ASRA Update

Guidelines Emphasize Need for Multimodal, Individualized Care for Surgery Patients

Sep 24, 2021

ASRA

Measures Can Prevent Chronic Pain, Opioid Reliance, and Other Negative Outcomes

A new multi-society organizational consensus statement published in Regional Anesthesia & Pain Medicine establishes seven guiding principles for acute perioperative pain management to help institutions better care for patients having surgery. These principles include the need for preoperative evaluation of medical and psychological conditions and potential substance use disorders, a focus on multimodal analgesia including nonpharmacologic interventions, use of validated pain assessment tools to guide and adjust treatment, and the importance of individualized care and education.

The seven principles are:

  1. Clinicians should conduct a preoperative evaluation including assessment of medical and psychological conditions, concomitant medications, history of chronic pain, substance use disorder, and previous postoperative treatment regimens and responses, to guide the perioperative pain management plan.
  2. Clinicians should use a validated pain assessment tool to track responses to postoperative pain treatments and adjust treatment plans accordingly.
  3. Clinicians should offer multimodal analgesia, or the use of a variety of analgesic medications and techniques combined with nonpharmacological interventions, for the treatment of postoperative pain in adults.
  4. Clinicians should provide patient and family-centered, individually tailored education to the patient (and/or responsible caregiver), including information on treatment options for managing postoperative pain, and document the plan and goals for postoperative pain management.
  5. Clinicians should provide education to all patients (adult) and primary caregivers on the pain treatment plan, including proper storage and disposal of opioids and tapering of analgesics after hospital discharge.
  6. Clinicians should adjust the pain management plan based on adequacy of pain relief and presence of adverse events.
  7. Clinicians should have access to consultation with a pain specialist for patients who have inadequately controlled postoperative pain or are at high risk of inadequately controlled postoperative pain at their facilities (e.g., long-term opioid therapy, history of substance use disorder).

The guidelines were developed in response to the United States Health and Human Services Pain Management Best Practices Inter-Agency Task Force’s 2019 report, which called for more individualized, multimodal, and multidisciplinary approaches to pain management to help decrease an over-reliance on opioids, increase access to care, and promote widespread education on pain and substance use disorders.

The American Society of Anesthesiologists convened the first Pain Summit involving multiple surgical specialty organizations: the American Society of Regional Anesthesia and Pain Medicine, the American Medical Association, American College of Obstetricians and Gynecologists, and American Hospital Association. In all, 14 societies, representing a vast spectrum of surgical care, formed a new consortium and participated in the two-year project, which culminated in a live virtual event in February 2021. Representatives identified, clarified, and finalized seven principles through three rounds of discussion and voting. Recommendations and best practices for dissemination and implementation were discussed, as well as several important themes:

  • Access to pain and addiction medicine specialists
  • Avoidance of stigmatizing language when caring for patients with substance use disorder
  • Commitment to patient and caregiver education and shared decision-making

Barriers to implementation were also addressed.

It is hoped that the guidelines will inform local action and future development of clinical practice recommendations, according to Edward R. Mariano, MD, MAS, FASA, professor of anesthesiology and perioperative pain management, Stanford University School of Medicine, who served as lead author.

“The fact that 14 professional health care organizations could agree on these seven principles means that the bar for acute perioperative pain management has been reset,” said Dr. Mariano. “The work product of this consortium can now form the basis of all future guidelines and influence the products of legislation and regulation that affect pain management for surgical patients.”

The consortium will next look at how to tailor the guidelines to more complex surgical populations, better assess barriers to change implementation, and provide each organization’s members with the tools they need to improve acute perioperative pain management where they are.

“There is still so much work to do,” said Dr. Mariano. “The formation of this consortium is a critical first step to widespread quality improvement in perioperative pain management for surgical patients across the country. Despite all the evidence generated across anesthesiology, pain medicine, and surgical specialties supporting the effectiveness of multimodal pain management, there continues to be unwarranted variation in the pain care that actual surgical patients receive.”

Read the full guidelines.

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