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Despite new standards, guidelines, and educational efforts, acute pain after surgery continues to be undertreated worldwide, according to a study1 published recently as part of The Lancet’s series on pain.

Up to 75% of surgical patients in the USA are still failing to receive adequate post-op pain relief, according to the paper by Drs Christopher L Wu and Srinivasa Raja from John Hopkins University and School of Medicine, Baltimore.  They claim that chronic pain after surgery is a bigger problem than previously recognised, affecting up to half of patients undergoing common operations. However, new pain medications and techniques under development could help improve symptom relief for patients, they say.

The authors review progress made in treatments for postoperative pain over the past decade and stress that despite advances in pain management, a high percentage of patients continue to experience moderate-to-severe pain after surgery.  Inadequate post-surgical pain management is not just limited to adults, they claim, citing a study from the USA reporting as many as 86% of children experiencing significant pain on the first day home after undergoing routine tonsillectomy.

Pain copyFindings also show that the development of persistent postsurgical pain [PPP] is a frequent outcome, affecting as many as 30–50% of patients undergoing common operations such as mastectomy, thoracotomy, hernia repair, and coronary artery bypass.

They authors say: “Why there has been little progress in the treatment of acute postoperative pain is unclear, but the causes might be multifactoral, including the continued paucity of pain assessment and documentation, heightened awareness and increased number of audits or surveys leading to increased identification of undertreatment of pain…deficiencies in educational pain management programmes for health-care workers, underuse of effective analgesic techniques, and poor adherence to available guidelines”.

However, some interventional techniques have had a substantial impact on pain control over the past decade, they claim. The report singles out regional analgesic techniques as associated with significantly lower pain scores, earlier mobility, reduced length of hospitalisation and risk of addiction compared with the use of systemic opioids.

Other interventions still under development include the transdermal patch for the patient-controlled delivery of pain medication (fentanyl) providing an alternative to the intravenous pump; extended-release local anaesthetics to prolong the action of commonly used local anaesthetics; and disposable devices to allow infusion of local anaesthetics on an outpatient basis reducing the need for opioids and their adverse effects.

The authors continue: “Additional studies on predictors of postoperative pain and persistent postsurgical pain, efficacy of multimodal analgesic regimens [using more than one class of pain medication or technique], and growth of promising new technologies might lead to substantial gains in the treatment of acute postoperative pain and potential reduction in the development of persistent pain states [a not uncommon outcome of surgery]”.

An accompanying editorial2 concludes that:  “Clinicians have an important part to play in advocating for improved access to opioid drugs for medical purposes, as well as in managing pain effectively. Keeping up to date with the latest advances in treatment and adhering to pain management guidelines should be standard practice, but, as the Series shows, the reality can be very different…To help eliminate or mitigate a individual’s pain is a privilege that clinicians must neither forget nor neglect”.


1 Wu CL, Raja SN.  Treatment of acute postoperative pain.  Lancet 2011;377:2215-25.  doi:10.1016/S0140-6736(11)60245-6

2 The Lancet.  Managing pain effectively. Lancet 2011;377:2151.  doi:10.1016/S0140-6736(11)60942-2

Published on: July 12, 2011

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