Six-year trends in the prescribing and use of multimodal analgesics for postoperative pain at Epworth.

Abstract

Background. The empirical literature and practice guidelines for the management of acute postsurgical pain recommend the administration of analgesics in multimodal combination to facilitate synergistic analgesia, reduce opioid requirements and opioid-induced side-effects. We evaluated the quality of postoperative pharmacological pain management on three orthopaedic wards at Epworth prior to, and following, audit and feedback of prescribing practice. Methods. In this observational trend study, we observed six-year trends in prescriptions for, and use of, multimodal analgesics following total hip and knee arthroplasty. Cross-sectional surveys of patients’ medication and acute pain outcomes were undertaken at Time 1 (2010,n=86), and after one (Time 2,n=262) and five years (Time 3,n=188). Audit feedback was provided to anaesthetists after Time 1. Surveys were sequential involving patient interviews and medical record audit, with survey days selected purposively to capture all surgeon-anaesthetist dyads. Results. We found statistically significant, sustained time trends of increased prescribing and use of multimodal analgesics following audit and feedback. Use of analgesics in multimodal combination was associated with modest improvements in rest pain and clinically significant reduction in patient-reported interference of pain with daily activities and sleep. However, ratings of dynamic pain (pain with movement) were high and rescue opioids were under-administered at all time points. Further, while patients reported high levels of medication induced side-effects (eg. nausea, constipation), use of appropriate treatments was low. Discussion. Findings suggest a sustained change in prescribing of multi-modal analgesics but a need for improvement in prescribing related to common opioid side-effects and a clinical gap in the bedside assessment and management of breakthrough pain and medication side-effects.