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Introduction 117
ApproachestoAnalgesia
The basic principles of achieving analgesia are:
a. the oral route is often best as it is less invasive,
b.
the regimen should be as simple as possible and
c.
to use the most efficacious medicines with the fewest adverse effects (Macintyre
and Schug2021).
In the intra- operative and immediate post- operative periods, maximum use
should also be made of locoregional techniques including nerve blocks, local anaes-
thetic infusions and neuraxial techniques to reduce opioid requirements. The intrave-
nous route is preferred for opioids if a patient is unable to take or does not tolerate
oral intake.
UnrelievedPain
The adverse effects of unrelieved pain can be physiological and psychological affecting
social functioning, for example, sleep, work and relationships (Kawai etal.2017). The
physiological responses to pain include increased sympathetic activity resulting in
tachycardia, hypertension and increased myocardial oxygen consumption; reduced
lung volumes; reduced gut motility; increased catabolic hormone production
(Hutchinson2020) and an increased risk of pain that persists and becomes chronic
(Schug and Bruce2017). Poor perioperative pain management, anxiety and depres-
sion increase the risk of persistent post- surgical pain (Schug etal.2020).
A combination of approaches should be used to manage pain. A highly anxious
patient may benefit more from speaking about what the pain means to them (con-
cerns about recurrence or progression of disease) than any benefit gained from medi-
cation. Early recognition and referral to psychology or talking therapies can reduce
pain related fear. Setting expectations before surgery, educating patients about self-
management, plus encouraging relaxation and distraction may be useful.
RoleoftheInpatientPainManagementService
The interdisciplinary inpatient pain team should manage inpatient acute pain result-
ing from surgery, procedures and chronic pain conditions.
The service has several roles including:
• Providing clinical support and expert advice.
• Providing education and training to patients, carers and staff.
• Promoting best practice based on best available evidence.
• Managing patients with complex pain– both acute and chronic.
118 Chapter 10 Pain Management
Patient Education
Patients need to take an active role in managing their pain. When a patient is sched-
uled for surgery, patient expectations and the analgesia plan should be discussed and
agreed upon the pre- admission appointment (Levy et al. 2021). Accessible patient
information should be provided that explains the pain assessment tool, sets expecta-
tions, describes the methods of providing analgesia and the importance of reporting
unrelieved pain. An example of an endorsed patient information is available here:
https://www.britishpainsociety.org/people-
with- pain/
patient- publications/#managing- pain- after- your- surgery.
ANALGESIC MEDICINES
The type of analgesia used for post- operative pain depends on various factors and include:
• Individual: Pain tolerance varies from person to person and how they metabo-
lise medicines.
• Pre- existing pain.
• Type, location and cause of pain.
• Type of surgery and time from surgery.
• Concurrent illness and medication.
• Opioid status: Naive, regular user (which increases tolerance) or dependence.
Multimodal Analgesia
Multimodal analgesia describes the combination of different groups of medica-
tions to achieve the optimal functional analgesia. The key underlying principle is
that using low doses of multiple medicines with different modes of action results
in synergistic effect (reduction in pain and adverse effects). For example, opioids
can be combined with a non- opioid or a local anaesthetic block can be combined
with systemic analgesia tailored to individual situations and for desired results.
The most commonly used combinations are local anaesthetics, opioids, non-
steroidal anti- inflammatory drugs (NSAIDs), paracetamol and alpha- 2- agonists,
for example, clonidine. Kianian et al. (2024) report that the use of multimodal
analgesia results in less pain, fewer side effects, fewer complications, faster recovery
and fewer days in the hospital.
Paracetamol
Paracetamol is widely used for its analgesic and antipyretic properties. It acts by inhib-
iting prostaglandin synthesis in the central nervous system (CNS) and blocks pain-
impulse generation resulting in the analgesic effect (De Coster etal.2020). It is a very
Analgesic Medicines 119
useful adjunct in the multimodal perioperative strategy for analgesia. Administration
of paracetamol pre- operatively has demonstrated useful opioid sparing effects and
should be considered as a component of any effective multimodal analgesic regimen
(Ng etal.2019). Intravenous paracetamol is used widely intraoperatively to provide an
initial analgesic effect as the patient wakes from surgery. Regular paracetamol postop-
eratively is reported to produce lower pain intensity and reduce postoperative opioids.
As soon as the patient is tolerating oral intake, the patient should be switched to the
oral formulation (dispersible, tablets or caplets).
Non- steroidal Anti- inflammatory Drugs (NSAIDs) and Cyclooxygenase
(COX) 2Inhibitors
NSAIDs exert their analgesic, antipyretic effects and anti- inflammatory effects.
There are two classes of NSAIDs:
1. Selective cyclooxygenase (COX) 2 inhibitors: These reduce the risk of
intra- operative and post- operative bleeding. Single doses or short courses of
COX- 2inhibitors such as parecoxib (IV) and celecoxib (oral) can be used safely
post- surgery or for patients with a history of or at risk of gastrointestinal bleed.
2.
Non- selective COX inhibitors (COX- 1 and 2): Due to their mechanism of
action and non- selective nature, these are used with caution in patients with
pre- existing cardiac disease, stroke or cerebrovascular disease. Non- selective
NSAIDs include aspirin, ibuprofen, diclofenac and naproxen.
The effects of both types of NSAIDs have been analysed for use in multimodal
treatment approach. Selective NSAIDs have not shown a significant reduction in
opioid- related adverse effects such as nausea, vomiting and sedation. Because selective
COX2inhibitors such as parecoxib have little or no effect on platelet activity they can
be used safely in the peri- operative setting for up to four doses.
Non- selective NSAIDs inhibit prostaglandin synthesis leading to decreased
platelet aggregation which increases the risk of gastrointestinal bleeding as well as
overall bleed for patients. If non- selective NSAIDs are used postoperatively ensure
that patients are prescribed proton pump inhibitors like omeprazole or lansopra-
zole as a precaution for gastrointestinal bleed. When considering the use of postop-
erative, NSAIDs (Sheth etal.2020) reminds us that it is important for the risk and
benefits of the potential side effects to be weighed alongside potential anal-
gesic effects.
Opioids
Post- operative pain is most often managed with opioids as central and peripheral
nociception modulators. Opioids work by a receptor- based mechanism: centrally (in
the CNS) by binding to opioid receptors situated in the dorsal horn of the spinal cord.
Opioids block the release of neurotransmitters, for example, substance P and there-
fore block the transmission of pain to the brain (James and Williams2020). The four
main opioid receptors and their actions are shown in Table10.2.
120 Chapter 10 Pain Management
Opioids can be administered by a variety of routes including oral, intramuscular,
subcutaneous, intravenous, epidural and spinal, hence, can be useful to manage
patients in pain. The most common methods for administering opioids postopera-
tively are via intravenous patient- controlled analgesia (PCA) infusions which allow
patients to self- administer.
Post- operative opioids can provide good quality functional analgesia cover; how-
ever, they have some limitations as some patients experience side effects that include
dry mouth, constipation, ventilatory impairment, nausea, vomiting, pruritus and
altered mental status or delirium which should lead to a review of opioid therapy use.
It is important to utilise enhanced pathways and tools that have been developed
to help with standardisation of post- operative pain management protocols and the
use of multimodal approaches with minimal use of opioids which leads to better
recovery (Loria etal.2022).
Gabapentinoids
Gabapentinoids are a class of medications that have been used within multimodal
analgesic strategies. They are structurally like the neurotransmitter, gamma-
aminobutyric acid (GABA); however, they do not bind to GABA receptors but are
predicted to bind to calcium channels to downregulate excitatory neurotransmitter
release, thereby producing a similar effect as endogenous GABA.
Gabapentin and pregabalin have been used frequently for the treatment of neuro-
pathic pain. Ladich (2022) reports clinically significant reductions in post- operative
pain and reduced opioid consumption and improved patient satisfaction scores in the
immediate post- operative periods with gabapentinoids.
TABLE. Characteristic ofopioid receptors.
Receptor Actions Opioid
Mu (μ) 1
and 2
Analgesia,bradycardia,sedationandinhibitGI
motility
Respiratorydepression,euphoriaandphysical
dependence
Morphine
Fentanyl
Codeine
Pethidine
Oxycodone
Delta (δ) Analgesia–weak,respiratorydepression,
hypotension,hyperthermiaandstress-induced
analgesia
Fentanyl
Alfentanil
Remifentanil
Kappa (k) Analgesia–weak,respiratorydepression,
sedation,diuresisanddysphoria
Fentanyl
Sigma (σ) Dysphoria,hallucinations,tachycardiaand
hypertension
Pentazocine
Source: Adapted from James and Williams (2020).
Analgesic Medicines 121
These medications may be useful in multimodal strategies where less opioids are
utilised; however, they have been associated with serious reports of concerns for
respiratory depression and even CNS depression. They should be used with caution in
some patient groups such as patients taking concurrent opioids (Levy etal.2021, the
elderly, those with obstructive sleep apnoea or kidney injury.
Alpha-2Agonists:ClonidineandDexmedetomidine
Alpha- 2 agonists such as clonidine and dexmedetomidine may have a potential role in
managing post- operative pain. The analgesic effect is produced from alpha- 2 receptor
stimulation where the dorsal horn of the spinal column inhibits nociceptive neurons
and decreases substance P release. Their use has demonstrated lower opioid require-
ments in some patients and reduced pain scores and may form part of a multimodal
strategy (Kianian etal.2024).
Clonidine and dexmedetomidine have some significant clinical side effects like
hypotension and bradycardia and must be carefully considered before using as part of
a multimodal protocol.
Ketamine
Ketamine primarily acts as a N- methyl- - aspartic (NMDA) receptor antagonist but
also interacts with μ opioid, GABA and muscarinic acetylcholine receptors, hence,
has sedative, analgesic and some dissociative effects. Ketamine has been shown to
reduce post- operative opioid requirements, pain intensity, nausea and vomiting in
some surgical patients.
Ketamine has sympathomimetic properties and is associated with dissociative
effect. Patients have reported delirium, vivid dreams and hallucinations with higher
doses (Brinck etal.2018).
LocalAnaesthetics
Local anaesthetics like lidocaine or levobupivacaine are often administered intra-
operatively to provide analgesia and accelerate recovery via their analgesic, anti-
hyperalgesic and anti- inflammatory properties. Local anaesthetics (LA) block sodium
channels and therefore block transmission of the stimulus via A and C fibres. They
inhibit nerve impulses and therefore pain impulses resulting in a reversible block to
conduction along nerve fibres.
LAs vary widely in their potency, toxicity, duration of action, stability, solubility in
water and ability to penetrate mucous membranes (Taylor and McLeod 2020).
Table10.3 illustrates the varied onset and duration of actions across four commonly
used LAs. They can cause side effects such as drowsiness and may cause symptoms
associated with local toxicity (e.g. tinnitus, perioral numbness, light- headedness, diz-
ziness, visual changes and more seriously arrhythmias and seizures). For procedures
under LA, an amide LA like lidocaine is most useful as it has a short onset of action
122 Chapter 10 Pain Management
(but a short duration of action). If analgesia is required for >two hours, ropivacaine
or levobupivacaine are preferred (less cardiotoxic than bupivacaine) and administered
as a nerve or field block continuous infusion (wound or plane block) or neuraxial
injection/continuous infusion.
A systematic review of the efficacy of intravenous lidocaine on post- operative
pain intensity and recovery was inconclusive (Weibel etal.2018).
Nerve Blocks
The injection of LAs around a nerve or group of nerves can provide surgical analgesia,
for example, the brachial plexus for surgery on the hand, arm or elbow. For some sur-
gery such as lower limb amputation, a continuous infusion may be delivered by a
catheter placed near the femoral or popliteal nerves.
Neuraxial Analgesia
This term covers epidural, caudal (at the base of the vertebral column) and spinal
(subarachnoid/intrathecal) techniques. Epidural analgesia involves the placement of
a catheter in the epidural space with administration of an initial bolus dose followed
by an infusion of a local anaesthetic agent with or without an opioid (e.g. in labour).
For spinal analgesia, a local anaesthetic +/− an opioid (e.g. preservative- free mor-
phine) is injected into the subarachnoid space with the cerebrospinal fluid (com-
monly used for hip and knee replacements).
Fascial Plane Blocks
Chin etal. (2021) describe fascial plane blocks as regional anaesthesia techniques in
which the space (“plane”) between two discrete fascial layers is the target of needle
insertion and injection. Analgesia is primarily achieved by local anaesthetic spread to
nerves travelling within this plane and the adjacent tissues. Examples include
TABLE. Characteristics oflocal anaesthetics.
Generic
(trade)
name
Lidocaine
(Xylocaine
®
)
Bupivacaine
(Marcain
®
)
Levobupivacaine
(Chirocaine
®
)
Ropivacaine
(Naropin
®
)
Onset Fast
5–10mins
Moderate
20–30mins
Moderate
20–30mins
Moderate
20–30mins
Duration Short
1–2hrs
Long
4–6hrs
Long
4–6hrs
Long
4–6hrs
Potency + +++ +++ +++
Toxicity + +++ ++ ++
Source: Adapted from Taylor and McLeod (2020).
References 123
paravertebral and erector spinae blocks for fractured ribs. For the management of
pain after abdominal, gynaecological and urological surgery, the transverse abdom-
inal plane (TAP) block is widely used.
CONCLUSION
Pain is a complex phenomenon that requires structured assessment by an experi-
enced practitioner to identify probable causes using patient self- report when pos-
sible. Multimodal analgesia should be used and the reverse pain ladder should guide
analgesia provision as recovery occurs. Patients with unrelieved pain should be
referred to the interdisciplinary inpatient pain team for specialist advice and
management. Pain is a complex, unpleasant and personal phenomenon that results
from a learned experience. Unrelieved pain has adverse effects on function, social
and psychological well- being.
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