Invited Commentary

Defining New Directions for More

Effective
Management of Surgical Pain in the United
States:
Highlights of the Inaugural Surgical
Pain Congress
GIRISH P. JOSHI, M.B.B.S., M.D., F.F.A.R.C.S.I.,* DAVID E. BECK, M.D., ROGER HILL EMERSON JR., M.D.,
THOMAS M. HALASZYNSKI, D.M.D., M.D., M.B.A., JONATHAN S. JAHR, M.D.,jj ARTHUR G. LIPMAN, P HARM.D.,{
MIKIO A. NIHIRA, M.D., M.P.H.,** KETAN R. SHETH, M.D., MELANIE H. SIMPSON, P H.D., R.N.-B.C., O.C.N., C.H.P.N.,
RAYMOND S. SINATRA, M.D., PH.D.

From the *Department of Anesthesiology and Pain Management, University of Texas

Southwestern
Medical Center, Dallas, Texas; the Ochsner Clinic Foundation, New Orleans, Louisiana; Presbyterian
HospitalPlano, Plano, Texas; Yale University School of Medicine, New Haven, Connecticut; jjDavid
Geffen
School of Medicine at UCLA, Los Angeles, California; the {University of Utah Health Sciences
Center,
Salt Lake City, Utah; the **University of Oklahoma, Oklahoma City, Oklahoma; Harvard Medical
School,
Cambridge, Massachusetts; and The University of Kansas Hospital, Kansas City,
Kansas
Despite advances in pharmacologic options for the management of surgical pain, there appears to
have been little or no overall improvement over the last two decades in the level of pain experienced by patients. The importance of adequate and effective surgical pain management, however,
is clear, because inadequate pain control 1) has a wide range of undesirable physiologic and
immunologic effects; 2) is associated with poor surgical outcomes; 3) has increased probability of
readmission; and 4) adversely affects the overall cost of care as well as patient satisfaction. There is
a clear unmet need for a national surgical pain management consensus task force to raise
awareness and develop best practice guidelines for improving surgical pain management, patient
safety, patient satisfaction, rapid postsurgical recovery, and health economic outcomes. To comprehensively address this need, the multidisciplinary Surgical Pain Congress has been established. The inaugural meeting of this Congress (March 8 to 10, 2013, Celebration, Florida)
evaluated the current surgical pain management paradigm and identified key components of best
practices.

Management of Surgical PainWhere Are We Today?

URING RECENT YEARS,

there have been major

in pharmacologic options for
managing

surgical
available and considerable progress has been
achieved with respect to peripheral nerve blocks, adjunctive systemic pharmacotherapy, parenteral
local

anesthetics, and in situ local anesthetics.

Despite these
advances, however, there appears to have
been little or
no overall improvement in the level of surgical
pain
experienced by patients.13 In fact, the
proportion of
patients reporting a significant degree of
surgical pain
Address correspondence and reprint requests to Girish P.
Joshi,
M.D., Professor of Anesthesiology and Pain Management,
University

of Texas Southwestern Medical Center, 5323 Harry Hines

Boulevard,
Dallas, TX 75390-9068. E-mail:
Girish.joshi@utsouthwestern.edu.

actually increased from 1995 to 2012.46 The proportion of patients reporting moderate to extreme
surgical pain remained at approximately the same level
over that period.
In 1987, Liebeskind and Melzack wrote by any
reasonable code, freedom from pain should be a basic
human right limited only by our ability to achieve it, 7
yet the importance of adequate and effective surgical
pain management extends far beyond its humanitarian
role. Inadequate pain control has a wide range of undesirable physiologic and immunologic effects, is associated with poor surgical outcomes, increased
probability
of readmission, and adversely affects the overall cost of
care as well as patient satisfaction.
An initiative to define procedure-specific pain management protocols has been underway for some time
and
is producing valuable insights (www.postoppain.org).
219

220

THE AMERICAN SURGEON

The concept of procedure-specific pain

management,
however, is not generally appreciated in the
United
States.8, 9 There is a clear unmet need for a
national
surgical pain management consensus task force to
raise
awareness and develop best practices for
improving
surgical pain management, patient safety,
patient satisfaction, rapid surgery recovery, and health
economic
outcomes. The Surgical Pain Congress,
comprised of
a multidisciplinary group of invited surgeons,
vancespain. New analgesic agents have becomeadanesthesiologists, pain specialists, pharmacists, nurses,
pharmacoeconomists, and other healthcare
professionals,
was established to comprehensively address this
need
and build on the experience of the PROSPECT
(Procedure Specific Postoperative Pain
Management)
collaborative group, which provided evidencebased
guidance for procedure-specific multimodal
opioidreducing pain management techniques and
protocols.
The inaugural meeting of the Surgical Pain

March 2014

Vol. 80

Congress
was held on March 8 to 10, 2013 (Celebration,
FL) as
a launching initiative embarking on the
challenge of
evaluating current surgical pain management
paradigms
and to identify key components of best
practices.
The Importance of Effective Surgical Pain
Management

Some degree of pain is usually an

unavoidable aspect of undergoing almost any surgical
intervention
and it is often inaccurately considered to be
simply
a patient comfort issue. However, severe acute
pain can
quickly become maladaptive and result in
prolonged
pain transmission, leading to perioperative and
postoperative disability, potential for organ
dysfunction,
and development of persistent chronic pain.
The clinical significance of acute pain is
diverse and
some of the direct and indirect negative
consequences
may include10, 11: hypertension,
tachycardia, arrhythmias, and hypervolemia with accompanying
risk of

myocardial infarction, congestive heart failure,

hemorrhage, and stroke; hypercoagulable state with
accompanying risk of thromboses and decreased
wound

perfusion; hyperglycemia, hypercatabolic state, negative nitrogen balance, and tissue wasting; compromised immune function, increased stress response, and
increased risk of infection; hyperalgesia, resulting in
decreased ambulation, poor rehabilitation, and atelectasis; increased risk of pneumonia; central sensitization
and progression to chronic pain; and anxiety, depression, fear, impaired sleep, and demoralization.
The potential for progression of acute pain to
chronic pain is now well established but not widely
appreciated. Chronic pain is defined as pain and pain
disability that persists for more than 3 months after
surgery. Thus, one reason for underrecognition of the
progression of surgical pain to chronic pain may be its
occurrence several months after the actual surgery.
Certain surgical procedures such as amputation and
cardiothoracic surgery are associated with an especially
high rate of chronic pain (Table 1).12 Other risk factors
for development of persistent surgical pain include
psychological vulnerability (e.g., anxiety, depression),
preceding pain that has been present for 1 month or
more
before surgery, severe acute surgical paincommonly
resulting from suboptimal analgesiaand certain genetic factors to mention a few.
Given the wide range of clinical consequences of
acute pain, it is not surprising that severe surgical pain
is often associated with increased rates of hospital
readmission. The impact of pain (both financial and
negative postoperative patient profiles) on readmission
is illustrated well by data from same-day surgeries,
which constitute, by far, the majority of surgeries performed in the United States today. The most common
reason for readmission after same-day surgeries was
shown in 2002 and again in 2010 to be inadequately
controlled pain (Fig. 1).13, 14 When patients do not receive appropriate analgesia before hospital discharge or
are sent home without enough information, instructional
guidance, or medication to manage their pain, there is
an increased probability that they will return to the
physicians office, emergency department (ED), or

TABLE 1. Incidence of Chronic Surgical Pain after Selected Surgical Procedures 12

Procedure
Amputation
Coronary artery bypass surgery
Thoracotomy
Breast surgery (lumpectomy and
mastectomy)
Cesarean delivery
Inguinal hernia repair

Estimated
Incidence of
Chronic Pain
30%50%
30%50%
30%40%
20%30%
10%
10%

Estimated Incidence
of Chronic Severe
(disabling) Pain*
5%10%
5%10%
10%
5%10%
4%
2%4%

Number of Surgeries
in the United Statesy
159,000 (lower limb only)
598,000
Unknown
479,000
220,000
609,000

* Five of 10 pain scores.

y National Center for Health Statistics, United States of America, 1996.
Reprinted with permission from Elsevier from Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors
and
prevention [review]. Lancet 2006;36:161925. 2006.

No. 3

MORE EFFECTIVE MANAGEMENT OF SURGICAL PAIN

Joshi et al.

221

event(s) may have been complicated by or resulted

from severe surgical pain.
Patient satisfaction cannot be ignored in this modern
era of medicine in which hospitals and healthcare
providers are graded according to patients perception
of the quality of the care that they receive. A recent
study demonstrated that surgical pain is the leading
driver of surgery patient dissatisfaction and liability
(Fig. 2)6 along with surgical care reimbursement increasingly being linked to the quality of pain management that a healthcare facility provides.
FIG. 1. Reasons for readmission after discharge in patients
who
have undergone same-day surgery.12 Reprinted with
permission
from Elsevier from Coley KC, Williams BA, DaPos SV, Chen C,
Smith RB. Retrospective evaluation of unanticipated
admissions
and readmissions after same day surgery and associated
costs. J
Clin Anesth 2002;14:34653.

Barriers to Effective Management of Surgical Pain

Approximately 43 million surgical procedures are

now performed annually in the United States,6 and,
unfortunately, nearly three-fourths of these patients
report surgical pain rated 7 or higher on a scale of 1 to
10.15 It has been suggested that an increase in the
performance and number of more aggressive surgical
procedures may have contributed to the lack of improvement in surgical pain management. However, one
hospital for further management of their
prevailing reason for suboptimal management of periinadequately
operative pain is more likely to be related to inadequate
treated surgical pain.
and/or improper application of available analgesic
Although there is relatively little data on the
options.16
ecoA factor that may be undermining the use of more
nomic implications of inadequately treated
effective analgesic regimens could be simply related to
surgical
the volume of new and sometimes conflicting inpain, there are several potential economic gains formation on perioperative pain management protocols
that
that are increasingly available.16 Several efforts have
can be achieved by improving acute perioperative been made to provide definitive guidelines for the
pain
management of surgical pain and trauma. From 1990
management. These benefits include early
to 1992, the Agency for Health Care Policy and
patient moResearch (AHCPR) worked with the University of
bilization, decreased major perioperative
Michigan to develop clinical practice guidelines for
complications,
acute pain management.17 The resulting guidelines
shortened intensive care unit and hospital stays,
positive impact on healthcare costs, and reduced
liability
exposure. For example, one study found that the
mean
cost per patient was $1869 for pain-related
admisFIG. 2. Most common reasons expressed by pasions or readmissions and $986 for ED visits for
tients for dissatisfaction after surgery.6 Reprinted
inwith permission from Oxford University Press from
appropriate surgical pain management.13 The
Gan TJ, Lubarsky DA, Flood EM, et al. Patient
preferences for acute pain treatment. Br J Anesth
cost
2004;92:6818.
of nonpain-related readmissions proved to be
much
higher, but in some of these cases of serious
events
(e.g., myocardial infarction), consideration must
be
extended and investigated if such an untoward

222

THE AMERICAN SURGEON

that were published provided four major

March 2014

Vol. 80

conclusions:
1) it is necessary to be more aggressive in
treating
acute pain because the risk of pain is often

greater than
the risk of the drugs used in management;
analgesic
agents should be adequately dosed to prevent or
halt
the pathophysiological cascade that can result in
acute
pain; 2) pain should be assessed and reassessed
regularly using only validated instruments; 3) patients
must
be taught and encouraged to report pain using an
appropriate instrument; and 4) all hospitals should
establish independent pain management plans with
clearly
defined lines of responsibility.
As was noted earlier, there have been major
advances in the understanding of pain and the
many diverse analgesic options since the development of
AHCPR guidelines; however, their broad
recommendations remain relevant more than 20 years later.
An important and significant barrier to
adequate
pain management is the underestimation of
potential
pain after various surgical procedures. A recent
study
found that some minor surgical procedures
that are
commonly performed in outpatient or short-stay
facilities such as laparoscopic cholecystectomy and
hemorrhoidectomy can often be associated with
a
greater degree of surgical pain than some of the
more
major surgical procedures.3 These
investigators
suggested that this phenomenon may be the
result of
physicians and nurses underestimating a
patients requirement for analgesic medication after minor
surgical procedures.
A procedure-specific approach to pain therapy
and
management was proposed by the Department of
Defense/Veterans Affairs.18 The resulting
guidelines
provided valuable direction because this group
adopted a highly systematic and evidence-based
approach
to assessing the treatment of surgical pain in the
military population. However, improved
understanding and
advances in scientific progress toward

pathophysiology
of pain that has occurred over the last decade
has not
permitted these guidelines to be updated since
2002.
The Joint Commission identified pain as the
fifth
vital sign and has emphasized that thorough
assessment of patients surgical pain should have
guideline
standards.19 These guidelines set target
pain scores
and have also penalized hospitals that fall
short of
those targets. Efforts to achieve these target
pain scores
have resulted in evidence of inappropriate and
overuse of opioids in addition to several studies
showing
an increase in opioid-related morbidity and
mortality
after introduction of the concept of pain as the
fifth
vital sign by the Joint Commission.2022 In
2012, the
Commission issued a Sentinel Event Alert
stating:
The Joint Commission recognizes that not all
pain
can be eliminated; therefore, our standards
provide
for goal-related therapy.23

Several specialty societies have also published independent pain management guidelines. For example,
the American Pain Society has now published six
editions of its Principles of Analgesic Use in the
Treatment of Acute Pain and Cancer Pain.24 Again in
2012, the American Society of Anesthesiologists released an update to its pain management practice
guidelines8 and emphasized that some of the principles of these guidelines have not been consistently
embraced.
A major shortcoming of some of the published existing guidelines is that they provide general recommendations that lack specificity for various surgical
interventions.25 In addition, the nature of surgery is
known to influence type, location, intensity, and duration of surgical/interventional pain as well as potential
complications (e.g., pulmonary or bowel dysfunction)
that may develop. Moreover, efficacy of different analgesics can often vary according to the surgery being
performed and the risk-to-benefit ratio for the many
differing analgesic techniques is also dependent on the
type of surgical procedure. In an effort to more comprehensively address this issue, the PROSPECT group,
a collaborative initiative involving both surgeons and
anesthesiologists, has begun the development and publication of an array of procedure-specific pain recom-

No. 3

mendations (www.postoppain.com).25
Perpetuation of the old paradigm for managing
surgical pain, systemic opioids, can reduce the many
newly developed and recent opportunities to benefit
from some of the evidence-based advances within
perioperative pain therapy. Although physicians today
have access to a broader range of analgesic agents and
pain treatment modalities, in many cases, there still
continues to be heavy reliance on traditional opioid
pain management therapy. In addition, concerns about
opioid side effects and risk of dependence can often
result in inadequate dosing of these agents or in certain
situations where concerned patients may not take them
at all.
Generally, there is an absence of organized acute
pain medicine services in many institutions. These
services have historically been based largely within
anesthesia departments, but economic obstacles encountered, particularly with respect to reimbursement,
has significantly curtailed their continued development.
However, in some hospital facilities, nurse practitioners
have taken over control of this function quite effectively.
Unfortunately, in many other hospitals, this service was
simply disbanded.
Under the existing treatment paradigm in far too
many healthcare facilities, pain often continues to be
managed in a reactionary manner at the end of surgical
procedures rather than preoperatively in a pre-emptive
manner (Fig. 3).26 A more proactive approach would

MORE EFFECTIVE MANAGEMENT OF SURGICAL PAIN

Joshi et al.

223

of 100, whereas the average pain score in patients receiving multimodal analgesia was higher
approximately
40 out of 100. However, epidural analgesia did not
offer any benefit to either time of oral intake or time to
ambulation, which were the more important outcome
measures for these patients. Therefore, it is essential to
focus attention on clinically relevant outcome measures such as quicker return of bowel and bladder
function, time to oral intake, time to ambulation, length
of hospital stay, readmission rate after discharge, ability
to take an active role in physical therapy, and an ability
to return to work more quickly.
Avoid/Limit Opioid Dose

The side effects of opioids are widely recognized

and there is an abundant amount of scientific data to
show that opioid-related adverse events can impose
thesiologist, and patient before surgery to
FIG. 3. Common approach to the management of postoperative pain.26 Reprinted with permission from Sinatra
determine
RS.
the most optimal plan for preventing and
Current management of postsurgical pain. In: Sinatra RS,
managing
Larach S,
Ramamoorthy S, eds. Surgeons Guide to Postsurgical Pain
perioperative pain. Such formally mandated
Management: Colorectal and Abdominal Surgery. 1st ed. West
discusIslip, NY: Professional Communications, Inc.; 2012:14.
sions would enable the surgical team to
consider predictors of perioperative pain and plan
involve formal discussions among the surgeon,
according to
anes-

procedure-specific analgesic needs. There has

significant economic burdens. In one study, patients
also
experiencing opioid-related adverse events were apbeen shown to be a qualitative correlation
proximately four times more likely to be outliers with
between
respect to healthcare cost and length of hospital stay
compared with patients who did not experience adattitudes of the patient in the preoperative
setting and
verse events secondary to opioids (Fig. 4).28 The adverse effects of opioid use underscore the importance
their postoperative pain score.6 Patients who
believed
of looking beyond these agents and incorporating adthat surgical pain was a necessity after surgery ditional alternative pain management options that can
revealed significantly higher pain scores
supplement and prove beneficial toward perioperative
pain therapy.
subsequent to
their surgery compared with patients who did not Complete elimination of opioid administration in
consider surgical pain to be necessary. In a
all surgical procedures is impractical, would be insimilar
appropriate, and not realistic. One large study found
manner, patients preoperative anxiety levels
that patients may have a cutoff point below which
also
opioids no longer seem to show adverse effects.29
correlated with their postoperative pain scores. Therefore, the focus should be to use opioids more
sparingly and reduce reliance on one analgesic option
by supplementing opioids with other nonopioid analPractical Considerations for Reducing Surgical Pain
gesic modalities. In addition to opioids, there is an arUse Outcome Measures as the Target
mamentarium of perioperative analgesic options that
include acetaminophen, nonsteroidal anti-inflammatory
Setting arbitrary pain scores as a target in
drugs, selective cyclo-oxygenase2 inhibitors, regional
perioperanalgesic techniques (e.g., neuraxial blocks, peripheral
ative pain management is often not meaningful
nerve blocks, wound infiltration), intravenous lidocaine,
because
and other analgesic adjuncts such as dexamethasone
those scores do not always correlate with the
and
overall
gabapentin/pregabalin.
clinical goal, namely allowing patients to return
to their
activities of daily living as soon as possible after Use of Rational Multimodal Analgesia
their
One proven effective and well-documented approach
surgical procedure. For example, a meta-analysis to reducing opioid use and adverse effect(s) profile is by
of
incorporating these opioid medications as part of a
several studies compared epidural analgesia with multimodal analgesic regimen. Pain has been shown to
mulbe both a complex and multifactorial phenomenon
timodal analgesia in patients undergoing
pain signals initiated by trauma and surgical injury
laparoscopic
can generate a secondary inflammatory response and
colorectal surgery.27 The average pain score
in patients
receiving epidural analgesia was approximately
20 out

224

THE AMERICAN SURGEON

March 2014

Vol. 80

FIG. 4. Effect of opioid-related adverse events on

the percentage of the percentage of patients who
were outliers with respect to cost or length of stay. 28
ORADE, opioid-related adverse events. Reprinted
with permission from Pharmacotherapy Publications,
Inc., from Oderda G. Challenges in the management
of acute postsurgical pain. Pharmacotherapy 2012;
32(suppl):1S5S, 6S11S. 2012.

produce peripheral and central sensitization that

often
amplifies and may prolong the effects of the pain
cascade.30 Multimodal analgesia was originally
defined
as a regimen of different medications used in a
variety
of small doses to block pain perception and trans- acceptance, and there is now data to show that
mission at different sites in peripheral and central procedure-specific analgesia improves outcomes. A
nerstudy from Germany published recently surveyed
vous systems.31 Multimodal analgesia now
patients opioid requirements, opioid-related side
extends
effects, and outcomes before and after implementation
beyond simply multidrug analgesia but includes a of PROSPECT guidelines.32 Data for both the first
ratiosurgical day and the day of discharge were compared.
nal combination of pharmacological agents and Although the PROSPECT guidelines varied for each
nonprocedure, the study consistently found that pain
pharmacological approaches depending on the
scores improved after implementation of proceduredegree
specific analgesic regimens. Furthermore, the opiof invasiveness of various surgical interventions oid-related side effects were significantly decreased
along
with procedure-specific pain management protocols
with a risk-to-benefit ratio of any chosen
(Fig. 5).32
analgesic
technique.
Avoid Analgesic Gaps (hand-offs)
It is not uncommon for many physicians to
Despite the use of effective analgesia, patients may
routinely
use a standard protocol (cocktail) of drug
still experience breakthrough pain for a host of reacombisons. They are most susceptible to breakthrough pain
nations in an effort to achieve multimodal
when analgesic gaps occur during transitional points in
analgesia.
the surgical care timeline. The entire timeline of
However, such a shotgun approach does not
surgical care involves a series of hand-offs or transnecesfers of responsibility for patient care. The surgeon
sarily provide multimodal analgesia nor provides and anesthesiologists see the patients during prefor
operative preparation to outline what is to take place
a rational or effective management plan of
during surgery/anesthesia and answer any questions.
surgical
The anesthesiologist ensures adequate intraoperative
pain for all patients. The combination of analgesic anesthesia and analgesia. After surgery, continued care
agents and the duration of effect required for a can involve a multidisciplinary approach.
patient
Pain management can often not be fully addressed
undergoing laparoscopic cholecystectomy, for
until after the surgical procedure; however, preproceexamdural interdisciplinary discussions and coordination
ple, would typically be quite different from the
focused on certain critical issues and time points can
regihelp prevent these analgesic gaps33:
men needed for a patient undergoing a major
open
abdominal procedure. Therefore, it is important
to
align the attributes of each analgesic component
with
the clinical needs of each individual patient
(Table 2)
when considering the development of any
multimodal
analgesic regimen.
Use Procedure-specific Pain Management

For the reasons described earlier, the need for

procedure-specific approaches to the
management of
surgical pain has begun to gain more widespread

No. 3

MORE EFFECTIVE MANAGEMENT OF SURGICAL PAIN

Joshi et al.

225

TABLE 2. An Overview of Nonopioid Options for Inclusion in Multimodal Analgesic Regimens*

Analgesic
Clinical Considerations for Surgical Pain
Nonsteroidal antiinflammatory
drugs (NSAIDs)

NSAIDs can reduce surgical opioid analgesia requirements when given in conjunction
with an opioid analgesic
NSAIDs provide superior analgesic efficacy compared with opioid analgesia alone
NSAIDs should not be used in patients at high risk for either clotting or bleeding
d Because of an increased risk of serious cardiovascular thrombotic events, NSAIDs
should not be used in patients undergoing coronary artery bypass graft
d Mechanism of analgesic action of COX-2 selective inhibitors is similar to that of
NSAIDs
d There is no difference in analgesic efficacy of NSAIDs and COX-2 selective inhibitors
when used at equipotent doses
d Administration of a COX-2 inhibitor together with a opioid analgesic significantly
reduces pain compared with opioid analgesia alone
d No difference appears to exist between COX-2 inhibitors and placebo with respect to
intraoperative bleeding
d Acetaminophen is a viable alternative to NSAIDs with a low incidence of adverse
effects
d Combination of an NSAID or a COX-2 selective inhibitor and acetaminophen may
provide additional efficacy compared with either agent alone
d When administered preoperatively, oral absorption of acetaminophen can be reduced
by fasting and stress
d When administered post-surgically, oral absorption of acetaminophen can be reduced
by stress and opioids
d Intravenous acetaminophen has been associated with significant reductions in pain,
opioid use, surgical nausea and vomiting, and length of hospital stay
d A single-dose steroid should be recommended for the majority of patients unless
there
is a contraindication
d Steroids have anti-inflammatory properties and, theoretically, should decrease
central
and peripheral sensitization resulting from acute surgical pain
d Dexamethasone at 4 mg to 8 mg reduces decrease surgical nausea and vomiting as
well
as surgical pain
d Although dexamethasone increases blood sugar levels, the clinical relevance of that
increase is negligible
d There are very few data on the use of multiple doses of dexamethasone, and
administration of more than one dose is not prudent at this time
d Gabapentinoids are increasingly being used for management of surgical pain, and
they
are particularly beneficial in surgical procedures where there is a high probability of
prolonged, persistent pain
d Gabapentinoids reduce both pain and opioid requirements
d The benefits of gabapentinoid with respect to opioid-related side effects are not clear
d Gabapentinoids can also improve surgical sleep and anxiety
d Although it is known that a single dose of gabapentin is inadequate for the
management
of surgical pain, the optimal dose and duration has not been established
d Side effects of gabapentinoid include sedation and dizziness, which may delay
discharge, and these agents are not recommended for use in outpatient procedures
d Ketamine is a potent N-methyl-D-aspartate (NMDA) receptor antagonist that is
particularly effective when the level of surgical pain is expected to be severe (i.e.,
score
of 7 or greater on a scale of 1 to 10)
d At very low, subanesthetic doses, ketamine decreases surgical pain, opioid
requirements, and, in some cases, opioid-related side effects
d Low-dose ketamine can also prevent central sensitization and prevent or reverse
opioid
tolerance and opioid-induced hyperalgesia
d Patients who are on long-term opioids, and therefore at risk of developing opioid
tolerance, are good candidates for ketamine
d There appears to be a higher occurrence of hallucinations and nightmares in patients
for
whom ketamine is more efficacious; the risk:benefit profile of ketamine, with respect
to
dysphoria and hallucinations, not clear as yet
d These agents exert their analgesic effects within the central nervous system
d Dexmedetomidine provides effective sedation and analgesia of relatively short
duration
d The short duration of action of dexmedetomidine restricts its value for the
management
of postoperative pain
d Infusion of dexmedetomidine in the ICU can be beneficial
d Because of its side effect profile, clonidine has very limited use in surgical pain
d
d

COX-2 selective inhibitors

Acetaminophen

Steroids

Gabapentinoids

Ketamine

a2 adrenoceptor agonists

(continued)

226

THE AMERICAN SURGEON

March 2014

Vol. 80

TABLE 2. Continued

Analgesic
Regional nerve blockade

Local wound infiltration

Clinical Considerations for Surgical Pain

Peripheral nerve blocks provide excellent pain relief and should be used whenever
possible
d Of note, lower limb peripheral nerve blockade can interfere with recovery of ability to
walk and increase falls.
d Patients receiving opioids and nerve blockade may be at increased risk for falling.
d Surgical wound infiltration provides excellent pain relief and should be used when
possible
d Use of infiltration is intended to promote early ambulation, allow for shortened
hospital
stay, and facilitate more rapid recovery
d Local infiltration can be an effective alternative to nerve blockade
d Although data on clinical outcomes with local wound infiltration are conflicting,
efficacy appears to be influenced by administration technique
d One of the major limitations of wound infiltration is that the duration of action is short
(approximately 12 to 16 hours)

* This information represents an extensive analysis of the body of literature relating to the use of agents together
with the
clinical experience and judgment of individual Congress members.
COX, cyclo-oxygenase; ICU, intensive care unit.

Special Populations Need Special Approaches

In the postanesthesia care unit:
End-of-case administration of long-acting
Opioid-dependent and opioid-tolerant patients
anincluding those on chronic opioid therapy and those on
algesics, and
maintenance therapy with methadone or buprenorphine
Titration to patient comfort before

implementing intravenous patient-controlled analgesia represent a complex challenge with respect to pain
management. There is a lack of data about optimal
or
surgical pain management in these individuals, so their
epidural analgesia;
Transfer between hospital services/locations: care tends to be based largely on the subjective views of
the healthcare providers. Concern about feeding the
Pain assessment should be a discharge
opioid addiction must not be allowed to prevent the
criterion;
Transition from intravenous patient-controlled patient from receiving adequate pain management.
Identification of patients who are opioid-dependent or
analgesia or epidural analgesia to oral
medication:
opioid-tolerant is a critical step followed by determining
Initiate oral medications before
what a patients total daily opioid dose may be and
discontinuation
whether they have experienced previous perioperative
of intravenous patient-controlled analgesia or
epidural; and
During physical therapy or movement of the
patient:
Administer additional analgesia through
most
noninvasive means available.
FIG. 5. Frequency of different pain intensities
(pain on movement) on the first postoperative day.32
Reprinted with permission from Oxford University
Press from Usichenko TI, Rottenbacher I, Kohlmann
T, et al. Implementation of the quality management
system improves postoperative pain treatment:
a prospective pre/postinterventional questionnaire
study. Br J Anesth 2013;110:8795.

No. 3

MORE EFFECTIVE MANAGEMENT OF SURGICAL PAIN

Joshi et al.

227

problems (e.g., opioid withdrawal, anxiety,

analgesic
gaps). A clear understanding of the patients
existing
drug use is essential, together with effective
communication and documentation, including a written
pain
management plan.
Develop Clinical Pathways Using a Procedure-specific
Approach

Most hospitals now have clinical pathways that

guide
interventions and timing of perioperative care
within a
specific episode of surgical care or a specific
procedure.
Several of these pathways are used today, for
example,
in hip and knee procedures, postpartum care,
and colorectal surgery, procedure-specific clinical
pathways
have been developed and implemented. The
goals of
these pathways are to reduce length of hospital
stay,
reduce rates of readmission/reoperation,
decrease morbidity and mortality, and improve pain control. A
metaanalysis of randomized controlled trials from
Europe
and North America has identified five key
components
to these pathways with acute pain control being
one of
those components.34
Basic science studies have clearly
demonstrated that
blocking pain before a surgical assaultthe
concept of
preemptive analgesiaprovides effective pain
management before surgery and can prevent a
component
of the pain wind-up phenomenon associated
with
surgery. Unfortunately, clinical data and
observation do
not mimic the scientific findings, and clinical
studies
have not been able to show clear evidence-based
benefit
of pre-emptive analgesia. There are several
systematic
reviews looking at studies of pre-emptive
analgesia that
show equivocal and even conflicting results.
However,
these studies tended to be small using singledose
medication and single-modality studies that did
not in-

clude optimal combinations of drugs, and most

also had
a limited duration of analgesic effect and poor
patient
follow-up. Another reason for the apparent lack
of
clinical efficacy with pre-emptive analgesia
may have
been administration of the analgesic regimens
before
the patient emerged from general anesthesia
rather than
before the start of surgery.35
After evaluation of the available evidence,
the
PROSPECT group recommended that
administration
of an analgesic(s) should occur in time to
provide
adequate pain relief on recovery from
anesthesia. If
administration of analgesia before the surgical
procedure is not possible, then it should at least
be performed early enough for peak effect to be
achieved
before patient emergence.
Summary

Inadequately managed surgical pain

continues to be
a common challenge that can have a wide
range of

serious clinical and economic consequences. During

recent years, the emergence of new information and
additional analgesic options has made effective management of surgical pain a reality.
However, what appears to be missing is an awareness of the need to improve surgical pain management
along with clear, specific, and actionable guidance.
There is ample evidence that the way forward should
be directed toward aggressive procedure-specific and
patient-specific multimodal analgesia that is initiated
early and continues until inflammation is resolved.
More detailed analysis of the available evidence is now
required to generate guidelines for each procedure to
provide optimal pain relief, promote mobilization, and
improve outcomes.
Acknowledgments
The Surgical Pain Congress is sponsored by the International Guidelines Center and supported by a grant from
Pacira Pharmaceuticals, Inc.
Charter Members of the Surgical Pain Congress: Paul
M. Arnstein, Ph.D., R.N.; Sarah A. Collins, M.D.; Brian J.
Dunkin, M.D.; John J. Engelbert, Pharm.D.; Debra B. Gordon,
D.N.P.; Jeffrey A. Gudin, M.D.; Anita Gupta, Pharm.D., D.O.;
W. Thomas Gutowski, M.D.; Tracy L. Hull, M.D.; John D.
Kelley, M.D.; Lee A. Kral, Pharm.D., B.C.P.S., C.P.E.; Barbara

228

J. Krumbach, R.N., M.S.N., C.N.S., C.P.A.N., C.C.R.N.;

Christopher R. Mantyh, M.D.; Lieschen H. Quiroz, M.D.;
Michael C. Samson, M.D.; Adam C. Steinberg, D.O.; Scott
A. Strassels, Pharm.D., Ph.D.; and Bernard N. Stulberg, M.D.
REFERENCES

1. Breivik H, Stubhaug A. Management of acute surgical pain:

still a long way to go! Pain 2008;137:2334.
2. White PF, Kehlet H. Improving postoperative pain management: what are the unresolved issues? Anesthesiology 2010;112:
2205.
3. Gerbershagen HJ, Aduckathil S, van Wijck AJM, et al. Pain
intensity on the first day after surgery: a prospective cohort study
comparing 179 surgical procedures. Anesthesiology 2013;118:
90313.
4. Warfield CA, Kahn CH. Acute pain management. Programs
in U.S. hospitals and experiences and attitudes among U.S. adults.
Anesthesiology 1995;83:10904.
5. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain
experience: results from a national survey suggest surgical pain
continues to be undermanaged. Anesth Analg 2003;97:53440.
6. Gan TJ, Habib AS, White W, Miller T. Postoperative pain
continues to be undermanaged. Poster presented at 11th Annual
Pain Medicine Meeting; November 1518, 2012; Miami, Florida.
7. Liebeskind J, Melzack R. The International Pain Foundation:
meeting a need for education in pain management. Pain 1987;30:12.
8. American Society of Anesthesiologists Task Force on Acute
Pain Management. Practice guidelines for acute pain management
in the perioperative setting: an updated report by the American
Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2012;116:24873.

THE AMERICAN SURGEON

9. Kehlet H. Updated pain guidelines: what is new? [Letter].

Anesthesiology 2012;117:13978.
10. Engquist A, Brandt MR, Fernandes A, Kehlet H. Blocking
effect of epidural analgesia on the adrenocortical and
hyperglycemic response to surgery. Acta Anaesthesiol Scand 1977;21:
3305.
11. Brandt MR, Fernades A, Mordhorst R, Kehlet H. Epidural
analgesia improves surgical nitrogen balance. BMJ 1978;1:
11068.
12. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical
pain: risk factors and prevention [Review]. Lancet 2006;367:
161825.
13. Coley KC, Williams BA, DaPos SV, et al. Retrospective
evaluation of unanticipated admissions and readmissions
after
same day surgery and associated costs. J Clin Anesth
2002;14:
34953.
14. Sommer M, de Rijke JM, van Kleef M, et al. Predictors of
acute surgical pain after elective surgery. Clin J Pain 2010;26:
8794.
15. Schug SA, Large RG. Economic considerations in pain
management. Pharmacoeconomics 1993;3:2607.
16. Joshi GP, Kehlet H. Procedure-specific pain
management:
the road to improve surgical pain management?
Anesthesiology
2013;118:7802.
17. Acute Pain Management Guideline Panel. Acute Pain
Management: Operative or Medical Procedures and Trauma.
Rockville, MD: Agency for Health Care Policy and Research

March 2014

Vol. 80

(AHCPR); February 1992. Available at:

www.ncbi.nlm.nih.gov/
books/NBK52153/. Accessed February 21, 2012.
18. Management of Postoperative Pain Working Group.
VHA/
DoD Clinical Practice Guideline for the Management of
Postoperative Pain. Washington, DC: Veterans Health
Administration,
Department of Defense. Version 1.2, July 2001; updated
May 2002.
Available at:
www.healthquality.va.gov/Post_Operative_Pain_
Management_POP.asp. Accessed February 20, 2013.
19. New clinical practice guidelines standards. Jt Comm
Perspect 1999;19:68.
20. Vila H Jr, Smith RA, Augustyniak MJ, et al. The
efficacy
and safety of pain management before and after
implementation of
hospital-wide pain management standards: is patient
safety compromised by treatment based solely on numerical pain
ratings?
Anesth Analg 2005;101:47480.
21. Frasco PE, Sprung J, Trentman TL. The impact of the
Joint
Commission for Accreditation of Healthcare Organizations
pain
initiative on perioperative opiate consumption and
recovery room
length of stay. Anesth Analg 2005;100:1628.

22. Smetzer JL, Cohen MR. Pain scales dont weigh every risk.
J Pain Palliat Care Pharmacother 2003;17:6770.
23. Safe use of opioids in hospitals. Sentinel Event Alert 2012;49:
15.
24. American Pain Society. Principles of Analgesic Use in the
Treatment of Acute Pain and Cancer Pain. 6th ed. Glenview, IL:
American Pain Society; 2008.
25. Kehlet H, Wilkinson R, Fischer HBJ, Camu F. on behalf of
the PROSPECT Working Group. PROSPECT: evidence-based,
procedure-specific postoperative pain management. Best Pract Res
Clin Anaesthesiol 2007;21:14959.
26. Sintra RS, Larach S, Ramamoorthy S. . Surgeons Guide to
Postsurgical Pain Management: Colorectal and Abdominal Surgery. West Islip, NY: Professional Communications, Inc.; 2012.
27. Joshi GP, Bonnet F, Kehlet H. PROSPECT Collaboration.
Evidence-based postoperative pain management after laparoscopic
colorectal surgery. Colorectal Dis 2013;15:14655.
28. Oderda G. Challenges in the management of acute surgical
pain. Pharmacotherapy 2012;32(suppl):6S11S.
29. Zhao SZ, Chung F, Hanna DB, et al. Doseresponse relationship between opioid use and adverse effects after ambulatory
surgery. J Pain Symptom Manage 2004;28:3546.

30. Woolf CJ. American College of Physicians; American

Physiological Society. Pain: moving from symptom control toward
mechanism-specific pharmacologic management. Ann Intern Med
2004;140:44151.
31. Kehlet H, Dahl JB. The value of multimodal or balanced
analgesia in postoperative pain treatment. Anesth Analg 1993;77:
104856.
32. Usichenko TI, Rottenbacher I, Kohlmann T, et al. Implementation of the quality management system improves surgical
pain treatment: a prospective pre-/post-interventional questionnaire study. Br J Anaesth 2013;110:8795.
33. American Society of Anesthesiologists Task Force on Acute
Pain Management. Practice guidelines for acute pain management
in the perioperative setting: an updated report by the American
Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2004;100:157381.
34. Adamina M, Kehlet H, Tomlinson GA, et al. Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal
surgery. Surgery 2011;149:83040.
35. Barreveld A, Witte J, Chahal H, et al. Preventive analgesia
by local anesthetics: the reduction of postoperative pain by peripheral nerve blocks and intravenous drugs. Anesth Analg 2013;
116:114161.

Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.