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From Opioid-Only to “Opioid-Free” –

Where Does Multimodal Analgesia Fit In?

Edward R. Mariano, M.D., M.A.S.

Professor of Anesthesiology, Perioperative & Pain Medicine

Stanford University School of Medicine

Chief, Anesthesiology and Perioperative Care

Veterans Affairs Palo Alto Health Care System

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Overview

• How did this happen?

• Where are we now?

• What do we do to move forward?

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Overview

• How did this happen?

• Where are we now?

• What do we do to move forward?

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The Opioid Epidemic

https://www.nytimes.com/interactive/2016/01/07/us/drug-overdose-deaths-in-the-us.html?_r=0

https://www.cdc.gov/drugoverdose/epidemic/index.html

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The Opioid Epidemic

https://www.nytimes.com/interactive/2016/01/07/us/drug-overdose-deaths-in-the-us.html?_r=0

https://www.cdc.gov/drugoverdose/epidemic/index.html

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Percentage of opioid need met to address serious health-related suffering

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Brummett, et al. JAMA 2017

Klueh, et al. JGIM 2018

The Role of Surgery

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Updates

Coming Soon!

“Acute pain can often

be managed without

opioids…. More than

7 days will rarely be

needed.”

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https://www.ncsl.org/research/health/prescribing-policies-states-confront-opioid-overdose-epidemic.aspx

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Overview

• How did this happen?

• Where are we now?

• What do we do to move forward?

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The Opioid Epidemic

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The Opioid Epidemic

https://www.cdc.gov/drugoverdose/epidemic/index.html

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S FA

Society for Paralysis-Free Anesthesia

BLOCK THE ROC

LET PATIENTS MOVE FREELY DURING SURGERY

☻2021 Society for Paralysis-Free Anesthesia. THIS IS TOTALLY FAKE.

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Elkassabany & Mariano. Anaesthesia 2019

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Elkassabany & Mariano. Anaesthesia 2019

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Opioid-Free Anesthesia: PRO?

Lavand’homme. EJA 2019

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Opioid-Free Anesthesia: CON

Lirk & Rathmell. EJA 2019

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Unintended Consequences

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The Opioid Epidemic

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Kharasch, et al. Anesthesiology Feb 2020

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Kharasch, et al. Anesthesiology Feb 2020

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Overview

• How did this happen?

• Where are we now?

• What do we do to move forward?

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@DrChadB

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ASA-Premier Pilot Collaborative

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ASA-AAOS Collaboration

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Turn Research into Action

2020: Now a National

Quality Metric

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Leadership Starts at the Local Level

Elements of Performance for LD.04.03.13

1. The hospital has a leader or leadership team that is responsible

for pain management and safe opioid prescribing and develops

and monitors performance improvement activities.

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Approach Pain as a Continuum

Mariano, Walters, Kim, Kain. A&A 2015

Walters, Mariano, Clark. Pain Med 2015

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Elkassabany & Mariano. Anaesthesia 2019

Opioid-Free

Potential

‘a strategy that

maximises non‐opioid

modalities for

anaesthesia and

analgesia and reserves

the use of opioids for

severe acute pain

unrelieved by other

methods from

admission to discharge

from the hospital.’

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Mariano, Schatman. J Pain Res 2019

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Multimodal Analgesia: a Checklist, NOT a Recipe

Class

Mechanism of Action Options Frequency Considerations

Nonpharmacologic

Variable Patient Education

Compression

Cryotherapy

Acupuncture

Electrical Stimulation

Routine No clear guidelines

NSAIDs

Nonselective COX-1,2 inhibition

Selective COX-2 inhibition

Ketorolac

Ibuprofen

Celecoxib

Routine Renal insufficiency,

gastric ulcers, platelet

dysfunction,

cardiovascular disease

Acetaminophen

Central prostaglandin synthesis

inhibition

Acetaminophen

(Paracetamol)

Routine Hepatic dysfunction

Gabapentinoids

Binding to alpha-2-delta

subunits of voltage-dependent

calcium channels

Gabapentin

Pregabalin

If indicated Renal impairment

NMDA Antagonists

N-methyl-D-aspartate blockade Ketamine

Magnesium

If indicated Severe psychiatric

disorders, raised

intracranial or intraocular

pressure (ketamine only)

Local and Regional

Analgesia

Sodium channel blockade Spinal/Epidural

Lumbar Plexus ± Sacral Plexus

Femoral Nerve ± Sciatic Nerve

Femoral Nerve ± LIA

Adductor Canal ± LIA

Adductor Canal ± IPACK

LIA Only

Routine Allergy to local

anesthetic, site infection,

available resources and

training level of staff

NSAIDs = nonsteroidal anti

-inflammatory drugs; NMDA = N-methyl-D-aspartate; LIA = local infiltration analgesia; IPACK = infiltration between

the popliteal artery and capsule of the knee

Kandarian, Elkassabany, Tamboli, Mariano. Best Pract 2019

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Patient Education

Yajnik, et al. Patient Educ Couns. 2018

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Patient Education

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Tamboli, Mariano, et al. Pain Med 2019

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Transitional Pain

Katz, et al. J Pain Res 2015

Huang, et al. Pain Manag 2016

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Postoperative Pain Varies by Procedure

Mariano, El-Boghdadly, Ilfeld. Anaesthesia 2020

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Postoperative Pain Varies by Patient

TEMPOS Group (Tighe PJ). Anesthesiology 2021

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Pain Medicine Should Not Be One Size Fits All

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Summary

• We discussed the role of multimodal

analgesia, “opioid-free” anesthesia, and

answered the following questions:

– How did this happen?

– Where are we now?

– What do we do to move forward?