A Multimodal, Customized Approach Works Best When Treating Postoperative Pain

Jeff Gudin, MD

Physicians today take postoperative pain more seriously, and treat it more effectively, than ever before. But pain specialists say new medications and new research make it possible to do even better—if clinicians remember two important concepts.

First, postoperative patients tend to hurt less and suffer fewer side effects when they receive small doses of several complementary medications rather than large doses of any one product. Second, individuals vary greatly, both in the amount of pain they suffer from a particular surgery and in the relief they get from any given medication, so physicians must learn to customize treatment regimes quickly.

“The most common error physicians make in treating postoperative pain is to choose a single opioid as their go-to medication, assign it to all their patients, and increase the dosage when it fails to work properly,” says Jeff Gudin, MD, Clinical Instructor, Anesthesiology, Mt. Sinai University School of Medicine, and Director, Pain and Palliative Care, Englewood Hospital and Medical Center. “It’s natural, for both doctors and patients, to want to simplify it down to one simple pill, but it’s well worth the effort for both doctor and patient to go beyond that.”

In addition to prescribing an opioid, caregivers should also consider including acetaminophen, one of the NSAIDs, and, for the first few days, a local treatment such as a peripheral nerve block. In some cases, topical pain treatments and anti-seizure medications such as gabapentin or pregabalin may also help. Massage, acupuncture, heat, ice, and especially meditation can provide additional benefits, if patients comply with the prescribed treatment programs.

For really challenging cases with patients whose pain simply cannot be controlled via the traditional regime of one strong opioid, the switch to multimodal cocktails usually produces the best outcomes. For relatively “easier” cases involving patients whose pain can be well controlled by opioids alone, the switch to multimodal cocktails allows doctors to use low dosages of each medication. Patients feel just as comfortable but suffer fewer side effects.

“We’ve had great success controlling pain by using peripheral nerve blocks,” says John J. Laur, MD, MS, Clinical Assistant Professor at the University of Iowa and Medical Director, of their Ambulatory Surgery Center. “Perioperative ketamine can also reduce post-operative opioid utilization, which reduces side effects. Multimodal treatments also reduce pain and medication side effects, thereby allowing patients to recover and return to normal daily function more smoothly.”

A sophisticated standardized multimodal pain program, tweaked for each particular surgery, should keep most patients comfortable and functional, but one size will never fit all. Indeed, research shows that the pain levels of ostensibly identical patients, who undergo exactly the same surgery, can vary by an entire order of magnitude.

"The most common error physicians make in treating postoperative pain is to choose a single opioid as their go-to medication, assign it to all their patients, and increase the dosage when it fails to work properly."

—Jeff Gudin, MD Clinical Instructor, Anesthesiology, Mt. Sinai University School of Medicine, and Director, Pain and Palliative Care, Englewood Hospital and Medical Center

The only widely recognized risk factors for severe postoperative pain are preexisting pain and long-term opioid use. Some experts, though certainly not all, believe that patients who, in looking back at previous injuries, report unusually severe pain are also at risk. Beyond that, however, predictions are tricky. Research has shown virtually no correlation between pain and obvious traits such as age, race, gender, and fitness, so many physicians typically wait until after the procedure to begin customizing pain care by titrating medications to the desired outcomes.

To assess patient needs, caregivers should regularly ask postoperative patients detailed sets of questions, not only about their pain but also about functionality and signs of side effects. When initial treatment fails, the most natural reaction is to boost the dosages of one or more medications, but many experts advise trying something else first: changing medications. One patient might get no relief from morphine but great relief from an equivalent dose of oxycodone. Another might have exactly the opposite reaction.

Two or three tweaks will often provide much greater pain relief, without any of the dangers or side effects of increased dosage. If not, more medication remains an option, as does a referral to a pain specialist, says James C. Crews, MD, Associate Professor, Regional Anesthesia and Acute Pain Management at Wake Forest University School of Medicine. “If you are legitimately out of ideas and your patient still hurts, or if your patient has a very unexpected reaction to pain treatment, then you need to turn to an expert.”