Clinicians should use multiple approaches to target different pain mechanisms when treating postsurgical pain, according to a Clinical Practice Guideline for this aspect of patient care published by the American Pain Society in the February issue of the Journal of Pain.
Postoperative pain management reportedly is inadequate for more than half of the adults and children who undergo surgery each year. In this setting, inadequate pain relief can contribute to impaired recovery, decreased physical function, postoperative complications, and poor quality of life, and it may even set the stage for the development of chronic pain, said Dr. Roger Chou, lead author of the guideline and professor of medicine and of medical informatics and clinical epidemiology, Oregon Health and Science University, Portland, and his associates.
The guideline includes 32 evidence-based recommendations for all clinicians who treat postoperative pain. It was compiled by a 23-member expert panel based on their analysis of 858 primary studies and 107 systematic reviews of the literature. Despite the panel’s efforts to obtain top-level evidence, of 32 recommendations, the panel rated only 4 as supported by high-quality evidence, and 11 recommendations were on the basis of low-quality evidence. The panel members had expertise in anesthesia, pain medicine, surgery, obstetrics and gynecology, primary care, pediatrics, hospital medicine, nursing, physical therapy, and psychology, said Dr. Chou, who is also director of the Pacific Northwest Evidence-Based Practice Center, Portland, and his associates.
The first strong recommendation, based on high-quality evidence, is to use a variety of medications and techniques that act on both the central and peripheral nervous systems and have been associated with both superior pain relief and decreased opioid consumption, compared with single agents or methods. For example, continuous nonopioid analgesia such as acetaminophen or NSAIDs can be combined with opioids that act on different receptors and with nonpharmacologic therapies. The guideline addresses several specific situations, and summarizes in a table the multimodal options for common surgeries such as laparotomy, total hip or knee replacement, coronary artery bypass graft, and cesarean section.
The guideline also strongly recommends that management of postsurgical pain should begin preoperatively, with assessment of the patient’s medical and psychiatric comorbidities; concomitant medications; and history of any chronic pain, substance abuse, and previous postoperative treatments and responses. Clinicians should use a validated pain assessment tool to track patients’ responses to postsurgical pain treatment and adjust treatment plans accordingly.
The guideline suggests that clinicians consider nonpharmacologic techniques including transcutaneous electrical nerve stimulation and cognitive-behavioral modalities such as guided imagery, relaxation methods, hypnosis, and intraoperative suggestion. At the very least, these are noninvasive and don’t appear to be associated with any harm. However, the guideline cautions that the evidence is insufficient to support cognitive-behavioral modalities in children. It also cannot recommend for or against several alternative treatments for which there is not yet sufficient evidence of efficacy, including acupuncture, massage, and cold therapy, Dr. Chou and his associates said (J Pain. 2016;17:131-57).
For adults who have no contraindications, a preoperative dose of celecoxib is strongly recommended because it improves postoperative pain and also reduces the need for opioids. One contraindication to celecoxib is CABG surgery, because of its attendant risk of adverse cardiovascular events. Preoperative doses of gabapentin or pregabalin also are strongly recommended as part of multimodal postsurgical analgesia, particularly for operations associated with substantial pain.
The guideline also strongly recommends epidural or spinal analgesia for major thoracic or abdominal procedures, especially for patients at risk for cardiac complications, pulmonary complications, or prolonged ileus. Compared with systemic analgesia, these forms appear to decrease the risk of death, venous thromboembolism, myocardial infarction, pneumonia, and respiratory depression. However, patients who receive neuraxial analgesia should still be carefully monitored, as they may develop respiratory depression, hypotension, or motor weakness, or the intervention might mask symptoms of compartment syndrome.
According to the guideline, all facilities that offer surgery should also provide clinicians with access to a pain specialist. The specialist should be available to consult for patients with inadequately controlled postoperative pain and to assist with diagnosis, interventions, or management of comorbid conditions. They may be especially useful for advising clinicians regarding patients who have opioid tolerance, especially if there is a history of substance abuse or addiction. Pain treatment should not be withheld from such patients “because of fears of worsening addiction or precipitation of relapse. In addition to the ethical requirement to address postoperative pain, poorly treated pain can be a trigger for relapse,” the guideline states.
The guideline also addresses the transition to outpatient care and identifies some research gaps. “Research is urgently needed on optimal methods for managing patients who receive opioids before surgery, effectiveness of opioid-sparing multimodal regimens, optimal methods of pain assessment and monitoring, and a number of areas related to management of perioperative pain in infants and children,” the panel concluded.