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1992.03.05 :  AHCPR Report -- Acute Pain Management

Contact: Bill Grigg (PHS) (202) 245-6867 Bob Isquith (AHCPR)
(301) 227-8370 
March 5, 1992

     In the first of a new series of federally sponsored medical
care guidelines, a panel of health care experts recommended today
that patients undergoing surgery should receive more active
management of pain through medication than is given under current
conventional treatment.
     The panel report, "Acute Pain Management: Operative or
Medical Procedures and Trauma," calls for "aggressive pain
management before, during and after surgery." It says failure to
control pain not only causes unnecessary suffering but can delay
recovery and prolong hospitalization.
     The clinical practice guideline was developed by pain
management experts assembled in 1990 under the sponsorship of the
Public Health Service's new Agency for Health Care Policy and
Research, which was authorized by Congress in 1989.  The
guideline was then tested in hospitals and other settings.
     "Put simply, the findings here indicate that we can do more,
and better, to control pain after surgery," HHS Secretary Louis
W. Sullivan, M.D., said.  "As clinicians, we need to plan ahead
for pain control -- and we need to work cooperatively with our
patients, both before and after surgical procedures."
        Secretary Sullivan also praised the medical effectiveness
effort which underlies the issuance of treatment guidelines, and
called it "the beginning of a peaceful revolution in American
medical care."
        "The guideline we are releasing today is just the first
of many that will result from that effort," he said.  "The
medical effectiveness program will mean better knowledge for
health care professionals, better care for patients, and better
effectiveness, including cost-effectiveness, for our health care
delivery system."

        He called the medical effectiveness effort "patient-
centered and quality-centered."

     In separate statements today, the American Medical
Association and the American Nurses Association also endorsed the
process and said it provides good advice while preserving
individual decision-making in all cases.

     James Mason, M.D., HHS assistant secretary for health and
head of the Public Health Service, said, "When doctors do things
the traditional way, simply calling for injections of such pain-
killers as morphine and codeine 'as needed,' the results are
often under-medication and unnecessary pain.  This occurs
particularly in infants, children and the elderly, who often
cannot express their needs.  I hope this report finally sets to
rest the myth that newborns feel no pain and do not need to be
medicated for pain, as well as the myth that the elderly have a
higher pain threshold."

        The report found that about half of the patients treated
with conventional therapy following surgery experience moderate
to severe levels of pain.  Over 23 million surgeries are
performed each year, and the majority are managed with
conventional pain therapy.

     "For infants and children, the percentage who are under-
medicated for pain is even higher than among adults," Mason said.

     The 18-member pain panel was headed by Daniel Carr, M.D.,
director of the division of pain management at Massachusetts
General Hospital; and Ada K. Jacox, R.N., Ph.D., Independence
Foundation Chair of Health Policy at the Johns Hopkins University
School of Nursing.  

        It included specialists in anesthesiology, neurology,
surgery, pediatrics, family medicine, nursing, pharmacy, physical
therapy, psychology and medical ethics, and a consumer
representative.  

     Findings included:

     -- Postoperative pain has been considered inevitable and
harmless.  However, unrelieved pain after surgery or trauma is
often unhealthy and can delay recovery.  Fears of post-surgical
addiction to opioids are generally groundless.  "Patients have a
right to treatment that includes prevention or adequate relief of
pain."  Doctors need to plan for pain reduction before surgery
and inform patients what to expect.

     -- Aggressive prevention of pain is better than treatment
because, once established, pain is more difficult to suppress.
For example, when pain is properly prevented during cesarean 
sections, patients may require less pain medication afterward.
In addition, patients should be encouraged not to be stoic but to
request pain medication before pain becomes severe and difficult
to control.  Patients who are told what discomforts to expect may
actually experience decreased pain, less use of analgesics and
shorter hospitalizations.

     -- Simply-taught relaxation techniques can help decrease
post-operative pain, and non-drug aids can help, as well as heat,
cold and massage.  

     -- When pain is controlled well (as when patients are able
to self-medicate with small intravenous doses of opioids such as
morphine via a metered infusion pump) the patients tend to be 
discharged from the hospital earlier and may have fewer chronic
pain problems such as phantom limb pain after some amputations.

     -- The most reliable index of pain is what the patient
reports, but misguided ideas of stoicism, especially in the
elderly, may lead to unnecessary pain.

     -- The practice of giving pain medication only "as needed"
can result in "prolonged delays" because the patient may hold off
asking for help, especially at night, and then the nurse must
unlock the controlled substances cabinet, obtain the pain-killer,
prepare it for administration and subsequently give it.  Far 
better, when the patient is likely to have pain for 48 hours 
after surgery: Provide pain medication at regular intervals for
the first 36 hours and then move to "as needed."

     -- Patient-controlled medication via an infusion pump is "a
safe method" that many patients prefer to repeated injections.
     -- Care for newborn infants, especially premature infants,
require special pain expertise but "clearly, neonates and infants
experience pain, and adequate analgesia is necessary for both
physiologic and ethical reasons." 
     -- Children experience moderate to severe pain in as many as
60 percent of procedures.  Many do not receive opioids after
surgery even though painful postoperative experiences are
expected.  Providing medication to inarticulate children only "as
needed" deprives them of pain-prevention.

     The guideline specifically calls into question the practice
of withholding pain-killers from very small infants because of
the belief they might dangerously depress their breathing.  On
the contrary, the panelists said, recent studies show that
careful pain treatment of infants reduces surgical stress and
postoperative deaths.

     According to the report, unrelieved pain not only stalls the
healing process, but also impairs the immune system, keeps the
patient from coughing as needed, raises the likelihood of
pneumonia, and delays the return of normal stomach and bowel
functions.

     The recommendations, which also cover pain management for 
trauma and certain diagnostic procedures, discuss types of 
analgesics that should be used and dosages and dosage schedules.  

        The expert panel drafted the guideline after obtaining
advice from medical, nursing and other professional specialty
groups, holding a public meeting, reviewing thousands of medical
studies, and consulting leading pain management experts.  Once
the initial guideline was drafted, numerous other experts in pain
management reviewed the document.

     The guideline was tested in hospitals and clinics in
different parts of the country, measuring its clarity and
applicability, as well as the training needed to implement it.

     AHCPR Administrator J. Jarrett Clinton, M.D., said the
guideline will be periodically reviewed and updated as needed.

     AHCPR will distribute the guideline to physicians, nurses,
medical and nursing societies, health professions schools, 
insurers, consumer groups and others.  Patient information, which
is now available in English, will also be provided soon in
Spanish. The clinical practice guideline, entitled Acute Pain
Management: Operative or Medical Procedures and Trauma, quick
reference guides for postoperative pain in adults and children,
and the patient's guide are available without cost from the AHCPR
Publications Clearinghouse, P.O. Box 8547, Silver Spring, Md. 
20907; tel:1-800-358-9295.

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