In post-operative patients, how effective is pharmacological intervention versus non-pharmacological for pain management?

PICOT: In post-operative patients, how effective is pharmacological intervention versus non-pharmacological for pain management?

Evidence-Based Practice Guideline Grid
Guideline # 1 Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations—2019 update
APA Citation for EBP Guideline Nelson G, Bakkum-Gamez J, Kalogera E, Glaser G, Altman A, Meyer LA, Taylor JS, Iniesta M, Lasala J, Mena G, Scott M, Gillis C, Elias K, Wijk L, Huang J, Nygren J, Ljungqvist O, Ramirez PT, Dowdy SC. Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update. Int J Gynecol Cancer. 2019 May;29(4):651-668. doi: 10.1136/ijgc-2019-000356. Epub 2019 Mar 15. PMID: 30877144.
URL for EBP Guideline (if applicable) https://ijgc.bmj.com/content/ijgc/29/4/651.full.pdf
Target Population Health care professionals including doctors and nurses who manage patients who underwent gynecologic surgery.
Purpose / Objective Provide up-to-date evidence-based recommendations in the Enhanced Recovery After Surgery (ERAS) pathway to provide optimal perioperative care for gynecological/oncological surgery.
Summary of Recommendations When post-surgical patients are mostly treated with opioids they develop adverse effects such as weakness, sedation, and nausea. This guideline recommends that a greater focus be placed on non-opioid medications which can positively impact the outcome of a patient’s recovery. A multi-modal approach has been recommended to be implemented in order to reduce opioid administration post-surgically and at discharge. This includes the use of non-opioid oral medication and local anesthetics which can target the pain locally which in turn reduces the requirement for systemic medications. Overall reduction of opioid use can help aid in reducing new prevalences of opioid dependence post-surgery.
Type of Evidence Used Literature search was conducted to review ERAS gynecological/oncology protocol. Studies with an emphasis on meta-analysis, randomized controlled trials, and large prospective cohort studies were reviewed and graded to update recommendations.

Guideline # 2 The American Society of Pain and Neuroscience (ASPN) Best Practices and Guidelines for the Interventional Management of Cancer-Associated Pain.
APA Citation for EBP Guideline Greenlee, H., DuPont-Reyes, M. J., Balneaves, L. G., Carlson, L. E., Cohen, M. R., Deng, G., Johnson, J. A., Mumber, M., Seely, D., Zick, S. M., Boyce, L. M., & Tripathy, D. (2017). Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment. CA: a cancer journal for clinicians, 67(3), 194–232. https://doi.org/10.3322/caac.21397
URL for EBP Guideline (if applicable) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5892208/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5892208/
Target Population Breast cancer
Purpose / Objective To provide updated clinical practice guidelines from the Society for Integrative Oncology on the use of integrative therapies for specific clinical indications during and after breast cancer treatment, including anxiety/stress, depression/mood disorders, fatigue, quality of life/physical functioning, chemotherapy-induced nausea and vomiting, lymphedema, chemotherapy-induced peripheral neuropathy, pain, and sleep disturbance

Summary of Recommendations
Type of Evidence Used

Guideline # _3__A systematic review of non pharmacological interventions used for pain relief after orthopedic surgical procedures
APA Citation for EBP Guideline Fan, M., & Chen, Z. (2020). A systematic review of non-pharmacological interventions used for pain relief after orthopedic surgical procedures. Experimental and therapeutic medicine, 20(5), 36. https://doi.org/10.3892/etm.2020.9163
URL for EBP Guideline (if applicable)
https://pubmed.ncbi.nlm.nih.gov/32952627/

Target Population This recommendation applies to clinicians and nurses who uses pain interventions for postoperative orthopedic patients
Purpose / Objective To evaluate the available evidence on the efficacy of various non pharmacological interventions to relieve pain after orthopedic surgical procedures.
Summary of Recommendations
PLS. ANSWER THIS. STEP 1
Type of Evidence Used This review was conducted following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta analyses state¬ment (PRISMA)and the Cochrane Handbook for Systematic Reviews of Intervention except for protocol registration.

Guideline #4
APA Citation for EBP Guideline Overton, H. N., Hanna, M. N., Bruhn, W. E., Hutfless, S., Bicket, M. C., & Makary, M. A. (2018). Opioid-prescribing guidelines for common surgical procedures: An expert panel consensus. Journal of the American College of Surgeons, 227(4), 411–418. https://doi.org/10.1016/j.jamcollsurg.2018.07.659
URL for EBP Guideline (if applicable) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6353661/

Target Population The target population is for opioid-naive adult patients without chronic pain undergoing uncomplicated surgical procedures
Purpose / Objective The purpose of this study is to determine which opioid is the ideal prescription for surgical procedures.
Summary of Recommendations The reviewers concluded that the minimum number of opioid tablets recommended by the panel was 0. Ibuprofen was recommended for all patients unless medically contraindicated. Overall, patients who had the procedures voted for lower opioid amounts than surgeons who performed them. Procedure-specific prescribing recommendations may help provide guidance to clinicians who are currently overprescribing opioids after surgery.
Type of Evidence Used An expert panel consensus was used to help create this guideline. The guideline used a 3-step modified Delphi method involving a multidisciplinary expert panel of 6 relevant stakeholder groups (surgeons, pain specialists, outpatient surgical nurse practitioners, surgical residents, patients, and pharmacists).

Guideline #5 _
APA Citation for EBP Guideline Chou, R., Gordon, D. B., de Leon-Casasola, O. A., Rosenberg, J. M., Bickler, S., Brennan, T., Carter, T., Cassidy, C. L., Chittenden, E. H., Degenhardt, E., Griffith, S., Manworren, R., McCarberg, B., Montgomery, R., Murphy, J., Perkal, M. F., Suresh, S., Sluka, K., Strassels, S., Thirlby, R., … Wu, C. L. (2016). Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. The journal of pain, 17(2), 131–157. https://doi.org/10.1016/j.jpain.2015.12.008
URL for EBP Guideline (if applicable) https://www.jpain.org/article/S1526-5900(15)00995-5/fulltext
Target Population Clinicians who manage postoperative pain.
Purpose / Objective To promote evidence-based recommendations for management of postoperative pain.
Summary of Recommendations The reviewers developed recommendations to promote the effective management of postoperative pain. The recommendations included various modalities of pain management including pharmacological and non-pharmacological to be used singularly or in combination to enhance effects depending on the individual patient needs. The reviewers assigned a grade to each recommendation based on the strength of the recommendation and the quality of evidence. Four out of 32 recommendations were rated high-quality evidence and one, in particular, recommended the use of a variety of analgesic medications and techniques combined with nonpharmacological interventions, for the treatment of postoperative pain in adults. The recommendations are guided by the premise that pain management begins during the presurgical period and is based on an assessment of the patient and the development of a care plan that is tailored to each patient. There were several gaps identified regarding the need for further research on methods of managing patients who receive opioid treatment before surgery, the effectiveness of opioid-sparing multimodal regimens, optimal methods of pain assessment and monitoring, and areas related to perioperative pain in infants and children. Furthermore, research is needed on practice gaps regarding the use of evidence-based interventions for the management of postoperative pain.
Type of Evidence Used 107 systematic reviews and 858 primary studies, conducted at the Oregon Evidence-Based Practice Center and commissioned by The American Pain Society (APS).

Guideline #6 _
APA Citation for EBP Guideline Effective management of acute pain – South Dakota. (n.d.). Retrieved April 22, 2022, from https://doh.sd.gov/documents/news/Opioids/07-10-19_SDSMAWhitepaper_AcutePainTreatment.pdf

URL for EBP Guideline (if applicable) https://doh.sd.gov/documents/news/Opioids/07-10-19_SDSMAWhitepaper_AcutePainTreatment.pdf

Target Population patients that present with acute pain or anticipated postoperative pain
Purpose / Objective to reduce the number of opioids being prescribed due to the high-risk harm they can bring to the patients health.

Summary of Recommendations The objective of this guideline recommendation is to treat acute pain or postoperative pain in a range of pharmacological and nonpharmacological ways. The use of opioids should only be used when necessary and if so be used at the lowest dose and shortest duration. Assessing the patients pain and primarily using non-pharmacological and non-opioid analgesics can relieve immediate suffering from patients and maximize their long term health.
Type of Evidence Used

Guideline # 7 Use of NS-NSAID or ISCOX2 used with morphine.
APA Citation for EBP Guideline Aubrun, F., Noutte-Gualain, K., Fletcher, D., Belbachir, A., Beloeil, H., Carles, M., Cuvillon, P., Dadure, C., Lebuffe, G., Marret, E., Martinez, V., Olivier, M., Sabourdin, N., & Zetlaoui, P. (2019). Revision of expert panel’s guidelines on postoperative pain management. Anaesthesia Critical Care & Pain Medicine 38(4), 405-411 https://doi.org/10.1016/j.accpm.2019.02.011.
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URL for EBP Guideline (if applicable) https://www.sciencedirect.com/science/article/pii/S235255681930075X
Target Population Health care providers giving care for patients in postoperative experiencing acute or chronic pain.

Purpose / Objective This paper assembles and evaluates 17 recommendations/guidelines for healthcare providers to utilize for patients postoperative with pain.
Summary of Recommendations The use of NS-NSAIDS and ISCOX2 can lead to the decrease use and need of morphine. Increasing showing an improvement in pain scores in patients who are in postoperative pain. Suggesting this alternative rather than moving onto non-opioid analgesics. Additionally, to reduce the risk of opioid dependence after a patient has had surgery. It is recommended to use NSAIDs if history of MI, stroke, atherothrombosis, and renal hypoperfusion.
Type of Evidence Used Conduction of literature search evaluating French Society of Anesthesia and Intensive Care Medicine (SFAR) guidelines on postoperative pain. Quantitative analysis using the GRADE method for literatures that did not consist of meta analysis of the patient’s responses. Systematic review done to evaluate the recommendations for the guidelines that did not address the questions as stated in the study.

Guideline #8
APA Citation for EBP Guideline Mott, J. F. (2020). Nonpharmacological techniques. In Schug, S. A., Palmer, G. M., Scott, D. A., Alcock, M., Halliwell, R., Mott, J. F. (Eds.), Acute pain management: Scientific evidence. (5th ed., pp. 1-43 of chapter 7). Australian and New Zealand College of Anesthetists and Faculty of Pain Medicine.
URL for EBP Guideline (if applicable) https://www.anzca.edu.au/getattachment/e380d339-8601-488d-b298-e8416fca02be/7-Nonpharmacological-techniques-Watermarked
https://anesthesiology.queensu.ca/sites/anesthesiology/files/inline-files/APMS-5th_1.pdf

Target Population The target population of these guidelines are patients experiencing acute pain who are also being treated with either pharmacological or physical interventions.
Purpose / Objective The purpose of these guidelines are to supplement pharmacological and physical interventions with psychological interventions in order to reduce acute pain. Specifically, psychological interventions can be used preemptively as well as to reduce the risk of postoperative pain becoming chronic.
Summary of Recommendations Nonpharmacological techniques, such as psychological interventions, which are used for acute pain management worked best when used as a supplement to pharmacological and physical interventions. Although the results did not have a significant reduction in acute pain, there were some techniques that resulted in some pain reduction. For example, hypnosis had one of the better interventions as it may reduce postoperative pain, anxiety, and analgesia consumption. Other examples include meditation, listening to music, virtual reality, and sense of smell. All of these things can help reduce postoperative pain.
Type of Evidence Used The study used a Cochrane meta analysis.

PLS ANSWER THIS Thank you STEP 2
1. Guideline Similarities and Differences. Analysis of how the different guidelines are the same or different in terms of target population, purpose, recommendations, and type of evidence used. USE ONE ADDITIONAL ARTICLE