Managing Pain Before and After Surgery
From preemptive doses to local anesthetics, research shows better ways to handle pain at the hospital ... and when you come home
En español | If you’ve ever had a major surgery such as a knee or hip replacement, chances are good that your doctors relied heavily on opioids to manage your postsurgical pain. But they carry side effects such as dizziness, nausea and constipation, and can be potentially addictive. Among knee replacement patients, 53 percent who’d taken opioids both before and after surgery were still taking them six months later. (Of those who did not report taking opioids before surgery, 8 percent were still taking them after surgery, according to a 2016 study published in the medical journal Pain.)
Thankfully, new research now suggests that there are much better options. Using at least three different meds to relieve pain, instead of just opioids alone, lowers the risk of respiratory and GI complications and also shortens hospital stays, according to a study published last year in the medical journal Anesthesiology, which looked at over 1.5 million joint replacement patients. And avoiding opioids entirely for presurgery, during surgery and postsurgery led to shorter hospital stays, according to another Cleveland Clinic study presented last October at the American College of Surgeons Clinical Congress.
“We’ve become much more sophisticated at targeting pain at different parts of the pain pathway, so we can get better pain relief without relying on opioids nearly as much,” explains Asokumar Buvanendran, M.D., professor in the Department of Anesthesiology at Rush University Medical Center in Chicago and chair of the American Society of Anesthesiologists’ committee on pain medicine. Buvanendran and Stavros G. Memtsoudis, M.D., director of Critical Care Services in the Department of Anesthesiology at the Hospital for Special Surgery in New York, shared the latest, and safest, ways to best handle postsurgery pain, below. Many are options you’ll need to discuss with your doctor if you’re scheduling surgery in the near future, and a few are things you need to do on your own — like not quitting any opioids you are given cold turkey, or making that physical therapy session a top priority.
Take meds presurgery. The Cleveland Clinic study had patients take a preemptive dose of three drugs: acetaminophen, the nerve pain medication gabapentin and the NSAID celecoxib (Celebrex). “Giving nonopioid pain medications before may help prevent the cascade of pain-causing chemicals that comes from your central nervous system after surgery,” explains Memtsoudis.
Another option: adding in a steroid, which helps tamp down the fight or flight response occurring right after surgery, which can ramp up pain.
Opt for a local. If possible, ask for a local anesthesia, which requires a lower level of opioids than general anesthesia, as well as a peripheral nerve block, where the surgeon injects an anesthetic near a specific nerve or bundle of nerves near the area to block pain, suggests Buvanendran. This can help reduce risk of needing opioids later.
Make sure you’re on the right drugs postsurgery. In general, there are four tiers of drugs for you and your doctor to consider when dealing with your pain.
- Over-the-counter (OTC) acetaminophen and NSAIDs. These are often both used together as first-line treatment for mild to moderate acute pain (you’re put on a schedule, where you alternate use of one or the other every several hours). “They work together well, since they have a synergistic effect: the acetaminophen is a general pain reliever, while the NSAID is an anti-inflammatory,” explains Buvanendran.
- COX-2 inhibitors. These prescription medications are a subclass of NSAIDs. They block a specific enzyme, COX-2, which is responsible for making prostaglandins, chemicals that trigger inflammation or pain. Generally, you alternate the use of a COX-2 inhibitor with acetaminophen.
- Nerve pain medications. Drugs such as gabapentin (Neurontin) or pregabalin (Lyrica) can help calm any neuropathic, or nerve-related, pain stemming from the surgery that can’t be controlled with these other drugs.
- Opioids. If the above three aren’t enough to quell pain, then opioids should be added. But before you get them, your doctor or nurse should do more than just ask how much pain you are in. Two people can have the exact same amount of pain but very different perceptions of it, says Buvanendran. “If someone tells me their pain score is a 10 but their heart rate and blood pressure is normal and they’re watching TV while eating a sandwich, I’ll be less likely to move to opioids than for an individual who's actively grappling with pain." It’s also unrealistic to expect that you won’t have any pain at all, especially after a major surgery such as knee surgery. Memtsoudis says he looks at how well patients are coping with pain, including are they distracting themselves from the pain. If they’re uncomfortable but able to get their mind off of it by talking on the phone or watching TV, then they really may not need an opioid.
Stay active postsurgery. Before you leave the hospital — generally anywhere from one to four days after surgery — you’ll need to prove you can do certain things — such as getting in and out of bed alone and walking with an assistive device like a cane or walker. But you want to get up and start moving as soon as possible after your procedure, ideally once the anesthesia has worn off, says Buvanendran.
This will help reduce inflammation that can cause pain. Once you’re home, it’s also important to follow any prescribed exercises and to start physical therapy as soon as your doctor tells you to.
Try meditation. Hospitalized patients who practice mindfulness techniques — such as deep breathing — report less pain than those who don’t, according to a 2017 study published in the Journal of General Internal Medicine. In fact, about a third of these patients were able to relieve pain by 30 percent, which is equivalent to taking 5 mg of the opioid oxycodone.
Don’t try to adjust your own medication doses. When you’re home, follow the medication schedule your doctor has prescribed. It’s important not to take more than that dose. Doing so with opioids can depress your breathing, but even OTC drugs such as ibuprofen can have dangerous side effects like GI bleeding if taken in quantities that are too high. If you’re still in pain, call your doctor instead. And don’t mix with certain meds: If you combine an opioid with either OTC or prescription sleep medications, or with anti-anxiety medications, it can increase potentially deadly side effects such as depressed breathing.
Don’t stop opioids cold turkey. Most of the time, there’s no need to take opioids for more than three days. But if you do have major surgery such as a joint replacement, you may need to be on them for longer. If that’s the case, talk to your doctor about setting up a tapering schedule, so you stop use gradually (for example, tapering use down by one tablet every three to four days) to minimize withdrawal symptoms.
Throw away any leftover pills. Over 60 percent of Americans prescribed opioids keep the extras around, according to a 2016 study published in JAMA Internal Medicine. But having them around when you don’t need them can become a recipe for disaster: 41 percent of people who misuse opioids get them from friends and family members, a 2017 study showed. Don't just toss them into the garbage, either, because they could end up in the wrong hands. You can contact your local police department or trash service to see if they have medicine take-back programs, or flush pills down the toilet. (You can find the Food and Drug Administration’s “flush list.”)