Pain medications after surgery

It's natural to have concerns about pain after having surgery — as well as the risks associated with powerful pain medications. Controlling pain and minimizing side effects are both important for post-surgical comfort, recovery and rehabilitation.

It's best to talk about post-surgical pain relief and pain medications before you have surgery. Being prepared can help you better manage your pain.

Before surgery, you'll likely speak with your surgeon or other members of your care team. You may discuss pain management, treatment options and your particular needs. This conversation may include topics such as:

• Pain expectations. Ask your doctor about pain typically associated with the procedure and how long your recovery is likely to last.
• Previous experiences with pain. Talk to your doctor about your experience with pain and different methods of pain control. Mention what has and hasn't worked for you in the past.
• Chronic pain. If you take drugs to treat chronic pain, list your typical daily medication usage and your typical pain levels. Your doctor will discuss options for treating both chronic pain and post-surgical pain.
• List of your medications. Include all prescription and over-the-counter medications in your list. Also include any supplements or herbs you've taken in the past month. Your doctor needs to know about anything that might interact with post-surgical pain medications. You may need to change your medications before and after surgery.
• Alcohol and drug use. Accurately describe your current use of alcohol, tobacco or illicit drugs. Your doctor needs to know if you are recovering from an addiction to — or currently misuse — alcohol or drugs, including prescription medications, in order to plan and monitor your pain management.
• History of medication misuse or addiction. If you are in recovery, or have a history of substance misuse, it is important to share this with your doctor. Some medications, like naltrexone or suboxone, that are used for addiction have important implications for your surgery.
• Side effects. Ask for written information about the drugs you will be prescribed and their side effects. Ask questions about what can be done to minimize side effects and when to get help for serious side effects.
• Additional pain management. Ask your doctor about interventions that may support your treatment plan, such as counseling to address anxiety or coping skills.
• Discussion of your concerns. If you're afraid of side effects or overdosing on pain medications, talk to your doctor. They can help you understand strategies to safely manage your pain.

Post-surgical pain is usually managed with multiple pain-reducing medications (analgesics). The appropriate type, delivery and dose of medications for you depend on the type of surgery and expected recovery, as well as your own needs.

Pain medications include the following:

• Opioids, powerful pain medications that diminish the perception of pain, may be given after surgery. Intravenous opioids may include fentanyl, hydromorphone, morphine, oxycodone, oxymorphone and tramadol. Examples of opioids prescribed in pill form after surgery include oxycodone (OxyContin, Roxicodone, others) and oxycodone with acetaminophen (Percocet).
• Local anesthetics, such as lidocaine and bupivacaine, cause a short-term loss of sensation at a particular area of the body.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) — such as ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve, Anaprox DS, others), celecoxib (Celebrex) or ketorolac — lessen the inflammatory activity that worsens pain.
• Other nonopioid pain relievers include acetaminophen (Tylenol, others) and ketamine (Ketalar).
• Other psychoactive drugs that may be used for treating post-surgical pain include the anti-anxiety medication midazolam or the anticonvulsants gabapentin (Gralise, Horizant, Neurontin) and pregabalin (Lyrica).

While opioids may or may not be appropriate to use after your surgery, your surgeon will likely prescribe a combination of treatments. These may help to control pain, lessen side effects, enable you to resume activity appropriate for recovery and lower risks associated with opioids.

Opioids are often critical for post-surgical pain management because of their powerful effect. But their side effects can be significant, including nausea, vomiting, constipation, urinary retention, drowsiness, impaired thinking skills and poor respiratory function.

Overdosing and misuse of opioids also are risks, particularly when opioids are used to treat ongoing (chronic) pain. Although the use of opioids after surgery is intended as a short-term strategy to relieve pain while the body heals, the risk of misuse is still a concern.

Because of the risks associated with opioids and their potential side effects, these drugs should be used carefully, if at all. Opioids should be used at the smallest dose effective for the shortest possible time.

You and your doctor should discuss steps you can take to reduce the risks associated with opioid use, including:

• Taking medication only as directed, minimizing dose and length of opioid use
• Talking to your doctor when your pain is not under control
• Not using alcohol while taking opioids
• Following your doctor's instructions about other drugs not to take while using opioids
• Storing drugs safely
• Disposing of unused drugs, ideally through a pharmacy take-back program
• Not sharing your medication with other people

A primary goal of pain management after major surgery is for you to awaken relatively comfortable and to experience an uninterrupted transition to pain control, but some discomfort is common and should be anticipated after surgery.

• Intravenous (IV) pain medication. Before surgery, you'll probably have a slender plastic tube (catheter) inserted into a vein in your hand or arm to give you fluids, sedatives, anesthetics, antibiotics or pain medications. The catheter can be used for delivering pain medications until you can take pills by mouth.

  Pain relievers, such as opioids, are usually injected into your IV catheter at regular intervals. Most hospitals also offer patient-controlled analgesia (PCA) — a system that allows you to give yourself a fixed dose of the medication by pushing a button. This way you don't have to ask a nurse for each dose of pain medicine.

  The PCA system has built-in safeguards to prevent you from overdosing on pain medication. If you push the button more than once within a set period of time, the dispenser ignores the second request.

• Wound infiltration anesthesia. Your surgeon may inject an anesthetic drug at the wound site during the procedure or place a catheter for post-surgical drug delivery. This means of local anesthesia may reduce the use of opioids during your recovery.

• Spinal anesthesia. Some surgeries can be done with spinal anesthesia, which involves medications injected directly into the spinal fluid.

  Spinal anesthesia is easier and faster than epidural analgesia is, but it doesn't last as long because there's no catheter to allow the administration of additional medication. Your doctor can add a long-acting opioid to the spinal medication that can relieve post-surgical pain for up to 24 hours.

• Nerve block. A nerve block uses a local anesthetic to provide targeted pain relief to an area of your body, such as an arm or leg. It prevents pain messages from traveling up the nerve pathway to your brain. Nerve blocks can be used for outpatient procedures or more-involved inpatient surgery.

  For pain relief lasting several hours, an injection is used for a nerve block. For longer pain control, a catheter may be inserted for continuous medicine delivery or patient-controlled delivery.

• Epidural analgesia. In epidural analgesia, pain medications are injected through a catheter inserted into the epidural space within your spinal canal but outside your spinal fluid. An epidural catheter is often used for labor and delivery, and sometimes before an operation, such as a cesarean section or a major abdominal surgery.

  The epidural catheter can be left in place for several days if needed to control postoperative pain. A continuous infusion of pain relievers, including local anesthetics or opioid medications, can be delivered through the catheter to control pain.

  Patient-controlled epidural analgesia (PCEA), similar to PCA, enables you to give yourself a dose of the pain medication by pushing a button. It, too, has built-in safeguards so that you don't give yourself too much medication.

Your doctor will provide you with instructions for general post-surgical care, such as rest, ice packs, rehabilitative exercises and wound care. Ask to have written instructions to bring home with you.

For minor surgeries these instructions may be the primary means for pain management. After major surgery, they will help you with a more comfortable transition off medication.

You will likely switch to oral pain medications before leaving the hospital and continue to take them at home to manage pain. You will probably take a combination of drugs in pill form, which may include the following:

• Opioids
• Acetaminophen
• NSAIDs, such as ibuprofen and naproxen

Be sure to understand what active ingredient is in each pain medication, what the appropriate dose is, and how frequently to take your medication. Also ask your doctor about possible interactions with over-the-counter drugs you might use, such as cold medicine, or other prescription medications or supplements you regularly take.

After surgery, work with your health care team to make your recovery as prompt and pain-free as possible. You'll need to communicate with your doctors and nurses to help them assess and adjust the pain management plan.

• Be honest about the pain you feel after surgery. Let your doctors and nurses know how much it hurts, where it hurts, and what activities or positions make it better or worse. Your health care team will want to know the intensity of pain on a 0 to 10 scale, where 0 is no pain and 10 is the worst pain you can imagine. The more specific you can be, the better your doctors can help you.
• Don't ignore side effects. Tell your care team if you experience sleepiness, constipation, nausea or other side effects of the medications. A different pain medication or dose can sometimes reduce uncomfortable side effects, and these side effects can often be treated and relieved.