Preventive Analgesia and Novel Strategies for the Prevention of Chronic Post-Surgical Pain

Abstract

Chronic post-surgical pain (CPSP) is a serious complication of major surgery that can impair a patient's quality of life. The development of CPSP is a complex process which involves biologic, psychosocial, and environmental mechanisms that have yet to be fully understood. Currently perioperative pharmacologic interventions aim to suppress and prevent sensitization with the aim of reducing pain and analgesic requirement in acute as well as long-term pain . Despite the detrimental effects of CPSP on patients, the body of literature focused on treatment strategies to reduce CPSP remains limited and continues to be understudied. This article reviews the main pharmacologic candidates for the treatment of CPSP, discusses the future of preventive analgesia, and considers novel strategies to help treat acute postoperative pain and lessen the risk that it becomes chronic. In addition, this article highlights important areas of focus for clinical practice including: multimodal management of CPSP patients, psychological modifiers of the pain experience, and the development of a Transitional Pain Service specifically designed to manage patients at high risk of developing chronic post-surgical pain. Key PointsThe development of chronic post-surgical pain (CPSP) is a complex process which involves biologic, psychosocial, and environmental mechanisms.Ketamine (an NMDA antagonist) appears to be the pharmacologic agent with the most consistent positive preventive analgesic results.The variation in patient response to pharmacologic agents can be explained, in part, by genetic polymorphisms.Understanding the heritability of CPSP will be useful when developing predictive algorithms to determine the preoperative risk for developing CPSP.Psychological treatments delivered before and after surgery have the potential to influence the trajectory of CPSP from the earliest days, in combination with multimodal, preventive analgesia.

Transitional Pain Medicine: novel pharmacological treatments for the management of moderate to severe postsurgical pain

“…[32] A comprehensive systematic review for the prevention of chronic pain after surgery in adults identified ketamine as the most reliable pharmacological agent for the prevention of CPSP.…”

Pregabalin reduces postoperative opioid consumption and pain for 1 week after hospital discharge, but does not affect function at 6 weeks or 3 months after total hip arthroplasty

“…gabapentin and pregabalin, α 2 δ subunit voltage-dependent calcium channel blockers) may prove to be a useful tool in the postdischarge time period with patients struggling from prolonged moderate-to-severe acute postsurgical pain. 51 In a recent systematic review, even though results between the studies included were heterogeneous at 3 month follow-up, pregabalin was proposed to have an effect with respect to modifying postsurgical pain trajectories and reducing the development of chronic postsurgical pain. 52 However, in light of a recent publication demonstrating that several cohorts of patients did not experience the preventive effect for pregabalin on chronic post surgical pain (CPSP) 53 and the evidence we present herein, this conclusion needs to be reassessed.…”

“…57 This emerging literature suggests that patients should be screened before surgery for psychological vulnerabilities, and based on the results, psychological interventions, in addition to multimodal preventive analgesic strategies such as the ones implemented in this trial, should become a mainstay for perioperative postsurgical care. 51 This is the first study to compare the efficacy of pregabalin vs placebo for recovery of physical function at three time points (baseline, 6 weeks, and 3 months) for patients undergoing total hip arthroplasty. Although negative for such outcomes, a reduction in cumulative 24 h opioid consumption and superior pain relief for 1 week postdischarge was evident.…”

Donor Hepatectomy Surgery using Ketamine to Compliment Analgesia and Reduce Morbidity - a Retrospective Chart Review Investigation

“…These pain management strategies of unimodal opioid administration for donor hepatectomy patients might result in suboptimal analgesic effectiveness that can introduce compromising adverse effects (AEs) and further predispose these patients to the potential of prolonged postoperative pain. Therefore, analgesic alternatives and other supplemental pain management strategies need to be considered (11). Postoperative liver dysfunction and the potential for compromised coagulation effectiveness can be an outcome from liver resection surgery.…”