Acute pain is 7 days
Subacute pain is 7-90 days
Chronic pain is 90 days+
Factors that negatively affect postoperative pain intensity include:
Psychological factors improving acute pain include:
- Preoperative self-distraction
- Emotional support and religious-based coping
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Opioid dose determinants in acute pain
Patient age is often a better predictor of dose requirement than weight
A two to four fold decrease in opioid requirements as age increases is usually due to pharmacodynamic (what a drug does to a body) changes rather than pharmacokinetic (what the body does to a drug) factors
Discharge factors
SR opioid formulations should not be used because of short-term titration difficulties
Transdermal patches - again - difficulty with titration makes these unhelpful
Methadone - Half-lives are very unpredictable
Driving on discharge
Health authorities often recommend that patients prescribed opioids for chronic pain or cancer pain not drive until their dose is stable (e.g. no dose change for 4 weeks) or for as long as they require a short-term opioid for treatment of acute pain.
Risk factor for prolonged opioid use
Affective distress is more predictive than length of opioid use or type of surgery performed
Particularly catastrophic thinking and depression
When are opioids contraindicated?
Misuse or abuse of drugs or alcohol, Potential interaction with other drugs, severe renal or hepatic impairment may affect use of some opioids, psychiatric comorbidities, increased falls risk, respiratory insufficiency, OSA, occupation limitations.
If opioids are not working appropriately on discharge - what next?
Assess for new red flags
Consider complication conditions such as CRPS or neuropathic pain
Consider psychological vulnerabilities
Assess for other risk factors such as tolerance, other pain locations
Check they are taking the medication
Look at non-pharm appropriate therapies
Risk factors for persistent postsurgical pain
1 in 5 patients post surgery will develop persistent postsurgical pain
References:
FPM - Better pain management
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