What's New in Post-op Pain Management

Amid our nation's opioid crisis, providers are shifting their focus to formulations and methods that make post-op pain more bearable instead of eliminating it completely. This new way of thinking represents an opportunity to get creative and collaborative to develop better episodes of care using an expanded palette of post-op pain management options.

"We're seeing novel drugs slowly try to make their way through FDA approval — longer-acting local anesthetics, drugs that combine anti-inflammatories with local anesthetics," says David Dickerson, MD, section chief for pain medicine at NorthShore University HealthSystem in Evanston, Ill., "but we've yet to see any of them really come on the scene."

Until they do, here are several new and revived post-op pain management options to consider:

• Sublingual opioids. It might seem counterintuitive in the current environment to tout a super-strong synthetic opioid, but sufentanil could be a worthwhile pain management tool. Several times more potent than its parent fentanyl, and hundreds of times more powerful than morphine, sufentanil has been administered intravenously for decades. But a sublingual form of the super-painkiller, approved by the FDA in 2018, is gaining favor by giving providers an option for rapidly addressing severe post-op pain without going through the time, expense and discomfort of placing an IV.

"It has some very beneficial qualities that can make it safer," says Dr. Dickerson. "It has a fast onset and it's potent. But what's really valuable is that, unlike opioids such as fentanyl, it provides a significant potency with a very predictable on-off time in all patients."

It's far cheaper to give a single dose of sufentanil to get patients comfortable so they can go home than it is to keep them for another hour in the recovery room.
— David Dickerson, MD

The pain relief lasts the same duration, regardless of dosage or patient size. "If you were to give a massive overdose of sufentanil, it's going to last the same amount of time as if you gave a single dose," says Dr. Dickerson. "Not a lot of pain medicines have that forgiving nature." This could be beneficial when you've taken the IV out of a patient who is still complaining of severe pain.

With sublingual sufentanil on hand, you can treat immediate and intense pain quickly, effectively and safely. "It's far cheaper to give a single dose of sufentanil to get patients comfortable so they can go home than it is to keep them for another hour in the recovery room," says Dr. Dickerson.

Reassuringly, a child won't find sufentanil in their parent's medicine cabinet. "It's not available for anyone to go home with," says Dr. Dickerson. "It's used exclusively for site-of-service-based care. This isn't a med that anyone can pick up at their pharmacy."

• Cryoanalgesia. Brian Ilfeld, MD, MS, professor of anesthesiology at UC San Diego (Calif.), says surgeons and anesthesia providers have either forgotten about cryoanalgesia or were never exposed to it in the first place.

Perioperative cryo is a long-lasting pain relief option — weeks or months rather than hours or days.

"The longest local anesthetic is going to last maybe 24 hours in some unusual cases," says Dr. Ilfeld. "If you want something longer, you're going to have to use a catheter with a continuous peripheral nerve block," a method that carries the risk of infection, and is more challenging to place and manage. "We're looking for something an anesthesia provider can apply once that has very few risks, and provides a very long prolonged block. Cryo appears to do those things, but we need to investigate it and demonstrate that."

To apply cryo, the clinician guides a probe — a tube within a tube — to the target nerve. Once in place, the probe's tip is frozen using carbon dioxide or nitrous oxide, which is then vented up through the probe. The resulting ice ball on the probe's tip freezes the nerve, interrupting its pain signals to the brain. The ice ball only seems to injure nerves, not tissue, notes Dr. Ilfeld. Some experts suspect that's because nerves don't have the level of blood supply (and accompanying heat) that tissue does. That's advantageous because clinicians "don't have to be particularly concerned with tissue in the immediate vicinity of the nerve," says Dr. Ilfeld.

He says the risks of cryo, a sterile procedure, are small, and nothing is injected into the patient. It could be applicable for "niche procedures" like breast, knee or shoulder surgery, he says. "It has to be a procedure where the person is okay if it lasts months. It decreases sensation, often to zero, and has the potential to decrease muscle strength dramatically, if not completely. There aren't many places in the body where you can do that. It's really most applicable to the trunk of the body."

• New blocks. QL and TAP blocks are a significant part of regional anesthesia aimed at the abdominal wall, and providers are doing these with longer-lasting local anesthetics like liposomal bupivacaine, says Dr. Dickerson. Newer QL blocks are rising in use, he says: "TAP blocks have been challenged because there's not a very clear response in patients that's consistent with how well it's going to cover their incisional pain. With QL blocks, you're going to a space that's more likely to reach the nerves you're intending to target in more robust fashion. It seems like it has a more reliable spread in the majority of patients."

Dr. Dickerson says that erector spinae blocks increasingly are being used to mitigate pain in the thorax. "For surgery on a rib or a chest wall, you can effectively, through a single injection site, cover multiple nerves that are providing sensation to that larger area," he adds.

As it becomes more multimodal, pain management is becoming more personalized. Factors like the type of surgery combine with individual patient traits like preoperative and chronic pain levels, relevant comorbidities, and health status and history, including anxiety and mood disorders. Non-opioid prescriptions and OTC medications like ibuprofen, acetaminophen and aspirin, along with heating pads, ice packs, and non-medication techniques like meditation, are being mixed and matched to develop individualized pain management plans.

Preoperative patient assessment is key. Dr. Dickerson uses prescription monitoring databases to see what a patient has been prescribed, what they're filling and who prescribed them medications — rather than relying on the patient's recollection or willingness to share. "We better know who the patient is based on the medications that have been dispensed, what kind of risks they might have and what their care needs might be," says Dr. Dickerson. "And we can see who else is managing their pain." That allows for collaboration between providers for more consistent care and monitoring, and evaluation of potential drug-drug interactions.

"We're moving toward a shared decision-making landscape with patients," says Dr. Dickerson. "We're trying to find ways to give patients the option to ask their clinicians, 'Can I have an opioid-free anesthetic? Are there other medicines you can give me?' It's no longer, 'Trust me, I'm your doctor, take these pills.'"

Instead, the approach is, in Dr. Dickerson's words, "Here are my goals and preferences for you. What are your goals and preferences, and how do we align those?" He says guidelines are moving in this collaborative direction.

"Patients now are really put off by not being able to participate in their care," he says. "They want to be informed of what the plan is. They want to be involved in making that plan. And they want to know that everything that could be done for them is being done. How do we achieve that? We need to give them the confidence that we're doing the best job we possibly can." OSM