Postoperative Pain Management
Of course most patients are concerned about postoperative pain management, Especially these days with all the news about the opioid epidemic there are concerns about the use of opioids. Alternatives exist and with the use of a minimal opioid protocol the postoperative course for patients can actually be better than one where the patient just takes opioids.
What are opioids?
Opioids are a class of drugs naturally found in the opium poppy plant and that work in the brain to produce a variety of effects, including the relief of pain with many of these drugs. Opioids can be prescription medications often referred to as painkillers, or they can be so-called street drugs, such as heroin. Many prescription opioids are used to block pain signals between the brain and the body and are typically prescribed to treat moderate to severe pain. In addition to controlling pain, opioids can make some people feel relaxed, happy or “high,” and can be addictive. Additional side effects can include slowed breathing, constipation, nausea, confusion and drowsiness. The most commonly used opioids are: prescription opioids, such as OxyContin and Vicodin fentanyl, a synthetic opioid 50–100 times more potent than morphine heroin, an illegal drug.
What is a minimal opioid approach to post operative pain control?
Pain management begins before a surgical procedure. Initiated by Professor Henrik Kehlet in the 1990s, ERAS, enhanced recovery programs (ERPs) have become an important focus of perioperative management. These programs attempt to modify the physiological and psychological responses to major surgery, and have been shown to lead to a reduction in complications and hospital stay, improvements in cardiopulmonary function, earlier return of bowel function and earlier resumption of normal activities. Preoperatively all of our patients are given Hibiclens to use when showering before the procedure. When patients arrive at the hospital they are given BAIR hugger or warming blanket. Before the surgical procedure medications are given which may include Tylenol, Gabapentin, a scopolamine patch and for patients with a history of severe postoperative nausea Emend. During the surgery a long lasting local anesthetic is injected. This is called Exparel and is Marcaine which is the longest lasting of the local anesthetics in a fat emulsion which is released for up to three days after the procedure.
What is EXPAREL?
The latest, innovative option to prolong the delivery of local anesthetic is EXPAREL. EXPAREL injected during a surgical procedure can provide up to 3 days of pain control without the need for any catheters or external devices.
Most patients are given a prescription for opioids to be used after the procedure. The goal is to use the lowest dose for the shortest time needed in the postoperative period. With the use of Exparel many patients find they only need an opioid for the first night after surgery and then can use Tylenol and a non steroidal anti-inflammatory (such as Naprosyn, Aleve or Ibuprofen) and are comfortable without the side effects of an opioid. Since Tylenol and non steroidal anti-inflammatories (NSAIDs) are metabolized differently by the body they can be used together in the postoperative period.