› General considerations in pain management include the following:
• Effective pain assessment is essential. The patient’s pain should be assessed preoperatively, then at regular intervals after
surgery to allow planning and revision of the pain management plan. These assessments may be based on the patient’s
self-report of pain and/or clinician observation of the patient’s facial expression, body positioning, and physical and vocal
behavior (e.g., in patients who are nonverbal or otherwise incapable of reporting pain)
• A preventive approach (i.e., treatment of pain before it becomes severe) is most successful in managing postoperative
pain. In most cases, regularly-scheduled administration of analgesics is preferable to as-needed dosing because scheduled
administration can prevent or alleviate pain before it becomes intense. This preventive approach can also promote early
recovery by easing movement and participation in treatments such as physical therapy
• It is important to consider individual and cultural differences in pain expression and treatment when assessing pain
–People of some ethnic groups are less likely to report pain because of a high cultural value on stoicism, while members of
other cultural backgrounds may talk freely about their pain experiences
–Individuals and families of some cultural groups may be likely to use complementary medical interventions such as
meditation or herbal treatments to manage pain
• For patients with chronic pain, postoperative pain is only one part of an ongoing pain experience. Chronic pain can
cause long-term changes in patients’ neural physiology that cause them to feel pain more intensely. Patients with chronic
pain may therefore experience more intense pain after surgery and require higher doses of analgesics for effective pain
management
› Tolerance to opioids reduces their analgesic effectiveness. Opioid analgesics can, however, be used safely and effectively to
treat pain in patients who are physically or psychologically dependent on them
• It is important for clinicians to understand the difference between opioid tolerance, physical dependence, and addiction to
these drugs
–Tolerance to a drug is defined as the failure of a steady dose of the drug over time to sustain the desired pharmacologic
effect. A patient who has developed tolerance to opioid analgesics will therefore require larger doses of opioids over time
to reach the same analgesic effect
–Physical dependence is a normal physiological response in which a patient treated with an opioid analgesic experiences
physical withdrawal symptoms when doses are reduced or when a narcotic antagonist such as naloxone is administered.
Physical withdrawal symptoms include, but are not limited to, depression, anxiety, panic attacks, leg cramps, abdominal
cramps, vomiting, diarrhea, insomnia, and muscles aches
–Physical dependence on opioid analgesics should not be confused with addiction. A person who is addicted to
(psychologically dependent on) drugs experiences both physical dependence and a strong psychological craving for the
drug. Drug addicts make obtaining and using drugs a primary focus of their lives. This situation is quite different from
that of a cancer patient who seeks drugs for the relief of chronic pain
• All patients who are physically dependent on or addicted to opioids will develop tolerance to these drugs. To effectively
relieve acute postoperative pain in a patient with opioid tolerance, the patient should be restarted on the original opioid
analgesic but at a higher dose. After the postoperative recovery period, the patient’s physical dependence on the medication
can be treated by gradual reduction of opioid doses with gradual addition of nonopioid analgesic doses to the treatment
regimen. This approach will likely reduce physical dependence on opioids while minimizing withdrawal symptoms
–Patients who are addicted to opioids should be treated with the above approach. Treatment for addiction may additionally
be prescribed
› The appropriate analgesic medication is chosen in part based on the patient’s level of pain as follows:• Mild to moderate pain: Nonopioid medications (e.g., acetaminophen, NSAIDs). Opioid analgesics (e.g., morphine) may be
added if pain persists
• Moderate to severe pain: Opioid and nonopioid analgesics in combination
–Limited evidence suggests that combining opioid and nonopioid medications may be more effective than administering
either drug type alone (see Facts and Figures, above)
• If moderate to severe pain persists, the following adjuvants may be prescribed:
–Muscle relaxants (if patient is experiencing muscle spasms after orthopedic surgery
–Antianxiety agents
–In addition to or in place of some of the above interventions, the patient may be prescribed patient-controlled analgesia
(PCA)
› Nonpharmacologic interventions that may be implemented with the cooperation of the patient/family include the following:
• Comfort measures such as repositioning, propping with pillows, and applying warm and/or cool packs
• The presence of family members and/or other support persons
• Visits from a cleric of the patient’s faith, and/or the presence of religious objects or symbols, if requested by the patient
• Environmental comfort measures such as privacy, dimmed lights, soft music, and a quiet room of appropriate temperature,
if desired by the patient
• Additional interventions, as appropriate, such as hypnotherapy, meditation, acupuncture, and herbal remedies
–Herbal remedies should be used only after consulting with the treating clinician, as some of them may interact with
medications
› During the preoperative period, it is important to assess the patient and family for knowledge deficits and anxiety regarding
surgery and the potential for pain during recovery; assess their coping ability and beliefs regarding postoperative pain
› Clinicians involved in postoperative pain management should have knowledge of the following six “rights” of medication
administration:
• Right patient
• Right medication
• Right time
• Right dose
• Right route of administration
• Right documentation following administration
› Preliminary steps that should be performed before implementing postoperative pain management interventions include the
following:
• Review the facility/unit specific protocol for postoperative pain management, if one is available
• Review the treating clinician’s orders for postoperative pain management
• Review the patient’s medical history/medical record for
–surgical history
–any allergies (e.g., to latex, medications, or other substances); use alternative materials, as appropriate
–chronic use of opioids, which can lead to tolerance and the need for higher doses for effectiveness
• Assemble supplies, including the following:
–Personal protective equipment (PPE, e.g., nonsterile gloves) as necessary depending on the patient’s infection status and
risk of exposure to body fluids
–A facility-approved, clinically-validated pain assessment tool appropriate for the patient’s individualized characteristics
(e.g., literacy level, primary language used, and ability to communicate verbally)
–Analgesic medications, as prescribed by the treating clinician
–Supplies for nonpharmacologic pain management appropriate to the patient’s needs and personal/family beliefs
–Written teaching materials to reinforce verbal instruction