Post-Surgical Pain Treatment

Annie Nakao thought she'd sailed right through her arthroscopic knee surgery. She came home from the operation that evening feeling fine, elated in fact, that her knee wasn't hurting. The former journalist called all her friends to tell them how great she felt, then dozed off without taking the prescription painkiller her doctor had given her.

The next morning, Nakao's good mood was rudely shattered.

"I woke up in the full throes of pain," says Nakao. "It was so agonizing that I couldn't even move my leg one iota to get out of bed."

Nakao had learned a quick, hard lesson that medical researchers have proven again and again: Patients who use their pain medication early and aggressively following surgery fare far better that those who don't. According to the National Institutes of Health, those who take their post-operative pain meds as prescribed tend to have shorter hospital stays, suffer fewer chronic pain problems, and end up using fewer painkillers overall than patients who try to avoid medication.

But managing pain effectively after surgery can differ from patient to patient. The type of procedure you have, the hospital you go to, and even the surgeon you work with may make a difference.

What should I do before my surgery?

Before you go in for surgery, you'll want to sit down with your doctors and a list of questions. Ask them how much and what kind of pain following the operation (in medical terms, post-operative pain) is most common with the type of surgery you're getting. Don't be afraid to ask your medical team detailed questions about what kinds of options the facility offers for treating the pain you may feel after the operation.

"There's a huge variability in how much pain a patient will feel when they wake up from surgery, depending on the procedure they've had done," says Jeffrey Swenson, MD, Director of Anesthesia at the University of Utah Orthopaedic Center. (Anesthesiologists like Swenson specialize in medicating patients undergoing surgery so that they'll lose sensation in the affected area -- and sometimes lose consciousness -- until the operation is over.)

All pain is relative. Arthroscopic surgery on a knee -- the use of a tube, visual scope, and surgical instruments to remove tissue in the knee joint -- sometimes causes excruciating pain after the operation, but it generally involves less pain than, say, a wisdom tooth extraction. However, "a rotator cuff repair on the shoulder, for example, is associated with a lot of post-operative pain for one to two days," Swenson says.

Likewise, different surgeons, clinics, and anesthesiologists will specialize in different treatments and have diverse philosophies about which methods are best for treating post-operative pain, says Swenson. "Go ahead and ask them how they plan to treat your pain and how good they are at doing it," says Swenson. If you'll be taking Vicodin (a prescription medication that includes hydrocodone and acetaminophen), for example, you may be offered the choice of swallowing it in pill form or receiving it through a device that delivers medicine in your bloodstream or near your spinal cord. Take the time to research your options, and before you make a final decision, have your doctor answer all your questions.

Finally, before your surgery, make sure you understand your doctor's instructions about eating and drinking. Anesthesia administered during surgery may require the patient to have an empty stomach.

What can I expect on the day of my surgery?

Many doctors will begin treating your post-operative pain before your surgery even begins, either with oral pain relievers (drugs taken by mouth) or with injectable drugs (shots). Research has shown that a preemptive dose of pain relievers can prevent the nervous system from experiencing pain from the trauma of surgery and thereby reduce post-operative pain as well. Pre-emptive pain relievers are usually given in addition to general anesthesia or other sedatives during surgery.

What are the common methods used to control post-surgical pain?

Post-surgical pain can be treated with one pain medication or with a combination of two or more drugs. They can be given orally (by mouth), through an IV (a tube feeding into a vein), or by injection. The most common medications prescribed post-operatively are:

  • Narcotics such as morphine and codeine. Also known as opioids, these drugs kill pain and make you very drowsy.
  • Acetaminophen. An analgesic drug that reduces pain and fever.
  • Combinations of acetaminophen and narcotics, such as Vicodin or Percocet.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. These drugs treat the irritation, inflammation, or infection around a wound that might be causing your pain.
  • Local anesthetics. Drugs that deaden the sensation of pain in a specific area are usually injected. They do not make you drowsy.

While recovering in the hospital, many patients receiving pain relievers (usually narcotics) directly into a vein or under the skin are given a device that allows them to push a button when they feel the need for more pain relief; this action gives them another dose of the narcotic. This is called patient-controlled analgesia (PCA). The devices are calibrated by hospital staff to a maximum dosage so that the patient cannot overdose on the drugs.

If you're staying in the hospital for a while after your surgery, doctors may use an epidural catheter. This delivers a continuous flow of medicine (often a combination of local anesthetics and narcotics) near the spinal cord as well as patient-controlled doses to block pain to the nervous system. The epidural catheter is often inserted before surgery to provide the preemptive dose of pain relievers as well as continual post-surgical relief for hours or even days after surgery.

Similarly, doctors may insert a catheter to form what is called a "continuous nerve block." The nerve block delivers a local anesthetic to block pain sensations in the nerves around the area where the operation was performed. According to some studies, epidural catheters and nerve blocks are more effective at relieving pain than oral medications and can significantly reduce the nausea and vomiting associated with taking oral narcotics like Vicodin. While post-operative nerve blocks are usually administered in an in-patient setting, some surgeons have had success sending patients home with the nerve blocks.

How much pain is "normal" or okay to feel?

You shouldn't have to endure severe pain at any time after your surgery. Exactly how much pain is okay is difficult to quantify, since everyone has a different pain tolerance. According to Swenson, the best sign of proper pain management is being able to sleep soundly.

"It's hard to put a number on how much pain is okay," says Swenson, "But what I tell patients is that if you can't sleep comfortably, then you probably are not getting adequate pain control."

Some studies show that extreme suffering from pain can slow healing and weaken your body's immune system. Severe pain could also be a warning sign of infection, so be sure to call your doctor if you have any doubts while recovering at home. Call your doctor if:

  • You are unable to sleep because of pain.
  • Your pain is increasing rather than decreasing during your recovery.
  • You feel you might be getting hooked on your pain medications. (For example, if you are no longer in pain, but still seeking out the drug.)

Who decides how much pain medication I need?

How much pain medication you're administered depends on your procedure, the treatment plan you and your doctor have come up with, and whether you will be recovering at home or in the hospital. Many doctors believe that patients should stick to a routine of scheduled medications in order to prevent pain from setting in and stressing out the body.

Other doctors believe it's okay to let a little pain set in before you take your pain medication. For example, patients being sent home after surgery are often told to take pain killers "as needed." Since some patients dislike the side effects of pain medications (narcotics often make people nauseous or constipated, for example), some will take very little medication or try to do without. Keep in mind, however, that extreme suffering could hamper your recovery. Also remember that it will take between 20 and 40 minutes for most pain medications to kick in once you take them, so don't wait until you can't stand the pain to take a pill.

What if I am opioid-tolerant?

Since it is more common today for people to be taking narcotics such as Lortab or OxyContin for chronic pain, more and more people are tolerant of the opioid drugs typically used in post-operative pain management. If you've been taking narcotics on a regular basis, be sure to discuss alternative treatments with your doctor and make sure that your hospital is equipped to treat you.

It is okay to take opioids around the clock if you have round-the-clock pain. But if you end up on narcotics for round-the-clock pain, you may become somewhat tolerant and need higher doses after surgery than others who have not become habituated.

"The number of people chronically using opioids has skyrocketed in the last couple of years," says Swenson, "and they can be grossly undermedicated after surgery if they aren't treated in a center that specializes in treating them."

How can I avoid nausea and vomiting after surgery?

Nausea and vomiting are among the most common side effects of surgery. Let your doctor know if you are particularly prone to nausea and vomiting. Before surgery, an anesthesiologist usually speaks to you about any sensitivities you have to medication. It's good to state whether you typically experience extreme postsurgery nausea or vomiting, so that he or she can select the optimal drugs for you to receive in the operating room and afterwards.

There are some things that can be done to alleviate nausea:

Use intravenous anesthesia (anesthetic drugs taken through a vein) for surgery instead of the kind you inhale.

Avoid using drugs that you know make you nauseous. For example, some people get nauseous with Vicodin but not Fentanyl, and vice versa. It's worth it to some testing with your medications to avoid bad experiences.

Decrease the amount of narcotics taken if possible. Use alternative drugs like anesthetics (such as lidocaine), acetaminophen, NSAIDs, or nerve blocks).

Ask your doctor for an anti-nausea medication.

Consider complementary treatments backed by research -- such as acupuncture -- for nausea and vomiting. A review of 19 studies suggests that getting acupuncture within six hours of surgery prevents nausea better than placebos. Acupuncture was also as effective at combating vomiting as prescription medications immediately after surgery and up to 48 hours later, the report said.

Are there complementary treatments available for post-operative pain?

Alternative therapies like acupuncture and relaxation techniques are increasingly being recognized as helpful in managing pain. A study published in the Journal of Advanced Nursing in October 2004 found that patients who used a relaxation technique called "systematic relaxation" experienced less pain than patients who did not. The technique involved relaxing each major muscle group of the body one by one, and was used on patients during the first 15 minutes after surgery.

References

Interview with Annie Nakao, knee surgery patient

Interview with Jeff Swenson, MD, Director of Anesthesia, University of Utah Orthopaedic Center.

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Gan, T.J. Post-operative nausea and vomiting -- can it be eliminated? JAMA. March 13, 2002: 287(10); 1233-1236.

Ke, R.W. et al. A randomized blinded trial of preemptive local anesthesia in laparoscopy, Primary Care Update Ob/Gyns. 1998 Jul 1; 5(4): 197-198.

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Klein, S.M. et al. Ambulatory surgery with long acting regional anesthesia. Minerva Anestesiol. 2002 Nov;68(11):833-41; 841-7

Muraski, J.D. et al. Peripheral nerve blocks for post-operative pain. AORN J. 2002 jan;75(1):136-47.

Lee, Anna PhD, MPH, and Mary L. Done, FANZCA The Use of Nonpharmacologic Techniques to Prevent Post-operative Nausea and Vomiting: A Meta-Analysis. Anesthesia and Analgesia 1999;88:1362.

American Academy of Orthopaedic Surgeons. Knee arthroscopy.

Roykulcharoen, V. et al. Systematic relaxation to relieve post-operative pain. Journal of Advanced Nursing. 2004 Oct;48(2):140-8.

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