Patients undergoing same-day surgery expect and accept postoperative pain

Post-op pain control techniques are not working — what can you do?

Your patient satisfaction surveys show that your patients are satisfied with your management of their postoperative pain, so you must have an effective pain management service, correct? But wait. Results of a study presented at the annual meeting of the Park Ridge, IL-based American Society of Anesthesiologists show that although patients say they are happy with the pain control offered them after surgery, 85% of the survey participants also report experiencing moderate to extreme pain following their procedure.

How can a patient be happy with pain management and still report pain? The best explanation for this apparent contradiction in experience and opinion is that patients expect pain and don’t think any method will relieve it, says Jeffrey L. Apfelbaum, MD, director of outpatient surgery at the University of Chicago Hospitals and one of the investigators on the study. The December 1999 telephone survey included 250 people who had undergone inpatient or outpatient surgery in the previous six years, he says. The experience and response from inpatient or outpatient surgery were similar, he adds.

Why should same-day surgery managers pay attention to a study that shows pain control is not as effective as patient satisfaction surveys indicate? Pain is the single biggest reason patients fear surgery, Apfelbaum says.

"Eight percent of all patients surveyed reported that they had postponed their surgery at least once for fear of the postoperative pain," he adds. The fear also increases the patients’ anxiety on the day of surgery, decreases their ability to absorb information you are giving them prior to and after surgery, and affects their entire experience, he explains. All of these conditions affect how well you can care for the patient, and the postponement can make the procedure more difficult, he adds.

Another reason to pay attention to the results is the implementation of pain management standards by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL, says T.J. Gan, MD, director of clinical research at Duke University Medical Center in Durham, NC, and lead investigator of the study. The new standards, effective Jan. 1, 2001, require same-day surgery programs to recognize pain management as part of the patients’ treatment and demonstrate that a process is in place to help patients manage pain. (For more information on the standards, see Same-Day Surgery, March 2000, pain management supplement.)

"We conducted this study to see if hospitals and surgery centers are ready for the new JCAHO standards," Gan says. "We knew that the number of pain management services had increased, so we assumed we were treating patient’s pain more effectively."

The study showed results that were not expected, he says. "We still are not doing a good job of managing pain. In fact, when we compare results of this study to results of a similar study conducted seven years ago, we see that we haven’t improved significantly."¹

No new, effective drugs or methods

There may be several reasons for the lack of improvement, says Jeffrey A. Katz, MD, assistant professor of anesthesiology at Northwestern University Medical Center in Chicago.

"We ship more patients out of our facility immediately after surgery as more procedures are performed on a same-day basis," Katz says. That means patients don’t have access to intravenous drugs and monitoring by health professionals who might treat pain more aggressively and earlier, he states. "At the same time, we ask patients to increase their activity sooner than we used to expect." While having the patient move around sooner does decrease recovery time, it also in-creases the amount of pain the patient will experience, he explains.

Another reason postoperative pain management has not improved is the lack of new methods that work for patients once they go home, says Katz. "Regional blocks work well, but they only last a maximum of 18 hours with the average time closer to eight to 12 hours." Once the block has worn off, the pain is there and the patient usually has to treat it with oral medication, he adds.

Other new methods and medications are being introduced, but current techniques have their drawbacks, says Katz.  "Most patients don’t want narcotics, but narcotics are what we give the vast majority of patients," he says. "Keep in mind that morphine and codeine are the same drugs people used in 4000 BC."

While narcotics can significantly reduce pain, 75% of the patients in the study did not want to use them, says Apfelbaum. "Patients are afraid of the side effects, which can include loss of control, lightheadedness, nausea, itching, and difficulty urinating," he explains.

Ketoraloc is another pain medication that is non-narcotic but also has serious side effects, Apfelbaum says. "Platelet aggregation, bleeding problems, and gastrointestinal upset are side effects that cause me to avoid the drug."

In addition to new medications and delivery systems, there are some simple steps to take to improve a patient’s postoperative pain control, says Apfelbaum. He suggests that "making sure that pain is assessed every time a temperature or blood pressure is taken would ensure that we are monitoring pain. Also, including very specific questions about level of pain in all post-op follow-up calls is critical."

Reference

1. Warfield CA, Kahn CH. Acute pain management: Programs in US hospitals and experiences and attitudes among US adults. Anesthesiology 1995; 83:1,090-1,094. 

Sources

For more information on the pain control study and pain control methods, contact:

• T.J. Gan, MD, Associate Professor, Department of Anesthesiology, Duke University Medical Center, 3094 Erwin Road, Durham, NC 27710. Telephone: (919) 681-4660. Fax: (919) 681-7901. E-mail: gan00001@mc.duke.edu.

• Jeffrey L. Apfelbaum, MD, Director of Outpatient Surgery, Department of Anesthesia and Critical Care, University of Chicago Hospitals, 5841 S. Maryland Ave., MC4028, Chicago, IL 60637. Telephone: (773) 702-0523. Fax: (773) 834-0063.

• Jeffrey A. Katz, MD, Assistant Professor of Anesthesiology, Northwestern University Medical Center, 251 E. Huron St., Chicago, IL 60611. Telephone: (312) 908-3276. E-mail: jkatz@nmff.org.