Critical Care Pain Management in the Era of Enhanced Recovery and the War on Opioids
Chronic pain syndromes are a persistent problem in the United States, with conservative estimates suggesting a cost $560 to $635 billion dollars annually1. Chronic pain following intensive care unit (ICU) survival is difficult to quantify, as patient populations vary across hospital centers and within different ICU settings; however, current evidence demonstrates that anywhere from 12-60% of patients remain affected by chronic pain at 6-months to a year following ICU admission, which contributes to a significant portion of diagnoses nationally2,3. Opioid-based therapies have been the mainstay for treatment of acute pain, sedation, and ventilator dyssynchrony in the ICU, as well as for chronic post-injury pain. Recent evidence highlights problems with maintenance of these therapies, ranging from inadequate treatment of acute pain, worsening of chronic pain, addiction and diversion4. As with many therapies initiated in the ICU, administration and continuation of opioid medications can have a lasting impact on the health of our patients for months to years following their hospital course. A systematic and multimodal approach to ICU pain management must be a consideration for the Anesthesiology Critical Care Specialist, as we work to improve long and short-term patient outcomes.
Inadequate or inappropriate sedation and pain management in ICU patients can contribute to a multitude of adverse effects delaying patient recovery involving the respiratory, cardiovascular, gastrointestinal, and endocrine systems5. Inadequate pain control is also a major contributor to post-traumatic stress disorder among ICU survivors, with psychosocial impacts affecting patient quality of life. Acute pain is most commonly managed with potent intravenous opioids, such as morphine or fentanyl, as first-line agents recommended by current guidelines6. Efforts to slowly taper these will often result in patients discharged on prescription opioid medications. Evidence tells us that without concerted effort to discontinue these drugs, patients will continue to take them and even escalate the doses, as they become less effective over time. The effects of postoperative opioid abuse and dependence is shown to have significant effects on health care utilization and patient outcomes, with higher 30-day readmission rates due to infection, overdose, or acute pain management being more common among these patients7. There is no question that survivors of critical illness are at risk for similar complications.
In the perioperative arena, implementation of enhanced recovery after surgery (ERAS) programs, with targeted interventions and focused care, has resulted in significantly improved postoperative outcomes8,9. One of the concepts common to all ERAS pathways is, notably, a reduction in the use of opioids for analgesia. Through the use of multimodal pharmacologic interventions, intentional reduction of intraoperative opioid administration, and appropriate regional and neuraxial analgesia, perioperative opioid use has decreased dramatically8. Logically, these strategies should be expected to help reduce unnecessary opioid use and abuse in the community, notably at a time where opioid reduction strategies are encouraged, if not mandated, from a national perspective.
While most of the benefits attributed to ERAS protocols, such as reductions in length of stay, opioid use and surgical site infection, have been seen in patients following elective colorectal, urologic and gynecologic procedures8,10, it is reasonable to expect many of them to translate to more complex patient situations, including those involving critical care patients. We have seen recent development of ERAS protocols for common cardiac11, thoracic10 and neurosurgical12 procedures, and their implementation will ideally shorten duration of mechanical ventilation and length of ICU stay, as well as reducing common ICU-associated complications such as delirium and health care-associated infection. Additionally, the appropriate management of pain and agitation associated with critical care, would be expected to help post-ICU recovery in these patients.
Some barriers exist to enacting ERAS-like protocols in an ICU setting. There is a relative paucity of evidence to support alternative pain management strategies in critically ill patients, especially those with medical illness, and many opioid alternatives are difficult to dose, given the variability in gastrointestinal function and availability. The patient with sepsis and ARDS may require different opioid-reduction strategies than the postoperative small bowel resection, so a one-size-fits-all approach is unlikely to be effective. Workload and knowledge deficits may contribute to reduced use of local anesthetic for incisional, procedural and traumatic pain. As an example, while it is fairly well-established that epidural analgesia is beneficial in thoracotomy and traumatic rib fracture, many other conditions may benefit from the pain relief and sympathetic outflow reduction associated with somatovisceral nerve blockade, such as pancreatitis, necrotizing superficial infections and burn injury.
We continue to rely on opioid and benzodiazepine infusions for analgesia and sedation of the critically ill patient. However, as evidence mounts to support reduction of deep pharmacologic sedation, even ventilated patients should be kept awake and interactive as tolerated. The role for non-opioid and non-sedating analgesia should therefore increase. Adjuncts such as acetaminophen, gabapentin, clonidine, ketamine, lidocaine infusions, regional analgesia, and non-steroidal analgesics have been increasingly studied and shown not only to be well tolerated, but also effective in decreasing opioid requirements13-17. Even still, there continues to be an over-reliance on opioid medications and a lack of utilization of multimodal adjuncts in the management of pain associated with critical illness. Surgical and nonsurgical conditions will obviously mandate consideration of different therapies, but awareness and availability of appropriate alternatives is paramount to any successful approach.
The next steps in the development of structured pathways for reduction of post-ICU opioid use should to be construction, implementation, and audit of a systematic and multimodal recovery program for ICU patients to address and potentially decrease the rate of post-ICU chronic pain syndromes. The focus would ideally be not only on enhancing multimodal adjuncts to limit patient reliance on opioid medications, but also include discontinuation regimens to prevent long-term opioid dependence and the poor outcomes associated therewith. Opioids have an important role in the treatment of acute pain for many ICU patients, but their use should be deliberate and balanced with other pharmacologic and non-pharmacologic therapies to continue to improve and advance patient care in both the hospital setting and following discharge.
- Institute of Medicine. Relieving pain in America: a blueprint for transforming prevention, care, education, and research. IOM. 2012;49(11):49–6323–49–6323. doi:10.5860/CHOICE.49-6323.
- Herrera-Escobar JP, Apoj M, Weed C, et al. Association of Pain after Trauma with Long-term Functional and Mental Health Outcomes. J Trauma Acute Care. July 2018:1. doi:10.1097/TA.0000000000002017.
- Puntillo KA, Naidu R. Chronic pain disorders after critical illness and ICU-acquired opioid dependence: two clinical conundra. Curr Opin Crit Care. 2016;22(5):506-512. doi:10.1097/MCC.0000000000000343.
- Rosenblum A, Marsch LA, Joseph H, Portenoy RK. Opioids and the treatment of chronic pain: controversies, current status, and future directions. Exp Clin Psychopharmacol. 2008;16(5):405-416. doi:10.1037/a0013628.
- Ehieli E, Yalamuri S, Brudney CS, Pyati S. Analgesia in the surgical intensive care unit. Postgrad Med J. 2017;93(1095):38-45. doi:10.1136/postgradmedj-2016-134047.
- Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263-306. doi:10.1097/CCM.0b013e3182783b72.
- Gupta A, Nizamuddin J, Elmofty D, et al. Opioid Abuse or Dependence Increases 30-day Readmission Rates after Major Operating Room Procedures: A National Readmissions Database Study. Anesthesiology. 2018;128(5):880-890. doi:10.1097/ALN.0000000000002136.
- Beverly A, Kaye AD, Ljungqvist O, Urman RD. Essential Elements of Multimodal Analgesia in Enhanced Recovery After Surgery (ERAS) Guidelines. Anesthesiol Clin. 2017;35(2):e115-e143. doi:10.1016/j.anclin.2017.01.018.
- Melnyk M, Casey RG, Black P, Koupparis AJ. Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Can Urol Assoc J. 2011;5(5):342-348. doi:10.5489/cuaj.11002.
- Rogers LJ, Bleetman D, Messenger DE, et al. The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer. J Thorac Cardiovasc Surg. 2018;155(4):1843-1852. doi:10.1016/j.jtcvs.2017.10.151.
- Li M, Zhang J, Gan TJ, et al. Enhanced recovery after surgery pathway for patients undergoing cardiac surgery: a randomized clinical trial. Eur J Cardiothorac Surg. 2018;54(3):491-497. doi:10.1093/ejcts/ezy100.
- Wang Y, Liu B, Zhao T, et al. Safety and efficacy of a novel neurosurgical enhanced recovery after surgery protocol for elective craniotomy: a prospective randomized controlled trial. J Neurosurg. June 2018:1-12. doi:10.3171/2018.1.JNS171552.
- Karamchandani K, Carr ZJ, Bonavia A, Tung A. Critical Care Pain Management in Patients Affected by the Opioid Epidemic: A Review. Ann Am Thorac Soc. May 2018. doi:10.1513/AnnalsATS.201801-028FR.
- Hah J, Mackey SC, Schmidt P, et al. Effect of Perioperative Gabapentin on Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: A Randomized Clinical Trial. JAMA Surg. 2018;153(4):303-311. doi:10.1001/jamasurg.2017.4915.
- Mitra S, Carlyle D, Kodumudi G, Kodumudi V, Vadivelu N. New Advances in Acute Postoperative Pain Management. Curr Pain Headache Rep. 2018;22(5):35. doi:10.1007/s11916-018-0690-8.
- Memis D, Inal MT, Kavalci G, Sezer A, Sut N. Intravenous paracetamol reduced the use of opioids, extubation time, and opioid-related adverse effects after major surgery in intensive care unit. J Crit Care. 2010;25(3):458-462. doi:10.1016/j.jcrc.2009.12.012.
- Brodner G, Pogatzki E, Van Aken H, et al. A multimodal approach to control postoperative pathophysiology and rehabilitation in patients undergoing abdominothoracic esophagectomy. Anesth Analg. 1998;86(2):228-234.