Thursday, June 23, 2011

Patients Continue To Receive Inadequate Pain Relief After Surgery, But Innovative Techniques Could Aid Pain Management - The Lancet Series On Pain

Despite new standards, guidelines, and educational efforts, acute pain after surgery continues to be undertreated worldwide, with up to 75% of surgical patients in the USA still failing to receive adequate post-op pain relief, according to the first paper in The Lancet Series on pain. The findings also reveal that chronic pain after surgery is a bigger problem than previously recognised, affecting up to half of patients undergoing common operations. However, new pain medications and techniques under development could help improve symptom relief for patients. 

In the paper, Christopher L Wu and Srinivasa Raja from John Hopkins University and School of Medicine, Baltimore, USA review the progress made in treatments for postoperative pain over the past decade and stress that despite advances in pain management, a high percentage of patients continue to experience moderate-to-severe pain after surgery. Inadequate post-surgical pain management is not just limited to adults, with a study from the USA reporting as many as 86% of children experiencing significant pain on the first day home after undergoing routine tonsillectomy. 

Recent research also shows that the development of chronic pain after surgery, known as persistent postsurgical pain [PPP], is a frequent outcome of surgery. As many as 30-50% of patients undergoing common operations such as mastectomy, thoracotomy, hernia repair, and coronary artery bypass have to cope with PPP. 

They authors say: "Why there has been little progress in the treatment of acute postoperative pain is unclear, but the causes might be multifactoral, including the continued paucity of pain assessment and documentation, heightened awareness and increased number of audits or surveys leading to increased identification of undertreatment of pain...deficiencies in educational pain management programmes for health-care workers, underuse of effective analgesic techniques, and poor adherence to available guidelines." 

However, some interventional techniques have had a substantial impact on pain control over the past decade. In particular, regional analgesic techniques (such as epidural analgesia and peripheral nerve catheters using local anaesthetics) have been associated with significantly lower pain scores, earlier mobility, and reduced length of hospitalisation compared with the use of systemic opioids. Furthermore, such techniques eliminate the risk of addiction. 

Other promising interventions still under development include the transdermal patch for the patient-controlled delivery of pain medication (fentanyl) providing a needle-free effective alternative to the intravenous pump; extended-release local anaesthetics to prolong the action of commonly used local anaesthetics; and disposable devices to allow infusion of local anaesthetics on an outpatient basis reducing the need for opioids and their adverse effects (nausea, constipation, respiratory depression). 

They conclude: "Additional studies on predictors of postoperative pain and persistent postsurgical pain, efficacy of multimodal analgesic regimens [using more than one class of pain medication or technique], and growth of promising new technologies might lead to substantial gains in the treatment of acute postoperative pain and potential reduction in the development of persistent pain states [a not uncommon outcome of surgery]."

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