Post-op Pain Management 101

pain control surgery postoperative care

Surgery hurts.  We (the pain-inflictors) are constantly trying to minimize postoperative pain but we’re not likely to realize pain-free surgery anytime soon.  People are very worried about taking narcotics these days.  In 10 years of practice I never had a patient become addicted to narcotics from purely post-operative use.  That said, use of over the counter meds and some other tricks may help get you off narcotics sooner.  BUT, pain should be controlled if at all possible, you get no points for suffering.  People heal better when they move, breathe, and poop.  So, pain control isn’t “If I stay completely still, I’m fine”.  You won’t be fine for long.

It’s easier to stay ahead of pain than to catch up with it.  Don’t wait until you’re in unbearable pain to take something.  It will take more medication to get you comfortable at that point than you’d have taken before the pain got bad.

LEGAL STUFF ALERT:  I am not responsible for how you use this information, to the best of my knowledge it is accurate.  I am not YOUR doctor.  This is meant to provide a framework for construction of a personal pain management plan.

Over the Counter (OTC) medication:

NSAIDS- Ibuprofen, Naproxen (there are others but you get the idea):  These can be used independently of your prescription pain medicine.  I like Ibuprofen, of these choices, dosing is more flexible, and it can be taken more frequently.  Most adults can take 2400mg (12-200mg pills) of Ibuprofen per day, this is based on weight (more than 50kg = 110lbs) and normally functioning kidneys. I usually recommend splitting this into either 6 doses of 2 pills or 4 doses of 3 pills.

Pros –

  1. Doesn’t have narcotic side effects.
  2. Works pretty well as a baseline pain reliever.
  3. Has an anti-inflammatory effect than can reduce swelling.

Cons –

  1. Can cause stomach irritation which can lead to ulcers / bleeding. Therefore, if you’re taking a lot of any NSAID, taking it with food and/or adding an antacid (see below) is a good idea.
  2. Can make bleeding worse. These NSAIDS aren’t usually strong enough to actually cause bleeding, but they may make whatever bleeding is already going on worse.  Usually this results in more extensive bruising and possibly some wound leakage but the benefit of the pain reduction outweighs this risk for most people. If you have bleeding problems already or are on blood thinners be careful.
  3. Some Orthopedic Surgeons don’t want their patients taking anti-inflammatories.There is some evidence they impair bone healing, for which inflammation is necessary.  So check with your surgeon to be sure NSAIDS are okay.

Acetaminophen(Tylenol) – Most people don’t get much benefit from Tylenol by itself but there is some indication that it may make NSAIDS work better (synergy).  A lot of prescription pain concoctions (Vicodin, Percocet, Norco, T#3) are combinations of a narcotic and Tylenol.  It’s important to know how much Tylenol you are already taking with your prescription before you add any more.  The adult maximum dose for Tylenol is 4000mg / day (again based on weight of at least 50kg and normal kidney and liver function).  So 8 maximum strength (500mg) pills per day, 12 regular strength (325mg) adds up to 3900.  Again I’d space these out over the day – Two 500mg pills 4 times per day for example (that’s assuming this is your only source of Tylenol).

Pros –

  1. Very few side effects. You can get into pretty serious liver trouble if you take too much Tylenol but for most of us that would be way beyond doses we’re discussing here.
  2. May boost the effectiveness of other pain meds. See above.

Cons –

  1. Not very strong.
  2. The math involved to stay under maximum dose is sometimes daunting.


H1 blockers - These are what we traditionally think of as antihistamines – Benadryl and its cousins. The generic name for Benadryl is diphenhydramine and the store brands work just as well as the expensive stuff. That’s true for all of this information.

Narcotics release histamine as one of their side effects, therefore they make most people itch. This is a generalized itchiness without rash, hives etc. and does NOT indicate an allergy to narcotics.  It can, however be very uncomfortable. Diphenhydramine can with help with this. Dosing is 25 – 50mg up to four times per day.  Maximum adult dose is 300 mg/day.

Pros –

It works.  Itching from narcotics goes away pretty quickly.

   Cons –

It makes most people sleepy.  If you are already comatose from your prescription meds it’s probably not a good idea to add diphenhydramine.  Sometimes, though, the sleepiness is a good thing.  Diphenhydramine is actually what’s in most OTC sleeping pills.

H2 blockers (also technically antihistamines).  These are antacids.  Examples are Zantac (ranitidine), Pepcid (famotidine), Tagamet (cimetidine), etc. If the generic name ends in –zole, it’s a different class of drug and, I think, doesn’t work as well for this purpose.

The lining of your stomach is pretty tough, it handles lots of acid all the time.  That’s because it has numerous mechanisms to protect itself, to balance the effect of the acid.  One of these is production of prostaglandins.  NSAIDS shut down production of prostaglandins and can, therefore, shift the balance toward stomach injury.  So, to shift the balance back, decrease production of acid (take an antacid).  Food helps too.  H2 blockers should be taken on a schedule while you are taking NSAIDS, 1-2 pills (depending on which one you’re using) twice a day.  There may be some cross-benefit with the itching too.

Stool SoftenersColace (docusate sodium), Milk of Magnesia, Miralax.

FACT:  Taking narcotics (and having surgery for that matter) is constipating.  Water, fiber, and moving can help mitigate this but I’m a strong proponent of everyone on narcotics taking a stool softener.  Diarrhea may be gross but it usually isn’t painful, can’t put you back in the hospital (not this kind of diarrhea anyway), or cause a bowel perforation (this is serious constipation but it is possible) and you can always back off on your stool softener if you need to.

Stool softeners draw water into your stool so, hopefully, even your sluggish colon will be able to move things through.  These are not laxatives and stimulant laxatives generally shouldn’t be used for this purpose.  The meds listed above are in order of potency.  I think Colace is more of a maintenance stool softener.  People chronically on constipating meds can keep themselves out of trouble with this.  It isn’t often strong enough to do much with narcotic-associated constipation. Milk-of-Magnesia is stronger but (I think) it’s gross.  Miralax is rarely overkill postoperatively, is tasteless, dissolves in anything, and it works (I own no Bayer stock).  If you are prone to constipation already, starting a stool softener pre-op is a good call.

Prescription medications:

Opioids.  These are the backbone of postoperative pain management in 2019.  Again, surgery hurts and right now these are the best drugs we have for relieving pain.  Most surgeons aren’t, however, long-term prescribers of pain meds.  I’d give one refill before needing to see the patient and find out why they’re still in so much pain.  At that visit we’d either diagnose a problem or work out a weaning schedule.  Surgeons are managers of acute, not chronic, pain.

There are numerous oral opioids.  Your prescription will tell you how to take them.  If it says 1-2 every 4-6 hours, the suggested minimum dose is 1 pill every 6 hours, the maximum 2 pills every 4.  Most postoperative prescriptions are written prn (as needed) and that’s how you should take them.  If you don’t hurt, don’t take the medication.  Each time you go to pop a pain pill in your mouth ask yourself, “Am I taking this because I hurt?”.  If the answer is “Yes”, go ahead; if it’s “No” or “Maybe not”, think again, pause especially if the answer is "I like the buzz I get from it".

That said, for the first few days after surgery pain medication of usually best taken on a schedule. It’s very likely you will need the medication the next time you can take it and it’s always better to stay ahead of pain.  You should always give the medication to yourself.  If you’re not with-it enough to open the bottle, get a dose, and take it with some water, you’ve had too much and you should wait to take more. That doesn’t mean skip doses because you’re asleep.  Sometimes you should set alarms to remind you to take meds but again, you are administering them to yourself.

So say your prescription says 1-2 pills every 4-6 hours.  One way to do it is to start with one pill every 4 hours.  If, 30 minutes after that dose you’re still uncomfortable, take another pill.  When it’s time to take more, take two pills every 4 hours for the next two cycles, then try to cut back to one etc.  Once you’re comfortable on one pill, try stretching out the interval, then take a half a pill and so on.  That is one way to do it, I’m not telling you that you HAVE to do it that way.  I hate having to say that stuff all the time but this is the world we live in.

Whew!  That turned out to be a lot of information.  So what’s the bottom line?  Below is a sample schedule for post-op pain meds:

Prescription:  Norco 5 / 325 (5mg hydrocodone / 325mg Tylenol), 1-2 every 4-6 hours as needed

8:00am – 1-2 Norco, 1 Pepcid, Miralax in water, juice, coffee…

10:00am – 3 Ibuprofen

12:00pm – 1-2 Norco (could be 1 Norco & 1 regular strength Tylenol, no Tylenol if taking 2 Norco)

2:00pm – 3 Ibuprofen

4:00pm – 1-2 Norco

6:00pm – 3 Ibuprofen

8:00pm – 1-2 Norco, 1 Pepcid

10:00pm – 3 Ibuprofen, 1 Benadryl

12:00am – 1-2 Norco

4:00am – 1-2 Norco, 3 Ibuprofen

8:00am – start over

Total Norco:  6 - 12 (12=3900mg Tylenol with 325 mg / pill)

Total Ibuprofen:  12

With this schedule you get something for pain almost every two hours.  It’s hectic to have to take something every two hours but your pain med levels stay pretty even throughout the day.  Another schedule might look like this:

8:00am – 1-2 Norco, 1 Pepcid, Miralax, 2 Ibuprofen

12:00pm – 1-2 Norco (could be 1 Norco & 1 regular strength Tylenol), 2 Ibuprofen

4:00pm – 1-2 Norco, 2 Ibuprofen

8:00pm – 1-2 Norco, 2 Ibuprofen, 1 Pepcid

10:00pm – 1 Benadryl

12:00am – 1-2 Norco, 2 Ibuprofen

4:00am – 1-2 Norco, 2 Ibuprofen

8:00am – start over

Total Norco:  6 – 12

Total Ibuprofen:  12

Same number of total pills but taken less frequently.  There is no right way to do it, only what works for you.  As long as you keep the maximums in mind you can pretty much mix it up any way you want.

There you go, my spiel on postoperative pain control.  I’m a HUGE fan of empowering patients with information but, I’ll say it one more time, this manifesto can’t take into account your specific physiology or needs, I can't be responsible for how  you use it. Use this as a (pretty extensive) start.

Be well.

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