Surgery is, by nature, an uncomfortable process, and the goal of healthcare teams is to minimize post-operative pain and disability as much as possible.
Ariana M. Nelson, M.D.
Associate Professor of Anesthesiology and Pain Medicine, Chair, Opioid Safety and Substance Use Disorder Special Interest Group, American Society of Regional Anesthesia and Pain Medicine
Patients may hear doctors and nurses talking about “multimodal analgesia,” a strategy where different pain treatments are used simultaneously to control pain and reduce side effects. Lower doses of different types of medications by mouth or IV are used to avoid high doses of any single medication. Other pain control treatments like physical therapy, alternative medicine like acupuncture, and behavioral interventions like meditation may also be offered. Additionally, there are important medication and procedure options that patients should know about before surgery.
Before surgery
Patients who take pain medications daily will be able to continue these leading up to surgery except for NSAIDs (ibuprofen, naproxen), which should be stopped because they increase the risk of bleeding. Patients should continue taking their regular doses of acetaminophen, nerve pain medications (antidepressant, gabapentin, or pregabalin), and opioid medications up until the morning of surgery. Patients taking buprenorphine may require higher doses of other opioid medications than the typical patient would to overcome the buprenorphine strength, but continuing buprenorphine during surgery is very beneficial. Starting a new prescription of gabapentin (commonly 300 mg three times a day for at least a week before surgery) can decrease the risk of pain and opioid use after surgery.
The day of surgery
Many surgeons use enhanced recovery after surgery (ERAS) protocols, where the patient may take pill-form medications in the pre-operative area before surgery (celecoxib, acetaminophen, and possibly gabapentin or pregabalin) and be considered for a nerve block or a spinal anesthetic. These medicines are given to decrease overall pain and opioid use during and after surgery. Nerve blocks and spinal anesthesia use a needle to deliver local anesthetic (numbing) medication to nerves, which provides strong pain relief for a period of time and slowly wears off. It is not necessary to take opioid medications while the patient is pain free, but it is wise to take them as soon pain starts to return.
After surgery
Inpatient (while patient is in the hospital after surgery)
Infusions can be used in some circumstances after very painful surgeries. Ketamine is a unique medication that is used as an infusion and, to oversimplify, causes the brain to forget that the body is experiencing pain. Most patients feel a little unusual while they are receiving this infusion, but that feeling resolves quickly after the medication is stopped. Ketamine is effective for about two days, and it can reset pain receptors, making it easier to control pain during and after treatment.
Sometimes the anesthesiologist can also place a small flexible tube to deliver an infusion of local anesthetic (numbing) to the spinal column (epidural catheter) or to a peripheral nerve that goes to the surgical site (regional nerve catheter). These options can give patients profound pain relief for days after surgery, decreasing the need for opioids and avoiding their side effects, like nausea and constipation. Epidural catheters can only be used for specific surgeries and must be removed before the patient leaves the hospital.
Outpatient (patient is discharged from the hospital)
Regional nerve catheters can sometimes be continued outside of the hospital by giving the patient a portable pump. Patients will receive prescriptions for all of the medications they have been receiving after surgery and should try to reduce the amount of opioids they take as much as possible. If opioids are necessary, patients should take medications to combat constipation as early as possible. Leftover opioid pills after the patient has fully recovered from surgery should be taken to a safe opioid disposal location rather than keeping them in the house.
