Postoperative pain control remains a common problem for patients undergoing breast cancer surgery. A recent survey showed that patients’ number one concern leading up to surgery is pain.1 Uncontrolled, acute postoperative pain can lead to an increased surgical stress response. This then has an effect on endocrine, metabolic, inflammatory, and immune functions, which can further stress various organ systems.2 Appropriate pain control can lead to improved postoperative outcomes as well as decreased pulmonary and cardiac complications.3,4 In addition, uncontrolled acute postoperative pain is associated with longer stays in the postanesthesia care unit, longer hospital stays, decreased patient satisfaction and quality of life, and increased costs.5-8 Furthermore, while multifactorial in nature, the incidence of chronic pain may be decreased by an aggressive multimodal approach in the acute postoperative setting.9,10 As many as 4% to 63% of patients suffer chronic pain after mastectomy,11-13 and as such, effective acute pain control remains paramount to patient recovery following breast cancer surgery.
The mainstay of perioperative pain control has been opioids. However, opioids are associated with significant risks and adverse effects (AEs) such as pruritus, constipation, nausea/vomiting, urinary retention, oversedation, and respiratory depression.14 A recent sentinel event alert by The Joint Commission expressed the need for safe use of opioids in the hospital setting.15 This alert identified those most at risk for respiratory depression, including patients with obstructive sleep apnea or those who are opioid-naïve or obese, which are common characteristics of patients undergoing breast cancer surgery. Furthermore, opioid abuse is an ever-increasing problem in the United States. A recent survey in 2010 showed that 5.1 million US citizens had used opioids illicitly within the past month.16 Finding ways to minimize opioids in the treatment of perioperative pain may not only decrease AEs, but also decrease the exposure and subsequent misuse of opioids in society.
A multimodal approach has been used for perioperative pain control in various surgical procedures. Multimodal analgesia is the use of more than 1 class of nonopioid medication to reduce pain and minimize the AEs of any 1 class of pain medication.17 These medications act via different mechanisms and produce a synergistic effect on acute pain control. A successful multimodal protocol requires coordination between all phases of care: preoperative, intraoperative, and postoperative. Furthermore, the surgical, anesthesia, and nursing teams must all work together to ensure that all aspects of the multimodal plan are followed.