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Managing Perioperative Pain

A clinical review and perspective on pharmacologic options for managing pain prior to, during, and following medical procedures.
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The mounting scrutiny over opioid prescribing in the United States has led to increased attention on alternate pain treatments not just in primary and specialty care, but also as part of the perioperative pain control cycle. Preoperative patients currently taking opioids or presenting with a history of opioid addiction, and those living with chronic pain, in particular, may require a unique approach, for which agreed-upon standards are lacking in such cases. While the pain management community seeks solutions to and guidance on the evolving situation, this paper offers a clinical perspective and review of full and partial mu opioid agonists, as well as alternative pharmacologic treatments, for perioperative pain control.

Preoperative History & Planning

Appropriate use of steroids, antibiotics, and presurgical patient education are well-established methods for decreasing pain and minimizing opioid consumption leading up to and following a major medical procedure. More intricate pharmacologic approaches are often necessary in complex cases where the surgical patient presents with chronic pain and/or pain-related comorbidities. The following section provides a range of available options as presented in the literature and currently used in clinical practice.

Pharmacologic Presurgical Pain Control

It has been extensively reported that preventive preoperative
use of gabapentin may result in decreased doses of required opioids and the likelihood of central sensitization post-surgery.1 A 900 mg to 1200 mg single dose has been deemed effective for these purposes.2 Not all studies support this notion, however, potentially due to their focus on the gabapentin’s effect on anxiety versus pain, or due to too low doses of the medication.3,4

A high initial dose of gabapentin may be poorly tolerated by many patients, so it is reasonable to start with lower doses in the two to three days before surgery (if the patient is not already on this medication) and increasing the doses as tolerated, ending with a maximal dose in the immediate preoperative period. The author recommends continuing gabapentin for 7 to 14 days after surgery.

Reported post-surgical regimens and doses vary greatly, with doses as low as 400 mg/day, deemed effective.5 The use of alternative, long-acting formulations of gabapentin and gabapentin enacarbil may be considered as well.

Pregabalin, expectedly, provides a similar effect on pain control and a decrease in opioid reliance.6 Unfortunately, optimistic results have not been universal: a Cochrane meta-analysis suggested a modest but statistically significant reduction in the incidence of chronic pain after surgery following treatment with ketamine but not with gabapentin or pregabalin7 (see also, sidebar–“Overprescribing Concerns”).

Preoperative use of celecoxib has also received much attention. This medication showed a modest decrease in pain and post-surgical opioid consumption.8.9 Cox-2 receptors are not present on platelets, so celecoxib should not influence bleeding time, but surgeons universally tend to avoid even a remote chance of coagulation problems.

Successful preoperative use of muscle relaxants and acetaminophen also have been reported.10 Of note, many muscle relaxants may be sedating and add to the risk of gait instability and confusion, as well as swallowing and respiratory problems.

The use of N-methyl D-aspartate (NMDA) receptor antagonists, including amantadine, in theory, may help to prevent pain chronification and opioid dependence.11 Ketamine may offer promising relief as well, but due to potential mental effects and potentially addictive nature, ketamine should be used with caution.12,13

For the Opioid-Managed Patient

There is no current consensus in the pain management community on how to effectively handle patients who are in need of surgery and already taking prescription opioids for related or unrelated condition(s), or who are undergoing opioid addiction treatment with, for example, methadone. Patients with a history of ongoing opioid use or addiction, mental health conditions (especially borderline personality disorder, anxiety, depression, and somatization), and/or a history of childhood or ongoing abuse should be considered at high risk of developing chronic post-surgical opioid abuse. Research by Sun et al,14 found that male gender, age older than 50 years, and a preoperative history of benzodiazepine or antidepressant use were also associated with chronic opioid use even among opioid-naive surgical patients.

Some physicians may instruct such patients to cease their opioid treatment for one, two, or even four weeks prior to a scheduled surgery. Motivated patients are likely to comply, particularly when the physician makes clear why preoperative dosage cessation may be beneficial long-term. To avoid potentially unnecessary suffering and contention, however, physicians may instead propose that patients decrease their full mu agonists’ dosages rather than go off opioids completely. A 50% reduction in a maintenance opioid dose for a brief period before surgery may be more practical and attainable, for instance. A rapid preoperative opioid detoxification has also been suggested,15 but has been associated with possible complications of its own.

When serious warning signs are exhibited, such as complete refusal of a patient to decrease high opioid dosages, active use of illicit substances, or ongoing psychiatric crisis, the situation may warrant delaying a scheduled surgery until reasonable stability is achieved. Consultation and clearance by an addiction or mental health specialist may be sought as a precondition to surgery.

In the case of an emergency surgery, a patient’s history and any prior opioid use or abuse needs to be identified and addressed in the immediate post-surgical period by the surgeon in consultation with appropriate social and psychiatric services.

For the Patient on Buprenorphine

A patient taking prescribed maintenance buprenorphine for pain or opioid dependence presents a unique challenge. This partial mu agonist exhibits potency of about 30 times that of morphine, thereby controlling pain reliably and decisively. At the same time, buprenorphine produces much-diminished euphoria and, as such, is often less preferred by patients with addiction challenges.

Patients who are established on such treatment may be prescribed an additional opioid to manage surgical and post-surgical pain if needed. Note that this method does not work the other way around; a patient taking a prescribed opioid who is then given buprenorphine may have the original opioid displaced and experience withdrawal symptoms.16 Experimental animal studies support the preoperative use of buprenorphine.17 In comparison with morphine and fentanyl, only buprenorphine is reported to prevent the neuroendocrine and immune system post-surgical alterations.18

Last updated on: January 31, 2018
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