Managing the acute pain that accompanies operative procedures is a challenging and risky process.  Studies suggest that opioid medications started for short term management of pain increase the risk of long-term use by up to 44%¹. To provide guidance on a more evidence-based set of pain management strategies post-operatively, the American Pain Society has recently issued an updated guideline. ²  Below are highlights of the 32 recommendations that they have made.

Multimodal therapy should be considered for all patients undergoing surgery. These options should be fully discussed with the patient and their families prior to surgery. These modalities include:

• Systemic pharmacotherapy including NSAIDS and/or acetaminophen, gabapentin or pregabalin, IV ketamine, or opioids (preferably oral)
• Local, intra-articular or topical therapies including local anesthetics at incision, or intra-articular anesthetic
• Regional anesthetic techniques- e.g. regional or paravertebral blocks
• Neuraxial anesthesia such as epidurals rather than general anesthesia
• Non-pharmacologic therapies including TENS and cognitive behavioral therapy (CBT)

Use of TENS and cognitive behavioral approaches may decrease the total need for opioid medications, and should be considered unless contraindicated.

If opioids are used, oral dosing is preferable over IV routes. Avoid long-acting opioids. Do not use opioids, long or short-acting, prophylactically pre-operatively. In addition, every patient started on opioid pain management therapy should be given a tapering plan prior to discharge. It is often adequate to discharge the patient on NSAIDs or acetaminophen rather than opioids. If discharged on opioids, tapering off within two weeks is appropriate. This can be done by decreasing the opioid dose by 20-25% of the discharge dose every day or two till off. Patients who were on opioids pre-operatively should be tapered back to the maintenance dose within two weeks.

NSAIDS and/or acetaminophen should be used along with or in place of opioids where possible and dosed therapeutically. Concerns about use of NSAIDs and the risk of non-union of bone or anastomotic leakage is not supported by the literature.

Use of gabapentin and pregabalin should strongly be considered as part of multimodal pain management post-operatively. Both reduce opioid requirements. IV ketamine also has moderate evidence to suggest it is effective and lowers opioid requirement.

For thoracic and abdominal surgery, consider use of epidural anesthesia rather than general anesthesia. Epidurals are associated with improved pain management scores post-operatively and have fewer complications than general anesthesia

¹ Alam A. et al, “Long-term Analgesic Use after Low Risk Surgery”. Archives of Internal Medicine, 2012, 172(5): 425

² Chou R. et al “Guidelines on the Management of Post-Operative Pain” Journal of Pain, 2016 17(2): 131

Scott Endsley MD, Associate Medical Director, Quality