LESS IS MORE Current pain control methods should aim at minimizing the overall use of opioids and focus on short-acting versions of the drugs when they're needed.

Your anesthesia providers or recovery room nurses likely have had conversations with patients that went something like this:

"I'm in agony. Give me the strongest pain meds you've got."

"But you might feel nauseous. You might throw up. You might be constipated."

"I don't care. Solve my pain now. Please."

It's understandable that patients in severe pain tend to focus solely on the source of their discomfort, which in turn causes anesthesia providers, surgeons and recovery room staffs to do all they can to lower pain scores to acceptable levels. Additionally, patients often accept any side effect associated with opioids as long as they're getting relief from the pain.

Patients who receive significant amounts of narcotics following surgery are at greater risk of suffering from constipation, nausea, vomiting and respiratory depression. If narcotics are associated with so many potential side effects, why are they used? They're used because they're highly effective for nearly immediate pain control.

What's the problem with opioids? Consider that they were created to control chronic end-of-life pain. They're powerful drugs originally intended to ensure a patient's last few weeks or days were as comfortably as possible. Gradually, opioid use became more widespread to treat everyday pain as well as the significant discomfort patients are in following surgery.

Many caregivers in the United States use narcotics to treat mild pain, more narcotics to treat moderate pain and even more narcotics to treat severe pain. That seemingly exaggerated approach to pain management is rooted in some truth, because a clear majority of the world's opioid consumption occurs in the U.S., which comprises only 5% of the world's population. In contrast, the World Health Organization recommends using oral or IV acetaminophen, NSAIDs and local anesthetics to control mild pain; all mild pain treatment options plus narcotics as needed to control moderate pain; and moderate pain treatment options plus narcotics as needed to manage severe pain.

The bottom line: Just because narcotics are effective doesn't mean they should be the only method you use to attack post-op pain. They should be a significant part of your plan for pain control, but not the basis for the entire approach.

Soothing solutions
The push has been to move away from narcotics in favor of pain-controlling methods that don't cause the 2 major consequences associated with powerful opioids: respiratory depression and potential addiction. An effective multimodal approach to pain management includes combining 2 or more of the following: intraoperative dexmedetomidine, ketamine, clonidine or remifentanil with NSAIDs (such as IV ibuprofen and IV acetaminophen) and local anesthetics.

• Local anesthesia. To limit the need for post-op narcotics, place regional blocks whenever and wherever possible. Epidurals are a great solution, as long as the pain is localized to a certain part of the body, usually under the nipples, as well as the lower extremities. Effective pain control following upper-extremity surgery often requires continual nerve blocks.
• NSAIDs. These drugs control swelling, which helps lessen post-op pain. It makes sense to use anti-inflammatories, but they have their own set of associated post-op adverse events, such as impeding normal renal function. When combined with other modalities, however, NSAIDs are very useful components of post-op pain control formulas.

IV acetaminophen is effective in patients with adequate liver function. In patients with good renal and liver function, you can combine IV acetaminophen with NSAIDs to hit pain pathways and receptors from multiple sides.

REALITY CHECK Patients who want to be pain-free after surgery have unrealistic expectations.

SUBJECTIVE SCORES
Surgery Is Supposed to Hurt

Educate patients about how they'll really feel in recovery and why your pain control regimen is designed to limit narcotic use. Pre-op conversations should alert them to the fact surgery will cause some pain, but your care team and anesthesia provider will do whatever they can to prevent the pain from becoming unbearable. Patients who are properly educated about surgical pain and enter the experience with realistic expectations about how they'll feel in recovery won't overrate their pain and push caregivers for more drugs to control their discomfort.

Recovering patients are often asked to rate their discomfort on a 1-to-10 pain scale, which is used to determine if and when patients receive narcotics. For example, perhaps patients reporting their pain as 6 or higher will receive the powerful drugs. But the scales are totally subjective. Pain that one patient describes as 7, another might describe as 2.

What are anesthesia providers supposed to do with that subjective information? They must instead assess how patients are acting. For example, when my patients complain of severe pain, I check their heart rates, blood pressure and respiratory rates, which could all be elevated. Beta-blockers could impact the heart rate and blood pressure, but the breathing rate is an excellent indicator of a patient's level of comfort. Patients in pain have rapid, shallow breathing. A comfortable patient does not.

— Ashish Sinha, MD, PhD, DABA

One dose of IV acetaminophen costs approximately $10, compared with 10 cents per dose of morphine. Administrators and providers who support the use of morphine to decrease their facilities' medication expenses are missing the big picture of pain control.

Timely ambulation following surgery is the single biggest predictor of quick discharge and decrease in post-op complications such as pulmonary emboli. Patients whose pain is well controlled, who aren't over-dosed on narcotics and are pain-free walk sooner after surgery, meaning they can be fast-tracked out of the recovery room. The extra expense of opioid alternatives will be more than made up in faster discharges, a PACU free of bottlenecks and, ultimately, the potential to add more cases.

LOCAL AID Regional anesthesia is an effective and efficient alternative to opioid use.

• Incision injections. A simple pain-control solution that isn't done enough is injecting local anesthesia at the incision site. For example, patients who undergo abdominal surgery experience somatic, not visceral, pain. It's not their stomach or intestine that is hurting; what's hurting is the skin around the incision site. Patients guard against the pain by breathing in short, shallow and multiple breaths, and by refusing to ambulate, which contributes to a host of potential adverse events. One solution: Injecting Exparel, a bupivacaine time-released bolus, at the incision site creates opioid-free pain relief for up to 72 hours.
• Ketamine. Administering this drug in small doses (0.5mg/kg at induction and 10mcg/kg/min intraoperatively) to narcotic-tolerant patients helps control the wind-up pain phenomenon, a chain reaction of stimuli that starts at the incision site and travels along peripheral sensory nerves to the central nervous system to intensify pain.
• IV lidocaine. There's growing interest in administering IV infusions of this local anesthetic to help control post-op pain. Research has shown that delivering the drug intravenously at induction and in the PACU reduces the amount of opioids needed to lower post-op pain scores. As long as it's given in small doses — 1 to 3 mg/kg per hour — IV lidocaine shows promise as a safe and effective addition to a multimodal pain regimen.

Acknowledge and act
Pain is subjective. If patients say they are in pain, you need to do something about it. Acknowledge their pain and let them know you'll control it to tolerable levels. How you chose to do so is critical. The answer lies in multimodal analgesia that combines a series of effective pain control methods aimed at limiting narcotic use while improving patients' post-op comfort.

Managing patients' post-op pain demands striking a delicate balance between anguish and euphoria. You want to treat pain, but you don't want to over treat it, especially if patients are obese, have sleep apnea or take medications that make them more prone to respiratory depression. When it comes to preparing satisfied patients for timely discharges, narcotics should be your last option, not your first.