Acute Pain Management

by Paulette Avery, R.N., M.S.N.

Pain is one of the realities of life that most of us would prefer to avoid. When we have a headache or other minor discomfort, many of us run to our home drug supply for relief. Even for minor dental procedures we request pain control measures to help us remain comfortable.

So, naturally, if we are facing major surgery, we assume our postoperative pain will be adequately managed. Unfortunately, this assumption may be wrong. Clinical studies indicate that the injections of narcotics routinely ordered to control surgical pain fail to provide relief in about half of postoperative patients. Aside from the discomfort that results from this failure, inadequate pain relief contributes to longer recovery periods and greater use of our scarce health care resources.

Recognition of the widespread inadequacy of pain management led the Agency for Health Care Policy and Research (AHCPR), U.S. Department of Health and Human Services, to convene an interdisciplinary team of health care experts to study the problem and make recommendations. The result of their work is a book titled: Clinical Practice Guideline-Acute Pain Management; Operative or Medical Procedures and Trauma." To quote from the book's executive summary, The guideline is designed to help clinicians, patients, and patients' families to understand the assessment and treatment of postoperative and other acute pain in both adults and children." Based primarily on the contents of this book, I'll devote the remainder of this column to providing some general information about pain. Future columns will cover ways to assess pain and specific pain management strategies.

To achieve adequate pain management, health professionals, patients and their families must understand what pain is and the factors involved in controlling it. The definition of pain used in the AHCPR book is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage." Pain is complex and very personal. Each of us experiences pain in our own unique way based on many variables, including our life history and the circumstances of the moment. For example, if you are well rested and having a good day, accidentally hitting your finger with a hammer will probably result in a brief episode of pain that is quickly forgotten. On the other hand, if the same accident occurs on a day when you are physically exhausted and burdened with an emotional problem, the pain may affect you for much longer.

Keeping our subjective response to pain in mind, it is still possible to quantify pain based on its intensity, time course, quality, impact, and personal meaning. To give another example, a woman who sees birthing as a rewarding, natural process, who has good support and remains in control, may go through a long labor without medication and experience very little pain. If asked to rate her pain on a scale from one to ten, with ten indicating intense pain, she might rate her labor pain as a three. In contrast, another woman, laboring alone and haunted by a litany of horror stories, may have what to an outside observer seems a similar labor. Yet she experiences intense pain and requests the most powerful pain relief available for what she rates as nine on the same scale.

According to the AHCPR book, pain is dynamic. In other words pain seems to feed on itself. Without treatment, pain sensations travel to the spinal cord and cause subsequent responses to the pain to increase. After injury, peripheral pain receptors become more sensitive and there can be long-lasting changes in cells within the pain pathways in responseto even a brief episode of pain. As a result, pain responds better to prevention than to treatment. In the case of postoperative pain, that means patients should request pain relief before the pain becomes severe and more difficult to control.

Next month I'll discuss the impact of patients' and health care providers' attitudes toward pain control and ways to assess pain.

Paulette Avery is a registered nurse and a freelance writer specializing in health issues.