It seems I've been having more and more visits from pharmaceutical reps pimping their various wares --and recently I've had a run of individuals selling various post operative pain medications.  It got me thinking about the variety among the current pain medications available (as well as the variety of dosing and treatment regimes that I've observed).  I'm curious what our collective wisdom is regarding pain management post operatively.  Each rep would tell you that their product is the best at limiting post operative pain, but which medications have you actually written for?  On which medications have you received positive feed back?  On which have you received negative feed back?

What is your standard post operative protocol with regard to pain following elective surgery?

Ryan,
I have always preferred an NSAID for anti-inflammatory pain control implemented by a narcotic pain control agent as a back-up as well. This was on top of a Marcaine block. I personally prefer the narcotic pain control at the beginning and allow the inflammatory factors to get to the wound and let them do what they are supposed to do.

Forgot to ask you, Ryan, what I intended to ask you.....I   wanted to know if you had an answer to this question: do you have a good solution to chronic pain management for patients, or even doctors who are in chronic pain. Travel is almost impossible for people in chronic pain, even with hydrocodone and Fentanyl patches. Is there something else out there that can offer some relief for those in chronic pain? Anything new on the horizon that can help patients to be functioning members of society?
                                                                          

At the University, our anesthesia group are heavy handed with regional blocks.  0.5% Ropivicaine pain as a popliteal and saphenous nerve block seem to provide our patients 12 to 18 hours of regional anesthesia.  We follow this with narcotic analgesics for acute pain management and avoid non steroidal antiinflammatories particularly in osseous work to prevent inhibition of the inflammatory phase of bone healing.  Though animal studies have suggested increased time to union and increase percentages of nonunions with routine daily doses of non steroidal antiinflammatories in experimentally induced fractures, there are no human clinical studies to demonstrate that there is such a clinically significant effect with non steroidal antiinflammatories to manage acute inflammatory phase associated with for the immediate postoperative period.  In fact, we used to give everyone non steroidal antiinflammatories immediate postop which decreases the need for narcotic analgesics as this was the recommendation of the American Pain Association and we did not see an alarming rate of nonunions then.....Someone please stop me I am rambling.  

I've also had a company that visited my office recently. They wanted to sell us a "mini pharmacy box" filled with narcotic medicine, and we are supposed to keep the inventory and sell schedule II to IV medications (along with common antibiotics) to our patients. To make a long story short, we said "thanks but no thanks."

Can you imagine the nightmare and headache if we were to be missing some of the pain medications at the end of day?  It is definitely NOT worth the small profit that we are supposed to make!

My post-op pain medication regimen is pretty simple; I start with Vicodin 5/500 (regular strength), then go up to 660/10 (Vicodin HP). I may give them low-strength percocet (oxycodone/APAP) if they don't agree with vicodin (hydrocodone).

I have prescribed ultracet (ultram/tramadol + APAP) a few times for the patients intolerant to vicodin/percocet, but I believe their analgesic effect is pretty weak, perhaps weaker than Vicodin 5/500.

I do combine vicodin with NSAIDs sometimes. I understand that some of you may say "how dare you! That's bad for bone healing!!!" ... but I think keeping the patient comfortable for a few days is probably more important to them. I actually think Celebrex is pretty good for acute pain (200mg PO BID dosing) and I don't hesitate to prescribe it, if my patient has a prescription plan to make it feasible and affordable.   

Just my 2 cents... 

I used the the Merck drug Vioxx routinely for post-op and post-trauma pain relief, and thought it was the most effective non-narcotic analgesic ever made, before it was abruptly taken off the market in Sept 2004.  Vioxx or Rofecoxib was an NSAID Cox-2 inhibitor, like Celebrex.  Unfortunately, it was found to double the risk of thrombotic events, heart attack and stroke, when taken for more than 18 months. Throughout our lifetimes, after such a finding, a drug would have received a package insert warning for that particular usage, and remain on the market for all it's other fine uses.  But apparently, Merck had not been 100% honest about previous studies that has shown the adverse effect, and due to the massive impending litigation, chose to pull the drug rather than issue the package warning.  Hence, we lost the safest (when used for short periods) most effective non-narcotic analgesic ever invented.

Has anyone else besides Dr. Suzuki had success using the similar Cox-2 inhibitor, Celebrex, for post-op or post-trauma analgesia ? 

 

Sure, Vioxx worked great! Bextra was even better for acute pain. Having said that, both of them are off the market, and I don't think we will ever see them again, despite the long-standing rumor that Merck may bring Vioxx back. I'm afraid there's too much stigma attached to those drug names already.

What we really need is injectable cox-2 for post-surgical pain. Pfeizer supposedly has one for many years, but I guess the data are not good enough, since it is not on the market yet?

You know how much toradol (ketorolac) gets used for post-surgical pain... it is nothing more than a sole injectable NSAID with mild analgesic effect. FYI, I would caution against using PO ketorolac for any reason, as it is one of the most nephrotoxic drug with black box warning not to use more than 5 days.   

I agree.  There was nothing comparable to VIOXX in regards to post operative pain management.  I used to routinely prescribe non steroidal antiinflammatories for pain control but have gravitated away due to the relative risk of delayed or nonunion in critical fusions or fracture management.  

I would not be afraid to prescribe narcotics for acute pain.  
I think narcotic analgesic have gotten a bad reputation for pain management because of physical and mental dependency issues.  Perhaps there are a variety of reasons from the prescriber who does want to get another 2 am call from their patient that they need more narcotics to a patient who is afraid of being in pain.  Regardless, when used accordingly, narcotic analgesics are effective pain modulators. Remember that narcotic analgesic modulate and does not eliminate pain.  I inform patients that they will still perceive pain but it should not be as unpleasant.  I prescribe narcotic analgesics and recommend us for the acute (1 to 2 weeks) and subacute pain period (2-3 weeks).  By the 4th week, no more narcotics.  Opioid dependency begins when we prescribe narcotic analgesics for non acute pain.

Why should you not be afraid of narcotic dependency during the inflammatory phase of bone and  soft tissue healing? Remember physiology? 
When the a patient is in acute pain, the kappa opioid receptor agonists are activated and increases the pain effect.  The other spinal opioid receptors, Mu and delta, are the receptors that lead to physical dependence if persistently activated.

Here is the interesting part.  
The activation of kappa receptor suppresses the activation of the mu and delta opioid receptor agonists.  In other words, when a patient is pain and kappa receptor is activated, it suppresses the mu and delta opioid receptor agonists which are responsible for physical and mental dependences.  If you prescribe narcotic analgesics for nonacute (non kappa receptor mediated) pain, mu and delta receptor agonists will be stimulated propagating euphoria and physical dependence.  

The bottom line acute pain follows a predictable timeline and our pain management regiment should correspond accordingly.   

Would there be a differance in drugs you would use for post-op pain if the patient had Heart Disease? How about Vein or Artery problems? I am a student and trying to learn more of what is really going on.

Daniel,

I think post-op pain is variable depending on the surgical procedure that you do, not so much with what kind of vascular problem they have; definitely bone procedures (osteotomy, fracture repair) are more painful than simple soft tissue manipulations.

Having said that, the pain severity, characteristics, and the response to various pain medicine is also incredibly variable depending on the patients.

What I usually do in the clinic is, I would just ask my patients to explain their pain in detail; then ask what kind of pain medicine they have taken and which one worked the best for them. If they say, Darvocet worked great!, I would just give them the darn Darvocet, although I think it doesn't work so great in acute pain. Some people swear by tramadol, Advil, etc... Do you get the picture? 

If you look up pain drug studies, you would see that many of the placebo subjects get pretty good pain relief (perhaps up to 20%). I think a lot of pain is "in their head"! For that reason, I tell my patients to get always brand-name Tylenol extra-strength, not generic acetaminophen. Why? In my experience, i think it "works better" for pain relief, simply because the patient associate "TYLENOL" with pain relief and believes it should help their pain.

Just my 2 cents here... 

i see that makes sense. thanks a lot.

Kazu,

I have to disagree with you on this matter.  The interpretation of pain is completely subjective, yet as a clinical provider, you are just acquiesing to the patient's desire for whatever pain medication they want, I think this is dangerous.

Having just gone through major back surgery, and having been on Percocet since November, I can tell you that we all had better be careful when prescribing ANY medication for a patient.

I went though oxycodone withdrawl after surgery, since my pain receptors were not firing as the neuropathic pain in my leg was practically gone, the surgical pain I felt was NOTHING compared to the leg pain.  As a result, I needed to go on Catapres (Clonidine) for the adverse withdrawl symptoms and it took a good 10-12 days to get out of my system.

On a positive note, I lost the 45 pounds I wanted to lose, but I would agree that this isn't the best way to do it :)

Summarizing, pain is subjective.  It is your job as the surgeon/doctor to determine what is the best combination of pain medications that will help the patient CONTROL their pain and titrate it.  It is not our job to determine what is their pain and you need X medication; in fact our job is to prescibe X and Y and Z becuase we need to control the mild, moderate and severe pain syndromes that occur with injury, disease and surgery.

Eric

I think it is just a matter of practicing philosophy. I was trained to be fairly "liberal" in prescribing pain medications. Yes, there are a few narcotic-seeking patients... but how do we know for certain? What if they are truly in pain, although they appear to be "drug seekers"?

I was trained to believe what the patient tells me, in terms of pain. A friend of mine (pain management doctor) told me once that her job consists of making excuse NOT to prescribe pain meds. I disagree with her approach, but again, I think it is just a matter of opinion how you want to practice medicine.

Kazu-

I am not suggesting that all patients with pain are drug seekers.  I am suggesting that if we truly are going to prescribe pain medications to patients, then WE need to do better with the controlling of the pain.


What I propose is a small flow chart that outlines the pain control pathway:

Pain has been defined as “An unpleasant sensory and emotional experience

associated with actual or potential tissue damage, or described in terms of such

damage”

Pain		Analgesic Advice		Comments
Mild		Start with regular Tylenol  500 mg one to two tablets po q 6 h prn
		Change to Tylenol plus an NSAID (e.g. ibuprofen)		Be aware of the side effects and contra-indications of NSAIDs
Moderate		Change to regular Hydrocodone 5-7.5/500  plus an NSAID (e.g. ibuprofen)		Be aware of the side effects and contra-indications of NSAIDs, and codeine. All these medications can be bought over the counter at your local pharmacy. Always read the instruction leaflet about dose and frequency. If you are taking any other medication from your doctor or you are pregnant, please ask your pharmacist or GP for further advice.
		See your doctor to change to regular Hydrocodone 10/500 plus an NSAID (e.g. ibuprofen)		7% of the population can't convert codeine to morphine in the liver, making codeine totally ineffective for them. Consider Tramadol / Buprenorphine / Morphine instead.
		See your doctor to change to regular Tylenol plus an NSAID (e.g. ibuprofen) plus either dihydrocodeine (Panlor)  OR tramadol		Dihydrocodeine and Tramadol are both available in normal release and slow release preparations.
Severe		See your doctor to change to regular Tylenol  plus an NSAID (e.g. ibuprofen) plus oral morphine (10 mg q 4 hr		If you have nerve type pain, see your doctor about medications specific for that type of pain.
		Calculate the 24 hour dose of morphine and convert if necessary to twice daily slow release oral morphine (MST). Use normal release morphine 4 hourly for breakthrough pain (single dose = 1/6th total daily dose). If necessary the daily morphine dose can be increased by 50-100% as smaller dose increases may not produce any clinically noticeable effect.		Alternatives to morphine include oxycodone, hydromorphone, fentanyl patches, and buprenorphine (patches and sublingually). Avoid oral pethidine as it only lasts 1.5 hours. Remember that morphine (and any other morphine-like drug) causes constipation. The best cure for this is lactulose (for lubrication) plus senna (for movement). Nausea and vomiting can be troublesome initially but usually passes with acclimatisation. If you are actively vomiting then anti-emetics by mouth will be ineffective. Some anti-emetics are available sublingually or by suppository and can therefore bypass this problem. Consider Pain Clinic referral for specific non-drug interventions e.g. nerve blocks, epidural injections, joint injections etc.

What I found very interesting in my research was the 7-10% of patients that do not convert codeine to morphine substrates in the liver.  These are possibly the people that have "pain issues" or it doesn't matter how much they are taking, if its not nerve pain then it might just be their biochemistry.


Eric