTHealth
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University of Texas Health Science Center at Houston implemented an opioid-minimizing, multimodal pain regimen to maximize pain relief and decrease patient exposure to opioids.
“We began using less intravenous opioids and began relying on oral non-opioid medications with as-needed oral opioids,” John A. Harvin, MD, associate professor of surgery, division of acute care surgery, department of surgery at McGovern Medical School at UTHealth, told Healio.com/Orthopedics. “Physicians, by nature, want to relieve pain and suffering. That is our calling. We used to believe that opioids were the best medication to do so. So, implementing this regimen was controversial at first. Over time, we all realized that this regimen provided adequate pain relief and was more responsible in that we began to decrease our patient's opioid exposure during their hospitalization.”
UTHealth implemented a pill-based, opioid-minimizing multimodal pain regimen in 2013 which included the use of acetaminophen, a gabapentinoid, lidocaine patches, tramadol and narcotics as needed.
Harvin said the standard multimodal regimen at the center includes the following:
- acetaminophen 1000 mg oral every 6 hours;
- naproxen 500 mg oral every 12 hours;
- gabapentin 300 mg oral every 8 hours;
- lidocaine patch as needed; and
- tramadol 100 mg oral every 6 hours as needed for uncontrolled pain.
If these medications did not work, Harvin said physicians would try other pain medications based on patients’ symptoms including muscle relaxers, opioids, ketamine and lidocaine.
“There are several emerging interventions for pain, such as music or aromatherapy and virtual reality,” Harvin said. “We have not begun to use such modalities, but will start considering them once we better understand how to do so.”
As published literature has shown NSAIDs may impact bone healing, orthopedic surgeons at first were hesitant about using these drugs, according to Harvin. However, orthopedic surgeons later agreed that use of NSAIDs should be increased.
Before the regimen was implemented, UTHealth heavily relied on opioids for pain relief, Harvin noted. Since the implementation of the regimen in 2013, physicians at UTHealth have prescribed 31% fewer opioids compared with the amount prescribed in 2010, he said.
“As the extent of the opioid crisis has become more apparent, we have ramped up our physician and patient education programs,” Harvin said. “These educational programs have resulted in an even more dramatic drop in opioid use. For example, in our ICU alone, we used 50% less fentanyl in 2018 than in 2017. That is an extraordinary reduction of opioid use in a critically ill patient population.”
Harvin said UTHealth just finished a randomized controlled trial of two multimodal pain regiments to improve their opioid minimization and pain management. Another study is being planned in which ketamine will be used early upon a patient’s arrival and continued for a few days to provide pain relief and opioid minimization.
“We just finished enrolling in a clinical trial comparing our original opioid-minimizing cocktail with a cheaper, widely available version,” Harvin said. “The results of this could improve our ability to treat patients in the most cost-effective manner.”– by Monica Jaramillo
Disclosure: Harvin reports no relevant financial disclosures.