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Barriers to Optimal Pain Management in the General Surgery Population 

Barriers to Optimal Pain Management in the General Surgery Population
Chapter:
Barriers to Optimal Pain Management in the General Surgery Population
Author(s):

Anand C. Thakur

DOI:
10.1093/med/9780190457006.003.0003
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date: 23 January 2020

Albert Schweitzer once said, “We must always die. But that I can save a person from days of torture, that is what I feel is my great and ever-new privilege. Pain is a more terrible lord of mankind than even death itself.”

Pain as described and defined by the International Association for the Study of Pain is “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

There has been a 30-year-plus assessment by multiple national health organizations and societies examining the factors which influence the treatment of pain in both the acute and chronic setting, adequate versus inadequate pain relief, and long-term and short-term pain management. Organizations such as the American Pain Society (APS), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the American Society of Anesthesiology (ASA) have helped the initial and ongoing efforts and in this constantly changing and challenging environment.1,2 In 2005, the APS made revisions with an expanded and updated reform of its 1999 criteria and recommendations regarding the management of acute postoperative and cancer pain.1,2

Revised APS standard recommendations focus on a safety driven, cost-effective, efficacious, patient-centered interdisciplinary approach with emphasis on improved assessment and cultural appropriateness and with a basis in evidence-based medicine.1

JCAHO has also focused on pain management with analysis of metrics that evaluate pain assessment and progress throughout the entire hospitalization stay encompassing initial evaluation, ongoing care, and discharge planning. Particular focus was also placed on education of doctors, nurses, and other team members upon the nature, subtype, and qualitative and quantitative assessment of pain.2,4

In 2012 the ASA presented updated criteria regarding safe and effective pain management in the perioperative time period, maintenance of the patient’s function and well-being, reduction of potential adverse outcomes, and improvement of the patient’s quality of life in the perioperative period.3

Unfortunately, despite the ongoing education reforms, attempts of standardization of care and updating of pathways, guidelines, and assessment strategies there continues to be a significant population of patients that continues to suffer from inadequate pain relief.4,5

There are significant barriers to the implementation of what is deemed to be adequate pain relief. We examine these significant barriers to pain management in the acute postoperative general surgery population. For the purposes of this chapter we allow general surgery to encompass both general surgical and subspecialty surgical populations. It would be quite difficult to stratify and separate each surgical subspeciality in regards to the specific surgical procedure and concomitant postoperative pain management. That would be beyond the scope of this chapter.

Suffice it to say that postsurgical pain regardless of the anatomical location and specific operation pathophysiologically travels the similar pain spinothalamic pathways and has similar treatment options medically and procedurally.

Barriers to the implementation of adequate pain control are multifactorial and extensive. A complete list of barriers to adequate pain control would involve biopsychosocial factors, the physiological factors, pharmacological concerns, and medical legal concerns that could compose a book itself.

A short list of barriers to adequate pain control can be separated into physician knowledge, expectations and perceptions, nurses’ and other ancillary providers’ knowledge, expectations and perceptions, patient expectations and perception, management of acute pain, management of chronic pain, discrepancies of pain perception and different population groups, and both regulatory and formulary issues.

Based on 2010 estimates, in the United States there were approximately 4,647 operations per 100,000 people.6 Extrapolating to today’s population of approximately 324 million, there are approximately 15 million operations in the United States performed yearly. We define a surgical operation as an operation that necessitates a general anesthetic, regional anesthetic, and/or a combination of both. This is a significant number of surgical patients with multiple outcomes and varying functional needs that require adequate and definitive postoperative pain management and control. Acute postoperative pain is experienced by greater than 80% of patients who undergo surgical procedures and about 70% of the population has described that pain as moderate, severe, or extremely painful. Less than 50% of patients who undergo surgery report adequate pain relief.5 When pain is less than adequately controlled, there is a risk of transition from acute (less than 12weeks) to chronic pain (greater than 12 weeks), increased risk of postsurgical complications, decreased quality of life, and decreased functional recovery postsurgery.

Pain relief has been recognized as a basic human right according to the World Health Organization and the International Association for the Study of Pain.7 Postoperative pain can be best addressed by a multimodal approach. A standard approach in the treatment of postoperative pain involves a complete history and physical with particular emphasis on functionality, age, and physician understanding of pain generators, as well as current opioid, non-opioid, and adjuvant medications, along with previously failed opioid and non-opioid medication.

Pain management during surgery is divided into three phases: the preoperative, intraoperative, and postoperative. Assessment of the baseline opioid usage, scope, and duration of the surgical procedure and anatomic regions of the body affected by this operation are evaluated during the preoperative phase. The next stage involves an intraoperative management by the anesthesiologist of the analgesic requirement commensurate to the operative procedure and its dynamic changes. The third stage postoperatively involves appropriate use of oral or intravenous non-opioid and/or opioid-related medication options in a scheduled versus as-needed dosing format. In some studies, intravenous acetaminophen has been shown to have an opioid dose-sparing effect of almost 20%.8,9 Patient-controlled analgesia via intravenous fixed-dose opioid basal dosing and demand dosing is also an option. Anesthetic regional and/or neuraxial anesthetic either single-dose blockade and continuous dosing catheters are other options which allow us to minimize pain and discomfort the pain postoperatively.

The net sum result of well-managed, multimodal perioperative pain management can lead to a decrease in negative potential postoperative outcomes such as tachycardia, hypertension, myocardial infarction, decreased alveolar ventilation, and poor wound healing,10 as well as a potential decreased hospital stay.3,11,12,13,14,15

The negative effects of undertreated pain in the postoperative patient can lead to multiple adverse outcomes. Inadequate postsurgical pain relief can lead to increases and catecholamines, heart rate, and systemic vascular resistance with an endpoint of increased risk of myocardial ischemia postoperative bleeding, stroke, and other adverse postoperative outcomes.

Also, the undertreatment of acute postoperative pain can cause pathophysiological changes in neural pathways leading to both peripheral and central neural sensitization, that ultimately have an endpoint of chronic pain. Chronic pain further devolves into psychologic, social, and familial outcomes which are maladaptive. Physiologically chronic pain can lead to immune dysfunction, sleep disturbances, limited mobility, functional impairment, codependency, and untoward secondary gain behavior. This constellation of biopsychosocial factors is a basic disease entity.

Studies have shown that physicians, nurses, and other members of the interdisciplinary health care team do not readily or accurately assess and/or recognize the patient’s pain and pain complaints and behaviors.16

Physician-Related Barriers

Poor understanding of the mechanisms of pain and pain management, coupled with inadequate pain assessment skills, negative perceptions and attitudes toward prescribing opioids, and fear of recrimination for the use of opioids can lead to poor outcomes and treatment of pain.17,18

The origin of this phenomenon starts in medical school. A significant number of physicians report inadequate teaching, training, and education in the pathophysiology of pain medicine. This lack of proper training and education of principles and practices of multidisciplinary pain management in medical school leads to anecdotal pain management practices being reinforced both in residency and fellowship, without using an evidence-based pathway.

Approximately 88% of physicians reported that their medical school education in pain management was poor. Additionally 73% of physicians reported that residency training was still fair to poor.17,19

A study by the Eastern Cooperative Oncology Group showed that approximately 900 physicians with direct patient care responsibilities documented their own sense of low competence with usage of opioid pain medications (76%). This is a major barrier towards effective pain management.17,20

The second most common barrier was physician reluctance (61%) to prescribed opioid medication. Pain medications usage by physicians was also limited due to fears of addiction, abuse, and inappropriate use by patients.21,22 The combination of these two barriers have led to a decrease in treatment of acute and chronic nonmalignant pain.17,20

Nursing-Related Barriers

The patient’s pain is usually assessed most frequently by nurses. Regular patient assessment, standardized pain rating scales, and consistent documentation are the main stays of nursing care that can lead to improved pain relief.23

There are multiple pain assessment tools such as pain thermometers, numeric rating scales, verbal descriptor scales, and facial pain scales, all of which are valid and reliable pain assessment tools.22,24

Nurse-related barriers as perceived by nurses were as follows: high patient to nurse ratio, low psychosocial support services, inadequate time for health teaching with patients, inadequate knowledge of pain mechanisms and pain management, and, to a much lesser degree, indifference toward the patient’s pain management.25

In the scope of nursing care, there are multiple barriers to pain management. An observational study in Melbourne, Australia, identified six main themes: managing pain effectively, prioritizing pain experiences for pain management, missing pain cues for initiation and or maintenance of pain management, stimulating and non-stimulating factors related to pain, pain prevention, and reactive management of pain. The study emphasized the importance of communication between patients and nursing care-givers.26

Patient-Related Barriers

Each patient is a unique individual opportunity to treat pain.1 Patients’ racial, ethnic, cultural, socioeconomical, historical, and geographical perspectives influence their perception of pain and concomitantly physicians’ and nurses’ interpretation and treatment of their pain.4 Patient-related factors include psychological, emotional, sensory, and communicative challenges in relating and describing their pain to caregivers.22

Pain is defined as a subjective and emotional experience with actual or potential tissue damage as referenced earlier. It is influenced by multiple factors including age, sex, culture, communication skills, demographics, psychological comorbidities, and fear of addiction.22,27,28,29 Patients typically regard a decrement of pain scores from 33% to 50% to be meaniningful.1

Communication barriers are a primary problem between patients’ description and explanation of their pain (or lack thereof) to doctors and nurses and doctors’ and nurses’ subsequent understanding and interpretation of their reported pain.

Poor communication between patients and doctors leads to poor pain outcomes and results as well.30 Specific barriers to opioid use come from patient attitudes toward pain and opioid medication. Fears of addiction to opioids, tolerance, and plateaus to pain relief, along with opioid-related side effects of constipation, nausea, and vomiting, were significant barriers to opioid medication use. The patient’s wanting to please the physician is also a significant barrier to optimal pain relief.31

There are also other factors that limited a patient’s reporting of pain and pain generators. Patients did not expect to obtain pain relief by taking medication. They also associated pain with worsening of the disease process and fatalism in cancer patients, which led to underreporting pain. Some patients also believe that pain is a natural and expected outcome of a disease process. Other patients also feel that their ability to tolerate pain is an admirable and/or beneficial quality. Patients’ expectation of pain relief was low.31

Management of Acute Pain

Numerous consequences of acute pain have been described.32,33,34,35,36,37 In the typical general surgery setting, management of acute pain revolves around evaluation of the acute abdomen, blunt and penetrating trauma in the emergency department, and acute postoperative pain. Abdominal pain is one of the most common reasons for emergency room visits and comprises about 5% of all visits to the emergency department each year.35 Acute pain is a homeostatic function of the body, offering a protective function and/or barometer of a potential adverse bodily event.38 Almost 80% of patients who come into the emergency department have a chief complaint of pain.39 Management of acute pain is a challenge to all physicians in the emergency department. Despite the presence of emergency doctors, nurses, and other consulting physicians, the treatment of acute pain is still lacking. Some factors which contribute to this are the patient is often interviewed for a short period of time, consultation and diagnostic testing can be time consuming until a diagnosis is established, and delivery of pain medication is often delayed during this workup. This unfortunately leaves the patient at risk of the adverse sequelae of untreated pain.4,40,41 An observational, prospective study at 20 emergency departments in the United States and Canada examining 842 patients with moderate to severe pain demonstrated that the acute pain was not well managed.39 Pain scores examined at admission and discharge were relatively unchanged. Patients’ expectations of pain relief were not met, and there was still a large time disparity between chief complaint of pain at onset and pain medication delivery.39

Unfortunately, physician-related barriers and nurse-related barriers as mentioned earlier are rate-limiting steps in the delivery of adequate pain relief.4,39

Management of Chronic Pain

Chronic pain occurs from 12 to 30 weeks postacute pain. It is characterized by sensitization of both the peripheral central nervous systems which leads to a maladaptive process and persistence of acute pain. Simply put, this is pain which goes past its expected time period and normal tissue healing time.42 This evolves into a primary disease process where pain is a primary pathologic state.43 The sequelae of chronic pain leads to anatomical, physiological, psychological, and functional changes in the patient which ultimately leads to decreased quality of life, decreased patient compliance and satisfaction, and increased morbidity, mortality, and medical costs of care.5,43,44

The appropriate use of both long-acting and short-acting opioids for the treatment of chronic pain is supported by both the APS and the American Academy of Pain Medicine joint consensus statement.45 The prevalence of treatment of chronic noncancer pain with chronic opioid therapy has increased over the last 30 years.46 The use of chronic opioid therapy for the treatment of noncancer pain is well supported.46 Unfortunately, despite the appropriate use of opioid medication with clinical and regulatory guidelines there continues to be a challenge to the medical health system with risks of abuse, diversion, addiction, and inappropriate medication usage leading to a systemic public health problem. Careful initiation, maintenance, and titration of opioid usage is paramount in this population. Endpoints to be evaluated are adverse effects, dose escalation, analgesic tolerance, and functionality.47,48 In 2004 a study in the Journal of Anesthesiology examined patients’ expectations of pain relief versus adverse effects of medications. Patients placed relatively equal importance on limitation adverse effects and pain relief.47 We are able to use a multimodal perioperative anesthetic plan including patient education and teaching and adjuvant and non-opioid medication in the perioperative phase to decrease opioid usage and increase regional anesthesia and minimally invasive surgeries to help patients reach this balance.49

Discrepancies of Pain in Different Population Groups

The treatment of all patients who have pain is not equal. There are fractures along the lines of racial, ethnic, and gender divisions. The groups that are at most risk for inadequate pain relief are racial and ethnic minorities.2 In a 13-year (1993–2005) study examining pain management and opioid delivery from the National Hospital Ambulatory Medicine Care Survey, despite a steady increase in the use of opioids over 13 years from 23% in 1993 to 37% 2005, there was still higher utilization of opioids for pain treatment for whites 40% versus nonwhites 32%.2 In decreasing order, the utilization rates of opioid for pain was 31% for whites, 28% for Asians, 24% for Hispanics, and 23% for blacks.2 There was still a significant difference in opioid-prescribing habits for all degrees of pain (mild, moderate, severe) and subtypes of pain.2 This shows that there is a clear imbalance in the delivery of pain medication and relief in different populations.

A patient’s gender male or female can also play significant role in the patient’s treatment of pain. In a cross-sectional survey of 368 physicians using clinical vignettes in the treatment of pain, more physicians chose to provide optimal pain relief for many versus when and after surgery. In the study, the clinical scenarios examined for postoperative pain were four prostatectomy, myomectomy, and cesarean section. The survey showed that approximately 56% of physicians provided optimal care for prostatectomy patients, 45% for cesarean section patients, and 42% for myomectomy patients.50

Regulatory Issues

Since the early 1990s, there has been an increase in the amount of opioids prescribed for both acute and chronic pain syndromes. Despite this increased awareness of pain and pain treatment options, there still remains a population of physicians who are unwilling, not adequately trained, and/or afraid to prescribe opioids in appropriate doses.2,51 A major concern for most physicians is the degree of scrutiny by regulatory authorities such as the Food and Drug Administration, Drug Enforcement Administration, and state medical boards. The Federation of State Medical boards updated 1998 policy in 2004 regarding recommendations of the use of controlled substances for the treatment of pain.51 This policy validates the use of opioids for the treatment of acute and chronic pain.52 A national survey of physician attitudes and knowledge for prescribing opioids in pain management was examined in 1991, 1997, and 2004 by the Wisconsin Pain and Policy Studies Group and the Federation of State Medical Boards.53 The treatment of cancer pain with opioids was found to be acceptable by 75% of respondents in 1991, 82% of respondents 1997, and 87% of respondents in 2004. For chronic pain of noncancer origin utilization rates were 12% in 1991, 33% in 1997, and 67% in 2004.53 On the surface, this does not appear to be significant progress, but 33% of respondents still questioned the use of opioids for the management of chronic pain of noncancer origin. There is a lot of confusion with physician understanding of the differences in addiction, dependency, and tolerance. Most physicians are unfamiliar with these guidelines and standards from the 1998 and 2004 APS recommendations regarding opioid usage. Unfortunately, there remains a population of physicians (41%) who believes that dose utilization greater than those listed in the physician’s desk reference or package insert are excessive and worrisome. Twenty-eight percent of physicians questioned usage of more than one opioid for an individual patient. There was an improvement in the understanding of the differences in condition, dependency, and tolerance.53 Despite an awareness and increased emphasis on pain treatment, guidelines, and standards, there is not uniform understanding and application of these principles by physicians.

Formulary Issues

Despite all the aforementioned regulatory concerns, formulary concerns regarding pharmaceutical company manufacture of opioid medication and the availability and accessibility of these medications continues to be a significant problem. There are many new and emerging opioids and mixed opioid formulations which can offer durable pain relief. Almost two-thirds of physicians who are prescribing opioid medications are not aware of the formulary status of the medications that they are prescribing, as described by the national ambulatory medical care survey in 2000.54 Many new and effective medications are not on the formulary plans for patients because of high cost concerns, changing insurance platforms with higher cost for copays and third-tier status medications, and/or preauthorization requirements. This leads to a disconnect in patients receiving prescriptions for pain medication who cannot afford them or who do not have access through their insurance.54 More awareness for both patients and physicians regarding what medications are and are not covered by insurance will hopefully help improve more adequate pain management.

Case Study 1

A 17-year-old right-handed African American female presents in the emergency room with a chief complaint of mild periumbilical abdominal pain, right upper quadrant pain, and low back pain. She also has nausea and vomiting prior to right upper quadrant and abdominal pain.

  • Past Medical History: Type 2 diabetes, juvenile rheumatoid arthritis, and mild obesity

  • Past Surgical History: Tonsillectomy

  • Meds: Methotrexate, Prednisone, and Hydrocodone/APAP 5/325 1 po tid (three years)

  • Allergies: NKDA

  • Family History: Negative

  • Social History: Negative × 3

  • ROS: Generalized malaise, anorexia, abdominal pain as mentioned, otherwise negative

  • Physical Exam: 5 feet 5 inches, 150 pounds. Vital signs are stable. Her exam is otherwise normal except for the abdominal exam which shows right upper quadrant tenderness and periumbilical tenderness; bowel sounds are positive, and abdomen is mildly tender and nondistended.

  • Initial Triage and Management: Placement of routine monitors and intravenous access. The FAST exam by the emergency room physician is initially unremarkable. Her urine HCG is negative. A general surgery consult is requested.

The patient starts to complain about diffuse joint pain in addition to her abdominal pain. Her abdominal pain is a 8/10 on a Visual Analog Scale (VAS) score. Her joint pain is a 6/10 VAS score and her usual baseline pain. She requests pain medication. You have reviewed her medical history. How would you proceed?

Discussion

The patient is opioid tolerant: Is she on sufficient opioids or does she require further opioid treatment?

The patient has abdominal pain: Do you continue her daily opioid medication?

Diagnostic testing FAST scan: The patient is stable clinically. A computed tomography (CT) scan of the abdomen, with and without contrast, is pending. How would you manage the patient’s pain during the waiting time for the CT scan?

The patient has a chronic autoimmune disease: How do you manage her chronic nonmalignant pain? Does she need a rheumatology consult?

This is an acute pain on chronic pain condition: Is a pain management consult necessary?

If the patient presentation transforms into an acute abdomen, what are the perioperative measures that would decrease the patient’s pain postoperatively?

This would be a good exercise to discuss with your colleagues and team to better address your ideas of undertreatment of pain in this challenging patient. There is no right answer to this scenario. The goal here is to challenge yourself and your thinking. Are you following best care guidelines and evidence-based principles, or are you practicing anecdotal medicine?

Conclusion

In conclusion, the barriers to the effective management of pain in the general surgery population is multifactorial and encompasses all caregivers. We have simplified these barriers into eight basic categories. It is important to have an understanding of the most up-to-date recommendations and standards regarding evidence-based pain management. This requires a multimodal approach with a team of physicians including surgeons, anesthesiologists, internists and other subspecialty physicians, nurses, and social workers. We have access to new regional anesthesia techniques including ultrasound guided regional anesthesia blockade, extended-release and immediate-release opioids with abuse deterrent technology, and minimally invasive surgical procedures, all of which help increase the ability to limit inadequate pain relief in postsurgical patients. We all have a role to play in the biopsychosocial treatment and management of pain. Hopefully taking a careful look at our own personal and professional barriers to pain relief for our patients will help advance our ability to offer more adequate and universal pain relief.

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