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LETTERS TO THE EDITOR

What Is Wrong with This Picture of Pain Management?

Department of Anesthesiology, Virginia Mason Medical Center, Seattle, WA

To the Editor:

Apfelbaum et al. remind us that we have not solved the issue of postoperative pain (1). They randomly surveyed 250 postsurgical patients, identifying that 82% reported some pain after surgery, with 39% of them experiencing "severe to extreme" pain. Their survey appears to have included only patients receiving parenteral or oral opioids: 23% of those patients reported experiencing adverse side effects.

Their report is frustrating because of the lack of acknowledgment of highly effective analgesic modalities developed in the last 20 years. Specifically, epidural opioid/local anesthetic infusions are superior to other forms of analgesia (2), especially following thoracotomy (3) and upper abdominal (4) surgery. For outpatients, regional techniques also provide significant postoperative analgesia without the side effects associated with opioids, both as single injections (5) and continuous infusions (6–8). The information supporting the use of these regional techniques has become so extensive that the Veterans’ Health Administration (VHA) and the Department of Defense (DOD) have made recommendations for procedure specific analgesic regimens emphasizing regional analgesia (9). These regimens, available on their Web page (www.oqp.med.va.gov/cpg/cpghtm), identify the use of regional techniques for many procedures based on the evidence-based data that supports significantly lower pain scores.

Why haven’t these modalities been included in the experience of the patients surveyed by Apfelbaum et al.? Is it because of reimbursement problems? Is it an issue of manpower? Do we not want to spend the time? Are we not familiar with the techniques (10)? More information is needed. What are the impediments to providing the level of care that we know can produce better results? Clearly, there are more questions here, and certainly challenges, for all of us in our profession to implement the technology that we have available to solve a problem that has persisted for far too long.

Footnotes

Dr. Apfelbaum did not send a response.

References

1. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg 2003; 97: 534–40.[Abstract/Free Full Text]
2. Block BM, Liu SS, Rowlingson AJ, et al. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA 2003; 290: 2455–63.[Abstract/Free Full Text]
3. Kavanagh BP, Katz J, Sandler AN. Pain control after thoracic surgery: a review of current techniques. Anesthesiology 1994; 81: 737–59.[ISI][Medline]
4. Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia: their role in postoperative outcome. Anesthesiology 1995; 82: 1474–506.[ISI][Medline]
5. Mulroy MF, Larkin KL, Batra MS, et al. Femoral nerve block with 0.25% or 0.5% bupivacaine improves postoperative analgesia following outpatient arthroscopic anterior cruciate ligament repair. Reg Anesth Pain Med 2001; 26: 24–9.[ISI][Medline]
6. Ilfeld BM, Morey TE, Enneking FK. Continuous infraclavicular brachial plexus block for postoperative pain control at home: a randomized, double-blinded, placebo-controlled study. Anesthesiology 2002; 96: 1297–304.[ISI][Medline]
7. Klein SM, Grant SA, Greengrass RA, et al. Interscalene brachial plexus block with a continuous catheter insertion system and a disposable infusion pump. Anesth Analg 2000; 91: 1473–8.[Abstract/Free Full Text]
8. White PF, Issioui T, Skrivanek GD, et al. The use of a continuous popliteal sciatic nerve block after surgery involving the foot and ankle: does it improve the quality of recovery? Anesth Analg 2003; 97: 1303–9.[Abstract/Free Full Text]
9. Rosenquist RW, Rosenberg J. Postoperative pain guidelines. Reg Anesth Pain Med 2003; 28: 279–88.[Medline]
10. Kopacz DJ, Neal JM. Regional anesthesia and pain medicine: residency training: the year 2000. Reg Anesth Pain Med 2002; 27: 9–14.[ISI][Medline]

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Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999