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care professionals who treat these patients must be
cognizant of the associated elevated risk, as surgical
patients on chronic opioid therapy may have significantly increased hospital lengths of stay, readmission
rates, health care expenditures, and mortality rates
than patients who are not on chronic opioid therapy.
7
Acute pain and chronic pain are distinct from one
another, with chronic pain management posing a par-
ticular challenge to patients and health care providers
alike.
8 Acute pain is part of a normal physiologic pro-
cess in which an uncomfortable external sensation,
such as tissue damage, leads to noxious neurologic
stimuli. By definition, acute pain lasts less than one
month, though it may be followed by dull pain as a
result of persistent inflammatory mediators within the
tissue. As this tissue damage is repaired, a temporary
period of hypersensitivity often is followed by resolu-
tion of the pain. In cases of chronic pain lasting more
than three months after injury, severity and duration
do not coincide with the presence of a noxious stimulus
nor with the severity of injury.
8 Risk factors associ-
ated with the development of chronic pain include
around-the-clock dosing of narcotics, overall duration
of narcotic therapy, and the specific type of narcotic
prescribed.
11
Most surgeons are amenable to operating on patients
with a chronic pain syndrome, despite knowing full
well that a surgical intervention will likely potenti-
ate both their acute and chronic pain. Furthermore,
control of procedural pain may be difficult in those
patients who have developed tolerance secondary to
chronic opioid use. The surgeon should feel comfort-
able involving other health care providers, such as
pain specialists and pharmacists, in the treatment of
patients who present with preexisting chronic pain or
who develop chronic pain after treatment of a surgi-
cal disease. Chronic pain is not a treatment failure. It
is a distinct clinical condition that requires consider-
able expertise, effort, and time to achieve adequate
treatment. Familiarity with the normal course of acute
postoperative pain following surgery aids in identifying
the early stages of chronic pain and opioid dependence,
and allows for early referral to a chronic pain specialist.
Implementation of ERAS protocols across many
specialties has been shown to reduce rates of opioid
use.
12, 13 Pioneered in colorectal surgery, these protocols address pre-, intra-, and postoperative variables,
such as fluid balance and nutrition to ensure a more
effective recovery from an operation. Multimodal pain
management is a critical component of these protocols,
with heavy reliance on non-narcotic pain medications
aiding in quicker recovery and reduction of postoperative narcotic use.
Effective development and execution of the ERAS
analgesic regimens requires multidisciplinary communication and care coordination. Surgeons must
collaborate with perioperative and floor nurses as well
as anesthesia providers to deliver analgesics beginning
in the preoperative patient holding area. Acetaminophen, cyclooxygenase (also known as COX) inhibitors,
and gamma-amino butyric acid (also known as GABA)
analogs administered preoperatively help to blunt
initial nociception and consequently may decrease
postoperative pain. These agents also constitute the
backbone of the multimodal postoperative analgesic regimen to be used in addition to narcotic agents.
Regional anesthesia modalities, including nerve blocks
and epidurals, also can decrease the need for global
anesthesia and/or systemic narcotics postoperatively.
Adjunct anesthesia agents like intravenous ketamine
and lidocaine can be continued postoperatively to
decrease immediate postoperative pain. Multiple
studies have shown that patients complain of less
postoperative pain after undergoing multimodal regimens.
13-15 Diminished opioid use is therefore secondary
to both decreased pain levels and the availability of
alternative analgesics.
Opioid management training
The patient pain management challenges that health
care professionals face are, in part, the result of their
limited education in the treatment of pain.
11 This
deficit becomes most noticeable when practice patterns are examined following the introduction of pain
management education. In one study, introduction of
