Taking the Pain Out of (Your Own) Pain Management

Being an anesthesiologist, I can say from experience that many individuals are more concerned with the pain they might experience after a surgical procedure above anything else. But the truth is, talking about pain is difficult... and sometimes results in no discussion with the patient of the expectations of pain after a surgical procedure.

While there is much to do regarding standardization of pain management discussions in the perioperative period, at the same time patients have a right and a responsibility to advocate for themselves as best they can. In this blog post I will make recommendations as to how you as a patient can begin a conversation with your provider about pain management after a surgical procedure. Similarly, these recommendations can be applied to medical conditions or in the setting of a physical trauma/injury.

And if YOU are the physician that treat these patients, this can serve as a reminder as to what you should be sharing with the patient regarding their treatment and recovery. It would seem all physicians would learn this in medical school but that is simply not the case.

While the pain experience may vary among individuals, surgical procedures can be classified by the expected intensity of pain. For example, laparoscopic procedures are typically associated with lower pain intensity than for example an open thoracotomy. It is important to have an understanding of the pain intensity in order to be proactive and anticipate the various agents and treatments that would be beneficial.

Your surgeon will likely have a very good understanding of how much pain a typical patient will experience with a surgical procedure. I think it is imperative for physicians to be proactive and make pain management a part of any discussion about surgery. But you can be a good advocate for yourself if you mention this area of concern prior to your procedure.

Here is a screen shot from the PreEmpt Pain app giving some examples of procedures associated with mild, moderate, and intense pain intensities.

What are First-Line Agents for Pain?

First-line agents are non-opioid medications for pain and are some of the safest and most simple medications to administer for pain. As the name implies, they should be considered first, above all else, unless contraindicated. Thus, they are appropriate for all levels of pain: mild, moderate, or intense pain.

First-line agents include acetaminophen (or paracetamol in Europe) and the non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or ketorolac. They are often administered as a premedication prior to the induction of general anesthesia or given in the operating room during the procedure in order to get a 'head start' on the pain management before it comes to the awareness of the patient.

First-line agents can be administered as needed (PRN) or around the clock (ATC). PRN administration relies on (1) the patient to express their discomfort and (2) for a nurse or other caregiver to provide them with the medication. In contrast 'around-the-clock' (ATC) administration entails providing the medication on a set schedule, ideally used when the pain is of a more intense, is ongoing, continuous. The latter results in a more steady level of the analgesic in the bloodstream and therefore better pain management, theoretically.

Ask your doctor if these medications will be prescribed for you during your hospital stay. Contraindications for acetaminophen include liver disease or allergy/sensitivity to acetaminophen. Contraindications for NSAIDs include kidney disease, bleeding problems but may also interfere with healing so should be left to the discretion of the surgeon.

Regional/Local Anesthesia Techniques for Pain Management

Injection of local anesthetics around a group of nerves or into tissue planes can be exceptionally beneficial for pain management. These techniques include epidural, spinal, and perineural (around the nerves) deposition of local anesthetics. On occasion, a small catheter is inserted to allow continuous delivery of local anesthetics to allow pain relief for a number of days. As the name implies, these techniques anesthetize a region of the body and in themselves do not result in sedation, etc. Topical local anesthetic products, such lidocaine patches, can also be applied to the skin for pain relief.

Ask your doctor if these techniques are appropriate for your condition.

What are the Non-Medicine Treatments for Pain?

Known as non-pharmacologic strategies, these treatments involve modalities that may be easier to deliver with fewer resources. Below is a list of treatments that may be offered.

These strategies are an important component of a sound pain management plan. Pain is a complex construct defined as 'An unpleasant sensory and emotional experience...' and, as such, can be influenced by participation in enjoyable and pleasurable activities.

Ice can help decrease inflammation while heat can bring increased blood flow to the region along with healing substances. TENS therapy helps to modulate the pain signals sent to the brain through delivery of a gentle electrical current to the muscles. Relaxation, meditation, and yoga can balance the sympathetic and parasympathetic components of the nervous system to modulate the pain signal. Sympathetic arousal accentuates pain; therefore creating a balance between these two components greatly affects the stress response and improves not only pain but sleep, anxiety, and mood. Acupuncture and acupressure can affect the energy pathways of the body to treat pain and promote health.

These treatments may be available as a service to you in the hospital. Other activities such as drawing, painting, reading, journaling, etc might be activities individuals enjoy at home and can be easily implemented in the hospital setting, with a little planning. It is known that pain can increase during times of boredom and often worsens in the later evening; these activities may serve as a source of distraction and have a positive impact on the hospital experience.

What are the Expected Side Effects from Medications or Surgery?

Muscle spasm, nausea / vomiting, constipation, pruritus: these side effects can significantly impact recovery after a surgical procedure. Some are predictable, for example, muscle spasm occurring after posterior spinal instrumentation or nausea / vomiting occurring in individuals with a history of motion sickness.

These side effects don't simply add to discomfort but may contribute to unnecessary morbidity in the postoperative period. The presence of side effects can prolong the time to tolerating a regular diet or might contribute to unsteadiness and increased risk of falls.

Moreover these side effects can be prevented or treated with early recognition. Making medication available prior to the onset of these symptoms can allow more timely treatment and improve patient comfort.

Will Opioid Medications Be Part of My Pain Management Plan?

Opioids can be an important tool in the management of pain but, as you may have heard, there are many pitfalls to their widespread use. With all the other pain medicine options available, opioids are used only for situations that are associated with the highest intensity of pain and for the shortest duration of time possible.

Opioids are often administered in the operating room during a surgical procedure with their effects often lasting hours to decrease pain. There are some important points to consider when using opioids. Consider the following...

'If the gut works, use it'. If opioids are indicated, you may be given oral opioids rather than opioids through an IV (intravenous) line. You should be tolerating a 'regular' diet at that point, eating small amounts every few hours to minimize the side effects of opioids on your stomach.

Continue to use the first-line agents prescribed by your doctor while taking the opioid medication. First-line agents make the opioid medication work better, allow a lower necessary dose of opioid, and minimize side effect of the opioid.

Keep track of when you take your medication and the dose. This is important for you to see how your need for the medication is decreasing over time and the progress you are making in functioning. The Sprout Medication Reminder smartphone app is invaluable for this task.

You may not 'need' to take all of your opioid medication... and often you should not! Unless instructed by your doctor, one usually does not take opioid medications until their pain is gone. To do so would result in prolonged course of treatment, increased side effects, and the chance you will have difficulty stopping the medication. Ask your doctor about what is right for you.

Ask your doctor how you should dispose of any leftover opioid medication (or other medications, having said that). It is unsafe to keep leftover medication in your home which could be misused by others who visit your household. Some hospitals have a dropbox where you can securely dispose of medications. The pharmacy destroys these tablets and they don't end up in our wastewater.

How Will I Know I Am Making Progress?

Knowing what to expect after a surgical procedure, an injury, or a medical condition is important to your healing and functioning in the future. 'Progress' after these conditions is your ability to return to your desired and necessary activities of daily life. Keeping this in mind is imperative while in the hospital. You should try to be involved in the activities you might be doing at home such as personal hygiene, eating meals, performing some physical activity. Your doctor will guide you in how to do this in the hospital dependent upon your condition.

Rather than simply focusing on your pain score, you might keep track of what you are able to do on a daily basis. This serves as a reminder to how you are improving. You should increase your activities in a gradual fashion and don't overdo it. Moderating your activity (even if you could do more) will allow you to heal and get back to the activities on the following days.

Ask what role you can play in healing after surgery. Your doctors will be happy you are taking a lead in your recover.

Have you had a surgical procedure in the past or recovered from a physical injury? What strategies were the most helpful for you? Everyone recovers at different rates, using strategies that work for them. Share your experience with this community.

Do you (or a loved one) have an upcoming surgical procedure? Reach out if you would like some recommendations of how you can be the best advocate for yourself or your loved one.