Unlocking Pain-Free Recovery: A Guide to Multimodal Pain Management after Surgery

Recovering from outpatient surgery can feel overwhelming, especially when anticipating postoperative pain. Modern medical practices emphasize a comprehensive multimodal pain management approach tailored specifically for outpatient recovery, aiming to optimize patient comfort, safety, and recovery outcomes. Pain free recovery after surgery focuses on planning ahead and anticipating pain breakthrough,

Multimodal pain management involves strategically combining various medications and techniques to manage pain effectively while minimizing side effects and opioid use. An effective strategy includes using medications with different mechanisms of action, different duration, and staggered at different times to stay ahead of the pain. Once, we fall behind in pain, it is hard to catch up. A detailed pain management plan created by your surgical team will typically include screening for opioid use risk factors, education about safe medication use, and clear instructions on managing pain at home.

Essential elements of outpatient multimodal pain management involve using a variety of medications that target pain through different mechanisms. When medications are strategically combined and administered at intervals, they provide superior pain relief. Patients often believe that some medications are ineffective; for example, many patients say, "Tylenol doesn't work for me." While it's true that Tylenol alone might not fully eliminate pain, it still contributes significantly to overall pain control within a comprehensive pain management plan.

Here are different classes of pain medications and typically dosing. 

1. Non-Opioid Medications, cornerstone of Pain Free Recovery after surgery:

A combination of these type of medications is very effective if taken regularly, particularly for prolonged pain management.

• Acetaminophen (Tylenol): Relieves mild-to-moderate pain and fever. Onset of action within 30-60 minutes.

• Typical dosing ranges from 325-1000 mg every 4-6 hours, not exceeding 4000 mg per day to avoid liver damage. Extra Strength, 500mg, Tylenol is sold over the counter

  • Tylenol 650mg every 4 hours

  • Tylenol 1000mg every 6 hours (Regimen starts 6am, 12pm, 6pm)

• NSAIDs: Non Steroidal Anti-inflammatory Drugs, Reduce inflammation and alleviate mild pain.

  • Ibuprofen: 200-800 mg every 6-8 hours. Onset of action within 30-60 minutes

  • Naproxen: 250-500 mg twice daily. Pain relief felt within 1 hour

  • Celecoxib: 200 mg once or twice daily. Pain relief felt within 1-3 hours

  • Toradol: 10mg every 4-6 hours. Onset of action approximately 30 to 60 minutes, with peak effects around 1–2 hours after administration.

  • Diclofenac 50mg ER every 8 hours.  Typically beginning pain relief within 1 to 2 hours, with peak therapeutic effects reached within approximately 3 to 5 hours. However, it provides sustained pain relief for about 12 to 24 hours.

  • Side effects: Gastrointestinal issues, increased bleeding risk, kidney impairment. Always important to take these medications with meals for protection. Celecoxib has less risk of gastrointestinal problems and ulcers in the short term. 

• Gabapentinoids Effective for nerve-related pain such as groin hernias, neuropathic pain, back pain. Initial pain relief typically begins within 1 to 2 hours, but optimal pain control may take several days of consistent use.

  • Gabapentin: 300-600 mg three times daily.

  • Pregabalin: 50-150 mg two to three times daily.

  • Side effects: Drowsiness, dizziness, blurred vision, peripheral edema.

• Antidepressants: Useful to manage chronic pain, nerve pain, and headaches. Pain relief typically begins within 1 to 2 weeks, with maximal benefit usually seen after 4 to 6 weeks of regular use.

  • Effexor XR: Typically 37.5-75 mg once daily.

  • Cymbalta: 30-60 mg once daily.

  • Savella: Starting dose of 12.5 mg, gradually increased up to 50-100 mg daily.

  • Side effects: Nausea, dizziness, sleep disturbances, changes in weight.

2. Muscle Relaxants:

Relieve muscle spasms, stiffness, musculoskeletal pain, muscle spasms. Onset of action generally 30 to 60 minutes after oral administration.

• Cyclobenzaprine: 5-10 mg three times daily.

• Methocarbamol: 500-750 mg every 4-6 hours.

• Tizanidine: 2-4 mg up to three times daily as needed.

Side effects: Drowsiness, dizziness, fatigue, dry mouth, potential dependency.

3. Journavx (Suzetrigine):

Manages neuropathic and postoperative pain by modulating nerve activity.

• Journavx (Suzetrigine): Typical starting dose is 100-150 mg once or twice daily, adjusted based on pain response and tolerability. New FDA approval!

Side effects: Dizziness, somnolence, nausea, headache

4. Opioid Analgesics (As Needed):

Potent pain relievers for moderate to severe pain. Onset of action is typically within 30-60 min 

• Tylenol #3 with codeine, 300mg tylenol/30mg codeine, 1-2 tab every 4-6 hours

• Tramadol: 50 mg every 4-6 hours as needed.

• Hydrocodone: 5 mg every 4-6 hours as needed. Typically contains tylenol 325mg

• Percocet: 5 mg every 4-6 hours as needed. Typically contains tylenol 325mg

• Oxycodone: 5 mg every 4-6 hours as needed.

• Morphine: 5 mg every 4-6 hours as needed.

• Dilaudid: 2mg every 4-6 hours as needed

Short-term opioids are used briefly at the lowest effective dose to minimize potential complications like addiction, respiratory depression, and constipation. Stool softeners are typically prescribed concurrently given the high risk of constipation. 

5. Local Anesthetics and Regional Anesthesia

• Local anesthetics provide immediate postoperative pain relief when injected around the surgical site.

• Regional nerve blocks substantially reduce pain intensity for hours or days after surgery, allowing easier home recovery.

6. Interventional Pain Management

• Includes anesthetic or steroid injections, spinal cord stimulation, drug delivery systems, or nerve blocks, providing targeted pain relief.

7. Non-Opioid Anesthesia

• Alternatives to opioids can be used during surgery to provide safe and effective pain management, reducing the risk associated with opioid use.

8. Topical Medications:

• Provide localized pain relief with fewer systemic effects. Onset of action usually 30 minutes to 1 hour after application, with localized effects.

  • Topical anesthetics (like Lidocaine patches) applied up to 12 hours daily.

  • Topical NSAIDs applied as directed, typically 2-4 times daily. Common brands include Bangay, Voltaren, Advil topical

  • Capsaicin cream applied 3-4 times daily. 

• Do not apply directly on open wounds or incisions 

9. Complementary and Non-Medication Therapies for Pain free recovery after Surgery

• Cold Therapy and Heat Therapy: Ice applied for 15-20 minutes every hour; heat applied for 15-20 minutes as needed. However, do not fall asleep with heat/cold compresses as it may cause burns

• Physical Therapy and Exercise: Gentle mobilization, stretching, walking, yoga, and tai chi as recommended by your therapist or physician.

• Acupuncture and Chiropractic Care: Regular sessions as recommended by practitioners.

• Behavioral and Mental Health Therapies: Scheduled sessions according to patient needs and therapist recommendations.

Effective outpatient pain management also emphasizes patient education, including:

• Prioritizing non-opioid options first.

• Understanding the safe use, storage, and disposal of opioids.

• Recognizing pain severity and matching treatments accordingly:

  • Mild Pain: Managed effectively by non-medication therapies and occasional non-opioid medication.

  • Moderate Pain: Routine non-opioid medications scheduled and complementary therapies.

  • Severe Pain: May require short-term opioids combined with scheduled non-opioid medications and therapies.

Safety precautions regarding opioids include taking medications exactly as prescribed, avoiding combinations with sedatives or alcohol, and gradually tapering under medical supervision to reduce withdrawal and dependence risks. Also, avoid crushing narcotics as this can lead to faster absorption and possible overdose. Narcan 0.4mg, nasal spray is a powerful reversal agent for opioids 

Our approach to pain management focuses on maximizing non opioid medications with complimentary therapies while focusing on opioids for breakthrough pain. Breakthrough pain is a sudden, temporary flare-up of intense pain that occurs despite regular use of pain medications. It can happen unexpectedly and typically lasts from minutes to an hour, even when baseline or background pain is well-controlled. Breakthrough pain often requires additional or supplemental medication for effective relief.

Typical schedule of pain medication can be personalized for different surgical procedures. For instance, Knee surgery is a more painful procedure than a hernia repair.

Our practice focuses on robotic surgery, and a typical regimen is as follows

• 7 am After Surgery: Take Ibuprofen 600-800mg with breakfast. Morning after surgery can be rough because you have not received any medications overnight. Adequate to take Opiod if pain is severe. Use Ice as needed throughout the day

• 8am Walk around if “gas pain” after laparoscopic/robotic surgery

• 9am Take tylenol 500mg or 1000mg depending on pain level. 

• 11am Repeat dosing of Opiod, Oxycodone 5mg. Ok to alternate with Muscle Relaxant such as Robaxin

• 1pm Take Ibuprofen 600mg with Lunch

• 2pm Take Tylenol 500mg

• 3pm Ok To take Opiod, 5mg Oxycodone as needed. Also remember to use Ice Liberally. Ok to alternate with muscle Relaxant such as 500mg Robaxin

• 6pm Take Tylenol 1000mg

• 7pm Narcotic As needed, ok to cut tablet in half, 2.5mg Oxycodone

• 8pm Ibuprofen 600mg with Dinner

• 9pm Ice/Walk

• 10pm Tylenol 500mg

• 11pm Ok to take Narcotic prior to going to bed to help with sleep. Muscle Relaxants are also effective

Effective outpatient multimodal pain management significantly enhances patient comfort, reduces risks associated with medication use, especially opioids, and facilitates quicker recovery and improved patient satisfaction. Collaborating closely with your healthcare provider to tailor a personalized pain management plan ensures optimal safety and effectiveness, setting you on the path to a smooth and successful recovery.

If you have any questions about your specific and tailored pain regimen plan, don’t hesitate to contact our office