Pain Management, a Balanced Technique

Older Analgesics in Combination Outmatch Expensive, New Non-Opioid Alternatives

In the midst of alarming headlines about the ongoing opioid epidemic, healthcare providers are turning to non-opioid alternatives and a multipronged, patient-centric strategy to manage the acute and chronic pain of patients. “Pain is a highly personal experience,” wrote Ofelia Elvir-Lazoa and Paul White in a 2010 article in the peer-reviewed Current Opinion in Anesthesiology. “It involves multiple mechanisms that ideally require treatment using a multimodal (or ‘balanced’) analgesic technique.”

Tried-and-True Choices

Jason Braithwaite, PharmD, MS, BCPS

The goal of multimodal pain management is to change provider thinking so that opiates are not always the first choice. “We’ve forgotten how to manage pain with other drugs, some of which have been on the market for decades,” says Jason Braithwaite, PharmD, MS, BCPS, senior director of clinical pharmacy services at HealthTrust. “Clinicians haven’t done a good job of optimizing the use of these other agents—what I like to call the ‘oldies but goodies.’ ”

Older analgesics such as acetaminophen, anticonvulsants, antidepressants and nonsteroidal anti-inflammatory drugs, including ibuprofen, can be combined to effectively manage pain and help to drastically decrease, if not eliminate the need for opioids.

Prescribing three drugs that work in different ways is more effective than prescribing a single opioid blocking one pain pathway and escalating the dosage over time. But “everyone’s gotten a little bit comfortable solely prescribing opiates for pain,” Braithwaite says. “A multimodal pain management strategy takes a little more thought; you have to space out the dosages so patients get optimal pain relief while avoiding the side effects that can occur with high doses of a drug.”

The approach can sometimes eliminate the need for opioids entirely. For certain surgeries and severe breakthrough pain, multimodal tactics incorporate opioids but at lower amounts and for shorter periods of time. In both cases, patients tend to move from an acute care setting to home more quickly because over-the-counter pain relievers and non-opioid prescriptions have few access barriers.

Considering New Options

In recent years, the Food and Drug Administration has given market approval to non-opioid options such as Exparel (liposomal bupivacaine), a long-acting analgesic. However, the drug has not been shown to improve pain management or reduce opioid use when compared to a multimodal pain strategy. And, at $285 a dose, it’s not an economical option.

“The first thing HealthTrust looks at is safety and efficacy,” Braithwaite explains. “And, from those perspectives, there haven’t been major improvements with Exparel. We promote innovation in patient care, but in this case, we just see an added expense.”

Ofirmev (IV Tylenol) is another debated alternative to opioids. At $40 a dose, it’s significantly more expensive than oral tablets, liquids or suppositories, which run just a few cents per dose. “It’s another example of a drug that hasn’t shown added safety or efficacy but has significantly increased patient costs,” Braithwaite says. While Tylenol is an old standby, the intravenous version has only been shown to improve the onset of pain relief—not overall pain relief.

Sparking Conversation

One unforeseen benefit from the launch of these new products is growing interest among providers in multimodal pain strategies and learning to optimize drugs that have been available for decades.

“The new drugs coming out have spurred a lot of discussion that has improved how we approach pain relief,” Braithwaite says. “That’s made a big impact on patient care and reducing opioid dependence overall.”

Many clinicians still see a role for opioids, though a much more limited one than in the past—less often and at lower dosages—a strategy that can address pain without creating long-term dependence.

Non-opioid analgesics like Exparel may bill themselves as the future of recovery, but to get a glimpse into where pain management is headed, don’t look to the new drugs hitting the market. The best multimodal approach for patients uses drugs that have stood the test of time.

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