Postsurgical pain is often undertreated.
Opioids are frequently used in perioperative
analgesia, but concern about side effects can result in administration of an inadequate dose for
pain relief. Nonsteroidal anti-inflammatory drugs (
NSAIDs) are used increasingly for postoperative
analgesia. The use of balanced
analgesia-a combination of
opioids,
NSAIDs, and
local anesthesia utilizing agents from other classes (eg,
ketamine,
clonidine)-improves the efficacy of
pain relief and decreases risk of side effects. While lacking some of the troublesome side effects of
opioids, nonselective
NSAIDs may cause
bleeding as a result of their inhibitory effects on COX-1. For this reason, COX-2-selective inhibitors (
coxibs) are attractive
opioid-sparing
analgesic options in the perioperative setting. Factors in addition to side effects such as time to onset of action, duration of action, maximum
pain relief, use of rescue medication, and other factors relevant to a given
pain model are important in determining overall
analgesic efficacy. Clinical studies show that COX-2-selective inhibitors are effective for the treatment of preoperative and
postoperative pain and reduce postsurgical requirements for
opioids. This evidence supports a role for COX-2-derived
prostaglandins as key mediators of
nociceptive pain and peripheral sensitization (
hyperalgesia).
Pain management in the perioperative setting and the role of COX-2-selective inhibitors in acute and
postoperative pain are reviewed here.