Kern Singh, MD, Professor of Orthopedic Surgery at Rush University Medical Center, talks about a new strategy to treat pain without narcotics.
What is multi-modal analgesia?
SINGH: Multi-modal analgesia is the belief that pain is generated at multiple points and as such should be treated with different low-dose medications. For example, when you stub your toe against the side of the bed, you immediately feel pain and that pain travels up to your brain. The first thing you do is start rubbing your toe. Why do you rub your toe? Because you start flooding your brain with good pain sensations in order to block out the bad. Multi-modal analgesia is based upon the belief that if you could stop that sensation from travelling up the brain with a variety of different medications, and each of them treating pain in a different pathway, then you can reduce the overall amount of medications you need. So, you don’t get too high a dose of any one medication.
How are you using it in your research?
SINGH: I call it precision anesthesia. We optimize and customize the amount of medication unique to each individual. If someone has been taking narcotics before, then we adjust each individual medication based upon their history. If they’re more narcotic naive and they’ve never taken medication, then we go down on the dosing. We adjust for all of those factors whether they’ve taken medications before, how old they are, how big they are… all those metabolic factors. That way we can customize it so that everyone experiences a very similar outcome. We’ve been taught since we’ve been in medical school that opiates are the medication of choice for pain. But as I mentioned before, pain is multifactorial. A lot of patients who have post-operative pain following a minimally invasive surgery, the pain typically comes from muscle spasm. Previously, we had to give them narcotics, but now we give them a muscle relaxant. Or it may be due to inflammation from some tissue trauma, so we give them an anti-inflammatory. So, pain is multifactorial, and opiates are just one pathway. We used to believe that if they still had pain with narcotics, to give them more narcotics. What we realized is there are different types of pathways for pain that are treated effectively with non-narcotic medication, depending on what the patient is experiencing. So, it’s been about seven years since we started this multi-modal analgesia. And now, it’s more commonly widespread and accepted across different institutions. Beforehand, we used to keep patients on narcotics for six to eight weeks after surgery. Now, because we are becoming so effective in treating their preoperative and then intra-operative pain, patients are now on narcotics for just two to three days after surgery. Then, after the first week, 90 to 95 percent of patients are on just a muscle relaxant or a non-narcotic pain medication.
Why have narcotics been the go-to medication?
SINGH: I think we have to look at ourselves as physicians. We’re part of the problem that created this epidemic of narcotic consumption. For us as surgeons, the importance is understanding the type of pain the patients have and then customizing their medication so that they never get to a point they become reliant or dependent on any one medication or one type of narcotic.
Does this have a major impact on insurance?
SINGH: Well I think that physicians and hospitals love it because we’re not dealing with chronic pain medication prescriptions. Overall, the complications that can occur from pain medications, whether that be respiratory arres (people stop breathing) or they have bowel and constipation issues, all those lead to increased medical costs. So, for the patient and society as a whole, I think eliminating or reducing the number of narcotics that we give while still treating people and their pain appropriately is a huge win.
How does a patient go about being sure they are using a multi-modal analgesia program?
Patients are becoming more sophisticated and the onus is on them to demand from their physicians a multi-modal analgesia program. Very few places are doing it. But I think the sophisticated patients are concerned about the narcotic consumption and they want a narcotic-free or narcotic-minimum surgery and outcome. As patients becomes more familiar with with multi-modal analgesia I think they’ll demand it from all physicians.
Is there anything else you would like to add?
SINGH: I have a little bit of a selection bias since we have developed some of these mult-modal analgesia pathways, so people specifically come for that, and the conversation is very healthy. I’ve had people who have failed surgeries who were rightfully on narcotics who want to get off the medication and get back to a normal type of lifestyle. I have patients who are fearful of becoming addicted to pain medications. In general, I think most patients that we treat want to be narcotic-free. They want to be active and want to be to a point that they don’t need narcotics after surgery. For my practice, there’s no patient that’s on pain medications after four weeks from surgery. And, a lot of that is preoperative education and patient motivation as well. I also would like to thank my colleague and friend, Dr. Kumar Buvanendran who has been instrumental in developing the multi-modal analgesia pathways we have been using in our minimally invasive outpatient spinal surgeries.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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