Faculty of Pharmacy
Department of Medicinal Chemistry
25/03/2012
Done By : Badr Mohammed Saleh ALGhamdi
Supervised By : Dr.Majdi Bakhitan
Management of Pain in Operative by Opioid and Non Opioid Agent
Introduction :
pain is “An unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in
terms of such damage. And divided into three stages mild pain , moderate and chronic pain .
Pain in a surgical patient can be due to pre-existing disease , or a combination of pre-existing disease and procedurerelated causes like surgical incision, and/or trauma to a peripheral nerve .
Choice of analgesic in operative are depend on many factor the state of the health of patient , depend also on the state
of the operation, also depend on the choice of analgesic must be with less side effect and good recovery after operation.
.
Analgesic drugs in operation can be divided into opioid and non-opioid drugs. Examples of non-opioid analgesics
commonly used to manage postoperative pain include NSAIDs, acetaminophen and opioids are the main of analgesic
therapy for moderate and severe pain .
Now, there is new technique to analgesia (multimodal analgesia ) means provides additive or synergistic analgesia with
lower doses compared to monotherapy, potentially minimizing adverse effects and improving recovery and function for
example non steroidal anti-inflammatory agent (NSAID) or acetaminophen combined with an opioid.
This journals will review the commonly used drugs in the management postoperative pain.
Body:

ACETAMINOPHEN : alone or in combination with an opioid or NSAID, is frequently used for treatment of mild-tomoderate postoperative pain. Acetaminophen most likely provides analgesia by inhibiting prostaglandin synthesis in the
central nervous system, with no peripheral anti-inflammatory effects. Acetaminophen may improve analgesia and has
been shown to have a morphine-sparing effect in the first 24-hours after surgery, but does not seem to be able to
reduce opioid-related adverse effects. Acetaminophen is an excellent alternative analgesic in a patient who should not
receive an NSAID (or celecoxib) .

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs) : are commonly used for postoperative pain
management. These agents are frequently the first-line therapy for mild to moderate postoperative pain. NSAIDs inhibit
the production of prostaglandins by inhibiting cyclooxygenase. NSAIDs have both a peripheral and central effect .
NSAIDs are known to reduce pain intensity, have a morphine-sparing effect and possibly reduce postoperative
nausea/vomiting and sedation from opioids .The preoperative limitation of traditional nonselective NSAIDs is most often
due to their potential to impair platelet aggregation, which can increase bleeding . Cases of gastrointestinal bleeding or
ulceration have been reported. Recent data suggests that all NSAIDs (nonselective agents and celecoxib) could
increase the risk of new onset hypertension, worsen pre-existing disease, and ultimately increase the risk of
cardiovascular events. In the postoperative setting, NSAIDs can increase the risk of severe bleeding .NSAIDs should be
administered in the lowest effective dose for the shortest duration possible .

OPIOIDS : are the main of treatment for moderate-to-severe postoperative pain management . They are commonly
used as the initial analgesic agent in the immediate postoperative period and are continued postoperatively, for days to
weeks, for moderate or severe pain. Opioids are administered by the oral, parenteral, or neuraxial route, with the
severity of pain and type of surgical procedure dictating the method in which they are administered. Oral opioids, either
alone or in combination with acetaminophen, are frequently administered for moderate pain. Parenteral and neuraxial
Faculty of Pharmacy
Department of Medicinal Chemistry
25/03/2012
Done By : Badr Mohammed Saleh ALGhamdi
Supervised By : Dr.Majdi Bakhitan
opioids are usually administered for severe pain. Opioids exert their effects by binding to central opioid receptors. The
activity of the specific opioid depends on the actual agent and how well it binds to a given opioid receptor. Unlike
NSAIDs and local anesthetics, opioids do not interrupt nociceptive transmission but rather decrease the ability to discern
pain . Opioids differ in potency, safety, and patient characteristics. Propoxyphene, codeine, and hydrocodone are less
potent opioids that are used in combination with acetaminophen. These combination products are indicated for
moderate pain. Higher doses of these opioids would be required to treat severe pain and would cause significant
adverse effects for the patient, including acetaminophen overdose. Morphine, hydromorphone, and fentanyl are potent
opioids that can be used alone in a dose that will treat moderate or severe pain. Oxycodone can be used for moderate
or severe pain, depending upon the product formulation. When combined with acetaminophen or aspirin, the dose is
limited by the amount of acetaminophen or aspirin in the product. Therefore, the dose of oxycodone needed to treat
severe pain could not be provided with a combination product .
Conclusion :

State of health of patient important in choice of analgesic agent for example NSAIDs impair platelet aggregation
and increase risk of bleeding , so should be avoided in cases of gastrointestinal bleeding or ulceration .

Multimodal technique new method used mean used synergistic analgesia to reduce side effect .

Acetaminophen used for treatment of mild-to-moderate postoperative pain and has been shown to have a
morphine-sparing effect in the first 24-hours after surgery, but does not seem to be able to reduce opioid-related
adverse effects.

NSAIDs These agents are frequently the first-line therapy for mild to moderate postoperative pain , have a
morphine-sparing effect and possibly reduce postoperative nausea/vomiting and sedation from opioids .

Opioids are the mainstay of treatment for moderate-to-severe postoperative pain management . used as the
initial analgesic agent in the immediate postoperative period and are continued postoperatively.

Opioids differ in potency, safety, and patient characteristics , Propoxyphene, codeine, and hydrocodone are less
potent opioids that are used in combination with acetaminophen for moderate pain , Morphine, hydromorphone,
and fentanyl are potent opioids that can be used alone in a dose that will treat moderate or severe pain
Oxycodone can be used for moderate or severe pain, depending upon the product formulation .