What are the most common narcotic (narcotic analgesics) medications prescribed for postoperative pain management following surgical hemorrhoidectomy?

Common Narcotic Analgesics for Postoperative Pain Management After Hemorrhoidectomy

Opioids are the first-line therapy for treating moderate to severe pain following surgical hemorrhoidectomy, with morphine, oxycodone, and hydrocodone being the most commonly prescribed narcotic analgesics.

Pain Profile in Hemorrhoidectomy

Hemorrhoidectomy is associated with significant postoperative pain, with research showing:

• Most patients require narcotic analgesics for 2-4 weeks following surgery 1
• Only 14% of patients experience severe pain, while 36.49% report moderate pain 2
• Pain is a major drawback of excisional hemorrhoidectomy, often delaying return to work 1

Recommended Narcotic Analgesics

Primary Opioid Options

1. Morphine

   • Remains the reference strong opioid in postoperative period 3
   • Available in IV and oral formulations (oral route preferred when possible)
   • Often administered via patient-controlled analgesia (PCA) for immediate postoperative pain 4

2. Oxycodone

   • Clinical efficacy equals morphine with a ratio of 1/1 for IV route and 1/2 for oral route (5 mg oxycodone = 10 mg morphine sulfate) 3
   • Often used as take-home medication for continued pain management

3. Hydrocodone (often combined with acetaminophen)

   • Commonly prescribed as a supply opioid for breakthrough pain 3

4. Other Opioids Used Less Frequently

   • Tramadol
   • Meperidine
   • Codeine (often combined with acetaminophen) 2

Multimodal Pain Management Approach

Recommended Administration Strategy

• "Around-the-clock" analgesic treatment is superior to "on-demand" treatment
  • Reduces pain from moderate to mild levels
  • Decreases overall opioid consumption (68% less meperidine, 44% less morphine, 47% less tramadol, 39% less oxycodone, and 53% less codeine) 2

Adjunct Medications to Reduce Opioid Requirements

1. Acetaminophen (Paracetamol)

   • Effective as an analgesic when used in combination with NSAIDs or morphine
   • Reduces opioid use 3
   • Should be administered on a scheduled basis

2. NSAIDs

   • Indicated for moderate pain when used alone
   • Reduces morphine consumption and related side effects 3
   • Caution with renal impairment (contraindicated if clearance <50 mL/min) 3
   • Avoid in patients with history of atherothrombosis or when using curative doses of anticoagulants 3

3. Local Anesthetics

   • Posterior perineal block with ropivacaine 0.75% significantly reduces opioid requirements 4
   • Local application at the operative site provides temporary relief 1

4. Other Adjuncts

   • Gabapentinoids (gabapentin, pregabalin) can be considered as components in multimodal analgesia 3
   • Dexamethasone IV at 8 mg may help reduce postoperative pain 3
   • Ketamine in small doses for surgeries with high risk of acute pain 3

Risk Factors for Increased Pain

• Higher BMI and younger age are identified as risk factors for elevated postoperative pain 2
• These patients may require more aggressive pain management strategies

Clinical Pearls and Pitfalls

• Pearl: Pudendal nerve block, with or without general anesthesia, is recommended for all patients undergoing hemorrhoidal surgery 5
• Pearl: Closed hemorrhoidectomy or open hemorrhoidectomy with electrocoagulation of the pedicle is recommended as the primary procedure to minimize pain 5
• Pitfall: Urinary retention is a potential complication occurring in 2-36% of patients, which can be exacerbated by opioid use 1
• Pitfall: Opioid side effects are dose-dependent, and at high doses, they can induce hyperalgesia 3

Special Considerations

For patients on buprenorphine therapy:

• Consider continuing buprenorphine if dose is 12 mg SL or less
• Use higher than normal doses of opioids to treat pain for 2-4 days post-surgery 3
• Multimodal analgesia and regional techniques are especially important in these patients

By implementing a multimodal approach with scheduled administration of analgesics, the overall opioid requirement can be significantly reduced while maintaining effective pain control after hemorrhoidectomy.