Postoperative Pain in Patients with Chronic Pain 

The National Center for Health Statistics estimates that 25% of the United States population suffers from chronic pain, incurring an annual cost of up to $635 billion [1,2]. This prevalence extends to a quarter of surgical patients as well, and this figure is expected to rise as the population ages and medical treatments become more advanced [2]. Postoperative pain affects as many as 80% of major surgery patients, and when poorly managed, it can lead to various complications, including chronic pain [2]. On the other hand, surgical patients who already receive treatment for existing chronic pain may have more complicated requirements for postoperative pain management. 

The opioid epidemic is closely tied to these issues, with one-fifth of Americans receiving opioid prescriptions, primarily from pain medicine and surgery providers [2]. The escalating prescriptions raise risks of tolerance, adversity, addiction, and overdose, prompting a shift towards limiting opioid use in pain management [2]. Despite these challenges, opioids remain some of the most potent pain relievers available. Perioperative healthcare providers must navigate the delicate balance between pain relief and minimizing adverse medication effects [1,2]. 

Postoperative pain remains a challenging and often undertreated issue for the more than 73 million patients undergoing surgery annually in the United States [3]. Over 80% of these patients experience postoperative pain, with more than 85% reporting it as moderate, severe, or extreme [3]. Inadequate pain control contributes to postoperative morbidity, prolonged recovery, and decreased satisfaction with care, with the potential for postoperative pain to develop into a chronic condition [3]. In addition, a 2023 retrospective study of 107,412 patients recovering from major surgery found that those with a preexisting diagnosis of chronic pain experienced significantly longer postoperative pain durations than those without [5]. 

A multimodal approach proves valuable for enhancing acute postoperative pain management, offering a solution to concerns associated with opioid use [2]. This comprehensive strategy involves using various pain medications with distinct mechanisms of action coupled with neuraxial and peripheral regional analgesia for thorough pain control [2]. Nonopioid medications for pain management commonly include acetaminophen, gabapentinoids, alpha-2 adrenergic agonists, NSAIDs, ketamine, lidocaine, and magnesium [2]. Neuraxial techniques, including epidural and spinal methods and peripheral nerve blockade, are widely adopted for managing acute perioperative pain, demonstrating effectiveness in achieving opioid-free analgesia [2]. 

Opioid analgesics are commonly used to manage moderate to severe acute pain, such as postoperative pain, but patients with chronic pain or opioid tolerance may require higher doses for the desired effect [2]. While dose escalation can achieve therapeutic outcomes, it heightens the risk of adverse effects such as excessive sedation, respiratory depression, constipation, nausea, vomiting, and hormonal dysregulation [2]. In the postoperative setting, these opioid-related adverse effects may prolong hospital stays, impede recovery, and increase morbidity and mortality [2]. A clinical practice known as opioid rotation, highlighted in a 2018 systematic review by Schuster et al., involves substituting one potent opioid with another when an optimal balance between pain relief and adverse effects is not achieved with the initial opioid [2]. This approach has shown significant benefits, particularly in chronic cancer patients, resulting in reduced opioid doses needed for analgesia and increased patient satisfaction [2]. Studies among noncancer patients have also demonstrated decreased opioid requirements and improved pain relief through opioid rotation [2]. 

Effective pain management is critical in the face of chronic pain and postoperative challenges. The opioid epidemic, escalating prescriptions, and associated risks emphasize exploring alternatives like multimodal approaches and opioid rotation [1,2]. These strategies offer promising avenues for optimizing acute postoperative pain management, enhancing patient outcomes, and minimizing reliance on opioids. 

References 

1. Chapman, C., Davis, J., Donaldson, G., Naylor, J., & Winchester, D. (2011). Postoperative pain trajectories in chronic pain patients undergoing surgery: the effects of chronic opioid pharmacotherapy on acute pain. The Journal of Pain, 12(12), 1240-1246. 

2. Aroke, E., McMullan, S., Woodfin, K., Richey, R., Doss, J., & Wilbanks, B. (2020). A practical approach to acute postoperative pain management in chronic pain patients. Journal of PeriAnesthesia Nursing, 35(6), 564-573. 

3. Chapman, C., Donaldson, G., Davis, J., Ericson, D., & Billharz, J. (2009). Postoperative pain patterns in chronic pain patients: a pilot study. Pain Medicine, 10(3), 481-487. 

4. Kubulus, C., Mahlstedt, S., Wagenpfeil, G., Sessler, D., & Volk, T. (2023). Chronic pain patients and time to sustained acceptable pain scores after major surgery-A retrospective registry analysis. Journal of Clinical Anesthesia, 89, 111152. 

5. Schuster, M., Bayer, O., Heid, F., & Laufenberg-Feldmann, R. (2018). Opioid rotation in cancer pain treatment: a systematic review. Deutsches Ärzteblatt International, 115(9), 135.