Insights into Chronic Postsurgical Pain

Most postsurgical patients experience moderate to severe acute pain which, in some patients, transitions to chronic postsurgical pain (CPSP). Optimal pain control of acute surgical pain will likely blunt or prevent the transition of acute postsurgical pain (APSP) to CPSP. While there are known risk factors for such chronification of pain type, and certain surgeries (such as limb amputation) and approaches (open versus laparoscopic) are associated with higher rates, it is impossible to predict which patients will transition to CPSP. Additionally, despite knowledge and an armamentarium of analgesics, APSP may be suboptimally controlled. Opioid analgesics can be safe and effective for APSP, but there are legal, social, governmental, clinical, and even cultural barriers to their use. Patients may be reluctant to take opioid agents even when available. Effective APSP control is essential to promote speedy recovery, rapid ambulation, good rehabilitation, and, ultimately, hospital discharge. Since, pain can be multimechanistic, multimodal or combination therapy may be required. Fixed-dose combination products are available that may reduce total opioid consumption by combining a small amount of opioid with an NSAID or paracetamol (acetaminophen). For CPSP, transdermal buprenorphine appears to offer certain advantages in that it is an effective analgesic, can be safely used without dosage adjustment in the elderly and in those with compromised renal function, and the patch delivery system reduces pill burden and reduces the problem of non-compliance. Since tolerability is an important consideration for any pain relievers, side effects should be managed proactively and promptly.