Multimodal analgesia (e.g., using drugs from two or more classes, or a drug plus a non- drug treatment) can produce synergistic effects, reduce side effects, or both. One example of multimodal analgesia is the use of both an NSAID and acetaminophen, plus physical approaches (e.g., cold, compression, or elevation) to manage postoperative pain. Demonstrated benefits of multimodal analgesia include earlier ambulation, earlier oral intake, and earlier hospital discharge for postoperative patients, as well as higher levels of participation in activities necessary for recovery (e.g., physical therapy). 105
Non-pharmacological treatments for acute pain When possible, non-pharmacologic methods should be used, alone or in combination with analgesics, to manage acute pain. 106 The degree to which this is possible depends on the severity, type, and origin of the pain, but many non- pharmacological approaches can be very effective and their use avoids the potential side effects and risks associated with pharmacological interventions. Physical methods of pain management can be helpful in all phases of care, including immediately after tissue trauma (e.g., rest, application of cold, compression, elevation) and later in the healing period (e.g., exercises to regain strength and range of motion).
Physical therapy may be useful for a range of musculoskeletal issues and can be helpful in recovering from acute pain-producing traumas initially treated with other methods. A 2018 study reported that patients with low back pain who first consulted a physical therapist were less likely to receive an opioid prescription compared to those who first saw their primary care physician. 107 Exercise therapy can take many forms, including walking, swimming or in-water exercise, weight training, or use of aerobic or strength-training equipment. According to a CDC review, conditions that may improve with exercise therapy include low back pain, neck pain, hip and knee osteoarthritis pain, fibromyalgia, and migraine. 108
BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 3.
Instructions: Spend 5-10 minutes reviewing the case below and considering the questions that follow. Case Study 3
Hannah, a 64-year-old female presents with severe pain in both anterior-lateral thighs and lateral shoulders, rated at 7/10 on the VAS. She reports that the pain is constant and that she gets only mild relief from NSAIDs. She cannot walk without a cane or walker. She had been diagnosed six years ago with severe peripheral neuropathy in her legs for which she was prescribed gababentin. She reports that gababentin gives her intense “brain fog” and forgetfulness, however, and that she has stopped taking it because of these side effects. The patient also has type 2 diabetes, initially treated with metformin but lately also with 50 units of insulin per day. The patient was given a treatment plan that included chiropractic adjustments and exercise rehabilitation exercises. She also adopted a “Paleo” diet, which she followed strictly for three months, although it did not significantly lower her hemoglobin A1c levels. She has come to you because the pain is eroding her quality of life, interrupting her sleep, and contributing to tensions with her partner.
1. Given the subjective nature of pain, how can a clinician more objectively assess the kind of pain reported by patients such as this?
2. Is it reasonable to believe that the gabapentin was responsible for her reported side effects?
3. Would Hannah be a good candidate for an opioid analgesic? Why or why not?
4. What non-pharmacological treatments might be tried for reducing this patient’s pain?
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