Pain Management Before and After Surgery

Introduction

There is a staggering incidence and prevalence of pain throughout the world. Pain is the most common reason for seeking medication. Musculoskeletal pain, low back pain, neck pain, and migraine are the leading causes of pain around the globe. Chronic recurring pain has been occurring in around 10 to 15 percent of the population. Uncontrolled pain has many potential negative impacts on health, well-being, and economic productivity. There is also an increased risk of myocardial infarction and chronic pain. Pain can be due to physiologic and pathologic reasons.

How to Manage Acute Pain?

Acute pain is an unpleasant experience that can occur as a tissue response to trauma, and it can either be sensory or emotional. Injuries or procedures related to bone and joints have been more painful compared to those related to soft tissues. Surgeries in the elbow, shoulder, hand, ankle, and knee, along with hernia repair and laparoscopic cholecystectomy (surgical removal of the gallbladder), have been perceived as more painful, according to the patients.

Acute pain can be due to the following reasons:

• Acute Illness: Myocardial infarction, appendicitis, and renal colic.

• Major and Minor Trauma: Motor vehicle accidents, sprain, lacerations.

• Burns: Fire and chemical burns.

• Perioperative: Head and neck surgery, abdominal surgery, orthopedic surgeries.

• Procedural: Endoscopy, bone marrow biopsy, suturing, and catheter placement.

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• Obstetrical: Childbirth by vaginal delivery or cesarean section.

Management is done through (flowchart):

• Step 1: Nonopioid analgesics like NSAIDs.

• Step 2: Weak opioids.

• Step 3: Strong opioids like Methadone. They can be administered either orally or as a transdermal patch.

• Step 4: Nerve block, epidurals, PCA (patient-controlled analgesia) pump, neurolytic block therapy, and spinal stimulators. These can be given along with NSAIDs (non-steroidal anti-inflammatory drugs) as adjuvants for treating chronic pain and cancer pain. PCA (patient-controlled analgesia) pumps are a safe administration of intravenous analgesics that is done by the patient. Neurolytic block therapy refers to blocking a group of the nerve through neurolytic like alcohol and phenol to provide pain relief. Spinal stimulators are implanted devices placed under the skin that send mild amounts of electric current to the spinal cord to relieve pain.

How to Manage Chronic Pain?

Chronic pain persists beyond the usual recovery time and worsens the patients to a debilitating condition. Cancer, arthritis, muscle pain, and back pain are some examples of chronic pain. Normal physiology of nerve cell function, cellular receptors, and ion channels is altered due to persistent pain. Interdisciplinary management of chronic pain must include specialists in psychology, physical therapy, occupational therapy, neurology, and anesthesiology. Drugs used for chronic pain are multiple the following:

• Opioids.

• Nonsteroidal anti-inflammatory drugs and antipyretic analgesics.

• Serotonin receptor ligands.

• Antiepileptics.

• Antidepressants.

• Topical analgesics.

• Adjuvants such as local anesthetics, alpha-2-agonists, Baclofen, botulinum toxin, antiemetics, and laxatives.

• Novel drugs such as cannabinoids and ion channel blockers.

What Are the Interventional Methods Used for Chronic Pain?

1. Nerve Blocks: Diagnostic nerve blocks are used as a diagnostic tool for understanding the mechanism underlying pain in an individual. Therapeutic nerve blocks are used only in a minority of patients who have cancer-related pain. Conservative pharmacological management has helped achieve pain reduction in 90 percent of individuals. Those patients who are untreated through conservative management benefit from therapeutic nerve blocks.

2. Continuous Catheter Techniques: Continuous drug delivery through intrathecal or epidural space can be accomplished by implanted accessible reservoir systems, programmable implanted pumps, and tunneled exteriorized catheters. Through this, the patient can benefit from the reduction of systemic side effects. The effectiveness of cancer pain is stronger through these approaches.

What Are the Perioperative Protocols for Managing Chronic Pain?

Chronic pain patients tend to have a higher preoperative expectation of pain, anxiety, depression, or hypervigilance. Preoperatively the patients should be enquired about chronic pain, regular use of analgesics, and any other medications that the patient consumes for pain management. Chronic pain patients usually suffer from neurological deficits or prolonged inactivity, or both. So there is an increased risk of developing adverse effects during the perioperative period. Hence patients who are suffering from chronic pain are pretreated with opioids, COX (cyclooxygenase) inhibitors, anticonvulsants, antidepressants, or a combination of these. Patients who are under opioid medications for too long tend to have higher degrees of postoperative pain. Oral valproic acid is commonly used for prophylaxis of migraine, and intravenous valproic acid may be used to control episodes. Antidepressants are frequently used for neuropathic pain and for associated depression. Adverse effects are numerous and include sedation, anticholinergic effects, and cardiovascular changes.

What Is Dependence?

Pain management should focus on reducing the pain levels and not making them zero. A pain that is tolerable with the use of drugs that are tolerable and not misused should be used. Physical dependence, addiction, and pseudoaddiction refer to the adaptation of the patient to a specific class of drug and its dependence. There can be a withdrawal syndrome once there is abrupt cessation, decreasing blood levels of the drug, and rapid dose reduction. All opioids, benzodiazepines, and many anticonvulsants produce clinically relevant physical dependence. If such drugs are administered for a prolonged time, a physical dependence can develop in the individual. So, those patients who are having continuous preoperative opioid medication and other drugs should be considered for withdrawal syndrome if the opioid is substituted with some other drug during the perioperative period.

What Are the Risks and Side Effects of Opioid Use?

Prescription opioids carry risks of addiction and overuse when used for a prolonged time. Side effects of opioids include

• There will be an increased tolerance to the drug. That is, the patient might need more of the same drug for pain relief over a period of time.

• Patients who regularly have it tend to develop physical dependence; that is, the individual tends to develop withdrawal syndrome when the medications are stopped.

• There can be an increased sensitivity to pain in patients who regularly consume opioids.

• There will be reduced levels of testosterone in males, accompanied by low sex drive, energy, and strength.

• There can be constipation, nausea, vomiting, and dry mouth.

• The individual will have depression, confusion, dizziness, or sleepiness.

• There can be sweating and itching.

• Risks are greater with overdose and in patients who have mental health conditions like depression or anxiety.

What Are the Non-pharmacological Treatments for Pain?

Cold application for 20 minutes every two hours can be made to ease the early stages of acute pain. Compression, elevation, and immobilization of the affected area help the injured area to rest and accelerate the healing. In the late stages of pain, physical therapy, yoga, or massage can be done. Multimodal therapy should be followed to reduce pain so that more than one of these approaches should be used.

Conclusion

Management of pain is one of the important aspects of providing patient care. Most of the patients that come to a clinic or health care setting complain of pain that is either acute or chronic. The physician should act swiftly in reducing the pain because it not only reduces the patient's suffering but also helps in the conversion of acute pain to chronic pain. The cause of the pain is to be identified, and the quick recovery of any illnesses that are causing pain should be carried out eventually. These methods can also be used as pain prophylaxis.