I usually write about health care economics and reform. Today I want to talk about my clinical passion– pain management, especially in the post-operative setting. It truly amazes me that despite our advances in medical care, many patients still do not receive optimal pain management after surgery. Here are three rules to consider as we minimize the patient’s experience to pain:
Rule #1- The probability of pain post-operatively is essentially 100%. Put another way, surgery CAUSES pain. Sounds obvious, but given that imminent probability, many patients are not appropriately prepared psychologically or medicinally for post-operative pain. Individual patient pain risk assessments should be done prior to surgery. The patient and the family should be educated as to the type of pain and what they can do to manage it. Pain scales should be reviewed with the patient and family. Not all patients perceive pain the same way and not all procedures cause the same degree of pain, but the ability to proactively plan and prepare the patient is essential. Presumptive orders should be written and the patient needs to be informed of exactly how/ by what route the medication will be given. There should be a thorough understanding of what is given automatically and what the patient should request. Since pain is expected, pain medications should be administered in advance whenever possible, not wait until after the pain starts. All too often pain management is retroactive.
Rule #2- Pain management is multi-modal. There are multiple ways of treating pain. Pain management alternatives should be considered, as they may act synergistically and quite effectively for mild to moderate pain. Non-steroidal medications, acetaminophen and non-pharmacological alternatives should be the mainstay of initial treatment, and many times should be given in advance in anticipation of the pain. Pain management protocols should start out with these initial modalities and then scale up accordingly to stronger medications such as opioids if the pain is not controlled or becomes more severe. There are many examples of multi-modal pain management protocols available for the practitioners.
Rule #3- Post-operative pain does NOT mean “narcopenia”. Too many health care professionals believe that parenteral narcotics are the initial choice and the mainstay of pain management. Opioids are far from benign. They are one of the most frequently implicated drug classes in adverse reactions ranging from nausea and vomiting to life-threatening respiratory depression. In 2012 the Joint Commission issued a Sentinel Alert on the safe use of opioids in hospitals and they endorsed the use of non-opioids as a first line approach to minimize total opioid consumption. Decreased opioid use has been shown to decrease respiratory depression, length of stay in PACU and in some cases, decreased length of stay and costs for the hospitalization. It has also been associated with higher patient satisfaction scores. Post-operative nausea, vomiting or constipation are not benign… they are a great discomfort to the patient in a very inconvenient situation and do contribute to longer lengths of stay and less favorable hospital experiences.
As such, we should commit to the following:
1. Individual pain assessment for the patient pre-operatively.
2. A multi-modal approach to pain management starting with non-opioid alternatives initially.
3. Minimizing the use of narcotics, especially IV and using them only for severe pain not controlled by the other alternatives. Patients should be assessed for their risk of hypotension and respiratory depression, and appropriately observed for signs of adverse events while taking IV narcotics.
Yes, there is a lot we can do. If you ever need surgery, I truly hope it is as boring and pain-free as possible.