How To Treat Severe Post-Op Pain

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Q: What about this patient you described who has been transferred to a skilled nursing unit (SNU)? What options do we have?
A:
Keep in mind that admission to the SNU is essentially a step below an in-patient status but certainly a step up from home or assisted living facility status. The only limitation one has in prescribing narcotics in the SNU setting is the inability to use intravenous narcotics. This basically eliminates PCA or any IV narcotic push. Options may still include intramuscular routes such as morphine and Demerol. Even Toradol can be used in this setting.
Once the acute phase of the post-op pain is over, it is simple to return to oral pain medications only. Initially, I would recommend Demerol 75mg and Vistaril 25mg IM q 4h prn for severe pain and Percocet 5/325 1-2 PO q 4h prn pain for mild to moderate pain. Once the patient no longer requires intramuscular orders, simply discontinue this route of narcotic administration.

Q: What about those patients in the SNU that require eight to 10 Percocet 7.5/500 per day or Vicodin ES per day? Do you feel comfortable keeping the patient on that kind of a dose?
A:
No, I feel this provides increased risk to the patient. Remember, the patient receives substantial amounts of acetaminophen with these dosages. The recommended upper limit of daily acetominophen intake is 4000 mg. Patients receiving more than this dose are predisposed to an increased risk of liver toxicity. In addition, the patient is still most likely developing significant breakthrough pain throughout the day.
My first inclination would be to use a safer short acting narcotic, such as MSIR (morphine sulfate immediate release), which does not contain acetominophen. An MSIR 15mg tablet is basically equivalent to one Percocet tablet. Because MSIR lacks acetominophen, it has no ceiling limit. My typical starting dose would be MSIR 15mg tablets, 1 to 2 PO q4h prn pain.

Q: Are there alternative narcotics available?
A:
Absolutely. There are long acting narcotics available that provide a constant plasma level of pain medication. This class of medication avoids the peaks and troughs of the short acting narcotics, thereby giving the patient a more consistent level of pain relief. In today’s clinical practice, you have four long acting narcotic options: MS Contin (long acting morphine), Duragesic Patch (long acting fentanyl), Oxycontin (long acting Percocet) and methadone.
In a patient receiving five to six Percocet per day, I feel very comfortable starting Duragesic Patch 25mcg/hr. At this dose, the patient should have significant relief and no significant side effects. This is even the case for elderly patients as well. In addition, this medication lasts 72 hours. I write my typical prescription as “Duragesic Patch 25mcg/hr, apply one to the skin and change q3 days, #5 (enough for 15 days).”

Q: The majority of my patients go home after wound care surgery. What are my options for those patients with persistent or severe pain?
A:
Once again, we are limited by the amount of acetaminophen found in the particular pain medication you prescribe. For example, what do we give the patient who is already taking 8 Percocet per day preoperatively for the pain? They will most likely need more at home. If you have enough time to anticipate this problem, simply refer the patient to a comprehensive pain specialist. Alternative narcotics such as MSIR will be recommended, with appropriate dosing, thus eliminating guesswork.
The pain physician will also recognize other causes (i.e. ischemic changes and ischemic neuropathy) that contribute to the patient’s discomfort. Antiseizure medications (i.e. Neurontin, Gabitril) and antidepressants (i.e. Elavil, Trazadone) are just a few classes of drugs for treating this kind of pain. By treating pain at different sites along the pain pathway, we can reduce the amount of narcotics this patient may need postoperatively.

Dr. Goldberg is board-certified in Pain Management as well as Anesthesiology.

Dr. Snyder (shown at right) is a Diplomate of the American Board of Podiatric Surgery and the American Academy of Wound Management.

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