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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


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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 these drugs can have side effects, such as dizziness, nausea and constipation, and they are potentially addictive. A review of studies that looked at data from more than 1.9 million people found that roughly 7 percent of patients continued to fill opioid prescriptions more than three months after surgery. The research was published in 2020 in the journal JAMA Network Open.

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Thankfully, recent research suggests that there are much better options. Using at least three different medications to relieve pain, instead of opioids alone, lowers the risk of respiratory and GI (gastrointestinal) complications and also shortens hospital stays, according to a study published in 2018 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 research from the Cleveland Clinic.

“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., a pain medicine expert and professor in the Department of Anesthesiology at Rush University Medical Center in Chicago.

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 some of the latest, and safest, ways to 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.

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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 non-opioid 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 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 to block pain, suggests Buvanendran. This can help reduce the 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 used together as a first-line treatment for mild to moderate acute pain (you’re put on a schedule where you alternate the use of one with 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 three options above aren’t enough to quell the 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 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 procedure such as knee surgery. Memtsoudis says he looks at how well patients are coping with pain, including if they are 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 may not really need an opioid.
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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 their 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 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-off schedule, so you stop using them gradually (for example, cutting use 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 check out the FDA’s advice on how to safely dispose of your medications at home.

Editor’s Note: This story, originally published Feb. 1, 2019, has been updated with new information.

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