Postoperative pain relief called inadequate: federal guidelines set

Healthfacts, April, 1992

Over 23 million operations are performed yearly in the U.S. ln the majority of cases, the standard methods for alleviating pain result in needless suffering and delayed recovery, according to a new Federal report.

Doctors have traditionally treated postoperative pain with a standing order for injections of morphine or codeine "as needed." Unfortunately, about half the people treated in this way report moderate to severe levels of pain. For infants, children and the elderly, rates of undermedication are even higher.

The new report sets guidelines for "more active management of pain through medication." The guidelines were developed by a panel of health care experts, which induded nurses, surgeons, a pharmacologist, pediatricians, a neurologist, a physical therapist, and a family practitioner. The report states: "Unrelieved pain not only stalls the healing process, but also impairs the immune system, keeps the patient from coughing as needed, raises the likelihood of pneumonia, and delays the return of normal stomach and bowel functions."

Communication is Key

In a telephone interview, lack of communication was cited as the heart of the problem by panel member Nancy K. Hester, R.N., Ph.D., associate professor at the University of Colorado Health Sciences Center School of Nursing in Denver. "One of the things we know is that a lot of patients don't tell [the nurse or doctor] when they hurt. Some research shows they just expect that someone is going to deal with it, but they don't communicate that they are having pain."

Dr. Hester said that it's helpful to have an advocate to communicate on behalf of the patient, for example, to tell the provider, "my father is having pain right now," or "my child's pain medication didn't work." Patients must communicate with the providers, she explained, and health care providers must prompt patients to communicate.

Studies indicate that people fare better when they are told what to expect beforehand. The new report says that such people may actually experience decreased pain, less use of painkillers, and shorter hospital stays. Like similar efforts before it, the

Federal report admonishes health professionals for their unfounded fears of drug addiction. Previous studies have shown this to be a common reason for undertreating postoperative pain. But Dr. Hester pointed out that the public shares this misconception.

"Often, the families don't want a child or other family member to get an opioid [e.g., morphine] because they don't want the relative to become addicted, but for postoperative pain, the amount is controlled, and addiction is very, very rare coming from a postsurgical experience."

Aggressive prevention of pain is advocated by the Federal report because once pain is established, it becomes far more difficult to suppress. The idea is to keep the pain from ever becoming extreme by putting immediate relief under the control of the patient, particularly in the 48 hours following surgery. Techniques have been developed to allow the individual to self-administer small doses of opioids by way of a metered infusion pump.

This overcomes the inevitable delays experienced by hospital patients requesting injections of morphine which, as a controlled substance, must be kept in a locked cabinet. It also cuts the usual time required for a drug to take effect. The report also urges greater use of non-drug approaches to pain alleviation, such as relaxation techniques,' massage, and the use of heat and cold.

The biggest changes in pain management, occurring over the last five years, are reported to be in the care of infants and small children. Long thought to be insensitive to pain because of an undeveloped nervous system, newborn infants used to undergo operations and other painful procedures without anesthesia.

"Doctors and nurses are being more aggressive now about treating pain more effectively in infants and children," said Daniel B. Carr, M.D., panel co-chair and director of the division of pain management at Massachusetts General Hospital in Boston. "It is not always a simple thing to do because very young children, or adults for that matter, who have tubes in their windpipe to support their ventilation cannot articulate pain," explained Dr. Carr in a telephone interview. "But there are means to evaluate pain using [pain measurement] scales that can be understood by children, or making indirect assessments based on the patient's blood pressure, pulse rate and so on."

Asked to comment on current medical thought regarding pain experienced during a common surgical procedure performed on newborn infants, Dr. Carr replied, "There is no question that infants do feel pain during circumcision. This has been assessed in careful research based on physiological responses, crying, and hormone secretion as indexes of stress."

Should people facing major surgery-for themselves or their children--plan ahead? Absolutely, said Dr. Hester. She recommends talking with the physician before surgery about the amount of pain to be expected and the plans for relieving it.