New Thinking in Post-Op Pain Management

Pain Management

By: Joe Paone

Published: 5/15/2020

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To move on from opioids, providers are tailoring varied regimens based on patients and procedures.


There’s no silver-bullet, one-size-fits-all replacement for opioids in the management of post-op pain, so clinicians are experimenting with various drugs and techniques, both old and new. In the process, they’re finding an expanded toolkit of pain management modalities to reduce pain more effectively by mixing and matching tools for maximum effectiveness for individual patients and specific procedures. Here are some recent and emerging approaches to reducing both pain and opioid use:

  • IV acetaminophen. Its onset is very predictable and quick, acting within five to 10 minutes, according to Ronen Shechter, MD, an assistant professor of anesthesiology at Johns Hopkins University in Baltimore and co-medical director of its Perioperative Pain Program (PPP). “It’s faster to use, especially in quick turnover places, where you want to know the pain is controlled so patients can be discharged,” he says. “The problem is it’s significantly more expensive than the pills.”
  • Ketamine. Dr. Schechter says this old anti-inflammatory drug has been shown to reduce opioid consumption by 30% to 45%. “It acts on many receptors, many locations, and is very effective,” says Dr. Schechter, who uses it frequently in inpatient surgeries. “It can reverse some of the side effects of opioids, like hyperalgesia. Patients wake up very nicely with it.” It might not be ideal for outpatient centers craving quick turnover, though. “If it’s used too long or too much, the patient may have lingering sedation,” says Dr. Schechter, characterizing it as a drug that should be employed for very painful procedures or for patients with high opioid tolerance.
  • IV lidocaine. Another medication commonly used in inpatient procedures, this also has sedative properties. “It’s very effective as an analgesic, but the recovery is much slower,” says Dr. Schechter.

LET'S TALK ?A holistic approach to post-op pain management requires patient engagement, education and communication in advance of surgery.

“Because of that, I’m not too confident it would be a great choice for outpatient settings.”

  • IV magnesium. This salt is an analgesic that Dr. Schechter says has been shown to effectively reduce opioid requirements.
  • Dexmedetomidine. Often used to prevent PONV, steroids like this, applied at higher doses, have been linked to reduced use of opioids. Dr. Schechter cautions their side effects, such as hyperglycemia and impaired wound healing, should be considered. Dexmedetomidine, which has been used as a sedative and analgesic, doesn’t suppress breathing like an opioid would. Cost is an issue, however. “About two years ago it would be very difficult to get it approved,” he says. “They would only approve it for very specific cases. But now it’s used a lot more.”
  • Regional anesthesia/nerve blocks. These injections, which deposit numbing or weakening medication, vary in length depending on the type of local anesthetic used. “You have perineural, when we get close to the nerve; incisional, which is often done by the surgeon, or intra-articular, where the surgeon can inject into the joint,” says Dr. Schechter. Provided as a single shot or continuously via pain pumps, they can provide long-lasting pain relief.
  • Take-home pain pumps. Available in electronic and elastomeric versions and used with a catheter, these range from devices that provide a steady-state drip of local anesthetic to more advanced, expensive devices that can provide demand dose, enabling patients to self-deploy extra analgesic. “This is a definitely a good tool to use,” says Dr. Schechter, who adds that educating patients on proper use, and informing them to recognize side effects and complications, are vital to success and compliance. He suggests daily follow-ups to check in on these patients at home. “Usually after two days, over the phone, the patient pulls the catheter,” he says, adding that the pumps work very well and problems are rare.
  • Neural modulation. Peripheral nerve stimulators are devices that can be placed with ultrasound, like other blocks, but can sit close to a nerve for two months or so. Dr. Schechter says proof-of-concept studies show potential for use in outpatient procedures like rotator cuff repair, and foot or knee surgeries. However, he says, they’re expensive, so you need to justify their cost. “This is electrical stimulation that’s applied before surgery, typically in the proximity of the major nerves,” says Anis Dizdarevic, MD, director of regional anesthesia and acute pain medicine at Montefiore Medical Center in the Bronx, N.Y. “Instead of using the local anesthetic, you apply the electrodes, leave them subcutaneously inserted, and then you stimulate the area. It’s definitely a promising technology. I see it being used more in the future for acute pain management.”
  • Intraoperative pain monitors. Dr. Disdarevic is excited about the possibility of objectively measuring a patient’s pain in real time in the OR using pain monitors that process EEG signals during surgery and produce an analgesia nociception index, or nociception level index. “We’re working on designing different algorithms that will use some EEG activities, but also sympathetic and parasympathetic systems of the body during surgery,” he says. “We want to see if we can extrapolate that to get some sense of how much pain the patient is experiencing. We can use that as a guide to provide additional analgesia if needed.” While not yet in use at Montefiore, Dr. Dizdarevic expects more research and devices to emerge around the concept.
  • Cryoablation. “This has been used for a long time in chronic pain management and sometimes for acute pain management,” says Dr. Dizdarevic. It involves applying low temperature therapy and changing nerve structure to blunt response. “We’re talking about situations where you don’t plan to destroy the nerves, but change the architecture of that nerve,” he says. “There’s some promising data there. We just have to figure out the safety of it.

Unpredictability is a factor with some of these technologies, because you can’t really predict how long you’ll have the effect of decreased pain sensation.”

Beyond the OR

Pain is not adequately controlled if it’s addressed only at the time of surgery, says Dr. Shechter. “It’s a broader view, starting way before surgery. It’s before, during and after. Having a good plan leads to better outcomes. If we don’t treat pain well at the time of surgery, patients may develop more postsurgical pain and chronic postsurgical pain.”

At Hopkins’ PPP clinic, the focus is on patients who are expected to be more challenging, specifically chronic opioid users. Clinicians there engage high-risk patients a month or so before surgery to educate and prepare them for the procedure, wean their opioid use, and optimize their care using multimodal techniques. “Hopefully by the time they come for surgery, they are less opioid-tolerant and it’s easier to treat their pain, reduce their anxiety, and improve satisfaction and also possibly the surgical outcome,” says Dr. Schechter.

This wider, broader view of pain management isn’t for every patient. “It should be tailored mostly for patients who are at risk, suffer from chronic pain, have taken opioids for a long time or are on medication-assisted treatment programs,” he says. “Time of surgery is very risky for them.” If these patients’ postoperative pain is not well-controlled, they could become addicted or relapse into addiction. Another trigger to employ this broader view is procedures that cause a lot of pain, he says.

In addition, not all pain is created equal. “There’s nerve pain, visceral pain, inflammatory pain, combination pain,” says Dr. Dizdarevic. “You have these different pain pathways and different ways to decrease your pain by using different types of medication.”

Preoperative assessments of high-risk patients are crucial — prior history of pain, opioid use, past surgeries — can help determine an optimal pain management path, says Dr. Dizdarevic. Then there’s the procedure to consider. “Is it a simple surgery, complex surgery, intermediate surgery?” he says. “What index of pain does that surgery carry? What’s the likelihood of this patient having severe pain after this surgery — or developing chronic pain?”

Combining the unique patient and procedure factors, an appropriate cocktail of analgesia can emerge. “For patients we don’t think would be at particularly increased risk, we designed a basic multimodal analgesia protocol,” says Dr. Dizdarevic. “If somebody is a higher risk, we go a step or two beyond and add extra measures. We look into multiple factors to come up with a plan that consists of some level of multimodal analgesia to begin. Then we develop a step or two or three beyond that depending on patient and surgery characteristics.” OSM

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