Multimodal Pain Management or Opioid Monotherapy?

Multimodal Pain Management or Opioid Monotherapy?

Multimodal pain management improves quality, financial outcomes over opioid monotherapy 

At one time, opioids were considered a mainstay for management of acute pain following surgery. For decades, however, virtually all leading authorities have recommended a multimodal approach in lieu of the traditional opioid monotherapy.  

Recommended course: The Role of the Pharmacist in the Opioid Crisis 

What is multimodal pain management?  

A multimodal approach is one that relies on the combination of therapies. These include non-opioid analgesics (e.g., NSAIDs, acetaminophen, cyclooxygenase-2 inhibitors, and local or regional agents) as a primary method for pain control.   

In a multimodal approach, opioids are used only to the extent that non-opioid analgesics have proven to be insufficient when managing acute pain. Some refer to this approach as a balanced, opioid-sparing, or non-opioid foundation.  

A multimodal pain management strategy can help to improve pain outcomes and quality scores while reducing the risks of opioid-related adverse events or potential addiction. The adoption of multimodal analgesia can help to reduce associated costs, length of stay, and liability risks.  

Although multimodal analgesia has proven to be both good medicine and good business, many hospitals continue to rely on opioids as the exclusive or near-exclusive method of managing the acute pain of surgery.  

Business benefits of multimodal pain management  

The list of authorities that recommend a multimodal approach is compelling, including the American Society of Anesthesiologists, American Society of PeriAnesthesia Nurses, Enhanced Recovery After Surgery Society, The Joint Commission, and the National Center for Biotechnology Information, amongst others.  

Recommended course: Pain Management: Evidence-Based Guidance for Prescribing Opioids 

Multimodal pain management guidelines: Side effects, adverse events and complications    

The recommendation for a multimodal approach is based primarily on recognition of the following factors:  

  • Numerous negative side effects of opioids  
  • High risk and severity of adverse drug events and complications  
  • Substantial proportion of the population falling into the higher-than-normal risk category for opioid-related adverse events  

The common side effects that can limit opioid therapy include respiratory depression, dizziness, nausea and vomiting. Other side effects may range from constipation, delirium, and hallucinations to falls, and depression. Patients may also experience hypotension, cognitive impairment, and aspiration pneumonia.   

Opioids impact multiple organ systems. In addition to side effects, opioids are implicated in the development of  adverse drug reactions to a greater degree than any other class of drugs. The Joint Commission cautions that “adverse events can occur with the use of any opioid.” The risk of addiction is also well known and well documented in literature.  

The risk is exacerbated by the fact that a substantial proportion of patients fall into the higher-than-normal risk category. According to The Joint Commission, this includes those with sleep apnea, the morbidly obese, the very young, the chronically or very ill, those who are over age 60, and those individuals on drugs that can central nervous or respiratory system.  

Multimodal pain management to decrease opioid dependence 

Opioids pose a higher risk of addiction than any other class of drugs. Hospital-administered opioids may lead to addiction in two different ways. The first is well-known. A person becomes dependent on and addicted to opioids because they provide pain relief, produce euphoria, or both.  

The second may be less well-known, but it is equally concerning. Often a clinician relies on opioids to manage a surgical patient’s pain. Concerned with the risks, however, the clinician might undermanage the patient’s pain with too low of a dosage. This contributes to a vicious cycle: Under-management of acute pain is a proven cause of chronic pain, and chronic pain is a proven cause of opioid dependence.  

Recent studies have documented the frightening transition from reliance on opioids prior to surgery to chronic opioid use in the year after surgery. A recent article in the Journal Pain reports that while 5-10% of opioid-naïve patients that underwent total hip or knee arthroplasties continued opioid use after six months, the percentage of opioid-reliant patients continuing opioid use was sharply higher. Nearly 54% of total knee patients and 35% of total hip patients. Those individuals taking greater than 60mg oral morphine equivalents prior to surgery had an 80% likelihood of chronic use.  

Post-op multimodal pain management in orthopedic surgery  

Certain procedures have shown higher incidences of chronic opioid use. Procedures such as total knee or hip arthroplasties have some of the highest increased risks for chronic opioid use in the year following surgery.  

Physicians can treat pain effectively and train patients to use them safely and responsibly. Physicians and pharmacists can help achieve this through counseling and consultations. Problems occur when people begin taking more tablets than prescribed or taking them more often than recommended. The risk of overdose also increases when people take the drugs for reasons other than pain relief — to help them sleep, for instance, or to self-medicate anxiety or depression.  

Multimodal pain management nursing to impact length of stay  

Studies have repeatedly documented the impact of opioid-related side effects and adverse events on length of stay. A study in Annals of Pharmacotherapy found a 10.3% increase in length of stay for patients experiencing opioid-related adverse events. Such events occurred more frequently as dosages increased.   

An Advisory Board study of over 2.5 million cases showed that patients on a lower-dose opioid regimen had a length of stay 29% shorter than those on a high-dose regimen.  

Patient satisfaction  

Opioids often decrease patient satisfaction in two specific ways:  

  • The associated side effects and adverse events are usually uncomfortable and painful  
  • Under-management of pain has been repeatedly documented as a primary cause of patient dissatisfaction  

While the Center for Medicare and Medicare Services (CMS) has proposed removing pain management scores from the payment calculation, pain management would remain a component of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction survey.  

Operations and supplies  

A study of total hip and total knee arthroplasty at the Mayo Clinic compared patients on a multimodal regimen with those on the traditional, opioid-reliant regimen. The study concluded that the multimodal regimen reduced the following Medicare Part A costs: room and board, medical/surgical supply, operating room, pharmacy, and anesthesia supply. Total costs (Parts A and B) were reduced by 11.77%.  

Liability costs  

It can be difficult to measure the liability costs of over-reliance on opioids, but several factors indicate that the costs are real and likely to grow exponentially. First, over-reliance produces negative side effects, complications, and adverse events, which may be the basis of liability claims. Second, over-reliance departs from the practice standards recommended by recognized authorities, which in itself risks liability.  

Third, there is a clear national movement toward holding clinicians liable for the consequences of drug dependence and addiction. Congress recently passed the Comprehensive Addiction and Recovery Act (CARA), a bipartisan act that will allow for more education research, treatment and funding for the opioid addiction.   

The movement is evidenced by the establishment of state-mandated prescription drug monitoring programs in 49 states, excluding Missouri, making prescribers responsible for knowing the controlled drug profiles and histories of their patients.   

Judicial precedents apply as well, such as the West Virginia decision permitting addicted patients to sue prescribers despite admission that they were addicted before seeing the prescribers and that they lied about symptoms and injuries.  

Opportunities to save  

The savings opportunity for any particular hospital depends on a number of factors, headlined by the number and nature of surgical procedures performed. An Advisory Board study found that the average 250-bed facility, by optimal intravenous acetaminophen use and opioid reduction, could reduce complication-driven charges from $1,480,000 to $110,000 and length of stay from 1,209 days to 19 days annually. The study concluded that opioid-related complications cost that 250-bed hospital $1.6 million annually.  

Multimodal approach to pain management: The issue and the opportunity  

Over-reliance on opioids to manage the acute pain of surgery remains widespread despite the ever-increasing knowledge that this is outdated medicine, is high risk and costly. This continuing over-reliance on opioids can be viewed as a problem or an opportunity for change to occur.   

By moving to a multimodal approach to acute pain management, hospitals can improve their quality of care and at the same time limit costs, reduce risk, and improve quality of care.  


  • Kampman, S., et al., “Cost and Quality Impact of Multi-Modal Pain Regimens,” Advisory Bd. R&D and Physician Executive Council (2014).  
  • Kessler, ER., et al., “Cost and Quality Implications of Opioid-Based Postsurgical Pain Control Using Administrative Claims Data from a Large Health System: Opioid-Related Adverse Events and Their Impact on Clinical and Economic Outcomes,” Pharmacotherapy, 33(4):383-391 (Apr. 2013).  
  • The Joint Commission, “Sentinel Alert: Safe Use of Opioids in Hospitals.”  
  • Kampman, S., et. al.,“Cost and Quality Impact of Multi-Modal Pain Regimens,” Advisory Board R&D and Physician Executive Counci.  
  • Davies, E.C., et al., “Adverse Drug Reactions in Hospital In-Patients: A Prospective Analysis of 3965 Patient-Episodes,” PLOS ONE, 4(2):e4439. 
  • Oderda, G.M., et al., “Opioid-related Adverse Events in Surgical Hospitalizations: Impact on Costs and Lengths of Stay,” Annals of Pharmacotherapy, 41(3):400-6 (Epub Mar. 2007).  
  • Duncan, C.M., et al., “The Economic Implications of a Multimodal Analgesic Regimen for Patients Undergoing Major Orthopedic Surgery: A Comparative Study of Direct Costs,” Regional Anesthesia and Pain Medicine, vol. 34, no. 4 (Jul.-Aug. 2009).  
  • Tug Valley Pharm. v. All Plaintiffs in Mingo County, 2015 BL 148172, W.Va. 14-0144 (W.Va. 2015).  
  • See note 2, supra.  
  • Cuomo A, Bimonte S, Forte CA, Botti G, Cascella M. Multimodal approaches and tailored therapies for pain management: the trolley analgesic model. J Pain Res. 2019;12:711-714. Published 2019 Feb 19. doi:10.2147/JPR.S178910