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Medical Meeting Reports

American College of Surgery Clinical Congress

October 10-15, 1999

font=>By Karen Sandrick

According to F. Todd Wetzel, MD, of the University of Chicago Spine Center, surgeons can improve their outpatient pain management skills by considering the different varieties of pain and the way they respond to intravenous or intramuscular pharmaceuticals, topical agents, or external or internal manipulations.

Categories of Pain

Outpatient pain falls into two broad general divisions -- acute and chronic. Acute pain is secondary to internal events and lasts a comparatively short time. It is a reflection of the stimulus-response effect that results from surgical intervention and assumes the patient's central nervous system is intact and tissues will heal.

Acute pain may be nociceptive or neuropathic. Nociceptive means it is mediated by nociceptors distributed in cutaneous tissue, muscles, and connective tissue. Patients with this form of pain have difficulty pinpointing a particular site of pain, and they describe a wide range of pain phenomena: aching, throbbing, sharp. The neuropathic form of acute pain is caused by damage to central or peripheral nerves. It is mediated by specific receptors and described by patients as burning or shooting, electric-like.

Neuropathic pain frequently is resistant to opiates. A distinguishing factor between nociceptive and neuropathic pain, in fact, is the patient's response to opiates. If a patient receives increasing doses of opiates but does not experience relief, the pain most likely is neuropathic.

The International Association for the Study of Pain defines chronic pain as any pain that persists longer than three months, has emotional as well as sensory components, and exhibits significant symptomatology.

Management Strategies

Systemic narcotic agents, particularly morphine, are the mainstays of treatment of pain in the inpatient setting and occasionally are part of outpatient pain management. Non-steroidal anti-inflammatory agents (NSAIDS) may supplement narcotics, although surgeons need to keep in mind that NSAIDs suppress the fever response to infection. Surgeons also may choose Cox 2 inhibitors, which are less likely than other pharmaceuticals to inhibit platelet function, or keterolac for managing acute pain.

When transitioning pain management between the inpatient and outpatient setting, the temptation is to move from strong narcotics (e.g., morphine, methadone, hydromorphone) to weaker ones (codeine, propoxyphene, oxycodone). However, segregating opioids into these categories has no pharmacologic basis as far as the dose-response curve is concerned. Dr. Wetzel consequently suggested that surgeons choose analgesics on the basis of a patient's postoperative needs -- not on any arbitrary definition of opiate strength.

If the pain is nocioceptive, for example, the surgeon may prescribe an NSAID as well as an opiate. For neuropathic pain, the surgeon may select among oral or epidural steroids, tricyclic antidepressants, or anticonvulsants. When pain is chronic, the surgeon may opt for a combination of opiates and NSAIDS. Surgeons may order topical agents, such as the substance A inhibitor capsacin or local anesthetics lidocaine or prilocaine, for treating peripheral neuropathic lesions or tactile electrical nerve stimulation to relieve persistent pain at the incision site.

Route of administration of pain medication is another consideration during the transition to outpatient care. While the goal in the past was to move patients from intravenous and intramuscular pain medications to oral agents before release from the hospital, surgeons today do not have to rely solely on oral medications subsequent to discharge; they can control postoperative pain in the outpatient setting with topical or parenteral medications.

Other Treatment Options

A reservoir for delivering local anesthetics directly to the surgical wound is a promising new form of pain therapy, Dr. Wetzel reported. Epidural catheters or peripheral nerve catheters are choices for managing chronic neuropathic pain after radiotherapy for neoplasia. Peripheral nerve and spinal cord stimulation as well as parenteral delivery techniques, including patient-controlled analgesia, are available for treating extreme cases.

By paying attention to the temporal aspects of pain and the nociceptive/neuropathic dichotomy, surgeons will increase patient satisfaction with their postoperative pain management, Dr. Wetzel said.

Ortho Biotech

Funded through an unrestricted educational grant by Ortho Biotech.

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