Contemporary trends in acute pain management

PURPOSE OF REVIEW: In the management of acute pain, the ability to prevent the onset of pain in the immediate postoperative period, lessen its intensity, and interfere with the development of sensitization contributing to hyperalgesia for days following a procedure can greatly benefit the patient, rather than postoperative attempts to decrease pain after it has reached full intensity. RECENT FINDINGS: Patients benefit from receiving optimal NSAID doses. These agents are effective, relatively safe, and reduce the need for opioids. In situations where pain can be anticipated, the NSAID may be optimized by preoperative administration and continuing to dose the NSAID on a regular schedule to minimize pain and inflammation. Selective COX-2 inhibitors can also prevent pain but without concern for effects on platelet function and have a longer duration of action than traditional NSAIDs. Once the dose of NSAID has been optimized, but pain persists, opioid use may be a consideration. A commercially available combination product containing opioid and acetaminophen may be a good option and is easy to prescribe. Acetaminophen's site of action differs from that of NSAIDs, and acetaminophen's analgesic effect is considered synergistic when combined with NSAIDs and opioids. When prescribing combination opioid and acetaminophen analgesic products or acetaminophen alone, the practitioner must caution the patient not to exceed 4 g of acetaminophen per day due to concerns with hepatic injury. Given that the patient has already been prescribed an optimal and/or ceiling dose of NSAID, combination products containing aspirin, an NSAID, should be avoided. As opioids have no ceiling dose, there are some situations where opioid dosing is better done with the opioid prescribed separately. This permits increasing the opioid to the needed analgesic dose with no concerns for acetaminophen toxicity. SUMMARY: Careful selection of an effective analgesic regimen can prevent the stress and anxiety associated with acute postoperative pain and breakthrough pain. Pain prevention has greater benefits than attempts at rescue therapy when pain exacerbation occurs. A variety of pain management regimens are presented based on empirical estimates of pain intensity and an application of sound pharmacological principles.