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*Department of Anesthesia and Critical Care, The University Chicago Hospitals, Chicago, Illinois;
Pharmacia Corp., Skokie, Illinois; and
Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
Address correspondence and reprint requests to Jeffrey L. Apfelbaum, MD, Department of Anesthesia and Critical Care, The University of Chicago Hospitals, 5841 S. Maryland Ave., MC 4028, Chicago, IL 60637. Address e-mail to j-apfelbaum{at}uchicago.edu
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Abstract |
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IMPLICATIONS: A survey of 250 US adults who had undergone a recent surgical procedure asked about their postoperative pain experience. Approximately 80% of patients experienced pain after surgery. Of these patients, 86% had moderate, severe, or extreme pain. Additional efforts are required to improve patients’ postoperative pain experience.
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Introduction |
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Although pain is a predictable part of the postoperative experience, inadequate management of pain is common and can have profound implications. Unrelieved postoperative pain may result in clinical and psychological changes that increase morbidity and mortality as well as costs and that decrease quality of life (6). Negative clinical outcomes resulting from ineffective postoperative pain management include deep vein thrombosis, pulmonary embolism, coronary ischemia, myocardial infarction, pneumonia, poor wound healing, insomnia, and demoralization (6,7). Associated with these complications are economic and medical implications, such as extended lengths of stay, readmissions, and patient dissatisfaction with medical care (8,9). It is estimated that the economic burden of treating chronic pain that develops from acute pain in a 30-yr-old individual over a lifetime could be as much as $1 million (10). Prevention and effective relief of acute pain may improve clinical outcomes, avoid clinical complications, save health care resources, and improve quality of life. Recognizing that some of the deleterious effects of acute pain can be avoided or minimized, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has incorporated new standards for pain management. Effective in 2001, the JCAHO requires as one condition of accreditation adequate assessment, monitoring, and treatment of pain (11). Pain management must become part of all patient care activities.
The Agency for Health Care Policy and Research issued guidelines for acute pain management in 1992 (12,13). The guidelines promote aggressive treatment of acute pain and educate patients about the need to communicate unrelieved pain. In 1995, the American Society of Anesthesiologists published guidelines for acute pain management in the perioperative setting (8). These guidelines promote standardization of procedures and the use of patient-controlled analgesia pumps, epidurals, and multimodal analgesia. They also recommend that proactive planning—including obtaining pain history and preoperative, intraoperative, and postoperative pain treatment—be a part of the institution’s interdisciplinary care plan.
Pain management guidelines appear to have had little influence on practice patterns or on improved pain control for patients. In a study conducted 1 yr after the introduction of the Agency for Health Care Policy and Research guidelines, Warfield and Kahn (4) found that the incidence and severity of postoperative pain was high. Three of four patients in their study reported experiencing pain after surgery, and 80% of these patients rated pain after surgery as moderate to extreme. The analysis in the study was somewhat limited because inpatients and outpatients were grouped together without factoring in the differences between the two patient settings. Similarly, assessments of pain levels taken before and after discharge were analyzed together, even though levels of pain are known to differ between these time periods.
Since the Warfield and Kahn study (4), newer protocols for patient-controlled analgesia and regional analgesia have been developed, and minimally invasive surgical techniques, such as endoscopic procedures, are used more frequently. These changes in practice patterns could affect the management of postoperative pain and patient attitudes about pain. An understanding of the postoperative pain experience from a patient’s perspective is important if health care professionals are to identify ways to improve care. The objective of this study was to characterize the postoperative pain experience, assess patient satisfaction with pain medications, evaluate the success of patient education, and assess patient perceptions about postoperative pain and pain medications.
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Methods |
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The predetermined questions, which were written in lay language and modified from a survey used previously (4), asked about the postoperative pain experience. Participants were asked how long ago their procedures had been performed, in what type of facility, and what their concerns were before surgery. Patients also were asked about the presence and severity of pain (verbal categorical scale), the medications received, adverse effects, and satisfaction with pain medications after surgery while they were still in the hospital and up to 2 wk after discharge. They were asked whether they had received pain management education and were asked to describe their perceptions of pain and pain medications after surgery. The questionnaire focused on major events and experiences that patients could reliably recall.
Data were stratified according to surgical setting. Results from patients who had surgery in a doctor’s office, outpatient clinic, or freestanding surgery center were combined with results from patients who had surgery as outpatients in the hospital setting. Percentages were calculated on the basis of the total number of patients who answered each question. Data were analyzed with descriptive statistics.
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Results |
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1 year category than the more than 1 yr category (22% vs 15%).
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Approximately 82% of all patients received pain medications in the hospital, doctor’s office, outpatient clinic, or surgery center. The most commonly administered medications were morphine (33%) and meperidine (27%) for inpatients and acetaminophen with codeine (23%) and ibuprofen (15%) for outpatients. Overall, one third of patients requested their first one to two doses of pain medication while in the surgical setting. Of these, 37% were inpatients and 25% were outpatients. After discharge, 76% of all patients received pain medications. The most frequently prescribed medications were acetaminophen with codeine (17%) or acetaminophen alone (17%) for inpatients and acetaminophen with codeine (21%) or oxycodone with acetaminophen (20%) for outpatients.
Of the patients who received pain medications, 23% reported experiencing adverse effects (Table 5). In the hospital, doctor’s office, outpatient clinic, or surgery center, 15% experienced adverse effects; 17% of patients experienced adverse effects after discharge. The most common side effects were drowsiness, nausea, and constipation.
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Approximately two thirds of patients reported that a health care professional talked with them before surgery about how their pain would be treated (Table 7). Overall, nurses were more likely than other health care professionals to educate patients about pain and pain management. Among surgical outpatients, surgeons were as likely as nurses to provide patient pain education, but nurses were more likely to provide this service for surgical inpatients. After surgery, two thirds of patients reported being asked by a health care professional about their pain, most frequently by a nurse.
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Discussion |
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When assessing the severity and effect of pain experienced after day surgery, Beauregard et al. (14) found that 40% of patients reported moderate to severe pain during the first 24 hours after discharge. Pain decreased over time but was severe enough to interfere with daily activities, even several days after surgery. Chung et al. (15) found that >25% of ambulatory patients reported experiencing moderate to severe pain after discharge. Another study, conducted by Lynch et al. (16), used a 1–10 numerical rating scale to assess the severity of pain among patients who had noncardiac inpatient surgery. The mean maximum pain score on postoperative Day 1 was 6.3 (moderate pain) and decreased only slightly to 5.6 by postoperative Day 3. The findings demonstrated that patients experienced intense pain after inpatient and outpatient surgery, which is consistent with the findings from our study.
A national study similar to ours assessed the status of acute pain management and attitudes toward postoperative pain in a random sample of patients (4). Although this study was performed approximately a decade ago, it provided a baseline against which later studies could be compared to assess improvement in pain management. In this study of 500 patients, 77% experienced pain after surgery, 23% experienced severe pain, and 8% experienced extreme pain. Similarly, we found that 82% of patients experienced pain after surgery: 21% of patients experienced severe pain, and 18% of patients experienced extreme pain. The percentage of patients with overall pain increased slightly in our study; however, the percentage of patients with extreme pain more than doubled as compared with the results from Warfield and Kahn (4) (Fig. 1). Patients seem just as concerned about experiencing postoperative pain today (59%) as they were almost a decade ago.
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We were surprised to find that more than half of the patients surveyed were concerned about experiencing pain after surgery and that this caused some of them even to postpone surgery. Although most patients claimed to receive preoperative education on postoperative pain management, our findings suggest that a patient’s real concern is not adequately addressed. Despite the increased focus on pain management over the last several years and the development of formal standards and guidelines for the management of acute pain, a significant number of patients continue to experience unacceptable levels of pain after surgery and after discharge. This fact is alarming, considering the trend toward ambulatory surgery and shorter hospital stays. Aggressive management could prevent complications that result from postoperative pain. The intense pain experienced after surgery and side effects from pain medications may explain why patients continue to fear postoperative pain.
Guidelines have been designed to improve treatment outcomes for patients with acute pain. In 1995, the American Pain Society’s Quality of Care Committee published a set of guidelines recommending quality improvement programs for acute pain, which include five key elements: 1) recognition and prompt treatment of pain, 2) provision to clinicians of information about analgesics, 3) promise to patients of attentive analgesic care, 4) implementation of policies for using modern analgesic technologies, and 5) assessment and continuous improvement of pain management (19). Such recommendations have the potential to improve patient satisfaction with medical care and remove some of the obstacles to optimally manage pain. However, as the results of this study show, postoperative pain is still not adequately managed. Recognizing the importance of the issue of undertreatment of pain, the JCAHO implemented new pain standards, which require that all patients be assessed for pain and then be appropriately treated and monitored. In 1999, the National Health and Medical Research Council of Australia published evidence-based guidelines on management of all forms of severe pain (20).
Other factors also may explain the inadequate management of acute pain after surgery. The pressure to discharge patients after surgery could limit the pain medications health care professionals are willing to prescribe. In our study, inpatients had more pain and were more likely to receive morphine and meperidine before discharge than outpatients, who were more likely to receive acetaminophen with codeine or ibuprofen before discharge. Both patient groups received similar medications after discharge. Physicians may be unwilling to discharge a patient medicated with potent, long-acting opioids from a supervised setting because of potential safety concerns. Also, patients may not have someone at home who can assist them during the first 24 hours after discharge, when the pain may be greatest, adverse effects can be common, and analgesia administered at the hospital is wearing off.
Although there is still some risk, when opioids are used for a medical purpose for a short time, the risk of addiction is small (21). Fearful of the addictive potential of opioids, many patients may prefer a non-opioid or a less potent opioid medication. Also, some patients may be so distressed by the adverse effects of opioids that they may prefer to experience pain rather than opioid adverse effects. Efforts toward multimodal analgesia with the combination of opioid and non-opioid medications, including nonsteroidal antiinflammatory drugs, cyclooxygenase-2 inhibitors, or local anesthetics, may result in more optimal pain management (22). Our findings suggest that greater awareness of the importance of managing pain and the dedication of resources to pain control are needed to improve postoperative pain management.
There are some weaknesses in this study. A retrospective survey of an event or an experience is likely to be influenced by the events occurring after the event in question, as well as by the time interval. Although many people are able to recall past events or experiences with reasonable accuracy, over long periods of time, the effect of recall bias and passage of time should be considered when interpreting a retrospective analysis. However, we believe that postoperative events are unique and significant enough that patients may be able to recall their general pain experience, even when it took place several years previously. Approximately 50% of patients who responded to this survey had had surgery within the year before the survey. In addition, these data should be interpreted in the context of 250 patients, with just slightly more female respondents (60%), because there can be some difference in pain experience between sexes. Finally, it is acknowledged that these results are based on a survey of only 250 randomly selected patients, spanning both inpatient and outpatient procedures. Nonetheless, these findings are consistent with previous reports and provide a current understanding of the potential challenges we still face in adequately managing pain.
In summary, most patients experience moderate to severe pain sometime during their postoperative recovery. The results from this study are even more relevant with the increasing attention to pain management in the hospital setting. Changes in medical practice patterns, continued research, development of newer analgesics with potent efficacy and minimal adverse effects, and use of balanced analgesia should enhance the potential to treat postoperative pain more successfully.
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Acknowledgments |
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