Multimodal Analgesia for Breast Surgery – Combinations of Pain Medications Reduce the Need for Opioids

In women undergoing outpatient breast surgery, multimodal analgesia techniques – using combinations of medications to control surgical pain – can lead to lower pain scores and less need for opioid pain medications, reports a study in the October issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

Multimodal analgesia (MMA) can improve pain control after a wide range of outpatient breast surgery procedures, suggests the new research by ASPS Member Surgeon Jeffrey E. Janis, MD, and colleagues of The Ohio State University Medical Center, Columbus.

Combinations of Oral Pain Relievers Help to Control Pain after Surgery

The researchers report their experience with MMA for patients undergoing outpatient breast surgery, such as breast reduction or secondary breast procedures (but not initial breast cancer surgery). Before surgery, two groups of patients received MMA, consisting of combinations of oral pain relievers that work by different mechanisms.

In 95 patients, MMA consisted of the over-the-counter pain reliever acetaminophen in combination with the anticonvulsant/nerve pain medication gabapentin. Fifty-four patients received the same two medications plus the selective nonsteroidal anti-inflammatory drug celecoxib. Another group of 78 patients received an intravenous (IV) form of acetaminophen during surgery.

Outcomes were compared to those of 333 patients receiving standard treatment, with no preoperative pain medication. All patients received opioids in the postanesthesia care unit (PACU or recovery room) after surgery.

Both oral MMA combinations were associated with lower pain scores and less need for opioids after surgery. "Giving preoperative oral MMA decreased both pain scores and opioid use in the PACU by about 40 percent," said Dr. Janis. Neither outcome was improved for patients receiving IV acetaminophen.

Local anesthetics were used during breast surgery in about 30 percent of patients. "Local anesthetic decreased PACU opioid use and pain scores, independent of preoperative MMA," said Dr. Janis. Nearly one-fourth of patients had a previous opioid prescription available at home; these patients tended to use more opioids after surgery.

As the opioid crisis continues, new approaches to controlling pain after surgery are urgently needed. Postoperative pain is the most common reason for opioid prescriptions. By combining different types of pain medications with different mechanisms of action, MMA is a promising approach to controlling surgical pain while reducing the need for prescription opioids. "Ambulatory breast surgery is an ideal opportunity to implement these strategies," according to the authors.

In addition to lowering pain scores and opioid dose, the medications used for MMA are inexpensive - the cost of the three-drug MMA regimen used in the study was just $2.28.

"At a minimum, we recommend administering an oral MMA regimen preoperatively and using local anesthetic for outpatient breast plastic surgery to reduce opioid use and improve pain scores," said Dr. Janis. The researchers are planning a further study to evaluate the benefits of continued MMA treatment after ambulatory plastic surgery, including monitoring of opioid use after the procedure.

Plastic and Reconstructive Surgery® is published by Wolters Kluwer.

Click here to read "Preoperative Multimodal Analgesia Decreases Postanesthesia Care Unit Narcotic Use and Pain Scores in Outpatient Breast Surgery"

Article: "Preoperative Multimodal Analgesia Decreases Postanesthesia Care Unit Narcotic Use and Pain Scores in Outpatient Breast Surgery" (doi: 10.1097/PRS.0000000000004804)