What kind of

pain is the
Self-Limited pain patient Pain the persissts
that occurs as the experiencing? beyond the natural
result of an injury healing Process
Peroperative
Pain
Musculoskeletal
Acute Characteristics:
Beneficial
Characteristics: - Chronic Pain
Persistent or intermittent
Pre-Op: 1 to 2 Adaptive - Pathologic
hours before Protective - Maladaptuve
Is it coming from Is there damage to Clear Cause
surgery. Prevent - Unclear Cause
stimuli causing a the tissues leading First Line
peripheral - Challenging
shark, shocklike to inflammation? Non-Pharm:
sensitization management
pain? Multidisciplinary
- Physchologic
management
Component Neuropathic and physical
Nociceptive Inflammatory Pain exercise
Pain Pain Diabetic
Trigeminal
Intra-Op: During the Peripheral
Neuralgia
operation. Prevent Neuropathy
Second Line
central sensitization due Pharmacologic:
to incisional injury Postherpetic
1st Line: Non-Pharm Fibromyalgia First Line APAP,
Neuralgia
Pharmacologic: NSAIDs
First Line: Duloxetine,
2nd Line: Pharm Carbamazepine How to Prevent: First Line: Pregabalin
Therapy Shingles Non Pharm Third Line
Post-Op: Want to Vaccination (Education Second Line Pharmacologic:
reduce acute pain and Second Line: (shingrix) and Pharmacologic: Weak
further prevent from Oxcarbazepine Psychological TCAs, opioids,
chronic pain (within APAP - for support & antidepressants,
gabapentin,
one week post-op) mild/moderate First Line Exercise!) muscle
venlafaxine
pain Pharmacologic: relaxants
Third Line: Lidocaine
Combination patch
NSAIDs - for Second Line
Therapy Third Line
inflammatory Pharmacologic:
Pharmacologic:
conditions, Duloxetine, Last Line
Second Line Combination
Overall treatments: APAP, watch for Milnacipran, Pharmacologic:
Pharmacologic: Therapy
NSAIDs, Pergabalin, bleeding risks Amytripyline, Strong opioids,
Gabapentin,
Gabapentin, Local Pregabalin, anticonvulsants
Pregabalin,
Anesthetics, Opioids Cyclobenzaprine,
Topical
Opioids - most Tramadol Last Line
Capsaicin, TCAs
effective, start with Pharmacologic:
combo products Opioids
(e.g codeine) Third Line
Third Line Pharmacologic:
Pharmacologic: Gabapentin,
Tramadol SSRIs,
Venlafaxine,
Cannabinoids

KEY:
Monitoring/Safety/AEs
APAP: Acetaminophen
- Many formulations, caution in alcohol use and liver dysfunction, maximum dose 4000mg/day, can cause hepatotoxicty and skin rxns (SJS, TEN, AGEP)
NSAIDs:
- Overall Counseling: Antinflammatory agents, decreased renal clearance, increased BP, increased risk of MI/stroke, avoid in pregnancy (third trimester), nausea, GI
Bleeds
- Non-Selective: Ibuprofen, Indomethacin, Naproxen, Ketorolac
- Counseling: Increased risk of GI bleeds, max of 3200mg/day (Ibuprofen), Risk of CNS effects (Indomethacin), short term use - risk of renal and liver failure
(ketorolac)
- COX-2 Selective: Celecoxib, Diclofenac
- Counseling: Increased MI/stroke
Skeletal Muscle Relaxants: Carisoprodol, Diazepam, Tizanidine, Baclofen, Dantrolene, Chlorzoxazone, Cyclobenzaprine, Methocarbamol, Metaxalone, Orphenadrine
- Monitoring: Can cause CNS depression and have additive effects, should be used short term, should be d/c if ineffective, add risk for polypharmacy
Opioids: Oxycodone, Morphine, Hydrocodone, Fentanyl, etc.
- Monitoring: Watch for - life threatening respiratory depression, addiction, interactions with alcohol, heat exposure, cytochrome P450 interactions, concomitant use
with MAOIs, tablet crushing (with specific formulations), life threatening QT prolongation, medication errors, nausea, vomiting
Combination Opioids: e.g Hydrocodone & APAP
- Monitoring: Watch for - life threatening respiratory depression, addiction, interactions with alcohol, heat exposure, cytochrome P450 interactions, concomitant use
with MAOIs, tablet crushing (with specific formulations), life threatening QT prolongation, medication errors, nausea, vomiting
Antidepressants
- SSRI: Duloxetine, Milnacipran, Venlafaxine
- Monitoring: Increased bleeding risk, dose adjustments with renal/hepatic impairment
- TCAs: Amitriptyline, Nortriptyline, Desipramine, Imipramine
- Monitoring: Lower doses necessary compared to MDD doses, multiple cardiac/anticholinergic effects
Anticonvulsants: Gabapentin, Pregabalin, Topiramate, Lamotrigine, Carbamazepine
- Monitoring: CNS depressions, risk for impairment, drug rashes, hepatotoxicity, blood dycrasias, bone loss, suicide risk