For this written assignment, select one recent (within the past two years) evidence-based article from a peer reviewed nursing journal that describes a "best practice" in an area of nursing you are interested in. For example, if you would like to be a pediatric nurse, select an article that discusses a best practice in pediatric care.
Cite the article and provide a brief overview of how the results or findings were obtained. Then describe the "best practice." Conclude your discussion by explaining whether you thought the research findings supported the conclusions and the best practice.
Use APA Editorial format and attach a copy of the article.
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A cute pain, characterized as sudden in onset and of limited duration, is one of the most common reasons people seek medical care.1 Acute pain has the potential to interfere with activ- ities of daily living, and if unrelieved, can progress to chronic pain. Inadequately managed postoper- ative pain can worsen patient outcomes and lead to increased hospital readmissions and health care costs.1 In 1996, amid numerous reports of inade- quately managed pain, the American Pain Society introduced the concept of “pain as the fifth vital sign,”2 which was soon widely promoted by orga- nizations such as the Joint Commission3 and the U.S. Department of Veterans Affairs.4 While an emphasis on appropriate pain management was intended to improve patient care, there is some evidence that this has instead contributed to the overuse of opioids.5
Opioid pain medications, which are often pre- scribed for acute pain, work by interacting with specific opioid receptors in the body and brain. When taken as prescribed by a physician for a short period of time, these medications are generally safe. But because they also induce feelings of euphoria, there is potential for misuse. As the National Insti- tute on Drug Abuse has cautioned, their “regular use—even as prescribed by a doctor—can lead to dependence and, when misused, . . . to addiction,” as well as to the abuse of unprescribed opioids such
The evidence supports the use of opioid-sparing strategies in managing acute pain.
as heroin and synthetic opioids such as fentanyl.6 The likelihood of developing an opioid use disorder depends on several factors, including the amount of opioid taken and the length of time the medication is used for acute pain.7
The misuse of and addiction to opioids has become a national health crisis of epidemic propor- tions.7, 8 In 2019, opioids accounted for more than 70% of all drug overdose deaths in the United States, with accidental opioid overdose claiming nearly 50,000 lives.9 The economic burden associ- ated with opioid misuse and addiction—including health care costs, lost productivity, and crime—has been estimated at $78.5 billion per year.7
Federal and nonfederal agencies have taken steps to address the opioid epidemic, including increased surveillance and tracking of drug overdoses, improved access to addiction treatment programs, enhanced prescription drug monitoring programs, and new prescribing practice guidelines.8, 10-12 Among the last are guidelines issued by the Enhanced Recov- ery After Surgery (ERAS) Society (https://erassociety. org/guidelines), which emphasize the use of multi- modal analgesia (also called opioid-sparing analgesia).13 (ERAS protocols also include other interventions such as preoperative counseling, nutritional recom- mendations, and early postoperative mobilization.14) Multimodal analgesia involves the simultaneous use of multiple analgesic agents, nonopioid and opioid, that
Combating the Opioid Epidemic Through Nurse Use of Multimodal Analgesia: An Integrative Literature Review
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ABSTRACT Background: Opioid misuse and addiction have become a national crisis. New pain management guide- lines call for the use of multimodal analgesia to manage acute pain. In hospital settings, a clinical decision aid that emphasizes multimodal analgesia may improve nurses’ use of this opioid-sparing strategy.
Purpose: This integrative review was conducted to provide nurses with evidence-based information on the opioid-sparing benefits of multimodal analgesia.
Methods: A literature search was conducted using several electronic databases and Google Scholar. These initial searches yielded 136 articles of interest. Twenty-eight were selected for retrieval and in-depth appraisal; of these, 13 met all inclusion criteria.
Results: Of the 13 reviewed studies, six were randomized controlled trials, six were retrospective cohort or population-based studies, and one was a qualitative study. Overall, the findings provided strong evi- dence that multimodal analgesia is effective in managing acute pain in surgical patients while reducing opioid requirements. Several studies also found that multimodal analgesia was associated with shorter hospital lengths of stay.
Conclusions: With the appropriate tools and education, nurses can make the transition from traditional opioids to multimodal analgesia strategies. In so doing, they can have a significant positive impact on the opioid epidemic. Hospital leaders must address nursing practice regarding the use of opioids alone versus multimodal analgesia for the management of acute pain. Clinical decision tools such as the Michigan Opi- oid Safety Score may help nurses adopt new acute pain management guidelines. Further research regard- ing nursing practice and the opioid epidemic is needed.
Keywords: clinical decision tools, multimodal analgesia, opioid epidemic, opioids, pain, pain manage- ment, surgical patients
act synergistically to reduce pain and minimize the risk of opioid-related side effects.13 (See Multimodal Analgesia and the Pain Pathway.15) In hospitalized patients, the use of multimodal analgesia has been further shown to reduce the risk of opioid-related adverse events, decrease hospital lengths of stay, and reduce opioid misuse and abuse after discharge.16
Yet despite compelling evidence demonstrating the benefits of multimodal analgesia for pain man- agement in the acute care setting and newer guide- lines directing prescribers to adopt an opioid-sparing strategy, nursing practice has largely not reflected this. Bedside nurses often practice autonomously in managing patients’ acute pain, selecting an analgesic from a list of ordered medications and basing this selection on a patient’s stated numeric pain score. Yet this practice has been associated with increased opioid-induced adverse effects.17 In a chaotic and demanding practice environment, it can be a chal- lenge to assess a patient’s pain and risk with regard to sedation and intervene in a way that promotes comfort while maintaining safety. Furthermore, the availability of previously used pain management order sets, as well as the expectation that patients should be relatively pain free, continue to influence nursing practice toward an overreliance on opioids.
Purpose. The aim of this review was to present evidence on the benefits of multimodal analgesia in reducing opioid use for pain management in the acute care setting.
METHODS Literature search. The integrative review method recommended by Whittemore and Knafl18 was used to search, analyze, and synthesize the literature rele- vant to the topic of interest. An initial search was conducted for peer-reviewed articles through the following databases: Academic Search Complete, CINAHL, Cochrane Library, Health Policy Refer- ence Center, MEDLINE, Nursing & Allied Health, ProQuest Central, and ScienceDirect. The following search terms were used in various combinations: multimodal analgesia, reduced opioid use, hospitalized patient, cardiac surgery, orthopedic surgery, spine sur- gery, and study. The search was limited to articles published in English between January 1, 2015, and July 31, 2020. Citations of randomized controlled trials, clinical practice guidelines, expert opinion, and primary qualitative and quantitative studies were carefully scanned for relevance to the topic of interest. The original search yielded 131 articles.
Another search was conducted via Google Scholar for seven articles of interest referenced by authors of articles obtained in the initial search. This second search was conducted using the authors’ names; pub- lication dates and language limits were not applied this time. Of the seven articles, five were selected as relevant, resulting in a total of 136 articles.
Inclusion and exclusion criteria. Inclusion was limited to articles reporting on studies that examined the effects of multimodal analgesia in patients over
By Jennifer René Tavernier, DNP, RN, CCM
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the age of 18 years and were available in full text and published in English in peer-reviewed journals. More specifically, studies evaluating multimodal analgesia strategies that involved medications likely to be administered by bedside nurses on a medical– surgical unit were eligible for inclusion. Studies involving childbirth or dental surgeries were excluded, as were those evaluating multimodal analgesia strat- egies involving epidural analgesia, nerve blocks, or inhaled medications (unless they also evaluated the postoperative addition of nonopioid analgesics). Also excluded were studies investigating pain man- agement for patients with cancer and patients in treatment for or with histories of opioid addiction, because of the unique pain management strategies required. Lastly, studies comparing the efficacy of different modes of analgesic delivery were excluded.
Twenty-eight articles were selected for in-depth appraisal; of these, three could not be retrieved. Regarding multimodal analgesia, the primary out- come of interest was the opioid-sparing effects of this strategy. Three secondary outcomes of interest emerged during the in-depth appraisal: the effects of multimodal analgesia on pain scores, hospital lengths of stay, and nurses’ feelings regarding acute pain management and the opioid epidemic. Stud- ies showing outcomes related to anything other than these four were excluded, leaving 18 arti- cles. Another five articles were excluded in a final appraisal round because the surgical procedures (laparoscopic cholecystectomy, laparoscopic pros- tatectomy) were performed in outpatient settings and were likely to result in less pain than is gener- ally experienced by postsurgical inpatients. Thirteen articles met all the inclusion criteria for this integra-
tive review. See Figure 1 for a flowchart of the liter- ature selection process.
Multimodal strategies for pain management include a variety of pharmacologic and nonpharma- cologic interventions. This review focused on stud- ies examining the effects of nonopioid agents used either as primary medication or as adjuncts to opi- oid medications. The specific medications used in these studies varied; and in a few studies, more than one nonopioid adjunct was used. While it may be important to understand the efficacy of individual medications used in a particular multimodal analgesia regimen, this review considered the opioid-sparing effects of any multimodal analgesia strategy.
The quality and strength of eligible studies, reviews, and guidelines were evaluated using the Johns Hopkins Evidence Level and Quality Guide (www.hopkinsmedicine.org/evidence-based-practice/_ docs/appendix_c_evidence_level_quality_guide.pdf).
RESULTS Study characteristics. Of the 13 studies included in this review, six were randomized controlled trials,19-24 six were retrospective cohort or population-based studies25-30 (including one retrospective cross-sectional cohort study29), and one was a qualitative study.31
Peri- and postoperative multimodal analgesia strategies investigated in the 12 quantitative studies included • oral or iv acetaminophen (also known as
paracetamol outside the United States).25, 27 • tramadol and paracetamol, given by mouth.19
• iv ibuprofen.21
• iv ibuprofen and iv acetaminophen.20, 23, 28
• one or more of these: acetaminophen, steroids, gabapentinoids, ketamine, nonsteroidal antiin- flammatory drugs (NSAIDs), cyclooxygenase 2 (COX-2) inhibitors, peripheral nerve blocks.26, 29
• celecoxib, pregabalin, and extended-release oxy- codone.22
• dexamethasone, gabapentin, ibuprofen, and paracetamol.24
• ketamine, ketorolac, and acetaminophen (as part of an ERAS protocol).30
The six randomized controlled trials provided the highest level of evidence and support for multimodal analgesia use. The study by Daniels and colleagues among 276 patients undergoing bunionectomy reported consistent results that are generalizable to others undergoing this surgery.20 The study by Gago Martínez and colleagues among 135 patients under- going abdominal surgeries also reported consistent results; and because this was a multisite study, the findings are more likely to be generalizable to others undergoing such surgeries.21 The study by Rafiq and colleagues had a robust sample size of 151 patients undergoing cardiac surgeries,24 although its open- label design carries a higher risk of bias. (In open-
Multimodal Analgesia and the Pain Pathway
Inadequately managed pain is harmful under any circumstances; in light of the ongoing opioid epidemic, researchers have been explor- ing ways to impact the pain pathway and alle- viate pain using opioid-sparing strategies. The pain pathway comprises four processes: trans- duction (the conversion of a stimulus into sig- nals at nerve endings), transmission (the relay- ing of signals from points of origin to the brain), modulation (neural regulation of pain signal- ing), and percep tion (subjective awareness of pain). Pain management involves influencing one or more of these processes. Multimodal analgesia targets all four, doing so by combin- ing individually tailored doses of nonopioid drugs, each with different mechanisms of action, along with smaller doses of opioids.15
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label studies, both the providers and the patients know the drug or treatment given.) The studies by Garcia and colleagues,22 Gupta and colleagues,23 and Altun and colleagues19 were each conducted at a sin- gle acute care site and had relatively small sample sizes of 22, 74, and 50 patients, respectively. Though these factors limit the generalizability of the findings, these studies demonstrated consistent results.
The six retrospective cohort or population- based studies also provided relatively good support for multimodal analgesia use, although retrospec- tive studies offer a lower level of evidence and can- not establish causation. Cozowicz and colleagues,26 Maiese and colleagues,28 and Memtsoudis and col- leagues29 each conducted large-scale retrospective cohort reviews from large databases representing a multitude of U.S. hospitals. Patients in these stud- ies underwent orthopedic surgeries. Orthopedic procedures are known to be among the most com- plex and painful procedures, and this specialty was among the first to investigate the use of multimodal analgesia.32 Three smaller-scale retrospective stud- ies contributed further useful findings. Bollinger and colleagues25 and Girardot and colleagues27 each con- ducted retrospective studies among patients under- going orthopedic procedures. Warren and colleagues conducted a retrospective review of patients under- going open ventral hernia repair.30
Lastly, Angelini and colleagues conducted a quali- tative study exploring how nurses and other health care providers feel about managing acute pain in patients undergoing planned lumbar spine surgery.31 Although qualitative studies provide a lower level of evidence and are subject to increased risk of bias, they can provide a deeper understanding of the com- plex experiences of providers.
Quantitative analytics were used to calculate mean values for demographic data when adequate data were provided. Of the 13 studies, nine were conducted either in U.S. hospitals (randomized con- trolled trials)20, 22, 23 or using U.S. hospital databases (retrospective cohort or population-based stud- ies).25-30 Three randomized controlled trials took place outside the United States, including single-site trials conducted in Denmark24 and in Turkey19 and a multisite trial conducted at nine hospitals in Spain.21 The qualitative study was conducted at a single hos- pital in Sweden.31 For the 12 quantitative studies, the mean or median age of participants ranged from 42.4 to 83.6 years. In the nine studies reporting par- ticipants’ sex, 56% of the participants were women and 44% were men. For detailed information on the 13 reviewed studies, see Table 1.
Findings. Though the 13 reviewed studies varied in the medications used, each demonstrated the effi- cacy and safety of multimodal analgesia in reducing opioid requirements among surgical patients. (One of these studies evaluated use of an ERAS protocol,
which included multimodal analgesia.30) In several of these studies, shorter hospitalizations were also reported.25, 26, 28-30
Reduced opioid requirements. The use of acet- aminophen, whether given orally or intravenously, was shown to decrease opioid use in both orthope- dic and cardiac surgeries. In a prospective, double- blind clinical study among 50 patients undergoing elective coronary artery bypass grafting, Altun and colleagues found that patient-controlled iv morphine requirements dropped by 50% in patients given a combination of oral paracetamol and tramadol (a synthetic opioid).19 In a retrospective comparative cohort study of 332 patients who had undergone surgery for hip fracture, Bollinger and colleagues
Figure 1. PRISMA Flow Diagram of Studies
Records identified through initial search of databases (n = 131)
and Google Scholar (n = 7)
Records screened (n = 136)
Full-text articles sought for retrieval (n = 28)
Full-text articles assessed for eligibility (n = 25)
Full-text articles not avail- able for retrieval (n = 3)
Studies included in integrative review (n = 13)
Full-text articles excluded (n = 12) • Outcomes not related to
effects of multimodal analgesia
• Study sample demograph- ics (outpatient surgery)
Records removed for duplication or other reasons (n = 2)
Records excluded (n = 108) • Study involved childbirth
or dental surgeries • Study evaluated epidural
analgesia, nerve blocks, or inhaled medication)a
• Subjects had cancer or were in treatment for or had his- tories of opioid addiction
• Study evaluated efficacy of different modes of anal- gesic delivery
• Article not in English
PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses. a The study remained under consideration if it also evaluated the postoperative addition of nonopioids.
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