A clinical review and perspective on pharmacologic options for managing pain prior to, during, and following medical procedures.
The mounting scrutiny over opioid prescribing in the United States has led to increased attention on alternate pain treatments not just in primary and specialty care, but also as part of the perioperative pain control cycle. Preoperative patients currently taking opioids or presenting with a history of opioid addiction, and those living with chronic pain, in particular, may require a unique approach, for which agreed-upon standards are lacking in such cases. While the pain management community seeks solutions to and guidance on the evolving situation, this paper offers a clinical perspective and review of full and partial mu opioid agonists, as well as alternative pharmacologic treatments, for perioperative pain control.
Preoperative History & Planning
Appropriate use of steroids, antibiotics, and presurgical patient education are well-established methods for decreasing pain and minimizing opioid consumption leading up to and following a major medical procedure. More intricate pharmacologic approaches are often necessary in complex cases where the surgical patient presents with chronic pain and/or pain-related comorbidities. The following section provides a range of available options as presented in the literature and currently used in clinical
practice.
Pharmacologic Presurgical Pain Control
It has been extensively reported that preventive preoperative use of gabapentin may result in decreased doses of required opioids and the likelihood of central sensitization post-surgery.1 A 900 mg to 1200 mg single dose has been deemed effective for these purposes. Not all studies support this notion, however, potentially due to their focus on the gabapentin’s effect on anxiety versus pain, or due to too low doses of the medication.
A high initial dose of gabapentin may be poorly tolerated by many patients, so it is reasonable to start with lower doses in the two to three days before surgery (if the patient is not already on this medication) and increasing the doses as tolerated, ending with a maximal dose in the immediate preoperative period. The author recommends continuing gabapentin for 7 to 14 days after surgery.
Reported post-surgical regimens and doses vary greatly, with doses as low as 400 mg/day, deemed effective.5 The use of alternative, long-acting formulations of gabapentin and gabapentin enacarbil may be considered as well.
Pregabalin, expectedly, provides a similar effect on pain control and a decrease in opioid reliance. Unfortunately, optimistic results have not been universal: a Cochrane meta-analysis suggested a modest but statistically significant reduction in the incidence of chronic pain after surgery following treatment with ketamine but not with gabapentin or pregabalin7 (see also, sidebar–“Overprescribing Concerns”).
Preoperative use of celecoxib has also received much attention. This medication showed a modest decrease in pain and post-surgical opioid consumption.8.9 Cox-2 receptors are not present on platelets, so celecoxib should not influence bleeding time, but surgeons universally tend to avoid even a remote chance of coagulation problems.
Successful preoperative use of muscle relaxants and acetaminophen also have been reported.10 Of note, many muscle relaxants may be sedating and add to the risk of gait instability and confusion, as well as swallowing and respiratory problems.
The use of N-methyl D-aspartate (NMDA) receptor antagonists, including amantadine, in theory, may help to prevent pain chronification and opioid dependence.11 Ketamine may offer promising relief as well, but due to potential mental effects and potentially addictive nature, ketamine should be used with caution.