Know your Pain Meds: Which One is Best Following Derm Procedures?

There are a wide variety of pain relief medications that can be prescribed after a procedure, with different mechanisms of action and varied side effects and concerns for patients. In the past, for example, there have been fears that NSAIDs come with an increased risk of postoperative bleeding, so typically providers avoid prescribing those to patients. Clinicians also need to consider patients’ history with medications, whether they expect pain levels to be mild or severe, or whether the patient will need to be alert post procedure.

A recent study looked at what we know about common analgesics and presented recommendations for each one depending on pain level and patient characteristics. For patients with mild pain that would be expected from an incision, for example, the author recommends acetaminophen for a first line treatment and NSAID for second line option. For moderate to severe pain, the authors recommend first line analgesics such as acetaminophen, NSAIDs and codeine, and for second line a weak opioid such as codeine or tramadol. The authors note that codeine may not be an optimal choice because it has to be converted to morphine in the body, and not all patients can metabolize codeine. Therefore, unpredictable metabolism must be considered especially in patients at risk of opioid toxicity.

For patients with moderate to severe pain that cannot tolerate opioids, tramadol may be a useful alternative. Although one of its mechanisms of action is via the opioid receptors, it causes minimal respiratory depression and reduced cardiovascular and gastrointestinal side effects. Looking at NSAIDs and bleeding risk, the authors state that based on several large studies there is no increased bleeding following the use of NSAIDs in the adult population. However, caution should be used if the patient is on an anticoagulant.

The authors state that clinicians should use an individual approach to managing post-procedure analgesia, and develop a thorough understanding of the pharmacology of analgesics. The two in combination should help determine which treatment would be best for each patient.