Postoperative pain control unsafe at any speed

Health-care providers need to focus on how to help patients undergoing major surgery effectively manage their pain.

Many providers are failing to help patients manage post-operative pain
Many providers are failing to help patients manage post-operative pain

 I've spent most of my 14-plus years as physician assistant (PA) in pain and addiction settings, and much of my work has been related to post-operative pain control in both inpatient and outpatient settings.

It never ceases to amaze and shock me how badly medical professionals do in helping patients manage pain. Medicine does some good things, but there were days when I had a hard time remembering what they were.

Let's catalog the ways post-op pain control fails our patient in an epidemic manner, and assign some grades.

Pre-operation patient education

A vast majority of patients who I saw and cared for post-operatively describe being completely unprepared for what they would experience after surgery.

Many patients become tearful when they even had to talk about the experience, noting “I had no idea it would hurt so bad! Why didn't someone tell me it would be like this? Why didn't someone tell me what to expect and how to communicate with providers about my needs?”

The unfortunate answer is that most clinicians who are doing the pre-op consults have no idea what it's like to have their liver taken out, have their skull cut open and their brain moved around, or have an incision from their sternum to their navel. Most providers have not experienced that level of pain themselves.

So, we downplay the reality of what feels like when our patients wake up. Then, when they freak out, accuse them of all kinds of things including being drug-seekers and/or just plain maladjusted.

Grade: F

Pain control in the immediate post-op setting

This is an area that would blow the public away if they saw how many patients suffer from pain after surgery.

Between the increased scrutiny and restriction of opiates; the increased anxiety and reticence on the part of providers who order and prescribe opiates; and the disturbing dearth of medical education about how to treat pain, patients who need opiates are made to feel like criminals for every milligram of pain medication they need.

Anyone who has worked in inpatient settings has heard the stories --

An opioid-naive patient has major surgery with a huge incision in his or her abdomen and then is put on a paltry amount of pain medication post-op. This patient can't find a way to actually talk to anyone on the surgical team, so he or she sees residents and providers-in-training who have no idea what they are doing or what the surgical team wants.

A patient starts suffering the night they come out of surgery and can't sleep because of their uncontrolled pain. When they talk to a resident about their pain, that provider tells to take a hormone to help them sleep.

Grade: F

Specialized perioperative pain control

This is an area that is changing, and medical centers are doing a much better job in addressing pain in specialized perioperative settings.

Many medical centers are now developing multi-professional teams who will identify patients likely to have post-op problems -- those with addition, chronic pain, are already on high-dose opioids, have a previous history of unsatisfactory post-op pain control.

These teams will work with surgical and anesthesia teams in order to pay extra attention to these patients' needs, and move them quickly out of the standard surgical team post-op care into specialized outpatient setting to be cared for by providers who are experienced with opioid prescribing and with tapering patients in such settings.

Grade: C, and trending up

We all know that the answer to these problems is not just to pour more opiates into patients; it can be dangerous, and can lead to more problems than it solves. The answer is better education for both patients and providers so that pain can be managed in a way that is safe and effective.

Jim Anderson, MPAS, PA-C, ATC, DFAAPA, is a physician assistant in Seattle, WA.
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