What are the controversies surrounding pain management in general surgery?

From the Guidelines

Pain control in general surgery is a complex and controversial issue, with the most recent and highest quality study suggesting that a multimodal approach, including medications like acetaminophen and NSAIDs, as well as regional anesthesia techniques, is the most effective way to manage postoperative pain. According to the study published in the World Journal of Emergency Surgery in 2022 1, acute postoperative pain is a major burden for most healthcare systems, with about 70% of postsurgical patients experiencing moderate-to-severe pain. The study highlights the importance of a multidisciplinary approach to pain management, including preoperative assessment, information, and optimization, reduction of surgical stress, rapid mobilization, and early oral nutrition.

Some of the controversies surrounding pain control in general surgery include:

• The overreliance on opioids, which can lead to addiction, respiratory depression, and prolonged hospital stays 1
• The use of regional anesthesia techniques, such as epidurals and nerve blocks, which can have risk-benefit ratios that need to be carefully considered 1
• The appropriate use of adjuncts, such as ketamine and gabapentinoids, which can be effective in managing postoperative pain but also have potential side effects 1
• The effectiveness of preemptive analgesia, which can be administered before surgical incision to reduce postoperative pain 1
• The debate between standardized pain protocols and individualized approaches, particularly for vulnerable populations like the elderly, opioid-tolerant patients, and those with chronic pain conditions 1

The study published in Anaesthesia in 2021 1 provides recommendations for the management of postoperative pain after primary elective total hip arthroplasty, including the use of paracetamol, cyclo-oxygenase-2-selective inhibitors, and non-steroidal anti-inflammatory drugs, as well as regional analgesic techniques like fascia iliaca block or local infiltration analgesia. However, the study also highlights the importance of considering the risks and side effects associated with each approach, and emphasizes the need for a balanced and individualized approach to pain management.

Overall, the key to effective pain control in general surgery is a multimodal approach that takes into account the individual needs and risks of each patient, and is guided by the most recent and highest quality evidence. This approach should include a combination of medications, regional anesthesia techniques, and other interventions, as well as careful consideration of the potential risks and side effects associated with each approach.

From the FDA Drug Label

If after increasing the dosage, unacceptable opioid-related adverse reactions are observed (including an increase ‎in pain after a dosage increase), consider reducing the dosage [see Warnings and Precautions (5)]. Although the risk of addiction in any individual is unknown, it can occur in patients appropriately prescribed Hydromorphone Hydrochloride Injection. Opioids can cause sleep-related breathing disorders including central sleep apnea (CSA) and sleep-related hypoxemia. Profound sedation, respiratory depression, coma, and death may result from the concomitant use of Hydromorphone Hydrochloride Injection with benzodiazepines and/or other CNS depressants, including alcohol

Some controversies with pain control in general surgery include:

• Opioid-related adverse reactions: Increasing the dosage of opioids like hydromorphone can lead to unacceptable adverse reactions, including increased pain 2.
• Risk of addiction: Opioids can cause addiction, even when used as prescribed, and patients with a history of substance abuse are at increased risk 2.
• Respiratory depression: Opioids can cause life-threatening respiratory depression, especially when used in combination with other CNS depressants like benzodiazepines or alcohol 2.
• Sleep-related breathing disorders: Opioids can increase the risk of central sleep apnea and sleep-related hypoxemia 2.
• Cardiovascular risks: NSAIDs like ketorolac can increase the risk of cardiovascular events, such as myocardial infarction and stroke, especially in patients with preexisting cardiovascular disease 3.

From the Research

Controversies in Pain Control

Some of the controversies in pain control in general surgery include:

• The use of opioids, which can lead to adverse effects such as sedation, postoperative nausea and vomiting, urinary retention, ileus, and respiratory depression 4
• The challenge of balancing the need for effective pain control with the risk of opioid-related side effects 5, 4
• The difficulty in determining the relative importance of different components of multimodal analgesia, including analgesia, in Enhanced Recovery After Surgery (ERAS) pathways 4
• The undermanagement of postoperative pain, despite the availability of various analgesic techniques and medications 4, 6
• The need for tailored pharmacologic management of acute pain, taking into account individual patient factors and treatment expectations 7

Multimodal Analgesia

Multimodal analgesia, which combines analgesic drugs from different classes and employs analgesic techniques that target different mechanisms of pain, is recommended for the treatment of acute postoperative and trauma-related pain 5, 4, 6, 8. This approach can help to:

• Maximize pain relief at lower analgesic doses
• Reduce the risk of adverse drug effects
• Prevent central sensitization and the development of chronic pain after surgery 8

Challenges and Limitations

Despite the benefits of multimodal analgesia, there are challenges and limitations to its implementation, including:

• The difficulty in carrying out randomized trials to determine the relative importance of different components of multimodal analgesia 4
• The need for ongoing education and training for healthcare providers on the use of multimodal analgesia and the management of acute pain 6, 7
• The importance of selecting the appropriate analgesics for each patient, taking into account individual patient factors and treatment expectations 4, 7