Evaluation of Practice in Postoperative Pain Management

This article evaluates the efficacy of opioid with adjunctive non-opioid therapy in comparison to opioids only in the management of pain. It discusses the barriers to implementing evidence-based practice in postoperative pain management and provides insights from high-level evidence studies. The article also suggests ways to overcome these barriers.

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EVALUATION OF PRACTICE
By (Name)
Course
Tutor
University
City
Date

Evaluation of Practice 2
Evaluation of Practice
Task 1: Area of Practice
I currently practice in the post operative department of South Western Sydney Local
Health District. From the provision of care in post anesthetic care unit (PACU), I have observed
that anesthetists use different modes of treatment in postoperative pain management. In
particular, I noticed that some patients in the recovery were charted with opioids only while
others are charted with opioids as well as adjunctive therapy. This implies that some anesthetists
use opioids only whereas others utilize multimodal analgesia consisting of both non-opioids
and opioids in postoperative pain management. This revelation has subsequently raised concerns
regarding the used analgesia in my area of practice.
Recovery nurses have reiterated that multimodal analgesia, that is, the combination of
opioids and non-opioids analgesia tend to have reduced postoperative pain as well as decreased
opioid related complications such as nausea, vomiting, respiratory depression and prolonged
recovery. Given that opioids are the first choice of drug in postoperative pain management, there
are rising concerns regarding dependence and addiction to opioids especially for surgical patients
who are under opioid medications (Martinez et al, 2017, p. 23). On the same note, it has come to
my attention that PACU patients under multimodal analgesia tend to have less usage of opioids
in comparison to patients who are under opioids only. In regards to these observations, there is
need to identify an alternative analgesia that can minimize adverse opioid effects and enhance
patient satisfaction and quick recovery process.
Task 2: Research Evidence
Searchable Question

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In light of the aforementioned dilemma there is need to determine the mode of pain
management that is effective in reducing pain, opioid dependency and enhancing patient
satisfaction and recovery. As such, the developed searchable question is to determine the
efficacy of opioid with adjunctive non opioid therapy in comparison to opioids only in the
management of pain. In consideration of my area of practice, this question can alternatively be
stated as; will the use of multimodal approach such as opioid adjunctive with non-opioids
reduce pain in PACU patients compared to the use of opioids only?
P – Post-operative patient with pain
I – Pain management using opioids only
C – Pain management with multimodal analgesia (opioids adjunctive with non-opioids)
O – Patient satisfaction, reduced pain, and reduced dependence on opioids.
Search Strategy
The search criteria included studies with the highest level of evidence comprising of
meta-analysis and systematic reviews. A search was conducted on PubMed dating from 2013 up
to 2019. PubMed was preferred because for each article is entered in a uniform and
structured way with tags of important information regarding the structure of the study.
Also, articles in this data base sit at the top of the pyramid of evidence. Included studies
entailed the efficacy of multimodal analgesia in comparison to the use of opioids only. Studies
excluded were those that explicitly focused on utilization of opioids only in treating post-
operative pain. Key words used in the search include; multimodal analgesia, post-operative pain

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management, opioids, non-opioids, PACU patients, patient satisfaction, reduced pain and opioids
dependence.
Justification of the Resources
Three studies were identified at the highest level of evidence. Study by Derry, Karlin and
Moore (2015) illustrated that combining two different analgesics (oral ibuprofen and codeine) in
a single dose provided improved relief of pain in acute pain compared to either of the
medications alone. This study sits at the highest level of the pyramid clarified as systems.
Findings by Desai et al (2018) also indicate that multimodal discharge analgesia had improved
aftermath pain and all-cause readmissions in comparison to opioid only analgesia. This study
similarly sits at the top-most level of the hierarchical pyramid of evidence. The finding by
Swift (2018) alternatively reveals that multimodal analgesia and non-opioid analgesia contribute
to reduction in long-term dependence on opioids. Also, given that the study was a systematic
review, the study sits at the top of the pyramid of evidence hierarchy.
Task 3: Comparison of Findings
Derris, Karlin and Moore (2015) used standardized trials to test the efficacy of
medications and hostile effects associated with usage of one dose of oral ibuprofen in addition
to codeine for acute postoperative pain in adults. 64% of the 443 participants who used a variety
of ibuprofen 400 mg with high doses of codeine ranging from 25.6 mg to 60mg experienced 50%
maximum pain relief compared to 18% in the placebo group (Derris, Karlin & Moore, 2015).
The NNT in this case was 2.2 (95% confidence interval) thus, indicating high quality evidence.
204 participants who used ibuprofen with any dose of codeine realized 69% maximum pain relief
compared to 55% with placebo (Derris, Karlin & Moore, 2015).

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Varrassi et al (2017) however warns that to realize the advantages associated with such
modes of treatments, the drugs must be administered at fixed dosage. Although combining drugs
from different classes provides better chances for effective analgesia and potential reduction in
adverse events, analgesic combinations ought to be provided in fixed dose ration so that the
resulting medication may offer desired advantages (Varrassi et al, 2017, p. 1165). Perhaps this
explains the reason why participants in the above study experienced varied levels of pain
relief in comparison to individuals who used fixed dosage of ibuprofen and codeine. In
current clinical practice similar trends are observed with patients receiving similar doses
also experiencing limited adverse effects.
Moore and Hersh (2014) also reveal that the amalgamation of APAP and ibuprofen are
more effective medications with limited adverse effects in comparison to opioid containing
medications. Their study indicated that this combination provided greater pain relief in
comparison to using ibuprofen or APAP alone when administered as a therapeutic strategy in
management of acute postoperative dental pain (Moore & Hersh, 2014, p. 898). This study
therefore, adds to the findings in the first high level evidence by illustrating the effectiveness of
multimodal analgesia unlike opioid only analgesia. Likewise, in my clinical practice, patients
who were charted using non-opioids with opioid analgesia often experienced reduced pain
compared to those who are charted with opioid only.
Another similar study conducted by Derry, Derry and Moore (2014) reveals that single
dose ibuprofen with oxycodone yields similar results in relieving pain during acute pain
management. Specifically, the findings in this study indicated that a combination of ibuprofen
400 mg plus oxycodone 5mg led to 50% pain relief within a 6 hour period in comparison to 17%

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pain relief experienced by the placebo group who used ibuprofen alone (Derry, Derry & Moore,
2014). Such findings further illustrate the efficacy of opioids with adjunctive non-opioids.
Desai et al, (2018) used different health settings (academic hospital and veteran health
administration) to test the association of multimodal analgesia with postoperative pain outcomes.
Multimodal analgesia in this study used a combination of opioids with acetaminophen (O+A)
drugs. The evidence in this case indicates that a combination of O+A led to decreased follow-up
pain and further reduced chances of readmissions. Furthermore, patients subjected to this mode
of medication received 10% to 40% less consumption of opioids compared to their counterparts
who were discharged with opioids alone. In general therefore, multimodal regimen can be
attributed to reduced pain after discharge and reduced chances of readmissions (Desai et al,
2018, p. 160). The findings of this study thus reveal that multimodal analgesia tends to be more
effective in pain reduction and also contributes to lesser consumption of opioids compared to
using opioid mono-therapy. In the current clinical practice however, the impact of
multimodal analgesia on consumption of opioids has not been determined because nurses
have not observed any significant reduction in opioid administration.
Aside from providing more effective pain control for surgical patients, the use of
multimodal analgesia which comprises two/more drugs or using non-pharmacological
interventions has been shown to limit opioid consumption and dependency (Ladha et al, 2016, p.
837). In her study, Swift (2018) attempts to expound on these sentiments regarding pain relief
and opioid dependency. According to this study, long term dependence on opioids can ideally be
reduced when multimodal or non-opioid analgesia is used as first line treatment in medium to
severe postoperative pain. The author acknowledges that long term use of such medications is
associated with increased risk of dependence. For the 411 patients who were involved in the

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study, the findings indicate that multimodal medications were the most preferable ranging
from 3.6 and 4.3 NRS points (Swift, 2018). This study provides useful insights by indicating the
effectiveness of both painkillers and non-opioids. Notably, both of these medications have
equal pain relief effects. However, when they are used simultaneously in a multimodal
analgesia, they both become more efficient in pain reduction. Also, such combinations reduce the
likelihood of dependency on opioids (Eccleston et al, 2017, p. 13). Thus, it becomes affirmative
that using opioids with non-opioids in a therapeutic treatment proves yield better results in
relation to pain management and reduction in opioid dependency.
Task 4: Barriers to EBP
For all surgical patients, it is recommended that multimodal analgesic be used in
perioperative pain management. However, such practice guidelines that are confounded in
evidence based research become highly limited due to multiple barriers. This limitation is
evidenced by the fact that there is only 90.4% mean probability of delivering multimodal
analgesia in hospitals (Ladha et al, 2016). It is alternatively anticipated that routine use of
multimodal analgesia should be the customary of care although the proportion of patients who
are ultimately subjected to this evidence-based approach remains unknown. It therefore, raises
clinical concerns especially considering the fact that 80% of surgical patients subjected to pain
after surgical procedures while another 30% of these patients tend to experience severe pain
(Liu et al, 2018).
More worrying concerns have also been touted considering the adverse effects associated
with undertreating postoperative pain. In essence, failure to manage this pain may result in
increased risk of myocardial ischemia and also impairs rehabilitation and wound healing. Such

Evaluation of Practice 8
failure is attributed to using opioid mono-therapy which could further cause respiratory
depression (Liu et al, 2018). It is also worthy to note that treatment of postoperative pain requires
exploration of clinical surgery heterogeneity a factor which inclines physicians to use specific
procedure surgical-based practical guidelines (Bujedo, 2014, p. 200). This ultimately limits the
implementation of evidence-based approaches especially if they are not comprehensively tested
or assessed.
Barriers
Opioids have multiple side effects and for this reason, scholars have garnered much
debate on discontinuing the usage of these medications in post-operative pain management. Even
so, the opioid epidemic where many patients have either been dependent or addicted to such
treatments has decreased the popularity of these therapeutic measures. Morphine,
hydromorphone and fentanyl are some of the most commonly used opioids in post-surgical pain
management. Multimodal regimen ideally uses a combination of such medications which further
increases opioid dependency (Garimella & Cellini, 2015, p. 191). Their side effects further limit
their use with respiratory depression that could result in respiratory arrest and hypoxia often
deterring many medical professionals from utilizing them. Other side effects including;
vomiting, nausea and reduction on bowel motility have also been associated with opioid usage
and subsequently hamper the implementation of opioid-based approaches.
In addition, a longer term use of such medications is likely to result in addiction and
dependence. Consequently, non-pharmacological interventions have become preferable as a
treatment plan in comparison to multimodal analgesia (Chung & Goddard, 2014). It has thus,
become increasingly difficult to implement the EBP given that although it focuses on limited use

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of opioids, most of the administered medications comprise of opioid regimen. This has always
been the case even in occasions where non-steroidal anti-inflammatory agents (NSAIDS) are
used to reduce the amount of opiates consumption (Ferguson & Hudcova, 2015).
Stephan & Parsa (2016) also emphasize that the prescription of opioid drugs could
worsen the side effects associated with these medications. In this regard, the authors reveal that
opioids impair the functioning of mu-opioid receptors and further inhibit the release of beta-
endorphin thereby creating feelings of euphoria. In such cases, as physicians continue to utilize
opioids in multimodal analgesia, they could be inadvertently be prolonging and increasing
postoperative pain in surgical patients (Stephan & Parsa, 2016, p. 63). In consideration of such
adverse effects, many clinicians prefer usage of opioid only medications instead of
supplementing such medications with additional opioids.
There are multiple other social-cultural barriers that could hamper the implementation of
the EBP. For one, lack of parental and child education on postoperative clinical outcomes could
significantly influence the perceptions held by the patient regarding the pain management
approach. With limited knowledge, the patient may become reluctant to use the medications as
prescribed and could likewise result in fears of addiction. A parent’s anxiety towards assessing
the pain of their child could also be a barrier in the implementation process. Cultural or language
differences are also considerable barriers to the EBP especially in cases where clinicians find it
difficult to communicate with the patient regarding the chosen treatment plan (Chou et al, 2017,
p. 132). Patients may alternatively perceive the medications to be in violations of their values or
beliefs thereby inclining them to discontinue the medication.
Overcoming Barriers

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Post-surgical pain ought to be effectively treated in a bid to reduce incidence of chronic
pain and increase patient satisfaction. Physicians and clinicians alike should be at the forefront of
implementing strategies that can enable them to overcome the above mentioned barriers. For
instance, they should provide family and patient-centered education that would enable such
parties to understand information on treatment options for managing postoperative pain.
Clinicians should also conduct a preoperative evaluation inclusive of assessing the medical and
psychiatric comorbities, history of lasting pain and drug abuse, and responses to previous
treatments for pain management in a bid to cub dependency and side effects associated with
opioids.
APPENDIX
Article 1
Single dose oral ibuprofen plus codeine for acute postoperative pain in adults.
Derry S1, Karlin SM, Moore RA.
Author information
Abstract
BACKGROUND:
This is an update of the original Cochrane review published in Issue 3, 2013. There is good
evidence that combining two different analgesics in fixed doses in a single tablet can provide

Evaluation of Practice 11
better pain relief in acute pain and headache than either drug alone, and that the drug-specific
effects are essentially additive. This appears to be broadly true in postoperative pain and
migraine headache across a range of different drug combinations and when tested in the same
and different trials. Some combinations of ibuprofen and codeine are available without
prescription (but usually only from a pharmacy) where the dose of codeine is lower, and with a
prescription when the dose of codeine is higher.Use of combination analgesics that contain
codeine has been a source of some concern because of misuse from over-the-counter
preparations.
OBJECTIVES:
To assess the analgesic efficacy and adverse effects of a single oral dose of ibuprofen plus
codeine for acute moderate-to-severe postoperative pain using methods that permit comparison
with other analgesics evaluated in standardised trials using almost identical methods and
outcomes.
MAIN RESULTS:
Since the last version of this review no new studies were found. Information was available from
six studies with 1342 participants, using a variety of doses of ibuprofen and codeine. In four
studies (443 participants) using ibuprofen 400 mg plus codeine 25.6 mg to 60 mg (high dose
codeine) 64% of participants had at least 50% maximum pain relief with the combination
compared to 18% with placebo. The NNT was 2.2 (95% confidence interval 1.8 to 2.6) (high
quality evidence). In three studies (204 participants) ibuprofen plus codeine (any dose) was
better than the same dose of ibuprofen (69% versus 55%) but the result was barely significant
with a relative benefit of 1.3 (1.01 to 1.6) (moderate quality evidence). In two studies (159

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participants) ibuprofen plus codeine appeared to be better than the same dose of codeine alone
(69% versus 33%), but no analysis was done. There was no difference between the combination
and placebo in the reporting of adverse events in these acute studies (moderate quality evidence).
Article 2
Utilization and effectiveness of multimodal discharge analgesia for postoperative pain
management.
Desai K1, Carroll I2, Asch SM3, Seto T4, McDonald KM1, Curtin C5, Hernandez-Boussard T6.
Author information
Abstract
BACKGROUND:
Although evidence-based guidelines recommend a multimodal approach to pain management,
limited information exists on adherence to these guidelines and its association with outcomes in a
generalized population. We sought to assess the association between discharge multimodal
analgesia and postoperative pain outcomes in two diverse health care settings.
RESULTS:
We identified 7893 patients at AH and 34,581 at VHA. In both settings, most patients were
discharged with O + A (60.6% and 54.8%, respectively), yet a significant proportion received
opioids alone (AH: 24.3% and VHA: 18.8%). Combining acetaminophen with opioids was
associated with decreased follow-up pain in VHA (Odds ratio [OR]: 0.86, 95% confidence
interval [CI]: 0.79, 0.93) and readmissions (AH OR: 0.74, CI: 0.60, 0.90; VHA OR: 0.89, CI:

Evaluation of Practice 13
0.82, 0.96). Further addition of nonsteroidal antiinflammatory drugs was associated with further
decreased follow-up pain (AH OR: 0.71, CI: 0.53, 0.96; VHA OR: 0.77, CI: 0.69, 0.86) and
readmissions (AH OR: 0.46, CI: 0.31, 0.69; VHA OR: 0.84, CI: 0.76, 0.93). In both systems,
patients receiving multimodal analgesia received 10%-40% less opioids per day compared to
opioids only.
Article 3
Non-opioid analgesia is as effective as opioid management in acute pain and supports a change
in prescribing practice to help address the ‘opioid epidemic’
Free
1. Amelia Swift1,2A
Implications for practice and research
 In some emergency department patients, combinations of non-opioid analgesia may be as
effective in reducing pain as opioids.
 Using non-opioid analgesia as a first-line treatment in short-term moderate to severe
trauma pain might contribute to reducing long-term dependence on opioids.
 Further research into dosing, adverse events, patient satisfaction and analgesia
combinations in other patient groups is required.
The aim of this study was to determine whether non-opioid analgesia could be as effective in
managing moderate to severe acute extremity pain as opioid analgesia.

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Findings
A total of 411 patients took part in the study. All the analgesia regimes were effective in
reducing pain between 3.5 and 4.4 NRS points: there was no statistically significant difference
between them. Eighteen per cent of patients took rescue medication during the trial but there was
no difference in the proportion from each of the groups.
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