Discussion and References

Discussion

The importance of managing patients' pain reflects the core value medicine places on the alleviation of suffering. Achieving this goal is a complex mission, and strategies must consider the biologic and psychosocial aspects of pain.

Strategies to relieve surgical pain have traditionally been dominated by postoperative opioid analgesia. The demand for opioid-sparing analgesic options, however, has been underscored by the desire for better pain management in general and concern about opioid side effects in particular. Reliance on opioids often leads healthcare providers to balance effective pain management with prodigious efforts to avoid complications from side effects.

Developments in the pharmacology of pain have created expanding vistas, allowing discovery of interventions that are both safer and more efficacious while being appropriate to contemporary understanding of clinical pain management. Understanding of pain mechanisms has revealed the importance of proactive interventions in analgesia that aim to prevent initiation of hyperalgesia and central sensitization through preemptive analgesia. An appreciation of balanced approaches to analgesia has allowed for safer pharmacologic strategies for analgesia.

Nonselective NSAIDs are not used in the perioperative setting. The analgesic benefit of NSAIDs, however, provides a germane standard of analgesic efficacy. Coxibs, the COX-2 selective inhibitors, have emerged as a class of analgesic agents that offers pain relief similar to nonselective NSAIDs without compromising platelet aggregation or causing GI toxicity.

Clinical data evaluating the use of coxibs before or after various surgical procedures showed that there was no increased blood loss associated with rofecoxib or celecoxib use. Moreover, many surgical outcomes (eg, time to recovery) often depend on how soon a patient can regain mobility. Across studies, patients with lower opioid usage regained mobility faster than their more opioid-dependent counterparts. This feature has obvious value in both the hospital and outpatient settings.

Studies of pain are limited by the subjectivity of pain and the lack of a gold standard for pain measurement. Most studies rely on the VAS as an important endpoint for measuring pain in the perioperative setting. Nevertheless, analgesic efficacy is the outcome of many factors: time to onset of action, duration of action, side effects, maximum pain relief, usage of rescue medication, and any other specific factors relevant in a particular acute pain model. Multiple studies of pain using these criteria have shown that coxibs are an effective analgesic option in the treatment of acute and perioperative pain. Additionally, clinical data have shown that rofecoxib has a longer duration of action than celecoxib or ibuprofen when used in both the preoperative and postoperative settings. The confluence of clinical data from randomized, blinded studies suggests that COX-2-selective inhibitors contribute to an enhanced standard of care for patients.

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