Abstract

Robert Farrar

Pain is the oldest medical problem and is of major concern in the surgical patient. Perception of pain is always subjective and is whatever someone says it is. While preparing the patient for an elective plastic surgical procedure it is important to neither minimize nor exaggerate the amount of pain the patient will experience in the post-operative period. Strategies for management of post-operative pain begin with an appreciation of neuro- anatomy and physiology.  Pain begins with application of a noxious stimulus which is conducted by several pathways to the cortex, limbic system and brainstem where pain is localized, emotionally registered and responded to. Endogenous systems are in place to modulate and minimize pain. The opioid centric model of pain management involves administration of exogenous opioids either orally or parenterally which act on receptors located throughout the central nervous system and the body. Concerns about exclusively utilizing the opioid centric approach are overdose, developing dependence as well as other side effects such as nausea and constipation. The approach used to treating the patient’s pain in the opioid centric model will differ depending on whether the patient is opioid naive or opioid tolerant.  Management of pain in the patient with a substance use disorder and the patient taking buprenorphine or naltrexone are special cases and need advance planning. The current approach to pain management minimizes excessive narcotic administration and instead utilizes a multi-modal and sometimes multidisciplinary methodology. This strategy emphasizes long acting local anesthetics, nerve blocks and a variety of other medications that work at different levels of the pain transmission continuum.  Additionally, adjunct techniques such as TENS, acupuncture, herbal remedies and guided imagery should be considered.