Table 1.

Medications to be Considered for Persistent Postsurgical Pain ^a .

Agents	Mechanisms	Comments
NSAIDs—ibuprofen, naproxen, and meloxicam	COX inhibition • Decrease peripheral production of inflammatory signaling molecules	Particularly effective during the acute phase of injury, although can be beneficial for chronic musculoskeletal pain. Chronic daily use caries increased risk of renal and cardiovascular complications.
Acetaminophen	COX inhibition • Central COX inhibition and other mechanisms	Separate mechanism for NSAIDs and can have a synergistic effect. Generally well tolerated when taken within recommended dose, but caution should be taken with hepatic impairment.
Gabapentinoids—pregabalin and gabapentin	Alpha2delta calcium channel inhibition • Decreased transmission of pain signals	First-line agents for treating neuropathic pain
SNRIs—duloxetine, venlafaxine, and milnacipran	Serotonin and norepinephrine reuptake inhibition • Modulation of descending inhibitory pathways	First-line agents for treating neuropathic pain, certain agents also have indication for other pain conditions including fibromyalgia and chronic musculoskeletal pain.
TCAs—nortriptyline, amitriptyline, and desipramine	Serotonin and norepinephrine reuptake inhibition. Also block histamine, sodium channels, and acetylcholine. • Modulation of descending inhibitory pathways	Well studied for neuropathic pain, in general, side effects can be more significant than SNRIs; however, dosing for pain is done at significantly lower doses than what is used for antidepressant effects.
Opioids—tramadol, oxycodone, hydrocodone, morphine, tapentadol, hydromorphone, methadone, and buprenoprhine	Opioid receptor activation • Central and peripheral analgesia	Considered for patients who have failed alternative medications and therapies and are appropriate candidates. Some opioids such as tramadol and tapentadol, which have SNRI properties, act at multiple sites on the pain pathway.

Abbreviations: NSAID, nonsteroidal anti-inflammatory; APAP, acetaminophen; SNRI, serotonin and norepinephrine reuptake inhibitor; TCA, tricyclic antidepressant.

^aThis table is not exhaustive but serves to highlight common medication classes used to treat postsurgical pain and examples of drugs in each class. In general, the type of pain that predominates for the patient should be considered. For example, a patient with predominantly burning, neuropathic pain following thoracotomy may have little effect from an NSAID and APAP, but respond favorably to a gabapentinoid and SNRI.