Treating Acute Pain

Treating Acute Pain

by Keith Candiotti, MD

Expert authors received compensation from Janssen Pharmaceuticals, Inc. for their contributions to PrescribeResponsibly.com

Case Study Profile

  • Treating an elderly patient with a recent knee replacement
  • Male
  • Age 65
Situation Overview

In the immediate period after surgery, especially following major joint replacements, the goal is to provide a patient with sufficient pain control to allow ambulation and rehabilitative therapy. After major joint replacement, all patients will need some type of pain medication. However, some of the side effects of pain medications can be so debilitating that some patients would rather have higher levels of pain than have side effects such as nausea and vomiting.2 Higher pain levels, though, may have their own deleterious physiological effects (eg, increased sympathetic activity) and can cause psychological stress. Additionally, providing a patient with sufficient pain control in a situation such as this may also have other health benefits. For example, while the use of anticoagulants helps prevent the occurrence of blood clots in the postoperative period, mobilizing the patient also is essential; however, it might be more difficult to achieve without sufficient pain control.3

Scenario

Mr. B is a 65-year-old patient who has just undergone a recent right knee replacement under spinal anesthesia. His past medical history is significant for hypertension and mild coronary artery disease with a single drug-eluting stent in one vessel placed more than 1 year ago. Cardiology has recommended he restart his antiplatelet therapy immediately after surgery. Mr. B is generally in good shape but is moderately obese. He plans to have rehabilitation therapy in the acute postoperative period. He is not able to tolerate intravenous patient-controlled analgesia due to side effects of itching, nausea, and mild agitation. By the patient’s own assessment, he has borderline pain control. His heart rate and blood pressure are mildly elevated despite restarting his antihypertensive medication. The patient also complains that he has not had a bowel movement since his surgery and is uncomfortable.

Key Learning

An initial response to this patient might be to attempt to control all side effects with additional medications. While adding drugs to treat side effects often occurs gradually over time and may solve the problem to some degree, it is far from ideal, particularly in an older patient, to prescribe several medications for the sole reason of controlling side effects.

Application

There are several other pain management options to consider. One option is to alter the pain management method completely. The placement of a perineural catheter often allows the patient to have significant relief of pain in the acute postoperative period by using the infusion of a local anesthetic agent. This form of pain control could be adjusted during periods of rehabilitative therapy and could be continued after discharge from the hospital. The use of regional anesthetic techniques is appealing but often is limited by short duration. In almost all cases, supplementation with other agents, such as opioid analgesics, is required and beneficial. It is obviously not desirable to completely block nerve function because this would limit the patient's mobility and the ability to participate in physical therapy.

Should regional techniques not be available, simply converting to another opioid analgesic could offer some benefit. While there is some debate, many practitioners have observed that simply changing from one opioid analgesic to another, for instance using hydromorphone in place of morphine, can meaningfully improve a patient's response. Many patients often are more responsive to, or have fewer side effects from, one particular opioid analgesic compared with another. The technique of polypharmacy to control a series of medication side effects is not always ideal. The use of multimodal therapy to maximize pain control and minimize side effects is appealing. Multimodal therapy may allow a more effective treatment of pain by approaching it through different mechanisms.4 While there is some debate on particular agents and their use in orthopedic surgery (eg, nonsteroidal anti-inflammatory drugs), the method of combining different classes of drugs appears to have good results. Patients may respond better to a combination of medications and experience reduced side effects.4 In general, multimodal therapy may allow the optimization of therapeutic effect with minimization of side effects.4

References Used in the Section:

  • 2 Gan TJ, Lubarsky DA, Flood EM, et al. Patient preferences for acute pain treatment. British Journal of Anaesthesia. 2004; 92(5):681-688.
  • 3 National Pharmaceutical Council in collaboration with Joint Commission on Accreditation of Healthcare Organizations. Pain: Current Understanding of Assessment, Management, and Treatments. 2001; 1-29.
  • 4 Pyati S, Gan TJ. Perioperative Pain Management. CNS Drugs. 2007; 21(3):185-211.