Pain Management Center

Potential Problems:

• Between 8-12% of people using opioids chronically will go on to develop an opioid use disorder; 4-6% who misuse prescription opioids will transition to heroin.
• 75% of people entering rehabilitation for IV opioid abuse began taking prescription opioids
• Most people’s first exposure to opioid pain medications is during or following surgery.  Excessive or needless opioid prescription may lead to addiction, overdose, and death.
• Many people have chronic pain before their scheduled surgeries.  Some may already have developed a tolerance to opioid pain medications.  Treating those patients’ pain may be challenging, and it requires weighing the risks and benefits of providing additional opioid pain medications.  
• Some patients may be recovering from an opioid addiction as well, and minimizing the risk of overdose or relapse is an important part of your post-surgery care and recovery.
• Some people are afraid to tell their doctor, surgeon, or anesthesiologist that they have had problems with drug abuse.

 

Should I Take Prescription Opioids After My Surgery?
Risks	Benefits
GI Upset (nausea, vomiting, constipation)	Relieves somatic and visceral pain
Itching	Suppresses cough reflex
Confusion/drowsiness	Decreases breath holding and shallow breathing caused by pain
Slower breathing (rare)
Potential for abuse (rare)
Overdose and death (very rare)

The Solutions:

• Before your surgery: 
  • You may want to ask how your surgical pain will be treated.  This is an especially important question if you have chronic pain, if you already take opioid pain medications routinely, or if you are recovering from opioid addiction.  
  • You may want to remind your doctor, surgeon, or anesthesiologist about any previous problems with drug abuse, if you have taken opioid pain medications for many years, or if you have any concerns about opioid addiction.  Alerting them which medication(s) you take, and how many milligrams of this medication you take, are incredibly important to our abilities to take care of you!
  • You may want to have a discussion about other recreational drug use, tobacco use, and alcohol use – all of them impact your anesthesiologist’s abilities to take care of you and treat your pain. 
  • A pain specialist, your doctor prescribing opioid pain medications, or your surgical team may consider changing your pain medication regimen. 
• On the day of your surgery: 
  • Utilizing regional anesthesia (also known as “nerve blocks”) may decrease or eliminate the amount of opioid pain medications you need, both during and after surgery.  With it, you may experience fewer opioid-induced side effects, such as constipation, nausea, vomiting, drowsiness, or irritability.  Depending on the surgery, you may still need opioid pain medications after the nerve block wears off, but nerve blocks help manage pain in the first few hours to days after your surgery. 
• During your recovery:
  • Utilizing many different types of pain medications at lower doses, a method known as “multimodal analgesia,” means using both opioid and nonopioid medications to treat your pain after surgery.  Using many different medications with different mechanisms may decrease or eliminate the need for opioid pain medications.
  • Opioids are generally safest when used for three or fewer days to manage acute pain, though exceptions exist.

What pain medications are used in “Multimodal Analgesia?”

• Multimodal analgesia represents an approach to preventing as well as treating post-surgical pain.  Patients are given a combination of medications, including both opioids as well as non-opioid pain medications we talk about below, before and after their procedure.  Utilizing a multimodal approach to preventing and treating pain minimizes the amount of opioids used, maximizes the number of ways your doctor treats your pain, and leads to improved pain control as well as fewer opioid-related side effects, such as nausea, constipation, and itching. 
• Acetaminophen, known by its brand name Tylenol®, helps treat your pain after surgery through a number of different mechanisms.  Using scheduled acetaminophen after surgery decreases the amount of opioid pain medication patients need to treat their pain. 
• Non-steroidal anti-inflammatory drugs (NSAIDs) are a class of medications which decrease the body’s natural inflammation following surgery.  Ibuprofen (Advil®) and naproxen (Aleve®) are two common types of NSAIDs you may take at home. Celecoxib (Celebrex®) is a common NSAID given before surgery.  By decreasing inflammation, these medications decrease your pain after surgery and also decrease the amount of opioid pain medications patients need after surgery.
• Gabapentinoids, which includes gabapentin (Neurontin®) and pregabalin (Lyrica®), are anti-seizure medications used to help treat surgical pain if given before and after surgery.  It is also used to treat chronic neuropathic pain, such as diabetic nerve pain. 
• Muscle relaxants, especially tizanidine (Zanaflex®), decrease pain by working at two different receptors in the body.  It can be given before or after surgery to decrease your pain after surgery. 
• Ketamine is a well known, well studied drug which acts at many different receptors in the body.  In severe cases, or in patients with chronic pain, ketamine can be continuously infused to help treat pain and decrease opioid tolerance.  Other drugs which work similarly to ketamine include amantadine (Symmetrel®), dextromethorphan (the active ingredient in Robitussin®), and the mineral magnesium sulfate. 
• Lidocaine, commonly used for spinal and epidural pain relief as well as nerve blocks, is a common, well studied, and safe local anesthetic that can be used to treat post-surgical pain in a number of ways.  Following major surgeries (such as abdominal surgery or spine surgery), lidocaine can be continuously infused through an IV catheter to decrease the body’s inflammatory response to surgery, leading to improved pain and deceased need for opioid pain medications.  It comes in patches and creams that can be purchased over-the-counter as well.
• Some antidepressant medications also help the body process pain signals in a way that decreases opioid pain medications and improves pain after surgery.  These medications usually take many weeks to take effect.  These medications include duloxetine (Cymbalta®), venlafaxine (Effexor®), and tricyclic antidepressants such as amitriptyline (Elavil®) and desipramine (Norpramin®).
• Dexmedetomidine (Precedex®) and clonidine (Catapres®) are two drugs that also treat post surgical pain and decrease the amount of opioid pain medications patients need following surgery. 
• Caffeine, a stimulant also used to improve pain relief in compounded over-the-counter pills such as Excedrin®, may also improve pain following surgery and decrease the amount of opioid pain medications one may need.
• By using smaller doses of many different types of medications, patients usually experience fewer side effects from any one given medication and ultimately utilize less opioid pain medications to treat their pain following surgery.

What is “ERAS?”

• Enhanced Recovery After Surgery, also known as ERAS, is a patient-centered, protocolized care pathway.  UVA employs multiple types of ERAS programs, tailor-made to you and your procedure.  They are evidence-based steps to helping you recover faster and return to normal as quickly as possible after surgery. 
• ERAS is usually explained in detail at your initial clinic visit with your surgeons or with UVA’s Perioperative Clinic.  They go over what you should expect before, during, and after surgery.
• Fundamental to UVA’s ERAS programs is YOU!  It is a patient-centered program that focuses on meaningful goals most important to our patients, such as early return to eating, walking, and individualized pain management programs. For more detail, please see UVA’s ERAS Website, located at https://uvaeras.weebly.com.

What are “nerve blocks,” and how can they help control my pain after surgery?

• Regional anesthesia is a method of preventing as well as treating surgical pain. It involves blocking painful nerve signals with a special type of medication called local anesthetics.  Specially-trained anesthesiologists try to identify patients who may benefit from nerve blocks before surgery.  Specialized, individualized nerve blocks often deliver profound pain relief, sometimes even complete pain relief, following surgery.
• The procedure itself is well tolerated.  Your anesthesiologist will speak with you about your procedure as well as the benefits and risks of a nerve block before the procedure.  If you consent to having a nerve block performed, they help position you, keep you comfortable during the procedure, and ensure the best possible chance that the nerve block delivers excellent pain control. 
• There are many types of nerve blocks, and the best nerve block for you depends on the procedure you’re having done as well as your own health!  These are some of the different types of surgeries that you may want to request a nerve block for: 
  • Surgery on your shoulder, arm, wrist, and hand may benefit from a brachial plexus nerve block to help with your pain after surgery.  This nerve block may be combined with other nerve blocks in the back or underarm to provide individualized pain control.
  • Surgery on your chest and upper stomach, such as breast surgery or surgeries involving your heart or lungs, may benefit from paravertebral nerve blocks or erector spinae plane blocks.  
  • Surgery on your stomach and trunk below your belly button, such as hernia repairs and colorectal surgeries, may benefit from abdominal nerve blocks, such as the transversus abdominis plane block and rectus sheath block.  These nerve blocks are usually performed after you are anesthetized, and they are useful nerve blocks for helping control pain after surgery.
  • Surgery on your hip, thigh, knee, leg, ankle, and foot may benefit from one of many Lumbar plexus block, femoral nerve block, sciatic nerve block, and other nerve blocks in the leg help patients recover from surgeries of the hip, thigh, knee, leg, ankle, and foot.  These nerve blocks are often combined and individualized for your specific procedure.  
• Nerve blocks have many advantages over opioid-heavy approaches to treating post-surgical pain:
  • Better pain control compared to intravenous opioids
  • Earlier return of bowel function
  • Less need for (and less utilization of) opioids
  • Less nausea
  • Improved breathing 
  • Improved participation in physical therapy
• Nerve injury is a known but thankfully rare occurrence.  Between 1:4000 blocks to 1:200,000 blocks will result in nerve injury, depending on the type of block and your other health problems.  People with preexisting nerve damage, muscle weakness, numbness, or tingling should alert their anesthesiologist during your consent.

What kind of non-medicational “modalities” can help my pain after surgery?

• Acupuncture – People having acupuncture have thin needles inserted into their skin in different places. The needles do not hurt, or they hurt very little.
• Pain psychology/ Mind-body techniques/Meditation – Examples include hypnosis and guided imagery. These techniques are supposed to calm you and help you change the way you think about your symptoms.
• Essential oils
• Herbal Remedies – usually pills or liquids that contain substances found in plants. Even though herbal remedies are “natural,” they are not always safe. Plants sometimes have chemicals that can hurt the body.
• Massage Therapy 

 

References:

1. Moore A, Collins S, Carroll D, McQuay H.  Paracetamol with and without codeine in acute pain: a quantitative systematic review.  Pain. 1997 Apr;70(2-3):193-201.
2. Elia N, Lysakowski C, Tramèr MR. Does Multimodal Analgesia with Acetaminophen, Nonsteroidal Antiinflammatory Drugs, or Selective Cyclooxygenase-2 Inhibitors and Patient-controlled Analgesia Morphine Offer Advantages over Morphine Alone?: Meta-analyses of Randomized Trials.  Anesthesiology. 2005 Dec;103(6):1296-304.
3. Kumar K, Kirksey MA, Duong S, Wu CL. A Review of Opioid-Sparing Modalities in Perioperative Pain Management: Methods to Decrease Opioid Use Postoperatively. 

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