Multimodal Strategy for Postsurgical Pain

The goal of a multimodal approach to postsurgical pain management is to provide adequate pain control while minimizing side effects, primarily from opioids, through prevention of pain at different levels of the sensory pathway.1,2 Opioids are the current mainstay treatment of acute, moderate to severe pain; however, there are numerous adverse events (AEs) that occur with opioid use. Therefore, initiation of opioid treatment should occur with the lowest effective dose, and multimodal therapy should also be utilized.3 When the combination of therapies is appropriately chosen, it is possible in some cases to completely eliminate the use of opioids.

A multimodal strategy is recommended to reduce opioid reliance4,5

American Society of Anesthesiologists (2012): Guideline Recommendations for Acute Pain Management

Whenever possible, anesthesiologists should use multimodal pain management therapy.4

The Centers for Disease Control and Prevention and The Joint Commission support an opioid-reducing strategy4,5

Strategies should reflect a [patient]-centered approach and consider the patient's current presentation, the health care providers' clinical judgment, and the risks and benefits associated with the strategies, including potential risk of dependency, addiction, and abuse.5

A multimodal approach uses a variety of therapeutics to minimize opioid use and ORAEs

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Important Notice

This site is for informational purposes only and is intended to address medical questions from healthcare professionals in the United States.

To report an adverse event, e-mail or dial 1-855-RX-EXPAREL (1-855-793-9727).

For medical inquiries related to EXPAREL, submit a request to Medical Information or call 1-855-RX-EXPAREL (1-855-793-9727).

These are not all of the potential important safety considerations for EXPAREL; please see the full Prescribing Information.


  1. Joint Commission on Accreditation of Healthcare Organizations and National Pharmaceutical Council. Pain: Current Understanding of Assessment, Management, and Treatments. December 2001. National Pharmaceutical Council website. Accessed May 26, 2016.
  2. Viscusi ER, Rothman RH. Special Report: A New Look at DepoDur for the Management of Postoperative Pain. New York, NY: McMahon Publishing; July 2009.
  3. Use, abuse, misuse, and disposal of prescription pain medication time tool clinical reference. American College of Preventive Medicine website. Accessed June 8, 2016.
  4. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2004;100(6):1573-1581.
  5. Clarification of the pain management standard. Joint Commission website. Accessed May 26, 2016.
  6. Gottschalk A, Smith DS. New concepts in acute pain therapy: preemptive analgesia. Am Fam Physician. 2001;63(10):1979-1984.
  7. Gandhi K, Viscusi E. Multimodal pain management techniques and knee arthroplasty. NYSORA. 2009;13:1-10.
  8. Kehlet H, Dahl JB. The value of “multimodal” or “balanced analgesia” in postoperative pain treatment. Anesth Analg. 1993;77(5):1048-1056.
  9. Yu H, Li Q, Wang D, Shi L, et al. Mapping the central effects of chronic ketamine administration in an adolescent primate model by functional magnetic imaging (fMRI). Neurotoxicology. 2012;33(1):70-77.

Important Safety Information

Warnings and Precautions Specific to EXPAREL

Warnings and Precautions for Bupivacaine-Containing Products

Please refer to full Prescribing Information.

Important Safety Information

Medical Information

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If you are not a healthcare professional, please discuss any questions you have regarding your health or treatment with your physician, pharmacist, nurse, or other healthcare professional.

Important information about EXPAREL®

The FDA confirms that EXPAREL has always been approved for "administration into the surgical site to produce postsurgical analgesia" for use in a variety of surgeries not limited to those studied in its pivotal trials.

"We are pleased to announce a successful collaboration with the FDA to resolve this matter in an expeditious and meaningful way that allows us to get back to the important task at hand—reducing postsurgical opioid exposure by providing a non-opioid option like EXPAREL to as many patients as appropriate."

- Dave Stack, Chief Executive Officer and Chairman of Pacira

The clinical benefit of the decrease in opioid consumption was not demonstrated in the pivotal trials.

Important Safety Information

  • EXPAREL is contraindicated in obstetrical paracervical block anesthesia
  • In clinical trials, the most common adverse reactions (incidence ≥10%) following EXPAREL administration were nausea, constipation, and vomiting
  • EXPAREL is not recommended to be used in the following patient population: patients <18 years old and/or pregnant patients
  • Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease. Patients with severe hepatic disease, because of their inability to metabolize local anesthetics normally, are at a greater risk of developing toxic plasma concentrations

Warnings and Precautions Specific to EXPAREL

  • EXPAREL is not recommended for the following types or routes of administration: epidural, intrathecal, regional nerve blocks, or intravascular or intra-articular use
  • Non-bupivacaine-based local anesthetics, including lidocaine, may cause an immediate release of bupivacaine from EXPAREL if administered together locally. The administration of EXPAREL may follow the administration of lidocaine after a delay of 20 minutes or more. Formulations of bupivacaine other than EXPAREL should not be administered within 96 hours following administration of EXPAREL

Warnings and Precautions for Bupivacaine-Containing Products

  • Central Nervous System (CNS) Reactions: There have been reports of adverse neurologic reactions with the use of local anesthetics. These include persistent anesthesia and paresthesias. CNS reactions are characterized by excitation and/or depression
  • Cardiovascular System Reactions: Toxic blood concentrations depress cardiac conductivity and excitability which may lead to dysrhythmias sometimes leading to death
  • Allergic Reactions: Allergic-type reactions (eg, anaphylaxis and angioedema) are rare and may occur as a result of hypersensitivity to the local anesthetic or to other formulation ingredients
  • Chondrolysis: There have been reports of chondrolysis (mostly in the shoulder joint) following intra-articular infusion of local anesthetics, which is an unapproved use

Please refer to full Prescribing Information.


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