Defining an Opioid Sparing Treatment Pathway for Chronic Abdominal Pain of Somatic and Visceral Origin: A Case Series.
Chronic non-malignant abdominal pain presents a treatment challenge for pain physicians. Treatment algorithms are often defined by single specialty and are unimodal with a dependence on opioids. We present a treatment algorithm for chronic abdominal pain using a combination of interventional therapy using transversus abdominis plane (TAP) blocks along with post injection medical management for treatment of somatic and visceral pain. This is a case series of 4 patients presenting with diverse causes of chronic abdominal pain were treated with the treatment algorithm defined below. Patients received either bilateral or unilateral TAP blocks based on pain location using a combination of 0.25% bupivicaine 10ml, 40mg triamcinolone, and clonidine 50 mcg by a single physician upon admission to our acute care hospital. Follow up treatment included a combination of gabapentin, nortriptyline, and an opioid + acetaminophen combination (hydrocodone/APAP vs. oxycodone/APAP) or continuation of the patient’s outpatient opioid regimen. Pre-injection opioid milligram morphine equivalents (MME) and post-injection MME were measured as well as pain along the visual analog scale (VAS). Readmissions for pain were also noted. Patients receiving TAP blocks along with post injection medical management saw their VAS scores decrease by 68.5%. Their total daily milligram morphine equivalents (MME) consumption decreased by a mean of 68.9%. There were no readmissions for abdominal pain within the 1 year follow up period.