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Postoperative Pain Management

For patients on chronic opioid therapy, it can be a challenge

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More than 70 million surgical procedures are performed in the United States each year.1 Postsurgical pain is an inherent risk associated with all operative procedures. Pain management after a surgical procedure is a challenge regardless of advances in knowledge about physiologic response to pain, new treatments and pain treatment protocols.2

In the last decade, the importance of assessing and treating pain has received widespread attention. Despite this, adequate postoperative pain control is elusive. Unresolved postoperative pain can lead to increased length of stay and impaired immune function.3

Opioids are the first line of treatment for postoperative pain. Numerous protocols and recommended standard doses are used, but such protocols do not address pain control in patients with chronic pain who are opioid dependent. These patients experience changes at the cellular level and synapses that alter pain receptor function. Dosages used for opioid-naive patients provide little physiologic effect in opioid-dependent patients.4

Due to these physiologic changes and what may be perceived as fear on the part of prescribers, pain is often undertreated in patients with opioid dependence. Providers need a more complete understanding of pain management and appropriate therapies in the treatment of acute postoperative pain in opioid- dependent adults with chronic pain.

Significance

More than 116 million Americans experience some form of chronic pain, exceeding the number affected by chronic diseases such as coronary artery disease, cancer and diabetes combined.5 The majority of these patients rely on opioid pain medications for controlling their pain, often developing a tolerance to standard dosages.

It is essential that clinicians who deliver postoperative care understand the differences in pain management strategies. Failure to recognize the postoperative pain management required by chronic pain sufferers leads to frustration for clinical staff and patients.

Current Literature

Pain management is a complex problem. It is also a fundamental right of all people. Therefore, clinicians should be well-versed in analgesics and interventional approaches to managing pain.6 Postoperative pain management is essential to optimal healing and recovery, and insufficient pain control can prolong recovery and reduce patient satisfaction.7 Many sources have identified the importance of postoperative pain management in general, but conclusive guidelines for variations in treatment between opioid-dependent and opioid-naive patients have not been developed.6,7 Despite the focus on pain management, many patients continue to experience extreme pain after surgery.1

Principles for Pain Management

Pain is subjective, and it is not easily identified in objective data. Pain influences patients in various ways and causes undesirable effects on immune and endocrine function that can delay healing.8 Other negative effects of pain include physical and emotional distress, cardiovascular implications such as hypertension and tachycardia, increased oxygen consumption, impaired respiratory and bowel function, as well as delayed mobilization that promotes thromboembolism.9

The goal of postoperative pain management is optimal patient comfort rather than reduced pain intensity.10 Reduction of side effects is also an important goal in pain management.10 Additional goals may include improved quality of life, reduced morbidity, timely discharge, and quick recovery and return of function.

Numerous factors influence postoperative pain, including previous pain experience, age, anxiety, fear, procedure type and patient and provider expectations.2,11 Many postoperative pain management protocols include general medications and dosages without regard to influencing factors. This can lead to ineffective pain management and delay of optimal pain control. Analgesic medications are not equally effective in all patients or circumstances because different types of surgeries require different types of analgesia. Options for pain control should take into consideration the procedure being performed. 2,9

The pain management plan should be started in the preoperative phase to help identify potential barriers to good pain control. A discussion focused on expectations and previous experience may help guide the clinician in formulating the pain management plan. Involving family members as appropriate may contribute to effective plan development.9 Postoperative pain management should not come from a standardized regimen; it should be adapted to the needs of the specific patient.12

Chronic Pain

Chronic pain is defined as pain lasting 6 months or longer that often has an unspecified pathology and may be associated with feelings of depression.13 The complex interaction of physical, emotional and mental sequelae makes it difficult for many clinicians to adequately treat chronic pain. Before being diagnosed with chronic pain, a patient should receive a comprehensive history and physical assessment plus interventional diagnostic procedures to help identify the source of pain. Therapies for chronic pain may include medications delivered via varying routes: oral, injectable or intrathecal, surgery, acupuncture, nerve or root blocks, injection therapy, electrical nerve stimulation, or a combination of these.14 Frequently patients with chronic pain are on opioid medications as well as other classes of medications as adjuvants to analgesia (e.g., antidepressants and steroids).

Chronic Opioid Therapy

The use of chronic opioid therapy (COT) for chronic pain management is increasing. When making decisions about COT, it is important to identify patients whose pain will respond well and who demonstrate low risk for abuse and addiction. Patients who utilize COT should receive adequate screening and assessment, provide informed consent, and agree to a management plan that includes surveillance for adherence and diversion.15 COT is most appropriately prescribed by a clinician specializing in pain management.

Postoperative Pain

Postoperative pain management can be difficult in chronic pain patients on COT. Tolerance is common in this population. This develops when a diminished analgesic effect occurs after prolonged exposure to an opioid, and it must be taken into account in postoperative pain management treatment plans. Opioid-dependent patients require larger doses of medications compared to opioid-naive patients.

Routine postoperative pain management orders do not address home pain medications requirements.12 Chronic pain patients who are opioid dependent require their regular home pain medication dosages as well as an additional amount to treat the acute postoperative pain.12 Patients with complex pain histories who are opioid dependent may be better served by a multidisciplinary team such as an acute pain service (APS).12 Smaller facilities may not have an APS, leaving pain management to surgeons and floor clinicians. It is essential that these providers have an understanding of chronic pain and the issues these patients may experience.

Barriers

The prescribing of chronic opioid therapy has historically been done by clinicians specializing in pain management, but this role has extended into primary care in recent several years.16 As a result, some discrimination in assessment and diagnosis has been lost. Criteria to determine pain as chronic are neither finite nor well known. Chronic use of opiates in persistent pain is controversial in many circles. The medications used for this population, in particular opiates, are often seen in cases of abuse and addiction.

For these reasons many providers are reluctant to prescribe these in above average doses or for the long term, even when appropriate.17 Another barrier to sufficient opioid prescribing in patients treated for chronic pain is the clinician's fear of being investigated and possibly facing disciplinary action. Other potential barriers that inhibit the clinician from prescribing sufficient analgesia for these patients include: personal bias, legal judgments or a lack of awareness about appropriate prescribing for these patients.

Optimizing Management

Patients on COT may have a difficult time achieving sufficient pain response if clinicians do not fully understand how to transition or identify equivalency among opioids. The lack of guidelines for this specific topic leaves facilities without an APS at a loss when dealing with these patients.

NPs and PAs are often the frontline providers for many surgery and specialty clinics. Understanding the needs of chronic pain patients on COT will help NPs and PAs provide more effective care, better healing and increased patient satisfaction. The algorithm accompanying this article identifies key points and gives a step-wise approach to care (see figure). I developed this algorithm after creating a research-based guideline for pain management my practice setting.

Principles of Management

The principles of postoperative pain management are as follows:

1. Pain is a subjective event, difficult to measure by objective data.

2. Negative effects of pain include physical and psychological alterations.

3. Goals of pain management include reduced pain, reduced side effects of medication, reduced morbidity, improved quality of life, timely discharge, and quick recovery and return of function. 4. Effective pain management should include plans tailored to specific patient needs through quality health assessment and physical examination, in collaboration with the patient.

Click to view larger graphic.

Preoperative Preparation

Optimal planning in the preoperative period will aid in effective pain management. A complete history and physical exam including a medication history should be performed, along with a review of the current chronic pain management regimen. Involve the patient and his or her support system in the plan. Provide education about pain assessment tools and pain expectations with the procedure. Calculate current opioid total daily dose and convert it into morphine equivalents. This baseline is the start of the postoperative plan. Dose increases based on expected pain and should be given above the baseline.

Pain Assessment

The pain score should be assessed at rest and with activity, as well as before and after dosing pain medication. The score should be documented at regular intervals and as needed. Response to pain medications should also be documented. Any unexpected, intense pain could indicate an emergent condition and a clinician should be notified.

Postoperative Therapies

Pain management should be individualized and titrated for best therapeutic effect and minimum side effects. The route of delivery selected should be based on clinical condition and patient needs; any adjuvant medications used for analgesia should be incorporated as early as possible. The focus should be on pain prevention. Multimodal analgesia should be used as appropriate. Calculate doses on current patient usage, switch to oral medications when possible. Consider use of long term agents with short acting agents available for rescue dosing. Include nonpharmacologic therapy such as music, relaxation or recreation therapy. The early use of physical and occupational therapy will help identify alternative needs and solutions to pain control.

Discharge Planning

Discharge planning should begin early in the hospitalization. The plan should address current pain management needs and discharge prescriptions should have a sufficient quantity for the patient to maintain current need until follow-up. The clinician and patient should discuss titration of medication back to the patient's baseline. Discuss titration and other concerns with the patient's pain management provider. Follow-up appointments for both the surgeon and the patient's COT provider should be completed within 2 weeks of discharge. Any titration plan should begin at that point, based on clinical condition and patient tolerance. Collaboration among the COT provider, patient and surgeon will ensure a bridge to better pain management and best possible outcome.

References

1. Apfelbaum JL, et al. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003;97(2):534-540.

2. White PF, Kehlet H. Improving postoperative pain management: what are the unresolved issues? Anesthesiology. 2010;112(1):220-225.

3. Hutchison RW. Challenges in acute post-operative pain management. Am J Health Syst Pharm. 2007;64(6 Suppl 4):S2-S5.

4. Mehta V, Langford RM. Acute pain management for opioid dependent patients. Anaesthesia. Mar 2006;61(3):269-276.

5. Institute of Medicine. Relieving Pain in America: A blueprint for transforming prevention. http://www.iom.edu/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-transforming-Prevention-Care-Education-Research.aspx

6. Brennan F, et al. Pain management: a fundamental human right. Anesth Analg. 2007;105(1):205-221.

7. Chapman CR, et al. Postoperative pain patterns in chronic pain patients: a pilot study. Pain Med. 2009;10(3):481-487.

8. Kiecolt-Glaser JK, et al. Psychological influences on surgical recovery. Perspectives from psychoneuroimmunology. Am Psychol. 1998;53(11):1209-1218.

9. Rawal N, et al. Postoperative Pain Management - Good Clinical Practice. http://polanest.webd.pl/pliki/varia/books/PostoperativePainManagement.pdf

10. Bonnet F, Marret E. Postoperative pain management and outcome after surgery. Best Pract Res Clin Anaesthesiol. 2007;21(1):99-107.

11. Ip HY, et al. Predictors of postoperative pain and analgesic consumption: a qualitative systematic review. Anesthesiology. 2009;111(3):657-677.

12. Bhavani-Shankar K, Jasmeet O. Management of postoperative pain. http://www.uptodate.com/contents/management-of-postoperative-pain

13. Mackintosh C, Elson S. Chronic pain: clinical features, assessment and treatment. Nurs Stand. 2008;23(5):48-56.

14. American Society of Anesthesiologists Task Force on Chronic Pain Management, & American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management: An updated Report By the American Society of Anesthesiologists' Task Force On Chronic Pain Management And The American Society Of Regional Anesthesia And Pain Medicine. Anesthesiology. 2010;112(4): 810-833.

15. Chou R, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130.

16. Angst MS, Clark JD. Ketamine for managing perioperative pain in opioid-dependent patients with chronic pain: a unique indication? Anesthesiology. 2010;113(3):514-515.

17. Fields HL. The doctor's dilemma: opiate analgesics and chronic pain. Neuron. 2011;69(4):591-594.

Melissa B. Parra is an acute care nurse practitioner at the Intermountain Blood and Bone Marrow Transplant/Acute Leukemia Program in Salt Lake City. She has completed a disclosure statement and reports no relationships related to this article.




     

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