patients with obstructive sleep apnea (OSA), additive central
depression and decreased neuromuscular tone can worsen
obstruction and pulmonary complications.
35, 36 Because of a
high percentage of undiagnosed OSA patients in the general
population, clinical perioperative suspicion should remain
35, 37 Successful pain management strategies to help the
surgeon with these populations include developing individualized plans, decreasing dosage amounts, and increasing
intervals between administration.
34, 36, 37
Patients with underlying mental illness and addictions can
be especially challenging due to the biopsychosocial interactions of previous life experiences, current expectations,
hypersensitivity to pain, and ineffective coping mechanisms.
26, 38, 39 Setting patient expectations, shared decision
making, and aggressive multimodal pain control postoperatively may improve pain outcomes.
28, 29, 38, 40
Multiple health care associations including the College,
the American Pain Society (APS), the American Society of
Anesthesiology, and the CDC have devised guidelines to
help physicians manage acute pain (see statement on page
28 Setting patient expectations is a common theme for
achieving overall improved pain control with less opioid use,
decreased anxiety, improved patient satisfaction, and even
decreased length of stay postoperatively.
28, 29, 40, 41 Strategies
include engaging patients in preoperative discussions on pain
control, shared decision making, and development of the post-operative pain plan.
40 These discussions may reveal previous
patient experiences, including personalized pain control that
has worked well in the past. Documenting these discussions
will help ensure continuity of care. It is also important to
anticipate the expected length of acute postoperative pain
and educate the patient on specialized chronic pain resources.
Alternative treatment modalities
The most recent APS postoperative pain management guide-
lines, released in 2016, present evidence-based nonnarcotic
interventions that should be employed for all patients.
The underlying principle guiding multimodal therapy is
the synergy gained by the use of multiple agents resulting
in an opioid-sparing effect.
28, 42-44 Therefore, the APS recom-
mends routine scheduled nonopioid analgesics as part of the
pharmacologic regimen. Cyclooxygenase (COX) inhibition
early recovery after surgery for patients undergoing
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prospective randomized study. J Urol. 2014;191( 2):335-
25. Pathan H, Williams J. Basic opioid pharmacology: An
update. Br J Pain. 2012; 6( 1): 11-16.
26. Kosten TR, George TP. The neurobiology of opioid
dependence: Implications for treatment. Sci Pract
Perspect. 2002; 1( 1): 13-20.
27. Patanwala AE, Jarzyna DL, Miller MD, Erstad
BL. Comparison of opioid requirements and
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opioid-naive patients after total knee arthroplasty.
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28. Chou R, Gordon DB, de Leon-Casasola OA,
et al. Management of postoperative pain: A
clinical practice guideline from the American
Pain Society, the American Society of Regional
Anesthesia and Pain Medicine, and the American
Society of Anesthesiologists’ Committee on
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Administrative Council. J Pain. 2016; 17( 2):131-157.
29. Arthur HM, Daniels C, McKelvie R, Hirsh J, Rush B.
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and postoperative outcomes in low-risk patients
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30. Gosch M. Analgesics in geriatric patients. Adverse
side effects and interactions. Z Gerontol Geriatr.
2015; 48( 5):483-492.
31. Richards S, Torre L, Lawther B. Buprenorphine-related complications in elderly hospitalised patients:
A case series. Anaesth Intensive Care. 2017; 45( 2):256-261.
32. Innaurato G, Piguet V, Simonet ML. Analgesia in
patients with hepatic impairment. Rev Med Suisse.
2015; 11(480):1380, 1382-1384.
33. Imani F, Motavaf M, Safari S, Alavian SM. The
therapeutic use of analgesics in patients with liver
cirrhosis: A literature review and evidence-based
recommendations. Hepat Mon. 2014; 14( 10):e23539.
34. Rolke R, Rolke S, Hiddemann S, et al. Update
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