Postoperative Pain is an Under Appreciated, Under Treated Problem in the United States

CHERRY HILL, N.J., Oct. 3 /PRNewswire/ -- At a time when both inadequate and overly aggressive pain management after surgery are commonplace in the United States, the American Society of PeriAnesthesia Nurses (ASPAN) has issued a 10-step action plan to address the factors that may lead to inappropriate medication use and potential adverse events for patients. ASPAN is the professional organization representing more than 55,000 nurses practicing in all phases of preanesthesia and postanesthesia.

The report -- The State of Postoperative Pain Management: A Need For Improvement -- states that only by elevating postoperative pain management as a priority concern among health care institutions, providers and policymakers, will the significant costs of inadequate care be reduced in the United States. According to studies cited in the report, up to 75 percent of patients experience pain after surgery. However, many receive inadequate treatment, which can result in extended hospitalization, delayed healing and mobility, higher morbidity and mortality, and the development of a chronic pain state.

Issued as a nationwide call to action, the report documents cases of overly aggressive pain management, which are associated with increases in over-sedation and fatal respiratory depression. In addition, the report cites the continuing problem of medication errors.

"Based on our assessment of the issues surrounding the management of acute postoperative pain, we know we need to address a number of complex problems, all of which impact patients receiving appropriate relief after surgery," said Pamela E. Windle, MS, RN, 2007-2008 Immediate Past President of ASPAN and Nurse Manager, St. Luke's Episcopal Hospital, Houston, Texas. "In focusing our efforts on creating identifiable action steps in this report, we believe we provide a blueprint for a successful plan to address this major public health concern."

In partnership with Ortho-McNeil, Inc., ASPAN convened an expert panel of specialists in the field of acute pain management, who prepared the report following a thorough assessment of the current state of postoperative pain management and those trends that may lead to increased safety and better patient care in the future.

Designed to provide the most up-to-date information about the state of postoperative pain management in the United States, the ASPAN report identifies those factors that contribute to inadequate pain relief after surgery: under-estimation of postoperative pain by physicians and nurses, deliberate under-treatment due to clinicians' concerns about the potential for adverse events, and a limited understanding among health care professionals about therapeutic strategies for treating postoperative pain, which usually involve the administration of opioids using intravenous patient-controlled analgesia (IV PCA). Although IV PCA is supported by favorable efficacy and patient preference data, this system has been associated with needle-related injuries and IV-related phlebitis, accidental overmedication, narcotic-induced respiratory depression, and other adverse events.

To address these challenges in using IV PCA, the report describes a number of promising technologies using different analgesic agents and methods to deliver patient-controlled analgesia, including the introduction of a "smart pump" and the use of regional neural blockades combined with oral opioids in patients recovering from orthopedic surgery. Additionally, in development is the first needle-free, patient-controlled iontophoretic transdermal system and patient-controlled intranasal analgesia (PCINA), whereby opioids, in either a dry powder form or in a saline solution, are delivered using a syringe, nasal spray, dropper or nebulized inhaler.

Taking Steps to Address Postoperative Pain Management

While advances in technology are important, the ASPAN report concludes that technology alone will not lead to safer and more effective postoperative analgesia. Accordingly, the expert panel identified 10 national priorities that will have the greatest impact in improving the state of postoperative pain management. Ultimately involving the support and active participation of many stakeholders -- the federal government, state and local government agencies, professional societies and health care practitioners, health educators, and patient advocates -- this platform calls for action in the following areas:

    1.  Elevate postoperative pain management as a priority concern.
        The report calls on the health care community to recognize the extent
        of postoperative pain and the impact of inadequate treatment, which is
        the first step in increasing the resources for research funding,
        education and the development of new therapeutic options.
    2.  Expand efforts to educate surgical patients about their rights to
        effective pain management.
        Because inadequate education of patients regarding postoperative pain
        is one of the factors leading to under treatment, the report calls on
        hospitals to utilize existing tools, such as the Patient Care
        Partnership: Understanding Expectations, Rights and
        Responsibilities(1), a document that incorporates the Patients Bill of
        Rights into plain language for patients and caregivers, to become
        better advocates for their patients. The report also calls on
        advocates to raise patient expectations about what is possible
        regarding treating postoperative pain.
    3.  Pass the National Pain Care Policy Act of 2007 during the 110th
        session of Congress.
        Introduced in July 2007 (H.R.1283/S.626), this bill would provide
        federal research funds to advance clinical and basic research on pain
        and its management.
    4.  Double the federal budget for research on pain management.
        Although the National Institutes of Health created a Pain Consortium
        to identify research opportunities at its 18 Institutes and Centers
        and funds research on pain as it applies to specific disease states,
        only one percent of the total NIH budget -- or $170 million -- is
        actually going into specific pain research. The report calls for
        doubling the NIH budget to $340 million for basic and clinical
        research on acute and persistent pain management.
    5.  Increase the visibility of pain research both within the NIH research
        community and with pain advocacy organizations and patient groups.
        With the goal of developing interventions to prevent and manage pain,
        the report calls for increased attention to the pain experience as a
        focus of NIH research and for wide dissemination of new research
        findings to the professional community.
    6.  Create the means to share information about best practices in
        postoperative pain management.
        In response to the 1999 Institute of Medicine report on medical
        errors, the health care community has put in place new practice
        guidelines and educational efforts, many of which address
        postoperative pain management. Now, the critical next step is for the
        federal government -- through the National Institutes of Health or the
        Agency for Healthcare Research and Quality -- to begin collecting data
        on best practices in the assessment, administration of analgesics, and
        documentation of pain management practices so that this information
        can be quantified and shared across specialties and health care
        facilities.
    7.  Eliminate the barriers to more effective postoperative pain management
        for the medically underserved.
        Because a number of studies have shown that minorities and the poor
        are at risk for inadequate pain control, pain advocates support new
        research initiatives that focus on cultural and ethnic differences in
        understanding and managing pain. Even in the absence of this data, the
        report states that it is incumbent on hospitals and community
        treatment centers to be more proactive in addressing postoperative
        pain management, so patients and caregivers will benefit from more
        aggressive and successful symptom management.
    8.  Develop a curriculum on pain management for use in medical schools and
        allied health care institutions.
        Today, only three percent of medical schools have a separate required
        course on pain management, which is one of the reasons why there is a
        persistent gap in professional awareness about this subject.
        Accordingly, the report calls for developing a curriculum for medical
        and allied health students that focuses on the evaluation and
        treatment of pain as well as courses for faculty at medical schools
        and allied health care institutions.
    9.  Immediately implement and increase the funding for professional
        training on postoperative pain management.
        Because inadequate postoperative pain management results when
        clinicians have an incomplete understanding about effective dose
        regimens and treatment options, an immediate need is for professional
        societies and recognized medical sub-specialty organizations to invest
        in expanded professional education through continuing education
        courses as well as lecture series on pain management issues.
    10. Move toward a less invasive, more cost-effective system for delivering
        acute postoperative pain management in the hospital setting.
        Besides expanding research funding and increasing professional
        education about postoperative pain management, the report concludes
        that new and better approaches to postoperative pain management are
        needed to improve the standard of care and calls for accelerating the
        adoption of new technologies that use iontophoretic transdermal,
        intranasal and transpulmonary routes to deliver analgesia in a much
        less invasive way.

About the Report

To prepare this new report, ASPAN, in partnership with Ortho-McNeil, Inc., convened an expert panel of five leading specialists in the field of acute pain management in October 2006 to examine the current state of postoperative pain management and those trends that may lead to increased safety and better patient care in the future. As part of this evaluation, the panel reviewed published studies on current treatment methods, data on new technologies in development, existing practice guidelines, position statements of government bodies and health care institutions, and new federal and state requirements for reporting medical errors. Further, the panel examined the current state of research funding for and education about postoperative pain and where major gaps exist.

Members of the expert panel are: 1) Pamela E. Windle, MS, RN, CNA, BC, CPAN, CAPA, Immediate Past President of ASPAN; 2) Robert Hutchison, PharmD, Clinical Assistant Professor of Pharmacy Practice at Presbyterian Hospital of Dallas; 3) Harold Minkowitz, M.D., Staff Anesthesiologist at Memorial Hermann Memorial City Hospital in Houston; 4) Javad Parvizi, M.D., FRCS, with the Rothman Institute of Orthopedics at Thomas Jefferson University Hospital in Philadelphia; and 5) Richard Payne, M.D., Director of the Duke Institute on Care at the End of Life at Duke University Divinity School in Durham. In addition to these researchers, Raymond Sinatra, M.D., Ph.D., the Director of the Yale University Pain Service at the Yale-New Haven Hospital provided technical assistance to ASPAN and contributed the foreword to this paper.

About ASPAN

The American Society of PeriAnesthesia Nurses (ASPAN) is the international professional specialty nursing organization representing the interests of over 55,000 nurses practicing in preanesthesia and postanesthesia care, ambulatory surgery, and pain management.

For additional information about ASPAN and to obtain a copy of the report, please visit our website at www.aspan.org.

1. Patient Care Partnership: Understanding Expectations, Rights, Responsibilities. The American Hospital Association. 2003.

    CONTACT: Kevin Dill
    Chief Executive Officer
    ASPAN
    (877) 737-9696 x11
    kdill@aspan.org