Requirements

• Pain intensity and relief must be assessed and reassessed at regular intervals.

• Patient preferences must be respected when determining methods to be used for pain management.

• Each institution must develop an organized program to evaluate the effectiveness of pain assessment and management. Without such a program, staff efforts to treat pain may become sporadic and ineffectual.

Principles

• Successful assessment and control of pain depends, in part, on establishing a positive relationship between health care professionals and patients. Patients should be informed that pain relief is an important part of their health care, that information about options to control pain is available to them, and that they are welcome to discuss their concerns and preferences with the health care team.

• Unrelieved pain has negative physical and psychological consequences. Aggressive pain prevention and control that occurs before, during, and after surgery can yield both short- and long- term benefits.

• It is not practical or desirable to eliminate all postoperative pain, but techniques now available make pain reduction to acceptable levels a realistic goal.

• Prevention is better than treatment. Pain that is established and severe is difficult to control.

Principles

• Patients who may have difficulty communicating their pain require particular attention. This includes patients who are cognitively impaired, psychotic or severely emotionally disturbed, children and the elderly, patients who do not speak English, and patients whose level of education or cultural background differs significantly from that of their health care team.

• Unexpected intense pain, particularly if sudden or associated with altered vital signs such as hypotension, tachycardia, or fever, should be immediately evaluated, and new diagnoses such as wound dehiscence, infection, or deep venous thrombosis considered.

• Family members should be involved when appropriate.

Pain Assessment Tools

• The single most reliable indicator of the existence and intensity of pain--and any resultant distress--is the patient's self-report.

• Self-report measurement scales include numerical or adjective ratings and visual analog scales (see Table 1 for examples).

• Tools should be reliable, valid, and easy for the patient and the nurse or doctor to use. These tools may be used by showing a diagram to the patient and asking the patient to indicate the appropriate rating. The tools may also be used by simply asking the patient for a verbal response (e.g. "On a scale of 0 to 10 with 0 as no pain and 10 as the worst pain possible, how would you rate your pain?").

• Tools must be appropriate for the patient's developmental, physical, emotional, and cognitive status.

Simple Descriptive Pain Intensity Scale [1]

|__________|__________|__________|_________|_________|
No      Mild      Moderate    Severe     Very      Worst
pain    pain        pain       paid     severe   possible
                                         pain      pain


0-10 Numeric Pain Intensity Scale [1]
|_____|_____|____|_____|____|_____|_____|____|_____|____|
0     1     2    3     4    5     6     7    8     9    10
No                      Moderate                        Worst
pain                      pain                         possible
                                                         pain
             

Visual Analog Scale (VAS) [2]
|_________________________________________________|
No                                                Pain as bad
pain                                              as it could
                                                  possibly be

[1]  If used as a graphic rating scale, a 10 cm
baseline is recommended.

[2]  A 10 cm baseline is recommended for VAS scales.

Preoperative Preparation

• Discuss the patient's previous experiences with pain and beliefs about and preferences for pain assessment and management.

• Give the patient information about pain management therapies that are available and the rationale underlying their use.

• Develop with the patient a plan for pain assessment and management.

• Select a pain assessment tool, and teach the patient to use it. Determine the level of pain above which adjustment of analgesia or other interventions will be considered.

• Provide the patient with education and information about pain control, including training in nonpharmacologic options such as relaxation ( see Table 2 for a sample relaxation exercise).

• Inform patients that it is easier to prevent pain than to chase and reduce it once it has become established and that communication of unrelieved pain is essential to its relief. Emphasize the importance of a factual report of pain, avoiding stoicism or exaggeration.

Table

Table 2. Sample Relaxation Exercise.

Postoperative Assessment

• Assess the patient's perceptions, along with behavioral and physiologic responses. Remember that observations of behavior and vital signs should not be used instead of a self-report unless the patient is unable to communicate.

• Assess and reassess pain frequently during the immediate postoperative period. Determine the frequency of assessment based on the operation performed and the severity of the pain. For example, pain should be assessed every 2 hours during the first postoperative day after major surgery.

• Increase the frequency of assessment and reassessment if the pain is poorly controlled or if interventions are changing.

• Record the pain intensity and response to intervention in an easily visible and accessible place, such as a bedside flow sheet.

• Revise the management plan if the pain is poorly controlled.

• Review with the patient before discharge the interventions used and their efficacy and provide specific discharge instructions regarding pain and its management.

Pharmacologic Management

• Pharmacologic management of mild to moderate postoperative pain should begin, unless there is a contraindication, with an NSAID. However, moderately severe to severe pain should normally be treated initially with an opioid analgesic, with or without an NSAID.

NSAIDs

• Even when insufficient alone to control pain, NSAIDS, including acetaminophen, have significant opioid dose-sparing effects on postoperative pain and hence can be useful in reducing opioid side effects (see Table 4 for information on prescribing NSAIDs).

• If the patient cannot tolerate oral medication, alternative routes such as rectal administration can be used. At present, one NSAID (ketorolac) is approved by the Food and Drug Administration for parenteral use.

• NSAIDs must be used with care in patients with thrombocytopenia or coagulopathies and in patients who are at risk for bleeding or gastric ulceration. However, acetaminophen does not affect platelet function, and some evidence exists that two salicylates (salsalate and choline magnesium trisalicylate) do not profoundly affect platelet aggregation.

Table

Table 4. Dosing Data for NSAIDs.

Opioid Analgesics

• Opioid analgesics are the cornerstone for management of moderate to severe acute pain. Effective use of these agents facilitates postoperative activities such as coughing, deep breathing exercises, ambulation, and physical therapy.

• When pain cannot be adequately controlled despite increasing the opioid dose, a prompt search for residual operative pathology is indicated, and other diagnoses such as neuropathic pain should be considered.

• Opioid tolerance and physiologic dependence are unusual in short term postoperative use in opioid-naive patients. Likewise, psychologic dependence and addiction are extremely unlikely to develop after the use of opioids for acute pain.

Choice of Opioid Agent

• Morphine is the standard agent for opioid therapy. If morphine cannot be used because of an unusual reaction or allergy, another opioid such as hydromorphone can be substituted.

• Meperidine should be reserved for very brief courses in patients who have demonstrated allergy or intolerance to other opioids such as morphine and hydromorphone. Meperidine is contraindicated in patients with impaired renal function or those receiving antidepressants that are monoamine oxidase (MAO) inhibitors. Normeperidine is a toxic metabolite of meperidine, and is excreted through the kidney. Normeperidine is a cerebral irritant, and accumulation can cause effects ranging from dysphoria and irritable mood to seizures.

Dosage of Opioid Analgesics

• Patients vary greatly in their analgesic dose requirements and responses to opioid analgesics. The recommended starting doses presented in Table 5 may be inadequate. Subsequent opioid doses must be titrated to increase the amount of analgesia and reduce side effects.

• Relative potency estimates provide a rational basis for selecting the appropriate starting dose, for changing the route of administration (e.g., from parenteral to oral), or for changing from one opioid to another. Equianalgesic doses for opioids are listed in Table 5.

• Patients who have been receiving opioid analgesics before surgery may require higher starting and maintenance doses post-operatively.

Table

Table 5. Dosing Data for Opioid Analgesics.

Dosage Schedule

• Opioid administration relying on patients' or families' demands for analgesic prn, or "as needed," produces delays in administration and intervals of inadequate pain control.

• Analgesics should be administered initially on a regular time schedule. For example, if the patient is likely to have pain requiring opioid analgesics for 48 hours after surgery, morphine might be ordered every 4 hours around-the-clock (not prn) for 36 hours. Opioid administration is contraindicated when respiratory depression is present (less than 10 breaths per minute).

• Once the duration of analgesic action is determined, the dosage frequency should be adjusted to prevent pain from recurring.

• Orders may be written so that a patient may refuse an analgesic if not in pain or forego it if asleep. However, since a steady-state blood level is required for the drug to be continuously effective, interruption of an around-theclock dosage schedule (e.g., during sleep) may cause a resurgence of pain as blood levels of the analgesic decline.

• Late in the postoperative course, it may be acceptable to give opioid analgesics prn. Switching to prn dosing later in the postoperative course provides pain relief while reducing the risk of adverse effects as the patient's analgesic dose requirement diminishes.

• Clinicians should assess patients at regular intervals to determine the efficacy of the intervention, the presence of side effects, the need for adjustments of dosage and/or interval, or the need for supplemental doses for breakthrough pain.

Route

• Intravenous administration is the parenteral route of choice after major surgery. This route is suitable for bolus administration and continuous infusion (including PCA).

• Repeated intramuscular injections can themselves cause pain and trauma and may deter patients from requesting pain medication. Rectal and sublingual administration are alternatives to intramuscular or subcutaneous routes when intravenous access is problematic. All routes other than intravenous require a lag time for absorption into the circulation.

• Oral administration is convenient and inexpensive. It is appropriate as soon as the patient can tolerate oral intake and is the mainstay of pain management in the ambulatory surgical population.

Nonpharmacologic Management

• Patient teaching should include procedural and sensory information; instruction to decrease treatment and activity-related pain (e.g., pain caused by deep breathing, coughing) and information about the use of relaxation.

• Cognitive-behavioral (e.g., relaxation, distraction, imagery) and physical interventions (e.g., heat, cold, massage) are intended to supplement, not replace, pharmacologic interventions.

• Cognitive/behavioral interventions include a variety of methods that help patients understand more about their pain and take an active role in pain assessment and management.

• Simple relaxation strategies can be effective in helping to manage pain. Basic approaches (see Table 2 for an example) require only a few minutes to teach and can reduce pain and anxiety. Patients benefit from periodic reinforcement and coaching in the use of relaxation techniques.

• Commonly used physical agents include applications of heat and cold, massage, movement, and rest or immobilization. Applications of heat and cold alter the pain threshold, reduce muscle spasm, and decrease local swelling.

• Transcutaneous electrical nerve stimulation (TENS) may be effective in reducing pain and improving physical function.

Special considerations for Elderly Persons

The Clinical Practice Guideline contains a more complete discussion of the special considerations for pain management in the elderly. A summary is provided here.

• Elderly people often suffer multiple chronic, painful illnesses and take multiple medications. They are at greater risk for drug-drug and drug-disease interactions.

• Pain assessment presents unique problems in the elderly, as these patients may exhibit physiologic, psychologic, and cultural changes associated with aging.

• Misunderstanding of the relationship between aging and pain is common in the management of elderly patients. Many health care providers and patients alike mistakenly consider pain to be a normal part of aging. Elderly patients sometimes believe that pain cannot be relieved and are stoic in reporting their pain. The frail and oldest-old (>85 years) are at particular risk for undertreatment of pain.

• Aging need not alter pain thresholds or tolerance. The similarities of pain experience between elderly and younger patients are far more common than are the differences.

• Cognitive impairment, delirium, and dementia are serious barriers to assessing pain in the elderly. Sensory problems such as visual and hearing changes may also interfere with the use of some pain assessment scales. However, as with other patients, the clinician should be able to obtain an accurate self-report of pain from most patients.

• When verbal report is not possible, clinicians should observe for behavioral cues to pain such as restlessness or agitation. The absence of pain behaviors does not negate the presence of pain.

• NSAIDs can be used safely in elderly persons, but their use requires vigilance for side effects, especially gastric and renal toxicity.

• Opioids are safe and effective when used appropriately in elderly patients. Elderly people are more sensitive to analgesic effects of opiate drugs. They experience higher peak effect and longer duration of pain relief.