From the Guidelines
Post-operative pain management should prioritize a multimodal approach, starting with acetaminophen and NSAIDs, and reserving opioids for rescue analgesics, as recommended by the most recent and highest quality study 1.
Key Recommendations
- The basic analgesic regimen should include paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) administered pre-operatively or intra-operatively and continued postoperatively 1.
- A single dose of intravenous (i.v.) dexamethasone is recommended for its analgesic and anti-emetic effects 1.
- Opioids should be reserved as rescue analgesics in the postoperative period 1.
Medication Regimen
- Acetaminophen (Tylenol) 650-1000mg every 6 hours (not exceeding 4000mg daily) combined with an NSAID such as ibuprofen (Motrin) 400-600mg every 6 hours or naproxen 500mg twice daily if not contraindicated.
- For more severe pain, add an opioid like oxycodone 5-10mg every 4-6 hours as needed, or hydrocodone/acetaminophen 5/325mg every 4-6 hours, typically for 3-7 days depending on the procedure.
Additional Considerations
- Stool softeners like docusate sodium 100mg twice daily should be used while taking opioids to prevent constipation.
- Patients should taper off opioids as soon as possible, transitioning to acetaminophen and NSAIDs alone.
- Postoperative pain assessment, at rest and—if possible—on movement, is strongly recommended to improve patient management after emergency surgery 1.
- Validated pain scales should be included in treatment planning, ongoing evaluation, and adjusting process 1.
From the FDA Drug Label
Tramadol hydrochloride has been given in single oral doses of 50,75 and 100 mg to patients with pain following surgical procedures and pain following oral surgery (extraction of impacted molars). In single-dose models of pain following oral surgery, pain relief was demonstrated in some patients at doses of 50 mg and 75 mg A dose of 100 mg tramadol hydrochloride tended to provide analgesia superior to codeine sulfate 60 mg, but it was not as effective as the combination of aspirin 650 mg with codeine phosphate 60 mg.
Post-operative pain management can be achieved with tramadol at doses of 50 mg, 75 mg, or 100 mg, with 100 mg providing analgesia superior to codeine sulfate 60 mg, but not as effective as the combination of aspirin 650 mg with codeine phosphate 60 mg 2.
- Key points:
- Tramadol can be used for post-operative pain management
- Effective doses range from 50 mg to 100 mg
- May not be as effective as combination therapy with aspirin and codeine phosphate
Controlled studies have demonstrated that ibuprofen tablets are a more effective analgesic than propoxyphene for the relief of episiotomy pain, pain following dental extraction procedures, and for the relief of the symptoms of primary dysmenorrhea In patients with primary dysmenorrhea, ibuprofen tablets have been shown to reduce elevated levels of prostaglandin activity in the menstrual fluid and to reduce resting and active intrauterine pressure, as well as the frequency of uterine contractions.
Ibuprofen is also an option for post-operative pain management, particularly for procedures like dental extraction, and has been shown to be more effective than propoxyphene for certain types of pain 3.
- Key points:
- Ibuprofen can be used for post-operative pain management
- Effective for pain following dental extraction procedures
- May be more effective than propoxyphene for certain types of pain
From the Research
Postoperative Pain Management
- Postoperative pain is a common issue, with nearly 20% of patients experiencing severe pain in the first 24 hours after surgery 4
- Multimodal approaches to pain management have been shown to be effective in improving postoperative pain and reducing opioid analgesic use 5, 6
- The use of nonprescription analgesics, such as ibuprofen and acetaminophen, can be an effective alternative to opioids for managing acute pain 7
Pharmacological Interventions
- Oxycodone/acetaminophen has been shown to result in slightly greater pain relief than acetaminophen alone for patients with acute musculoskeletal pain refractory to oral ibuprofen, but is associated with more medication-related adverse events 8
- Gabapentinoids, acetaminophen, neuraxial blockade, and extended-release local anesthetics have good evidence to support their use in reducing postoperative pain and narcotic requirements 6
- Nonsteroidal anti-inflammatory drugs (NSAIDs) have fair evidence to support their use in reducing postoperative pain, with no long-term reduction in bone healing or fusion rates with short-term use 6
Non-Pharmacological Interventions
- Preoperative education and planning, as well as organizational policies and transition to outpatient care, are important aspects of postoperative pain management 5
- Assessment of the patient's biological, psychological, and social dimensions of the pain experience is crucial for providing optimum pain management in the postoperative setting 4