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Operationalizing the Recent

Multisociety Postoperative
Pain Guidelines
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DAVID M. DICKERSON, MD
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Assistant Professor, Anesthesiology and Pain Medicine

Director, Acute Pain Service
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Department of Anesthesia & Critical Care

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University of Chicago Medicine

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Chicago, Illinois
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Dr Dickerson reported no relevant financial disclosures.

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and their professional societies have in the public

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health crisis. This crisis, a national emergency, creates

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ollowing the guidelines on acute a robust leverage point for garnering institutional sup-
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port for improvement in the quality of pain care.

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postoperative pain management To bridge the gaps between science and practice
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requires the hard work of requires a discussion on how to translate research into
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practice. Practice guidelines are one tool in transla-

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institutionalizing and implementing the tional research, but guideline adoption relies on sev-
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eral factors:
recommendations.
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• knowledge diffusion and dissemination,

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• systematic implementation,
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• ongoing utilization analysis, and

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• frequent reevaluation of the impact and value

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Updating the 2012 practice advisory of the American created for patients, providers, and health care
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Society of Anesthesiologists (ASA) on acute postop- systems.

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erative pain management, the multisociety postopera- The 32 recommendations in the guidelines and the
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tive pain guidelines offer a blueprint for best practices strength of the evidence and level of recommenda-
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in postoperative pain care.1,2 Published last year, the tion for each are presented in the Table. This article dis-
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guidelines incorporate 8 years of development and
review by the American Pain Society, the American
Society of Regional Anesthesia and Pain Medicine, the
ASA Administrative Council, the ASA Executive Com-
mittee, and the ASA Committee on Regional Anesthe-
siology. The publication presents 32 evidence-based
recommendations for the relief of acute postsurgical
pain. In the current opioid epidemic, the guidelines
illustrate the role that pain clinicians, anesthesiologists,
cusses key recommendations and a framework for their
implementation.
Surgical Medicine and the Opioid Epidemic
Modifying postsurgical prescribing can curb the opi-
oid epidemic, especially if patients are receiving more
pain medicine than they need.3 Ninety days after sur-
gery, 6% of previously opioid-naive patients continue
to take opioids.4

44 A N E ST H E S I O LO GY N E WS .CO M
 The guidelines for opioid prescribing by the Cen-
ters for Disease Control and Prevention recommend
for acute pain “the lowest effective dose of immediate-
release opioids” and “no greater quantity than needed
for the expected duration of pain severe enough to
require opioids.” The norm is 3 days or less and rarely
more than 7 days.5 Defining the lowest effective dose
depends on several factors: patient expectations; uti-
lization of effective, nonopioid techniques; and pre-
scriber awareness of the amount of medication needed
after a specific procedure.
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Instituting a Governing Body
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For Implementation
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If surgical care is indeed a gateway to persistent opi-
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oid use, excellence in perioperative pain assessment
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and treatment aims to reduce pain and prolonged opi-
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oid use.5 As pain specialists and anesthesiologists con-
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tinue to emphasize their role as experts who can curb
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the opioid epidemic, institutional support evolves for
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quality improvement initiatives in perioperative pain
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care. Coupling expertise and influence with an institu-
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tional mandate is necessary as the efforts required and
benefits obtained reach far beyond the anesthesia or
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pain management group.
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Implementing a protocol for guideline-based care
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conserves resources and aligns patient, provider, and
institutional goals. Recommendation 29 suggests sur-
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gical facilities develop an infrastructure to create pol-
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icies for safe and effective pain care. With a low level
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of evidence and a strong recommendation, successful
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delivery of the recommendations relies on institutional
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initiatives and a burgeoning consensus.
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Clinical effectiveness and quality leadership must
prioritize patient satisfaction, safety, and quality met-
ric reporting. Reimbursement, patient outcomes, and
market share drive this effort. High-quality pain care
is an integral part of institutional expense and patient
experience.
Building a task force or committee with membership
from pharmacy, nursing, clinical leaders, and adminis-
tration is one mechanism for influencing ongoing prac-
tices in pain management. One of the primary activities
of such a working group would be to use the guidelines
as a rubric for a gap analysis and a road map for quality
improvement. Implementing this recommendation early
may enable success across multiple domains, many of
which depend on data and institutional buy-in.
A Novel Model for Implementation:
Pain Stewardship
A stewardship model is one guide for implementation.
In 2016, at the University of Chicago Medicine, a stew-
ardship program was instituted analyzing pain manage-
ment. The program offered key institutional initiatives:
• patient and provider education,
• provider-level and procedure-specific opioid pre-
scribing reports,
• standardized preoperative nonopioid analgesics,
• electronic health record integration with state-
based prescription monitoring, and
• safe opioid medication return via a cam-
pus-based Drug Enforcement Administra-
tion–approved MedSafe medication collection
system with ongoing messaging to patients and
providers.
Patient Engagement: Preparation and Education
Recommendations 1, 2, 4, and 32 focus on patient and
caregiver engagement. Patients want to be informed
participants in decision making and want to feel that
the care team is doing everything it can to minimize
their pain.6,7 The panel highly recommends providing
patients and caregivers with education on treatment;
specifically, how pain will be assessed and treated as
well as a plan for post-discharge pain management and
analgesic tapering. The panel also recommends docu-
mentation of the treatment plan and goals of therapy.
At our institution, standardized materials are a part
of a patient-centered booklet for surgical preparation.
The booklet explains the role and risks of opioids, the
importance of nonopioids and nonpharmacologic inter-
ventions, and how pain is assessed. It gives a timeline
for discontinuing analgesics postoperatively, and the
steps for returning surplus medications to the medical
center via MedSafe. Patient literacy experts reviewed
and revised the materials for comprehension across
various levels of education.
Pain Specialist Availability and Pain Screening
Recommendation 28 from the postoperative pain
guidelines suggests that surgical facilities consult with
pain specialists for challenging care scenarios. Even
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with standardized protocols, patients with special pain
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care needs can be underserved without treatment plan-
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ning and care coordination. Identifying these patients
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has been well described in the literature.
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The third recommendation is for preoperative evalu-
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ation for factors that increase risk for uncontrolled pain
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or affect pain management.8,9 Policies and procedures
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describing treatment planning and triggers for escala-
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tion standardize individual treatment planning. Screen-
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ing can trigger evaluation by a pain specialist.
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At our institution, all patients are screened preoper-
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atively for daily preoperative opioid use or daily pain
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over the preceding month (recommendation 3). This
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information drives clinical decision making, such as
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broadening multimodal analgesic exposure (recom-
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mendations 15-19), instituting continuous regional anes-
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thesia (recommendation 24), or including the chronic
pain clinic or acute pain specialists perioperatively (rec-
ommendation 28).
Broadening Multimodal Analgesic Use
Recommendations 15 through 17 suggest using
nonsteroidal anti-inflammatory drugs (NSAIDs) such
as celecoxib, acetaminophen, and gabapentin as part
of multimodal treatment. Creating a standardized
A N E ST H E S I O LO GY N E WS S P E C I A L E D I T I O N 2 0 1 7 45
pathway ensures adequate medication availability in
perioperative areas, streamlines ordering by surgical
services, supports timely administration, and permits
analysis of ongoing utilization.
As a quality improvement initiative at our institution,
a survey of orthopedic surgeons, anesthesiologists,
and nurses found that the majority of clinicians and
nurses supported using nonopioid analgesics preoper-
atively for ambulatory orthopedic surgical procedures.
Yet a limited number of outpatient orthopedic surgical
patients received a dose of acetaminophen, an NSAID,
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Eliminating IV Opioids for Some Patients
The guidelines recommend the elimination of some
practices. These recommendations appear in red in
the Table. Intrapleural catheters should not be used
for thoracic surgery, and neuraxial administration of
magnesium, benzodiazepines, neostigmine, tramadol,
and ketamine is not recommended. Eliminating intra-
venous opioids for patients able to take oral medica-
tions challenges the current practice of many groups,
including ours. Creating initiatives that support oral
opioids as a first line of treatment can be challenging.

or gabapentin, and less than 1% of patients received all In one randomized study, oral opioid regimens
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3 agents. After a didactic session for orthopedic sur- decreased opioid exposure with similar analgesic effi-
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gical residents and implementation of a standardized cacy when compared with intravenous regimens.10
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preoperative order, concomitant administration of all There is a distinct difference in duration of action of
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3 medications increased by 50-fold. oral agents and intravenously administered opioids.

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Table. Recommendations From the Multisociety Acute Postoperative

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Pain Guidelines2
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Level of Strength of
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Recommendations Evidence Recommendation

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1 Provide patients, their families, and caregivers with education on treatment Low Strong
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options; document a plan and treatment goals

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2 Educate parents of pediatric patients on developmentally appropriate methods Low Strong

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for pain assessment, educate on analgesics and treatment modalities

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3 Conduct pre-op evaluation assessing for factors that increase risk for Low Strong
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uncontrolled pain or affect pain management or patient risk

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4 Frequently adjust pain management plan based on adequacy of pain relief or Low Strong
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adverse events
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5 Track treatment response with validated pain assessment tool; adjust treatment Low Strong
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accordingly
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6 Offer children and adult patients multimodal analgesia combined with High Strong
nonpharmacologic interventions
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7 Consider TENS as an adjunct to other treatments Moderate Weak

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8 Acupuncture, massage, cold therapy may or may not have benefit Not sufficient No recommendation
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9 Consider cognitive-behavioral modalities in adults Moderate Weak

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10 Oral opioids are preferred to intravenous opioids in patients able to use the oral Moderate Strong
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or enteral route
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11 Avoid using the intramuscular route Moderate Strong

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12 When parenteral route is needed, IV PCA should be used Moderate Strong

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13 Avoid routine basal infusions with IV PCA in opioid-naive adults Moderate Strong
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14 Appropriately monitor for sedation, respiratory depression, and other adverse Low Strong
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events when systemic opioids are used

15 Acetaminophen and/or NSAIDs should be used for adults and children without High Strong
contraindication as part of a multimodal approach

16 Preoperative celecoxib should be given to adults without contraindication Moderate Strong

17 Consider use of gabapentin as a component of multimodal analgesia Moderate Strong

18 Consider IV ketamine as a component of multimodal analgesia in adults Moderate Weak

46 A N E ST H E S I O LO GY N E WS .CO M
Transitioning a patient from a primarily intravenous
regimen to an oral regimen is challenging and may
be best avoided by using oral opioids as first line.
By eliminating parenteral opioids, a potentially pro-
longed hospital stay and suboptimal satisfaction may
be prevented.
Infusion Therapies: Ketamine and Lidocaine
The panel recommended considering intravenous
ketamine and lidocaine infusions as a component of
multimodal analgesia. Many anesthesia and surgical
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With provider education, order sets, evidence-anno-
tated institutional guidelines, pharmacy premixed med-
ication bags, and standardized narrow-range pump
library programs, consistent and safe infusion therapy
can be readily available for patients. Since implement-
ing these standard pathways at our institution, utili-
zation of these infusions dramatically increased and
variation in dosing of ketamine and lidocaine for anal-
gesia has decreased.
Optimizing Use of Regional Anesthesia

providers do not utilize these agents in standard prac- Recommendations 23 and 24 indicate site-specific
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tice. At our institution, a pain care subcommittee of peripheral regional anesthesia for adults and children
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the Pharmacy and Therapeutics Committee standard- with a continuous technique when pain is expected to
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ized workflows for ketamine and lidocaine infusions for exceed the duration of a single-shot injection. Recom-
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intraoperative and postoperative analgesia. mendation 31 suggests that policies guide neuraxial
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Table. Recommendations From the Multisociety Acute Postoperative

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Pain Guidelines2 (continued)

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Level of Strength of
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Recommendations Evidence Recommendation

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19 Consider IV lidocaine infusions in adults for open and laparoscopic abdominal Moderate Weak
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surgery
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20 Consider surgical site–specific local anesthetic infiltration Moderate Weak

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21 Use topical local anesthetics in combination with nerve blocks before Moderate Strong
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22 Avoid intrapleural analgesia with local anesthetics after thoracic surgery Moderate Strong
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23 Consider site-specific peripheral regional anesthetic techniques in adults and High Strong
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children for procedures with established efficacy

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24 Use continuous, local anesthetic–based peripheral regional analgesic techniques Moderate Strong
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when pain is expected to exceed the duration of a single-shot injection

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25 Consider adding clonidine as an adjuvant to prolong single-injection peripheral Moderate Weak

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26 Offer neuraxial analgesia for major thoracic and abdominal procedures, High Strong
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especially if concerns for ileus, or pulmonary or cardiac complications

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27 Avoid neuraxial magnesium, benzodiazepines, neostigmine, tramadol, and Moderate Strong

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28 Appropriately monitor patients receiving neuraxial interventions Low Strong

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29 Surgical facilities should develop an infrastructure to develop policies and Low Strong
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processes for safe and effective pain care

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30 Surgical facilities should have pain specialist consultation for challenging care Low Strong
scenarios
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31 Policies and procedures should guide neuraxial and continuous peripheral block Low Strong
procedures

32 Adults, children, and caregivers should be provided education on post- Low Strong
discharge pain plans and analgesic tapering

Recommendations in red refer to practices that should be avoided.

NSAIDs, nonsteroidal anti-inflammatory drugs; PCA, patient-controlled analgesia; TENS, transcutaneous electrical neural stimulation

A N E ST H E S I O LO GY N E WS S P E C I A L E D I T I O N 2 0 1 7 47
and continuous peripheral blocks to ensure safety and
efficacy.
During specific procedures when benefit has been
demonstrated relative to general anesthesia, regional
anesthesia should be supported by payors and institu-
tions as an evidence-based component of value-based
care.
There are many obstacles, however, to the utilization
of regional anesthesia, despite its established benefits.
From concerns about potentially delaying the start of
the case to availability of skilled regionalists at every
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The anesthesia coordinator making the schedule
incorporates the requests into the specific case assign-
ments. This process reduces case delays and improves
care coordination by communication through a con-
served workflow.
Translating Guidelines Into Practice:
Timing, Effort, Support
It has been suggested that it takes 9 years to fully
implement practice guidelines.11 Understanding factors
that impede and those that predict successful imple-

surgical site on the day of surgery, the specific cultural mentation of practice guidelines is key to translating
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and logistical issues must be identified. Institutions the recent multisociety postoperative pain guidelines
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must support: into practice.

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• development of a skilled regional anesthesia Successful implementation is associated with ample

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team, resources, supportive social conditions, presence of a

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• block rooms and block carts, champion for new knowledge, openness to change, no
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• a framework for perioperative communication strong political or bureaucratic opposition, incentives

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before the day of surgery, to change, leadership by example, and support for a
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• standardized anticoagulant and antiplatelet man- long-term interactive relationship.12

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agement guidelines, and Others have suggested 32 barriers to dissemination

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• a formal request process for booking regional of evidence-based interventions.13 The barriers depend
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anesthesia or continuous catheters. on the characteristics of the interventions; attributes of

Most important is a method for evaluating utilization, the innovations and rate of adoption; situation or con-
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process, and effect on patient care. text of the intended audience; and limitations of the
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At our institution, a perioperative pain care list cir- research being promoted such as cost, validation, meth-
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culates the day before surgery to perioperative lead- odology, or interaction between these factors.
ership and clinical personnel. The list is compiled from Most groups already practice the recommendations
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requests entered into a multidisciplinary care section of the postoperative pain guidelines to some extent. The
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of the electronic health record’s case booking form. An guidelines are not only a blueprint but also a diagnos-
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email lists all requests for regional anesthesia, includ- tic tool for anesthesiologists and pain medicine physi-
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ing epidurals and continuous nerve catheters; patients cians to assess their own practice. The opioid epidemic
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who will need the acute pain service care; and patients makes the guidelines timely. They offer support to phy-
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with treatment plans for perioperative ketamine or lido- sicians who seek to improve pain care while reducing
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caine infusions. opioid exposure as much as possible.

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References
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