Question 3

Use of a combination of scheduled non-opioid multimodal analgesics (MMA) such as acetaminophen, NSAIDs, and gabapentin have been shown to decrease opioid requirements for patients with acute pain by 30-50%.  Their initiation may allow overall better pain control than with opioids alone.  An important concept is that the use of multiple medications in combination should require less of each individual medicine, in order to keep the side-effects lower while the benefit of combination treatment is obtained.  High doses of several medications in combination with opioids may only increase risks. So, when using MMA, opioid dose should be reduced to lower the risks while attaining the same level of pain control.

Acetaminophen

As with any medication, appropriate dosage should be administered, which is a maximum of 10mg/kg for ibuprofen and 15 mg/kg for acetaminophen.  Doses must be adjusted for liver or kidney disease.

Gabapentin

For gabapentin, starting at 300 mg TID is reasonable for patients <70 years old, and 100 mg TID for those >70 years old.  However, as gabapentin has a dose-response effect (albeit non-linear due to increased protein binding with increased dose), more rapid escalation in the inpatient setting is often done to quickly evaluate for efficacy while monitoring for side effects (e.g. sedation, dizziness).  Gabapentin dose needs to be reduced in those with acute or chronic renal disease. Gabapentin can be sedating and may not improve pain cessation after surgery, but has been shown to promote earlier taper off opioids after surgery (see references below). Gabapentin itself can be misused so it is now considered a controlled substance in Tennessee, and prescriptions for gabapentin can be viewed when looking in the CSMD. 

Clonidine and other Alpha-2 agonists

Alpha-2 agonists have also shown benefit for pain and for muscle spasm that contributes to pain, but caution should be taken with patients at risk of hypotension and/or bradycardia.  Caution should also be taken in elderly patients due to risk for dizziness or falls.

Additionally, when treating medical or surgical patients with acute or chronic pain, some guiding principles for use of non-opioid pain medications include the following 3 key points:

  1. non-opioid pain medications should be added and tried first
  2. non-opioid pain medications should be prescribed as scheduled medications when possible (i.e. every 8 hours)
  3. non-opioid pain medications should be on longer and taken off of the pain regimen last (i.e. taper off opioids first, then start taper of non-opioids last)

 These principles are relevant to the inpatient and post-discharge/outpatient settings.  By following these principles, total opioid dose can be reduced and tapering sooner can be attained.

References:

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