Event 1: Meet Charlie

 Charlie is a 17-year-old Caucasian male, who is accompanied by his mother Sarah. Charlie, with his mother’s support, has decided to undergo the surgical extraction of his maxillary third molars, as he was experiencing pain from an impaction for a few years. They are both in the office today.

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Charlie, a male teenager, sits in a dental chair as his mother Sarah looks on.
Charlie and his mother, Sarah.

Managing Acute, Perioperative Pain

Dr. Bauer counsels Charlie and his mother Sarah about managing pain following his wisdom teeth extraction.

Thought Starters

Oral Surgeon's Description of Realistic Pain Expectations

After watching the clinical vignette, how do you feel about the Oral Surgeon’s description of realistic pain expectations?  True or false? The healthcare provider asked about pain expectations during interview.

Correct. The oral surgeon during the clinical vignette did a great job of speaking to the patient as well as his mother regarding appropriate pain expectations after the surgery.
Incorrect

Concrete Treatment Plan

The health care provider identified a rational, patient-centered course and planned utilization of opioids.

Correct. The oral surgeon in the clinical vignette did a great job of providing a rational, patient-centered course, and how he was going to utilize opioids within his therapeutic treatment plan.
Incorrect

Social History

The health care provider obtained a thorough social history (including previous and/or active tobacco, alcohol, and illicit drug use).

Incorrect
Correct. Obtaining a social history is crucial when considering opioids as part of a therapeutic pain plan. However, many clinicians in practice often miss this crucial piece of information. As described later on in this module, you will learn about some of the risk factors for opioid misuse, abuse, diversion, and opioid use disorder. Some of which are included when taking a thorough social history.

Acute Perioperative Pain

  • Acute pain typically arises as a direct result of soft tissue damage and resolves during the appropriate healing period
    • Usually less than 3 months
  • Treatment goals include: 
    • Early intervention, with prompt adjustments in the regimen for inadequately controlled pain
    • Facilitation of recovery from underlying disease or injury 
    • Reduction of pain to a tolerable/acceptable level

Acute pain typically arises as a direct result of soft tissue damage, and resolves during the appropriate healing period. This is usually less than three months. If the patient’s pain continues longer than a three-month period, healthcare practitioners must consider that the patient may be suffering from chronic pain.

With acute pain our overarching goal is to return the patient to a functional state. We do this by providing early and aggressive pain control. The reason for early intervention, with prompt adjustments to a patient’s pain regimen, is that inadequate acute pain control can dramatically increase a patient’s risk for chronic pain.

Additionally, it is important to reduce a patient’s pain level to an acceptable or tolerable level. This piece of information can be especially valuable to healthcare practitioners, as many patients rate pain severity differently. It is important that we ask patients both, “what is your pain now?” as well as, “what level would be tolerable for you?” For example, if the patient reports a pain score of an 8 out of 10 and a tolerability level of a 6 out of 10, your therapeutic regimen may be different than for a patient who reports a pain score of an 8 out of 10 and a tolerability level of a 2 out of 10.

Acute Perioperative Pain Treatment Options

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A step pyramid showing the three levels of treatment options for acute perioperative pain. The bottom tier includes non-pharmacological interventions; the middle tier includes non-opioid analgesics; and the top tier includes opioid agents.
Step pyramid of showing the three levels of treatment options for acute perioperative pain.

When considering acute perioperative pain treatment options, utilize this graphical representation. It is important to utilize nonpharmacological interventions, followed by both non-opiate and adjuvant pharmacological agents, and lastly opioids. It is important to combine these strategies to form a multimodal treatment plan. We have seen that when combining these strategies together, there appears to be a synergistic effect for reducing a patient’s pain. Next we’ll explain each of these strategies.

Non-Pharmacological Interventions

  • RICE:
    • Rest
    • Ice (applied for 20 minutes every hour)
    • Compression
    • Elevation
  • Relaxation and imagery techniques
  • Biofeedback (with other behavioral medicine approaches)
  • Rehabilitation (late during healing period)

Some non-pharmacological interventions include RICE, acronym standing for R. I. C. E., relaxation and imagery techniques, biofeedback, and rehabilitation.  The acronym, RICE, stands for rest, ice, compression, and elevation.

The two components that should be emphasized to patients include icing the injury for only 20 minutes every hour; and, lastly, elevation—elevating the injury above the heart as much as possible.

Next, relaxation and imagery techniques are utilized to induce relaxation and decrease stress and anxiety. Their role in acute perioperative pain is to essentially distract the brain from the pain signal, as well as allow the body to heal in a more relaxing way. Some of these visualizations and guided imagery techniques are available online for free.

Biofeedback involves the use of electronic monitoring of a normally automatic bodily function to train individuals on how to voluntarily control that function.  For pain, this allows patients to control the pain signal to the brain.  For these patients, biofeedback is utilized via a machine.  It is best utilized under the supervision of a medical professional, and is available within specific healthcare systems. Lastly, rehabilitation programs (specifically physical therapy) should only be considered late during the healing period. Again these programs are best utilized under the supervision of a medical professional.

Pharmacological Options

  • Non-opioid analgesics:
    • Acetaminophen (APAP)
    • Non-steroidal anti-inflammatory drugs (NSAIDs)
    • Non-selective (e.g., ibuprofen)
    • COX-2* selective (e.g., celecoxib)
  • Opioids: 
    • e.g., morphine, hydrocodone/APAP (Norco®)
  • Combination of both non-opioid and opioid analgesics

*COX-2: cyclooxygenase-2

Once again it is important to combine both non-opioid and opioid analgesics.

APAP*

  • Mechanism of action: unknown (thought to be due to COX-2 inhibition)
  • Most common cause of acute liver failure in the United States
    • Contraindications: chronic and severe liver disease, and chronic alcohol use
  • Dosing:
    • Initial: 325-500mg by mouth every 4-6 hours 
    • Maximum: 4,000mg/day 
      • Also consider other products containing APAP

*APAP: Acetaminophen

Acetaminophen is a non-opioid analgesic. Its mechanism of action is currently unknown.  However it is thought to be due to COX-2 inhibition. This inhibition is similar to the analgesic effects of NSAIDs. Acetaminophen is mainly tolerable for patients; most commonly causing nausea or dyspepsia. It however carries one significant and serious adverse drug event which is acute liver failure.

Acetaminophen is the most common cause of acute liver failure in the United States. It is contraindicated for patients with chronic severe liver disease or chronic alcohol use. It is dosed 325 to 500 mg by mouth every 4 to 6 hours, either scheduled or as needed, with a maximum daily dose of 4000 mg (or 4 g) a day. This 4-gram a day maximum limit is to reduce the risk of acute liver failure.

It is also important to counsel patients on the awareness of acetaminophen in other over-the-counter products. If a patient is consuming other acetaminophen-containing products, it is important that the dosage of those products also be taken into consideration so as not to exceed the maximum daily dose.

NSAIDs*

  • Mechanism of action: inhibition of COX-1** and COX-2 (varying degrees)
  • Little evidence to suggest one NSAID over another
    • Typically consider ibuprofen or naproxen sodium
  • Dosing: (ibuprofen)
    • Initial: 200-400mg by mouth every 4-6 hours with food 
    • Maximum: 2,400mg/day 
  • Adverse Drug Reactions: 
    • Nausea/vomiting
    • Renal dysfunction
    • Gastrointestinal bleeding

*NSAIDs: Non-steroidal anti-inflammatory drugs; **COX-1: cyclooxygenase-1

Nonsteroidal anti-inflammatory drugs (or NSAIDs) can be a useful class of medications for acute perioperative pain. These medications work by inhibiting cyclooxygenase-1 (or COX-1) and cyclooxygenase-2 (or COX-2) enzymes. The COX enzymes are responsible for the formulation of prostanoids in the body.

There are many commercially available NSAIDs on the market, each with varying degrees of COX-1 and/or COX-2 inhibition. There is little evidence  to support the use of one NSAID over another; therefore we typically consider using either ibuprofen (with a brand name of Advil) or naproxen sodium (brand name Aleve), as both of these agents are available over-the-counter at low cost.  Located on this slide are the dosing recommendations for ibuprofen.

The initial dosing of ibuprofen is 200 to 400 mg by mouth every 4 to 6 hours.  This can be both scheduled or as needed. The maximum daily dose of ibuprofen is 2400 mg a day. With short-term use there are three main adverse drug reactions to be aware of. These include: nausea and vomiting, renal dysfunction (more specifically acute renal injury), and gastrointestinal bleeding. When counseling patients it is important to stress that NSAIDs should be taken with food as well as plenty of water.

If a patient experiences any of these intolerable adverse drug reactions, or finds the presence of blood in either their urine, feces, or vomit, they should report this to their health care team immediately.

Opioids

  • Mechanism of action: mu-agonists
  • Little evidence to suggest one opioid over another
  • Typically consider hydrocodone/APAP (Vicodin®), oxycodone, and morphine 
  • Dosing: (hydrocodone/APAP)
    • Initial: 1-2 tablets every 4-6 hours as needed
    • Maximum: (due to APAP: 4,000mg/day)
  • Adverse Drug Reactions: 
    • Constipation (consider prescribing sennosides or other bowel regimen)
    • Nausea/vomiting

Opioid agents induce analgesia through mu-receptor agonism. Opioids essentially reduce pain by slowing the pain signal from the periphery to the brain; modulate (or reduce) the pain signal within the brain, and lastly gives the brain a bit of pleasure (through the release of dopamine within the dopamine reward pathway).

There is also little evidence to suggest one opioid over another, therefore we usually consider combination non-opioid/opioid products, such as Norco, as seen in the clinical vignette. The initial dosing of Norco is 1 to 2 tablets every 4 to 6 hours as needed with a maximum daily dose of 4000 mg of acetaminophen a day.

The most common adverse drug reaction for opioids is constipation. It is important to note that constipation can occur after even one dose of the opioid medication and that this particular reaction will not subside until the opioid medication is discontinued. Patients will also not become tolerant to this adverse drug reaction over time. Therefore, it may be appropriate to prescribe a bowel regimen (such as sennosides or Senna) for a patient throughout the duration of their opioid therapy. Lastly nausea and vomiting can also occur at the initiation of opioid therapy. It is important to counsel patients on the expected duration of this reaction. The patient should become tolerant to the nausea and vomiting after a few days.

Estimated Equianalgesic Doses of Non-Opioid and Opioid Agents
  • 5mg hydrocodone =
    • 650mg APAP
    • 200-400mg ibuprofen
    • 275mg naproxen sodium
  • Consider utilizing these non-opioid agents in specific populations

One other important parameter to mention is that there has been evidence suggesting comparable equal analgesic effects across non-opioid and opioid agents. Literature has suggested that the analgesic properties associated with 5 mg of hydrocodone (the opioid agent found in Norco) has equivalency to: 650 mg of acetaminophen, 200 to 400 mg of ibuprofen, or 275 mg of naproxen sodium. Consider these equal analgesic properties—or pain-reducing properties—of some of these non-opioid agents in specific populations, especially when you’re considering low dose opioids in their therapeutic plans.

Pain Expectations and Setting Limits

Clinical Pearl 1

Next: Maximizing Opioid Safety

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