**4.5 Postsurgical pain**

Surgical pain may be nociceptive, neuropathic, mixed, psychogenic, or idiopathic, depending on the surgical procedure. The value of balanced analgesia in treating postoperative pain was recognized by Kehlet and Dahl [9] over two decades ago. Non-opioid analgesics are the cornerstone of postsurgical pain multimodal management: in addition to their opioid-sparing effects, many of these agents are highly effective in reducing postoperative pain and allowing for faster mobilization [50].


#### **4.6 Neuropathic pain**

The International Association for the Study of Pain defines neuropathic pain as "Pain caused by a lesion or disease of the somatosensory system." This includes central disorders (e.g., spinal cord injury pain, multiple sclerosis pain, and poststroke thalamic pain) as well as peripheral disorders (e.g., diabetic neuropathy and postherpetic neuralgia) [43].

Both tricyclic antidepressants and gabapentinoids are proposed as firstline agents for neuropathic pain [67]. These medications have completely different mechanisms of actions:


Opioids and gabapentinoids were also studied for neuropathic pain and the combination was found to be positive [68–70]. However, given the limited trial size and the short duration of the studies conducted so far, it is not possible to make recommendations for any specific combination for neuropathic pain [43].

### **5. Conclusions**

As illustrated above, in recent years, the WHO ladder approach has gradually been replaced with the multimodal approach, customized from patient to patient taking into account the characteristics of pain (based on pain generator, its cause, type, and intensity) and patient comorbidity. This allows to control not only chronic pain but also its exacerbations, through the association to long-term analgesic therapy of additional drugs for acute pain as needed. In this respect, multimodal therapy represents a useful tool, not only for specialists but for general practitioners as well to personalize analgesic treatment according to the patient's characteristics and needs [71].

The availability of FDCs of most recommended combinations may help in the implementation of multimodal analgesia in clinical practice, improving patient adherence to treatment and contributing to the optimization of pain management.

### **Acknowledgements**

The authors are particularly grateful to ContentEdNet for the editorial support. Editing has also been supported by Paolo Procacci Foundation (Via Tacito 7, 00193 Roma, Italy).

#### **Conflict of interest**

The authors do not have any potential conflict of interest related to this chapter.

**211**

**Author details**

Antonella Paladini1

and Giustino Varrassi2,3\*

1 Department of MESVA, University of L'Aquila, L'Aquila, Italy

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

2 Paolo Procacci Foundation, Rome, Italy

provided the original work is properly cited.

3 World Institute of Pain, Winston-Salem, NC, USA

\*Address all correspondence to: giuvarr@gmail.com

*Multimodal Pharmacological Analgesia in Pain Management*

*DOI: http://dx.doi.org/10.5772/intechopen.93620*

*Multimodal Pharmacological Analgesia in Pain Management DOI: http://dx.doi.org/10.5772/intechopen.93620*

*Pain Management - Practices, Novel Therapies and Bioactives*

The International Association for the Study of Pain defines neuropathic pain as "Pain caused by a lesion or disease of the somatosensory system." This includes central disorders (e.g., spinal cord injury pain, multiple sclerosis pain, and poststroke thalamic pain) as well as peripheral disorders (e.g., diabetic neuropathy and

Both tricyclic antidepressants and gabapentinoids are proposed as firstline agents for neuropathic pain [67]. These medications have completely different

• tricyclic antidepressants have multiple mechanisms of action, including norepinephrine and serotonin reuptake inhibition, and so are logical candidates

Opioids and gabapentinoids were also studied for neuropathic pain and the combination was found to be positive [68–70]. However, given the limited trial size and the short duration of the studies conducted so far, it is not possible to make recom-

As illustrated above, in recent years, the WHO ladder approach has gradually been replaced with the multimodal approach, customized from patient to patient taking into account the characteristics of pain (based on pain generator, its cause, type, and intensity) and patient comorbidity. This allows to control not only chronic pain but also its exacerbations, through the association to long-term analgesic therapy of additional drugs for acute pain as needed. In this respect, multimodal therapy represents a useful tool, not only for specialists but for general practitioners as well to personalize analgesic treatment according to the patient's characteristics

The availability of FDCs of most recommended combinations may help in the implementation of multimodal analgesia in clinical practice, improving patient adherence to treatment and contributing to the optimization of pain management.

The authors are particularly grateful to ContentEdNet for the editorial support. Editing has also been supported by Paolo Procacci Foundation (Via Tacito 7, 00193

The authors do not have any potential conflict of interest related to this chapter.

• gabapentinoids are alpha-2-delta calcium channel modulators;

mendations for any specific combination for neuropathic pain [43].

**4.6 Neuropathic pain**

postherpetic neuralgia) [43].

for combination therapy.

mechanisms of actions:

**5. Conclusions**

and needs [71].

Roma, Italy).

**Acknowledgements**

**Conflict of interest**

**210**
