Here's something that flies of the face of conventional logic: A little post-op pain is all right. Patients are often willing to put up with some pain and discomfort if they can avoid nausea or numbness.

But healthcare providers don't always realize this. To wit: In 1999, researchers polled patients and found they wanted to avoid PONV more then anything else, says says Barry L. Friedberg, MD, of Cosmetic Surgery Anesthesia in Corona del Mar, Calif. The anesthesiologists polled, on the other hand, picked pain as patients' top concern.

So your challenge is finding a balanced treatment: One that will kill pain so the procedure and recovery go well - but not deliver so much medication that patients experience PONV or numbness.

Here are three things you can do to find the elusive middle ground of post-op pain control.

1 The pre-op pre-empt
Think of the nervous system as having gates that sensations have to go through to create pain. As the gates open, pain intensifies. But if you can lock the gates, you can stop sensation from becoming pain - which is more efficient than trying to close each of the gates once they've been opened.

A study eight years ago at the University of Pennsylvania showed that patients who had a pre-emptive epidural narcotic or local anesthetic before receiving general anesthesia for prostate surgery reported 33 percent less pain during their hospitalization and were more active more quickly after surgery. Less pain means fewer post-op opiates, which helps cut down on PONV.

Back to the analogy, what if you didn't have to lock all the gates? Instead of treating pain as a monolithic event that requires a blanket treatment of, say, morphine (or Motrin, for less intense pain), researchers have been looking at more tailored pain control, says John Dombrowski, MD, an anesthesiologist and pain medicine specialist at Georgetown University Hospital in Washington, D.C. "Pain is unorganized nerve activity," he says. You may be able to get better results if you treat the individual gates, as it were.

Some studies propose off-label use of anti-depressants and anticonvulsives as pre-emptive medication. "The two drugs are still more likely to be used in treatment of chronic pain, but their use a day or so before an outpatient procedure has been catching on," says Dr. Dombrowski. Certain anti-depressants increase serotonin levels, which dilutes the pain message to the spinal cord. Anti-convulsants work by changing how the nerves work. They help to slow and even stop the nerves' firing.

Jeffrey Richman, MD, assistant professor and director of regional anesthesiology at Johns Hopkins University in Baltimore, says there may not be enough evidence to start prescribing anti-depressants and anti-convulsants for operative pain.

2 The intraop block
Anesthesiologists are getting better at placing peripheral nerve blocks and using them with better discretion. As a result, PNB use is becoming more accepted as a means for managing pain, especially in orthopedic surgery.

Blocks are supplemented by oral opiates, but because the local anesthetic provides much of the analgesia, only small doses of opiates need be administered. Further, they take only five to 10 minutes before a procedure. Terese T. Horlocker, MD, professor of anesthesiology and orthopedics at the Mayo Clinic College of Medicine in Rochester, Minn., has seen the benefits of shortened hospital stays and happier patients.

"People used to hurt so much," says Dr. Horlocker. "If you were to tell me five years ago that people would feel so great, I would not have believed it."

Adam F. Dorin, MD, MBA, the medical director of Grossmont Plaza Surgery Center in La Mesa, Calif., says using a nerve block (with indwelling catheter and pain pump) for every knee arthroscopy - including 30-minute meniscectomies and chondroplasties - is "overkill."

He thinks it's a better idea to be selective and to gauge surgeon and patient preferences. Where some would routinely perform a pre-procedure block, Dr. Dorin thinks a surgeon-administered local is the best and most balanced choice for limited surgery, or if the patient prefers to avoid prolonged limb numbness or other block side effects.

"They get a nausea-free anesthetic, and good, solid pain control for some hours post-operatively. They expect and deal with some degree of pain during the recovery process," he says.

3 The post-op pump
Using a continuous nerve block, a type of PNB, lets patients go home with a catheter and a pain pump - and a continuous flow of pain-killing medication. These are ideal for those cases that might otherwise hobble patients for a few days, such as knee and shoulder arthroplasties. If you can tackle these, patients will reap the benefits of a more comfortable recovery (and so will you, when they return their satisfaction surveys).

But pain pumps can also become their own worst enemies. Outpatients who get take-home pumps must be educated and given literature so that they're aware of the potential hazards and how to react. For one thing, a patient must protect the blocked extremity until the block completely resolves so he doesn't inadvertently injure his still-numb body part, says Dr. Horlocker. Dr. Dorin warns that patients should be aware of the possibility of infection (catheters may let bacteria traverse) and blood clots. Lower extremity blood clots could dislodge, travel to the lungs and result in fatal pulmonary emboli.

Pumps can also increase the anesthesiologist's liability, says Brian Ilfeld, MD, MS, assistant professor of anesthesiology at University of Florida: If a patient falls days after a procedure, he could blame the anesthesiologist, even if the fall has nothing to do with the catheter.

Another issue with pain pumps is that some insurance companies have balked at paying for take-home versions. But disposable pumps are much cheaper than in the past, with many models selling for about $200, says Dr. Dombrowski. If you can't get reimbursed, one solution may be to offer the patient the opportunity to pay out-of-pocket.