Closing the Gaps in Postsurgical Pain Management.

Analgesic gaps--periods of inadequate pain control--commonly compromise the management of pain after joint arthroplasty. Such gaps can and should be prevented. The use of well-designed, balanced multimodal analgesic regimens that comprise a combination of agents working independently in both the peripheral and central nervous systems is an effective way to prevent gaps in pain control. Medications that have been shown to be beneficial as components of multimodal regimens include acetaminophen, cyclo-oxygenase 2 (COX-2) inhibitors, gabapentinoids, glucocorticoids, periarticular injections using agents such as bupivacaine HCl and bupivacaine liposome injectable suspension (EXPAREL®, Pacira Pharmaceuticals, Inc), and long-acting opioids. Multimodal analgesia should take into consideration not only the mechanisms of the individual medications, but also their timing of onset and duration of effect. And to avoid continual reestablishment of the pain pathways, it is also important to administer the medications on a scheduled basis rather than as needed.