**6. Pharmacological pain management after thoracic and breast surgery**

Current postoperative pain management methods have recommended the use of multimodal analgesia approaches to improve analgesic efficacy and minimise side effects. The multimodal analgesia is acknowledged in its significant role in all enhanced recovery after surgery pathways (ERAS) to manage pain, reduce stress responses, facilitate early mobilisation, and normal respiration [25, 43]. According to Montgomery and McNamara [44], multimodal analgesia has been acknowledged as effective pain management especially for preventing and controlling postsurgical pain as well as reducing side effects of opioid, hastening recovery, and shortening hospital stay. In the multimodal analgesia regimen, two or more analgesia and/or analgesic techniques with different mode or site of action are combined to produce moreeffective analgesia than a unimodal regimen [25]. In multimodal approach, individual analgesia is recommended to be used at lower doses as this helps to reduce the side effects of each medication. Importantly, the central aim of multimodal analgesia is to avoid using opioids or reduce opioids consumption and thereby reduce the risk for opioids side effects that cause delay in recovery [25, 43].

For patients undergoing thoracic surgery, multimodal analgesia includes regional anaesthetic blockade in combination with using systemic nonopioid analgesia with opioid sparing [45]. Post-thoracic surgical pain therefore is expected to be treated with combinations of local anaesthetics, acetaminophen, non-steroidal

*Non-Pharmacological Management of Acute Pain after Breast and Thoracic Surgery DOI: http://dx.doi.org/10.5772/intechopen.109863*

anti-inflammatory drugs (NSAIDs), anticonvulsants, adrenergic agonists, and opioid-sparing methods [45–47].

Meanwhile for women undergoing breast surgery, typical pain management is a combination of opioids, non-opioids, non-pharmacological techniques, anaesthesia techniques, and patient-controlled analgesia techniques [47]. With these approaches, pain management can span through the intraoperative and postoperative periods. Intraoperatively, preventive pain medications employed for mastectomy patients include drugs such as nefopam, ketamine, and bupivacaine, with or without clonidine. All these medications have been reported to significantly reduce pain intensity after BC surgery, and they have long-term effects on pain experienced after surgery [48–51]. Moreover, the techniques employed in delivering the preventive medication (e.g. thoracic paravertebral block) reduced the pain score in one study [52], while a combination of paravertebral block with propofol significantly reduced the pain score in another study [53].

For both thoracic and breast surgery patients, the non-opioid drugs such as acetaminophen, NSAIDs, local anaesthetics, and anticonvulsants are combined with opioids-sparing analgesics or lower doses of opioids to manage postoperative pain [14, 25, 45]. These non-opioids limit the adverse effects of opioids including sedation, urine retention, nausea, pruritus vomiting, and slow gastrointestinal functioning in the multimodal regimen [46]. There is limited evidence about the recommended analgesic regimen for patients undergoing breast surgery in the ERAS pathway. However, the analgesics regimen recommended as multimodal analgesia for pain management in ERAS after thoracic surgery by Mehran et al. [45] are illustrated in **Figure 1**.
