What are the options for a multimodal pain regimen?

From the Guidelines

A multimodal pain regimen should include a combination of acetaminophen, NSAIDs, and gabapentinoids to provide effective pain relief with minimal side effects, as recommended by the most recent guidelines 1. The regimen should prioritize the use of non-opioid medications, with opioids reserved for breakthrough pain.

• Acetaminophen (1000mg every 6 hours, not exceeding 4000mg daily) is a valid and effective option for multimodal analgesia, as it reduces opioid use and improves postoperative outcomes 1.
• NSAIDs, such as ibuprofen (400-600mg every 6 hours) or ketorolac (15-30mg IV every 6 hours for no more than 5 days), are also recommended for their analgesic and opioid-sparing effects 1.
• Gabapentinoids, like gabapentin (300mg three times daily, titrated as needed) or pregabalin (75mg twice daily), can be added for moderate to severe pain, targeting neuropathic pathways 1.
• Non-pharmacological approaches, including ice/heat therapy, physical therapy, and cognitive behavioral techniques, should be incorporated to enhance pain management. The use of coxibs, such as celecoxib, may be considered in certain cases, but with caution due to potential cardiovascular and renal risks 1. Ketamine may also be used in severe pain management, with subanesthetic doses (boluses < 0.35 mg/kg and infusions at 0.5-1 mg/kg/h) showing evidence of efficacy in acute pain 1. Dexmedetomidine, in combination with fentanyl-based intravenous PCA, may be considered for major abdominal surgery, but its use in emergency abdominal surgery requires further study 1.

From the FDA Drug Label

Use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals Initiate the dosing regimen for each patient individually, taking into account the patient's severity of pain, patient response, prior analgesic treatment experience, and risk factors for addiction, abuse, and misuse Reserve oxycodone hydrochloride tablets for use in patients for whom alternative treatment options (e.g., non-opioid analgesics or non-opioid combination products): Have not been tolerated, or are not expected to be tolerated, Have not provided adequate analgesia or are not expected to provide adequate analgesia.

Multimodal pain regimen options may include:

• Pregabalin for the management of fibromyalgia and neuropathic pain associated with spinal cord injury 2
• Oxycodone for the management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate 3 3 Key considerations for a multimodal pain regimen include:
• Using the lowest effective dosage for the shortest duration consistent with individual patient treatment goals
• Initiating the dosing regimen for each patient individually, taking into account the patient's severity of pain, patient response, prior analgesic treatment experience, and risk factors for addiction, abuse, and misuse
• Reserving opioid analgesics for use in patients for whom alternative treatment options have not been tolerated or have not provided adequate analgesia.

From the Research

Multimodal Pain Regimen Options

• The use of multimodal pain regimens, which involve combining two or more different drugs, may improve analgesic efficacy and reduce overall side effects 4, 5, 6.
• Studies have shown that combining opioids with other agents, such as gabapentin or pregabalin, can be effective in treating neuropathic pain 4, 7.
• The combination of controlled-release oxycodone and pregabalin has been shown to be more effective than monotherapy with either agent in patients with neuropathic pain 7.
• Other agents, such as alpha 2 agonists, NMDA receptor antagonists, and NSAIDs, may also be used in multimodal pain regimens to target different pain pathways 6.
• The use of oxycodone/acetaminophen has been compared to acetaminophen alone in patients with musculoskeletal pain refractory to ibuprofen, with results showing slightly greater pain relief with the combination, but also more medication-related adverse events 8.

Key Considerations

• When using multimodal pain regimens, it is essential to consider the potential for increased side effects, particularly when combining agents with similar adverse effect profiles 4, 6.
• The development of non-sedating neuropathic pain agents could lead to the identification of more favorable analgesic drug combinations 4.
• Further studies are needed to determine the optimal combinations and dosing regimens for multimodal pain management 4, 6, 7.