Treating Postoperative Acute Pain- New Frontiers

Author: Charles E. Argoff

In surveys that have been done, 95 percent of the drugs that are used to control acute postoperative pain are opioid-based and that’s been done for many years. There is a general movement through the anesthesia and surgical community to what’s known as enhanced recovery after surgery, or ERAS. There are even national organizations that support this. Using multimodal therapy, which is another way of saying opioid sparing approaches, you can enhance recovery, reduce length of stay, and reduce chronic pain. So really, what it comes down to is, what can we do that’s different? We can address acute pain with assessment and measures to preoperatively, intraoperatively, and postoperatively manage people’s pain more aggressively. With respect to who is at risk, I would say that’s important for providers to recognize the well documented groups of individuals, people with certain body habits, lifestyle, habits of smoking, and other premorbid conditions. It’s very important to recognize those factors before the person undergoes treatment, so that the most careful care can be given to preventing those morbidities from complicating their recovery.

What’s very interesting, coming out of Nobel Prize-winning chemistry work is a new understanding of mu receptor activation. It turns out, when the mu receptors are activated, that downstream it can activate a pathway, called the beta-arrestin pathway, which is what’s responsible for most of the side effects, as well as pathways which are responsible for the analgesic effects. And it has been understood for years that G protein signaling agents can allow for a more selective downstream activation of the positive aspects of an opioid while minimizing the activity of the downstream pathways that you would not want to activate. In other words, in plain language, you get the analgesia without activating the beta-arrestin pathway which is where novel analgesics in this class are being developed that might take us to a whole new plateau.

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