This document discusses the pharmacology of postoperative pain management. It outlines various tools for pain assessment and factors to consider when evaluating a patient in pain. It then covers the principles of multimodal analgesia, including both pharmacological and non-pharmacological modalities. The major drug classes discussed are NSAIDs, opioids, and various adjuvants. Risks and guidelines for use are provided for different analgesic classes.

1. PHARMACOLOGY OF
POSTOPERATIVE PAIN- OUR
ARSENAL
DR. ANANYA NANDA
ASSISTANT PROF.,
ESICMCH

2. OUTLINE…
How do I assess a patient in pain
Analgesic modalities
Mix and match ( multimodal analgesia )
Drugs and adjuvants
How i choose ideal modality and ideal analgesic
Management in Specific Clinical Settings

4. TOOLS FOR PAIN ASSESSMENT
Visual Analogue Scale (VAS)
Verbal rating scale (VRS)
Numerical rating scale (NRS)
Clinical Pain Observation Tool (CPOT)…
And many others….

5. EVALUATION OF PATIENT
This includes….
 General examination- Look at the VITAL SIGNS
Systemic examination
( Renal, cardiac, liver )
Psychological condition – females and children
panic disorder patients
 Children- is it feeding well, sleeping well..
Counselling regarding the pain and management strategies
TACHYCARDIA
NEW HTN
TACHYPNEA
SWEATING
PAUCITY OF
MOVEMENTS

6. ALSO DEPENDS ON…
Location of surgery- Thoraco abdominal surgeries >>>> peripheral
limb surgeries
the bigger the incision size=> more pain
as it involves more
dermatomes.
Duration of surgery
Tissue dissection
Degree of preoperative preparation of the patient- adjuvants/
counselling
Comorbidities

7. PRINCIPLES OF TREATMENT
Reduction of
pain
• Drugs
• Blocks
• Adjuncts
Rehabilitation
• Physical methods
• Psychological prep.
Coping
• Residual pain
management
MULTI MODAL ANALGESIA

8. MULTI MODAL ANALGESIA
Pain is complex and multifactorial, thus appropriate management requires a “balanced” &
“multimodal ” therapeutic approach.
The rationale for multimodal analgesia is achievement of sufficient analgesia due to additive
or synergistic effects between different analgesic groups with concomitant reduction
in side effects.
‘‘There is no magic bullet--- no single cure’’
KEY COMPONENTS
Opioids or other analgesics,
 regional analgesic techniques,
Adjunctive medications,
Physical modalities like rest-ice-compression-elevation (RICE), and rehabilitation.
 Psychosocial intervention including distraction, meditation, and deep breathing.

9. OUR ARSENALS
Pharmacological
NSAIDs/ PCM
Opioids
Local Anaesthetics
NMDA Receptor antagonists
Misc. – Tramadol, Tapentadol
Adjunctives-
 α2 agonists
 α2δ calcium channel blockers
 Magnesium , steroids
Neuroaxial/peripheral nerve blocks
Non
Pharmacological
Rest- Ice- Compression- Elevation (RICE)
Stimulation.
Physiotherapy.
TENS (transcutaneous electrical nerve
stimulator)
Acupuncture
Radiation
Psychological- Distraction, Meditation, And
Deep Breathing.

10. NON PHARMACOLOGICAL
Meditation- yes ‘A’, Cochrane
Strong evidence for the use of relaxation & hypnosis in reducing pain in a variety
of medical conditions
Music Therapy: Yes, ‘A’, Cochrane
Pre-Op counselling: Yes, ‘B’, Cochrane
 Ice: Yes, “B”, Cochrane
Exercise – yes

11. PHARMACOLOGI
CAL
MODALITIES…

14. REMEMBER BASIC PRINCIPLES:
Use WHO pain ladder
 Take a careful drug history
 Know the pharmacology of the Rx
 “Start low, go slow”
Regularly review the regimen and pain
 Remember that drugs have side effects
 Selection of appropriate drug, dose, route
and interval
 Aggressive titration of drug dose
 Prevention of pain and relief of breakthrough
pain
 Use of coanalgesic medications
 Prevention and management of side effects

15. PRE-EMPTIVE - PREVENTIVE
ANALGESIA
1. Many studies show that intravenous NSAIDs are quite effective when used
alone, as well as with low dose iv ketamine, preoperatively to provide adequate
postoperative analgesia.
2. LA at the incision site reduces postoperative pain, but achieves an analgesic effect
similar to that of post incisional anesthetic infiltration as does intra peritoneal
administration.
3. Preemptive epidural analgesia has proved its efficacy in controlling perioperative
immune function and pain in comparison to parenteral opioids.
4. Gabapentin and pregabalin have great potential as preemptive analgesic with the
added advantage of its anxiolytic effect.
Katz J, Clarke H, Seltzer Z. Preventive Analgesia: Quo Vadimus? Anesth Analg 2011;113:1242-53.
Mishra AK, Afzal M, Mookerjee SS, Bandyopadhyay KH, Paul A. Pre-emptive analgesia: Recent trends and evidences. Indian J Pain
2013;27:114-20

16. CLASSIFICATION
DRUGS
1. Opioids
2. NSAIDs
3. Ketamine, dextomethorphan
4. Misc. Analgesic Agents- tramadol,
tapentadol
5. Alpha 2agonists
6. Alpha 2 delta calcium channel
binding agents
Procedures
1. Neuroaxial nerve blocks
2. Peripheral nerve blocks
3. Local infiltration

17. PARACETAMOL
First-line treatment for mild to moderate acute pain.
PCM 600 mg= celecoxib 200 mg =aspirin, 600 to 650 mg = naproxen 200 to 220 mg.
Dose- 15-20mg/kg PO. 650-1000mg/dose Max. Dose not to exceed 3 g/day.
MOA- inhibit prostaglandin synthesis in CNS probably via COX-3 → analgesia, antipyretic
Intravenous acetaminophen can be used in a variety of other orthopedic procedures, including hip fracture
patients, adolescent scoliosis surgery, and pediatric hip surgery.
Intravenous acetaminophen has no affect on gastrointestinal motility, platelet function and bleeding, renal
function, or bone healing, and is not associated with confusion, respiratory depression, and ileus.
Study by Sinatra et al 2005. reported that IV acetaminophen in orthopedic patients was efficacious for moderate-to-severe pain.

18. BENEFITS…
well-tolerated
few drug-drug interactions
can be used during pregnancy and
is the analgesic of choice for episodic use in patients with impaired renal function.
No need to Avoid in patients with liver damage, chronic alcoholics, but dose modification is
required.
Similar overall incidence of adverse events as compared to placebo
No clinically significant changes in vital signs or laboratory tests.
Craig M, Jeavons R, Probert J, Benger J. Randomised comparison of intravenous paracetamol and intravenous
morphine for acute traumatic limb pain in the emergency department. Emerg Med J. 2012; 29(1):37- 39.

20. NSAID S WORK

21. ASPIRIN
 mild acute pain.
Aspirin irreversibly inactivates COX-1 and COX-2 by acetylation of a specific serine residue.
This distinguishes it from other NSAIDs, which reversibly inhibit COX-1 and COX-2.
Aspirin 600 mg < Codeine 60 mg < 6 mg Morphine
effectively relieves inflammation, tissue injury, connective tissue and integumental pain, but is
relatively ineffective in severe visceral and ischaemic pain.
Over a dose range of 500 to 1,200 mg, aspirin exhibits a dose-response relationship
aspirin can cause gastrointestinal hemorrhage and ulcer.
Patients with chronic urticaria and asthma have a greater likelihood of salicylate
hypersensitivity, which can manifest as bronchospasm (20% and 4%, respectively, compared
with 1% in the general population).6

22. NSAIDS
NSAIDs possess anti-inflammatory effects that are lacking with PCM ,
and they can be especially useful for the treatment of acute pain
associated with prostaglandin-mediated activity, such as
osteoarthritis
Ibuprofen and diclofenac are among the most commonly used
NSAIDs because of their effectiveness, adverse effect profile, cost,
and over-the-counter availability
No physical dependence
no tolerance
No ceiling effect

23. NSAID Drug NSAID Drug Dosage Maximum daily dose
Diclofenac 1mg/kg 200 mg
Piroxicam 20 mg OD 40 mg
Ibuprofen 200-800 mg q 6 hr 3200 mg
Ketorolac 30-40 mg/day (only IV form)
tid
Ketoprofen 4 x 50 mg/day
Celecoxib 100-200 mg PO bid 400mg
Parecoxib 40 mg followed by 1-2 x 40
mg/day (IV form)

24. EFFECT ON GIT

25. RISK FACTORS FOR GI
COMPLICATIONS ASSOCIATED WITH
NSAIDS

26. ANALGESIC NEPHROPATHY
The incidence rate of renal side effects
associated with the use of selective
and nonselective COX-2 inhibitors is
low in otherwise healthy subjects but
can get as high as 20% in high risk
patients .
Of 1799 frail elderly patients
hospitalized with community-acquired
ARF 18.1% were current users of
prescribed NSAIDs . In this study, a
strong dose-dependent increase of risk
for ARF was observed in those 35%
subjects taking ibuprofen as NSAIDs
Griffin M.R., Yared A., Ray W.A. Nonsteroidal antiinflammatory drugs and acute renal failure in elderly persons. Am. J.
Epidemiol. 2000;151:488–496

27. ANALGESIC NEPHROPATHY

28. AKI AND NSAIDS…
 Risk of AKI was found to be lower with more selective agents than with naproxen or other non-
selective NSAIDs
celecoxib < diclofenac < piroxicam < ibuprofen < naproxen < indomethacin
The highest risk (OR = 2.90; 95% CI:2.62–3.22) for AKI was fond in patients using multiple
NSAIDs
Analgesic nephropathy was five to seven times more common in women than in men
Hörl, Walter H. “Nonsteroidal Anti-Inflammatory Drugs and the Kidney.” Pharmaceuticals (Basel, Switzerland) vol. 3,7
2291-2321. 21 Jul. 2010, doi:10.3390/ph3072291

29. SELECTIVE COX II INHIBITORS
An analysis of six randomized, placebo-controlled trials evaluating
the cardiovascular risk associated with celecoxib use showed that
the risk increases by 37% with dose and that patients with higher
baseline cardiovascular risk are more likely to experience a
cardiovascular event while taking celecoxib.

30. Avoid or exercise caution in
 Patients with coronary artery disease, stroke (COX II inhibitors block PGI 2 activity with
no effect on platelets),
renal disease, asthma
significant peptic ulcer or gastroesophageal reflux disease (GERD),
 bleeding disorders .
The cardiovascular risk is also thought to be greater with greater COX-2 selectivity
(celecoxib > diclofenac > ibuprofen > naproxen
Celecoxib is the only COX-2 selective NSAID still available in the United States.

31. Ketorolac-
A novel NSAID with potent analgesic and modest antiinflammatory activity. In postoperative
pain it has equalled the efficacy of morphine, but does not interact with opioid receptors and is
free of opioid side effects. it inhibits PG synthesis and relieves pain by a peripheral
mechanism.
Diclofenac-
similar in efficacy to naproxen. It inhibits PG synthesis and is somewhat COX-2 selective. The
antiplatelet action is short lasting. Neutrophil chemotaxis and superoxide production at the
inflammatory site are reduced.
Aceclofenac-
COX-2 selective congener of diclofenac having similar properties. Enhancement of
glycosaminoglycan synthesis may confer chondroprotective property. More GI friendly

32. SELECTION OF NSAIDS

33. 2ND STEP- COMBINATION
THERAPY
If nonopioids do not adequately control pain, the next step of the WHO pain relief
ladder includes considering an opioid, with or without a non opioid.
Weak Opioids such as codeine, hydrocodone and oxycodone are typically
combined with acetaminophen or an NSAID
Full opioid agonists, such as morphine, are potent analgesics that may be used as
per 3rd step if opioids combined with acetaminophen or NSAIDs are insufficient to
control moderate to severe pain
Adverse effects of opioids include nausea, vomiting, constipation, sedation, pruritus,
urinary retention, and respiratory depression. Opioid-induced emesis is mediated by
histamine release and can be treated with antihistamines or selective serotonin
antagonists (e.g., ondansetron

34. OPIODS
 Opioid medications can provide a short,
intermediate or long acting analgesia.
Opioid medications may be administered orally, IM , via nasal mucosa or oral mucosa,
rectally, transdermally, intravenously, epidurally and intrathecally
Although opioids are strong analgesics, they do not provide complete analgesia
regardless of whether the pain is acute or chronic in origin.

35. OPIOIDS
Agonists : stimulate receptor : no ceiling effect ( no limit mg/kg) : moderate
to severe pain : Codene, morphine, pethidine, fentanyl, methadone
 Partial agonists : ceiling effects eg. Buprenorphine
Agonists-antagonists : agonist-κ or σ receptor but antagonist to μ receptor
used in mild to moderate pain : ceiling effects : precipitate withdrawal in
opioids dependent E.g: Pentazocine, Nalbuphine, Nalorphine
‘‘Among the remedies which it has pleased Almighty God
to give to man to relieve his sufferings, none is as universal
and so efficacious as opium.’’
Sydenham, 1680

36. Annals of Oncology, Volume 24, Issue suppl_11, December 2013, Pages xi33–xi40,
https://doi.org/10.1093/annonc/mdt501
The content of this slide may be subject to copyright: please see the slide notes for details.
FIGURE 3. FORMULARY AVAILABILITY AND COST TO PATIENTS OF THE SEVEN ESSENTIAL OPIOID
FORMULATIONS OF THE INTERNATIONAL ...

37. Most commonly used-
Fentanyl
Morphine
Buprenorphine
Pentazocine

38. SIDE EFFECTS

39. OPIOID OVER DOSAGE
Somnolence
Respiratory depression
 Cardiovascular collapse-bradycardia
the prevalence of opioid misuse (defined in the study as “opioid use contrary to the directed
or prescribed pattern of use, regardless of the presence or absence of harm or adverse effects”)
in the United States to be 21.7–29.3 percent and the prevalence of addiction (defined as
continued use despite harm) to be 7.8–11.7 percent
(Vowles et al., 2015).
In the elderly and other patients with a higher risk of cognitive impairment, opioids may
result in further impairment of cognition and executive function (Schiltenwolf et al., 2014).
There is a risk of death from these drugs due to opioid-induced respiratory depression (Chou
et al., 2015).

40. The CDC report in 2010 indicated that the dose and duration of the treatment
represented important factors leading to addiction.
 In this report, it was also suggested that a treatment as short as 10 days can lead to
opioid dependency.
 Recent data also suggested that up to 15% of surgical patients may become
dependent following the perioperative use of opioids.
 This re-enforces the recommendation of limiting the amount of opioids used
during the perioperative period and favors a multimodal approach that includes
regional anesthesia.

41. RISK FACTORS FOR RESPIRATORY DEPRESSION:
1. Age >70 years
2. Renal, hepatic, pulmonary, or cardiac impairment
3. Sleep apnea (suspected or history)
4. Concurrent central nervous system depressants
5. Obesity
6. Upper abdominal or thoracic surgery
7. IV PCA bolus >1 mg along basal infusion

42. DUAL-ACTION MEDICATIONS
TRAMADOL
Mild to Moderate Post-op pain
Mechanisms Of Action: binding to the μ-opioid receptor and
inhibiting the reuptake of serotonin and norepinephrine.
 Theoretically, its weak opioid effect makes it desirable (less respiratory depression,
pruritus)
Dose- 3mg/kg can be given oral, IV, IM
50-100 mg PO q 4-6 hr. Max. 400 mg/d
Side effects:
AVOID IN in epileptics and patients at risk of seizures.
Caution in patients on SSRI’S, MAO Inhibitors and anti psychotics, anti depressants

43. TAPENTADOL
a Schedule II controlled substance
 is a mu opioid receptor agonist and norepinephrine reuptake inhibitor
 can be used orally for relief of moderate to severe acute pain.
Tapentadol has a much lower affinity (20 times less) to the mu receptor than morphine,
and its analgesic effect is only around three times less than morphine.
significantly lower incidence of nausea, vomiting, and constipation.
 Tapentadol should be used cautiously with serotonergic medications because of the risk of
serotonin syndrome.
Can cause respiratory depression like opioids- caution in elderly n debilitated

44. ADJUVANTS

45. NMDA RECEPTOR ANTAGONISTS
Ketamine
magnesium
Dextromethorphan
and dexamethasone – anti inflammatory , local site action when instilled into the joint
Ketamine :
Low-dose ketamine (0.25- to 0.5-mg intravenous bolus followed by an infusion of 1 to 3
µg/kg/min) can provide significant analgesia and is opioid- sparing.
ideal intravenous PCA regime is morphine/fentanyl – ketamine infusion.
If the infusion is administered over a prolonged period of time (48 hours) for more invasive and
routinely painful procedures, patients can be at lower risk for developing persistent
postoperative pain in the subsequent months.

46. DEXTROMETHORPHAN:
does not have a direct analgesic affect; rather, analgesia is likely mediated by its
NMDA receptor antagonism.
It has been used as an antitussive
It can be administered orally, intravenously, and intramuscularly
inhibit secondary hyperalgesia following peripheral burn injury and cause a
reduction in temporal summation of pain.
preoperative administration of 150 mg of oral dextromethorphan can reduce the PCA
morphine requirements

47. MAGNESIUM
In a meta-analysis of data from more than 1,200 patients,
systemically administered magnesium decreased postoperative pain
a small, statistically significant amount; a reduction in morphine use
was clearly evident
 HJ. Shin, EY Kim, HS Na, TK. Kim, MH. Kim, SH Do, Magnesium sulphate attenuates acute
postoperative pain and increased pain intensity after surgical injury in staged bilateral total
knee arthroplasty: a randomized, double-blinded, placebo-controlled trial, BJA: British
Journal of Anaesthesia, Volume 117, Issue 4, October 2016, Pages 497–503.
 Gildasio S. De Oliveira, Lucas J. Castro-Alves, Jamil H. Khan, Robert J. McCarthy;
Perioperative Systemic Magnesium to Minimize Postoperative Pain: A Meta-analysis of
Randomized Controlled Trials. Anesthesiology 2013;119(1):178-190
“Oh
MG!”

48. MAGNESIUM AND ASRA
GUIDELINES
“Although its analgesic properties may have been
overlooked for newer and more sophisticated
drugs, magnesium has resurfaced in the era of
bundled payments, enhanced recovery pathways,
and multimodal analgesic plans.’’

49. ALPHA 2 AGONISTS
CLONIDINE AND DEXMEDETOMIDINE

50. provides analgesia, sedation, and anxiolysis.
MOA- by decreasing release of norepinephrine- mediate analgesia.
CLONIDINE :
• Analgesia is mediated supraspinally (locus coeruleus), spinally (substantia gelatinosa), and
peripherally
can be administered orally, transdermal, intravenous infusion and intrathecal for
perioperative pain management.
• Premedication with 2-5 µg/kg/day of oral clonidine in patients decrease the use of PCA
morphine and decrease the incidence of postoperative nausea and vomiting.
doses of 0.5 to 1 µg/kg enhance the efficacy and increase the duration of local anesthetics in
peripheral nerve blockade
Side effects - sedation, hypotension, and bradycardia if the dose exceeds 150 µg

51. DEXMEDETOMIDINE
Highly selective α2-agonist
Does not depress the respiratory drive
Analgesia, titratable sedation (“cooperative sedation’’), and anxiolysis
The centrally mediated reduction in sympathetic tone is reported to have a
cardioprotective effect
Dexmedetomidine infusion combined with peripheral nerve blockade may
provide superb analgesia, anxiolysis, and sedation during prolonged
procedures.
Side effects : bradycardia and hypotension

52. GABANOIDS
Gabapentin, and pregabalin are anticonvulsants but are also called neuromodulators,
as they reduce neuronal excitability by inhibiting the α-2-δ subunit of calcium-gated
channels on presynaptic axons, as well as in lessening spinally mediated hyperalgesia
seen after sustained nociceptive afferent input caused by peripheral tissue injury.
 Combined with an NSAID, the combination has been shown to be synergistic in
attenuating the hyperalgesia associated with peripheral inflammation.
 Gabapentin also appeared to enhance spinal morphine analgesia in a laboratory
model of nociceptive pain.1
Gabapentin and pregabalin for pain - is increased prescribing a cause for concern?Goodman CW, brett AS. N engl J med. 2017
aug 3; 377(5):411-414
GABAPENTIN 1200-3600 mg/day
PREGABALIN 75-300 mg/day

53. Although several single clinical trials report that gabanoids decrease the
postoperative use of opioids,
the Pfizer multi-centric phase III program failed to confirm these findings and to
demonstrate any effectiveness in three different models .
Nevertheless, the use of gabanoids for acute pain is extensive, even if it is not an
approved indication.

54. PATIENT-CONTROLLED ANALGESIA
Allows the patients to administer their own analgesia on demand.
Variables associated with all modes of PCA include:
1. bolus dose,
2. incremental (demand) dose,
3. lockout interval,
4. background infusion rate
5. 1- and 4-hour limit

55. REGIONAL ANALGESIA
Meta-analysis have found epidural analgesia to be superior to systemically
administered opioids
Ideally, the epidural catheter is positioned congruent with the surgical incision.
Thoracic epidural catheter placement is recommended for both thoracic and upper
abdominal surgical procedures.
Combining a local anesthetic plus an opioid in the epidural space is believed to
have a synergistic effect. Epidurally administered opioids have the distinct
advantage of producing analgesia without causing significant sympatholytic effect
or motor blockade.
Recommendations are that the infusion be continued for at least 2 to 4 days

56. PERIPHERAL NERVE BLOCKADE
Single-injection peripheral nerve blockade provides pain control that is superior to opioids
with fewer side effects.
complications – rare, neurologic and infectious
CPNB in the ambulatory setting include prolonged postoperative analgesia, facilitated discharge from
the hospital, fewer opioid-related side effects, and greater patient satisfaction
Includes-
Ilioinguinal/hypogastric : herniorrhaphy Brachial plexus : Arm, Hand
Abdomen :TAP block
Thoracic: Intrapleural Regional Anaesthesia (IPRA), Paravertebral, intercostal blocks
Intercostal/paravertebral : breast
Femoral, sciatic, popliteal nerve blocks : TKR, THR, Lower limb surgeries
Paracervical : F&C, D&C, cone biopsy

57. PERIPHERAL NERVE BLOCKS
Brachial plexus femoral nerve block Sciatic nerve
block

58. PLAN
 Preoperatively –
 Inform and prepare patient and attendants for the intervention and anaesthesia with emphasis on
postoperative pain alleviation.
 Start physiotherapy and in some cases adjuvant drugs which will continue postoperatively
Intraoperative-
 Plan regional/peripheral nerve blocks with or without general anaesthesia.
 Before incision- give 1 gm PCM and or NSAID if not contraindicated and adequate local site
infiltration. (Even with regional anaesthesia)
 Minimise tissue manipulation
Consider using magnesium sulphate
Postoperative –
Continue epidural/PNB/ PCA infusion for 2 days atleast along with scheduled dose of PCM/
tramadol withsdoses of opioids, nsaids

59. IN CONCLUSION…
E
R
A
S

60. Thank you

62. OPIATE AGONIST
Relieve severe pain without loss of consciousness
– Stimulate opiate receptor in CNS
– Produce physical dependence – Prolonged use produce tolerance or
psychological & physical dependence (addiction)
• Uses: relieve acute or chronic moderate to severe pain…injury,
postop, renal or biliary, MI or cancer
CAE: lightheaded, dizziness, sedation, confusion, orthostatic
hypotension, N/V, constipation
SAE: respiratory depression, urinary retention, abuse• Interactions
CNS, Dilantin, Tegretol, SSRI—tramadol, warfarin

63. OPIATE PARTIAL AGONIST
• Nubain, Talwin, Stadol…etc.
Potency 1st few weeks similar to Morphine
• Prolonged use tolerance
• Increasing dose doesn’t produce increase analgesia but increase
adverse effects— ceiling effect• Will induce withdrawal in those
addicted to agonist opioids•
Uses: short term relief up to 3 wks of moderate to severe pain in
cancer, burns, renal colic, preop, obstetric
CAE: clamminess, sedation, sweating, dizziness, N/V/dry mouth,
constipation• SAE: confustion, disorientation, hallucination,
respiratory depression, Abuse

64. OPIATE ANTAGONISTS
• Naloxone pure because it has no effect on its own other than
reverse CNS depressant• Withdrawal in addicted clients of agonists
• Choice treatment for reversal of respiratory depression• CAE:
apathy, N/V, anorexia, mental depression

65. TRANSDERMAL PATCHES
OPIOID PATCHES- FENTANYL
BUPRENORPHINE
NON OPIOD PATCHES- DICLOFENAC

66. INTRAVE
NOUS
ORA
L
INTRAMU
SCULAR
TRANSDE
RMAL
PER RECTAL SUBLINGUA
L
EPIDURAL/
CAUDAL
SUBARA
CHNOI
D
INHALA
TIONAL

69. TAKE HOME POINTS
Multimodal analgesia
Maximise use of regional blocks

71. approach to patients with acute pain begins by identifying the underlying cause and a disease-specific
treatment. The first-line pharmacologic agent for the symptomatic treatment of mild to moderate pain is
acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID). The choice between these two
medications depends on the type of pain and patient risk factors for NSAID-related adverse effects
(e.g., gastrointestinal, renovascular, or cardiovascular effects). Different NSAIDs have similar analgesic
effects. However, cyclooxygenase-2 selective NSAIDs (e.g., celecoxib) must be used with caution in
patients with cardiovascular risk factors and are more expensive than nonselective NSAIDs. If these
first-line agents are not sufficient for mild to moderate pain, medications that target separate pathways
simultaneously, such as an acetaminophen/opioid combination, are reasonable choices. Severe acute
pain is typically treated with potent opioids. At each step, adjuvant medications directed at the
underlying condition can be used. Newer medications with dual actions (e.g., tapentadol) are also an
option. There is little evidence that one opioid is superior for pain control, but there are some
pharmacologic differences among opioids. Because of the growing misuse and diversion of controlled
substances, caution should be used when prescribing opioids, even for short-term treatment. Patients
should be advised to properly dispose of unused medications