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prevents the generation of inflammatory mediators, like
prostaglandins, that further increase the propagation of
nociceptive pain. Nonsteroidal anti-inflammatory drugs
(NSAIDs) block this conversion and provide significant
reduction in pain. When Tylenol and NSAIDs are combined, postoperative pain control improves, resulting in
decreased opioid intake. Other nonopioid options include
gabapentin or pregabalin, the selective COX- 2 inhibitor
Celecoxib, and the intraoperative use of ketamine. Gabapentin is thought to decrease the neuropathic component
of pain and, as previously mentioned, COX inhibition
effects nociceptive pain, thus together having an additive,
45, 46 Pre-incisional tissue infiltration of
local anesthesia, anesthesia-administered nerve blocks and
epidurals, transcutaneous electrical nerve stimulation, and
cognitive behavioral strategies all represent additional
interventions that can be employed.
Evidence supporting the use of these multimodalities
abounds in the medical literature, and it is beyond the
scope of this article to fully explore each modality. Surgeons should familiarize themselves with all the possible
perioperative interventions that are available to reduce
pain and opioid use, specifically starting with consensus
guidelines like those provided by the APS and the ACS.
The over-prescription of narcotics in the U.S. has resulted
in an opioid crisis. Surgeons will play an important role in
addressing and mitigating this scourge. Continued efforts
aimed at patient education regarding narcotics will be
critical, and a team approach involving the patient, physicians, and other members of the health care team are
essential to successfully curbing opioid misuse. Eradicating the opioid epidemic is a moral and ethical obligation
for all surgeons in all specialties. ♦