Multimodal Analgesia
Introduction
Multimodal analgesia is a pharmacologic method of pain management which combines various groups of medications for pain relief. The most commonly combined medication groups include local anaesthetics, opioids, NSAIDs, acetaminophen and alpha-2 agonists.
In laymen terms, multimodal analgesia involves a selective use of specific drugs, in a scientifically determined combination.
Working Principle
Using multiple analgesic drugs, with different modes of action, simultaneously, form the key underlying principle of the concept of multimodal analgesia. Alternatively, drugs might also be administered via different routes under this concept.
For instance, opioids can be combined with non-opioids according to the individual situation. A local anaesthetic block can also be combined with a systemic analgesic for the desired results.
Experts also strongly suggest that it is advisable to avoid an intense, single modality treatment in acute pain management.
Research and Analysis
Research strongly indicates that this approach improves the effect of analgesia to quite an extent, owing to the additive or synergizing effects. Moreover, the doses of individual drugs can be reduced thereby cutting down on the incidence and severity of side effects. In addition, multimodal analgesia can also be used for day cases as well as for inpatient surgery.
Another research was conducted to analyse the impact of multimodal analgesia post-surgery. It was thereby concluded that the combination of nonsteroidal anti-inflammatory drugs with patient-controlled analgesia morphine, shows significant advantages over morphine alone.
The effect of multimodal analgesia in Laparoscopic Cholecystectomy has also been studied. As in a majority of other cases, the results indicated a favourable impact of the approach.
Similarly, the perioperative multimodal analgesia (MMA) was also found helpful in increasing the effectiveness of intravenous nutrition (IVN) as a means of preventing protein wasting following major upper abdominal surgery.
The Analgesic Ladder
A set of random studies and research reports have furnished a specific analgesic ladder, which lays out the guidelines for the medicines to be used in combination.
Here we list the main components of this analgesic ladder, along with the stages.
Slight pain – Paracetamol Mild pain – Paracetamol + NSAID Moderate pain – Paracetamol + NSAID + Codeine Severe – Paracetamol + NSAID + Morphine (PCA + NCA)
Multimodal Analgesia – Drug Usage
In accordance with the individual patient’s medical history and present complications, a series of drugs can be used and combined under the concept of multimodal analgesia.
In this section, we briefly outline the various drugs involved.
1) Non-opioids
This is one of the most important background medications for perioperative pain. Paracetamol is the most commonly accepted form of medicine and drastically improves the quality of analgesia when combined with opioids.
2) Opioids
This class of medication is one of the most significant components of perioperative analgesia. Tramadol is the most common drug used in this category.
3) Local Anaesthetics
Local anaesthetics are also widely used to alleviate pain. In the recent years, newer alternatives to the local anaesthetics have also been used, such as Lignocaine and Bupivacaine .
4) Adjuvants
Ketamine is one of the most well known drugs in this category. Such drugs are commonly used to treat acute pain which otherwise responds poorly to opioids including neuropathic pain.
