ACS Bulletin - August 2017

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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 high. 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 58). 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. 28
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
radical cystectomy for bladder cancer: Results of a
prospective randomized study. J Urol. 2014;191( 2):335-

340.

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 analgesic response in opioid-tolerant versus opioid-naive patients after total knee arthroplasty.

Pharmacotherapy. 2008; 28( 12):1453-1460.

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 Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016; 17( 2):131-157.

29. Arthur HM, Daniels C, McKelvie R, Hirsh J, Rush B.

Effect of a preoperative intervention on preoperative and postoperative outcomes in low-risk patients awaiting elective coronary artery bypass graft surgery. A randomized, controlled trial. Ann Intern Med. 2000;133( 4):253-262.

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.