Opioids are medications intended to control acute pain when used as directed by your doctor. This medication is commonly prescribed after surgery. Risks associated with opioid medications are increased when used incorrectly.

What opioid medications do

Opioids are prescription drugs that are intended to relieve pain by interacting with opioid receptors throughout your central and peripheral nervous system. Historically, opioids were derived from the poppy plant, most opioids are synthesized in a laboratory. 

Opioid medications can be ingested in pill form and absorbed through the gastrointestinal system or given by intravenous (IV) methods. These travel through your blood and bind to opioid receptors in your brain and nervous system. Cells throughout your body release signals that mute the perception of pain.

When opioid medications are dangerous

Opioids are notorious for having a reputation to be dangerous and rightfully so when they are taken incorrectly. What makes opioid medications effective for treating pain can also make them dangerous.

These medications may make you feel sleepy and sedated, and at higher doses they slow your breathing and heart rate. This can ultimately lead to death especially when the brain and vital organs do not receive enough oxygen. 

The feelings of pleasure that may result from taking opioid medications may result in addiction.

These dangerous side effects can be reduced by carefully following your doctor’s instructions and taking them exactly as prescribed and taking less when possible. Combining other medications and alcohol with opioids heightens the risk of death. It’s also important to avoid driving and operating heavy machinery when taking opioids.

When comparing general anesthesia to twilight sedation with a regional nerve block, often times the recovery after surgery is quicker with less pain and side effects. After receiving a regional anesthetic nerve block, you will wake up from surgery numb which will provide more comfort. The worst pain is not felt immediately while waking up from surgery as in general anesthesia. The regional nerve block will give you time to wake up without pain and ease into the emergence from your twilight sleep. 

Regional anesthesia and sedation does not require a breathing tube or assistance of breathing by a ventilator which usually eliminates sore and scratchy throat after surgery. There is also less risk for post operative nausea and/or vomiting. 

With this anesthesia 

Twilight sedation, no breathing tube or ventilator required for this

No sore throat, less PONV, less POCD

Temporary nap during surgery using sedation which is also known as twilight

The most common indication for stellate ganglion block is complex regional pain syndrome of the upper extremity. Additional indications for stellate ganglion blockade include: neuropathic pain of the hand or arm, symptoms of menopause, refractory ventricular tachycardia, cardiac electrical storm, vascular insufficiency, hyperhidrosis, among others. 

The stellate ganglion is formed by the fusion of the inferior cervical ganglion and first thoracic ganglion, normally located at the level of cervical vertebral body, C7.  The target stellate ganglion blockade is most commonly the transverse process of C6 (Chassaignac's tubercle). Needle placement occurs at the level of C6 to avoid side effects of pneumothorax, nerve root injury and vascular injection. 

Common side effects of stellate ganglion block are: Horner’s Syndrome (ptosis, miosis, anhidrosis, enophthalmos), Hoarseness (Recurrent Laryngeal Nerve), as well as Hemidiaphragm (Phrenic Nerve). Horner’s syndrome is by far the most commonly encountered side effect and is considered by some practitioners to be an indicator of successful blockade.

Post herpetic neuralgia (PHN) is a sequelae of herpes zoster infection. Herpes zoster infection typically begins with flu like prodromal symptoms and progresses to a rash of grouped vesicles on an erythematous base as the reactivated virus replicates and spreads to dermoepidermal junction. Herpes zoster most often affects thoracic dermatomes in 50% of cases followed by the face in 10-20% of cases. Diagnosis of herpes zoster is made clinically with history and symptomatic dermatomal rash not crossing the midline. Risks factors for herpes zoster include older age and immunosuppression, greater severity of acute pain, presence of painful prodrome, greater rash severity. Treatment of herpes zoster rash with antiviral therapy has been shown to decrease acute and chronic pain and should be initiated within 72 hours of rash onset if possible. Herpes zoster treatment should also include effective multimodal pain therapy which may decrease the risk of PHN. Herpes zoster vaccination in adults is recommended in healthy adults 50 years and older with live attenuated vaccine or the new recombinant zoster, which is preferable.

Herpes zoster pain can precede or accompany the rash and mostly resolves as the rash resolves. When persistent pain results, it can be defined as post herpetic neuralgia if the pain that persists for more than 90 to 120 days after rash onset. Risk of PHN after herpes zoster varies from 5% to more than 30% worldwide depending on the study.

Treatment of postherpetic neuralgia is mostly pharmacological with a limited role of interventional and alternative modalities. Anticonvulsants, tricyclic antidepressants, serotonin norepinephrine reuptake inhibitors, opioids, and topical modalities are often used. Anticonvulsants are first line therapies and include gabapentin and pregabalin. Tricyclic antidepressants are also effective in PHN and act by inhibiting reuptake of norepinephrine and serotonin and sodium channel blockade. Opioids are effective, however, adverse effect profile must be considered including nausea, sedation, urinary retention, pruritis, constipation, immune suppression, hypogonadism, as well as tolerance, dependence and opioid induced hyperalgesia. Topical therapies including lidocaine and capsaicin are also attractive therapy in the older patients who are sensitive to side effects. Interventional therapies including nerve blocks, neuraxial blockade, dorsal root ganglion pulsed radiofrequency ablation, botulism injection, and sympathetic nerve blocks have been performed for PHN.

Post amputation pain (PAP) is a challenging constellation of painful disease states caused by the surgical or traumatic removal of a limb or appendage.  The most common causes are vascular disease and trauma.  The two most common causes of PAP are residual limb pain and phantom limb pain.  Residual limb pain is often referred to as stump pain.  This is pain which can be localized to the residual appendage after an amputation.  There are multiple causes which include infections, soft tissue injuries, bony injuries, nerve lesions or neuromas, hematomas, and even local ischemia or poor healing.  The treatment for stump pain is often treating the underlying cause.  When identifiable anatomic pathology is identified, surgical exploration can be helpful.  Also, neuroma injections have shown anecdotal benefit.  Often times, this pain can be resolved by reviewing the fit of a prosthesis or through exercise based physical therapy.  Often times, musculoskeletal issues can arise due to gait changes and prosthetic devices can cause irritation at the stump site which can be extremely uncomfortable.  

While over 90% of patients do experience phantom sensations after an amputation, only about 80% experience phantom limb pain.  This is described as dysesthesia in the absent part of the affected limb.  While phantom limb pain is extremely common in this population, it is also extremely difficult to treat.  While examination can rule out stump pain causes, it is rarely helpful in pointing to a cure of this disease.  Many neuropathic pain medications such as tricyclic antidepressants, gabapentinoids, NMDA antagonists, and calcitonin have shown promise in the treatment for this disease. 

 
Psychologic therapies such as cognitive behavioral therapy (CBT), hypnosis, and mirror therapy have shown some benefit for patients with this condition.  TENS therapy has also been found to be effective.  When conservative treatment have failed, interventional procedures like neuromodulation can be effective.  Dorsal column stimulation has been shown effective in case series and other anecdotal data.  More recently, dorsal root ganglion stimulation and peripheral stim is being studied specifically for phantom limb pain.  While these technologies are exciting, we are still awaiting true, concrete evidence.