Multimodal-pain Management By Dr. Nelson Multimodal-pain Management

A transcript of an interview by Bill Klaproth of Doctor Podcasting

A service of Marin General Hospital

 
David Nelson, MD is a nationally-recognized expert in managing post-operative pain with minimal opioids (often but incorrectly called "narcotics").

Learn more about David Nelson, MD

 

Bill Klaproth (Host): The opioid crisis has caused many physicians to rethink pain management and stop turning to opioids as the default solution.

Surgeons are increasingly turning to multimodal solutions including setting patient expectations through preoperative education, ice, elevation, pre-operative blocks, and over-the-counter analgesics.

Board-certified in orthopedics, Dr. David Nelson is the only hand surgeon in the US to hold a membership in the International Association for the Study of Pain. Dr. Nelson has been researching post surgical pain and pain management for twenty-seven years. Here, he discusses his professional experience, his research findings, and how to approach pain management from a whole-patient perspective.

Most patients who undergo surgical procedures experience acute post-operative pain, so the question is with our current opioid crisis, how to manage the pain with minimal opioids? And here to talk with us about this is Dr. David Nelson, who is board certified in orthopedics, board certified in hand surgery, and is the only hand surgeon in the United States who is a member of the International Association for the Study of Pain, and he's been doing research in pain after surgery for twenty-seven years. Dr. Nelson, my goodness, thank you for your time. I appreciate you being here. So let's start here, and this probably goes without saying, but your goal as a surgeon for post-operative pain management is to reduce or eliminate pain and discomfort with a minimum of side effects for the patient. Is that right?

Dr. David Nelson, MD : Absolutely. I think that's what all of us want from our own surgery, is that we want the surgery to be successful, but we don't want to have any pain, and we don't want to have any complications either from the surgery or from treating the pain. And the nice thing is that we can do this.

Bill: So the opioids crisis has really blown up and shed a lot of light on this, and I know you've done your own study on this. Can you tell us about the studies you've done?

Dr. Nelson: Yes. I was doing these studies starting twenty-seven years ago, long before we recognized we had an opioid crisis. I was interested in hand surgery and how can I manage my patients well without any pain? And one of the best ways to start for any physician is to just interview your patients after surgery and find out how they did, how much of the pain medicine they took, and did they have any pain.

I did my first study asking about this, and I was giving all my patients ten pills of Vicodin. And it was interesting, the nurses in the recovery room told me everybody else was giving thirty and once I did the study, I found that actually my patients were taking less than five. It also allowed me to look at the various components of this, because it's not just giving opioids. The concept of treating the whole patient, which is one of the themes at Marin General, is to make sure you educate the patient about what their pain is likely to be, and you can give them pain blockers, just like the dentist gives for your tooth. You can do that at the time of surgery and it can be incredibly effective if you set up the first experience when the patient wakes up from surgery of not having any pain, and that helps a lot.

In addition, we're giving them other things, it's called multimodal analgesia, or pain management, and Tylenol and Aleve are amazingly powerful in relieving post-surgical pain. A lot of people think that they don't work at all, but research has shown with the proper combination of other things the surgeon does during surgery Tylenol and Aleve can be very powerful.

Bill: Dr. Nelson, you just mentioned multimodal pain management. Can you explain to us what that is?

Dr. Nelson: Yes. It's, uh, a little bit like using both nails and screws and glue to hold something together. That is, we can get better pain relief if we give the person a small amount of Tylenol, which works in the brain, a small amount of Aleve, which works in the area of the incision give them a numbing shot so that actually no pain signals are coming up to their brain, and then give them a small amount of opioids - narcotics - for breakthrough pain, if they have enough to require it. So by attacking the pain in multiple directions, we can actually get fewer side effects with better pain relief.

Bill: This sounds like very smart pain management and a lot of common sense. How did we get to this huge opioid crisis of people over-prescribing? What you just said sounds perfect and smart. How did we get to where we're at?

Dr. Nelson: Well I think we got here because most surgeons have no training in pain. All of their focus has been learning the proper anatomy, and the proper surgery, and developing the skills to do the surgery well, and pain has really not been something surgeons have been taught about. But the multimodal approach has probably come up in the last approximately twenty years, but it started in the anesthesia field, and it's only slowly come to the surgical field. But by doing a smart approach of multimodal analgesia, we can get the number of opioids down and yet still get great pain relief.

The trouble is the federal government started, scrutinizing doctors or rating them on how well they manage pain, and most surgeons were taught you manage pain by giving opioids. And what happened is we just gave too many. We're learning now about that, and most doctors are incorporating some kind of multimodal analgesia in their post-operative regimen so we can give patients great pain relief and still not use a lot of opioids.

Bill: So this multimodal approaches are there established protocols for this then? It sounds like you just kind of alluded to that.

Dr. Nelson: Many of the national pain organizations, as well as some of the surgical organizations have tried to, teach certain kinds of programs for pain management, and there are protocols available. When you are doing different kinds of surgery, different protocols would be appropriate. So for instance, hand surgery is very different than back surgery or brain surgery. The same concepts apply, but there are many different tools in the toolbox, and you have to use the ones that are appropriate for your surgery and your patient.

But there are general protocols available. In hand surgery, or orthopedic surgery in general, the protocols almost all involve pre-operative teaching and when a patient has better understanding of what he can expect, they just have less pain.

We also give blocks prior to the incision so the brain doesn't even know the body is having surgery. Then we give long-acting blocks just at the end of surgery so the patient wakes up in the recovery room, and we try to have zero pain if possible. Then we're also using Tylenol and Aleve just prior to surgery and then after surgery.

And other things such as elevation, ice, and rest are also useful, and studies have shown that when you put these all together, patients have a much better post-operative experience and much less pain than when we ignore these factors.

Bill: So if you educate the patient on what to expect and how to manage pain, and potentially the side effects of opioids, they are able to make much better informed decisions when it comes time for rehab. Is that right?

Dr. Nelson: You're absolutely correct, but not only that. In addition, their experience of their pain will be less. I'll give you just a couple of examples. If I tell you I'm going to stab you with a knife in your back, and I touch your back with a piece of ice, you will experience pain. But if you were to take a sliver out of your finger, you'd know when it's going to hurt because you're the one that's doing it. When you know when it's going to hurt, and you can control it and stop it at any time, you just experience that as less pain.

So there's a lot of variation in how we experience pain, and when a person knows what to expect, and they're prepared for it, they simply hurt less.

Bill: Wow, that's really interesting. And one last point here before we wrap up. You said in your study, people actually took less opioids than you prescribed them, if I heard that correctly. So do people as an inclination want to take less medication, and if we teach them that this could turn bad if you take too much of these, they will take less. Is that kind of what your study might have shown?

Dr. Nelson: Yes. Virtually all patients want to take a minimum amount of medication, and they certainly want to take a minimum amount of opioids, and if you give them pre-op education and use a multimodal approach where you're using education, ice, elevation, Tylenol, Motrin, pre-op blocks; they experience much less pain and they can have a lot less.

I've done a study where I looked at radius fractures in the United States, and I interviewed seventy-nine surgeons. The number of opioids they gave ranged from five to 160. I was giving five, and in another study I found that 72% of the patients never took any of the drug that I gave them. The multimodal pain approach is so effective, they never took any narcotics. Patients love that. They get less sedated, they have less complication, and there's less risk of being part of the opioid epidemic.

Bill: Well, Dr. Nelson, I hope more surgeons adopt this multimodal approach, and thank you for a great discussion on a very important topic. And for more information, please visit www.MarinGeneral.org. That's www.MarinGeneral.org. Dr. Nelson, thank you again. This is The Healing Podcast brought to you by Marin General Hospital. I'm Bill Klaproth, thanks for listening.
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