The consequences of widespread opioid misuse have focused the nation's attention on the issue of pain and the limited options for treating pain. Both our conceptual models for understanding pain and our efforts to improve pain management through evidence-based approaches have evolved over the past five decades and continue to do so (see Table 1 1-19). But while public advocacy and legislative efforts focus on combating prescription opioid misuse, nurses must continue providing evidence-based care to patients with pain, which includes opioid administration as part of a multimodal approach to postoperative pain management.
In this article, we review the evidence-based clinical practice guideline on the management of postoperative pain, which was approved by the American Pain Society (APS), the American Society of Regional Anesthesia and Pain Medicine (ASRA), and the American Society of Anesthesiologists’ (ASA) Committee on Regional Anesthesia, Executive Committee, and Administrative Council.12 We explain the strength of guideline recommendations and the quality of supportive evidence, point to evidentiary gaps that provide research opportunities for nurses, and suggest ways that nurses can implement this guideline. In addition, we provide the historical context in which the guideline emerged and highlight current health care policy initiatives that may influence guideline implementation.
THE IMPORTANCE OF ADEQUATE POSTOPERATIVE PAIN RELIEF
More than 50 million surgeries are performed in the United States each year.20-22 Research suggests that fewer than half of patients undergoing surgery will report adequate postoperative pain relief and more than 80% will report moderate to severe postoperative pain.12, 23 Inadequately controlled postoperative pain is well known to impede functional recovery and reduce quality of life. Several studies of postoperative pain further suggest an association between the intensity of pain following various types of surgery and the subsequent development of chronic pain.24
Postoperative patients with chronic pain. It may be particularly challenging to manage acute postoperative pain in patients who have been using analgesic opioid therapy to treat their chronic pain. In the United States, more than 100 million adults have chronic pain,25 and those who require surgery may be at risk for inadequate postoperative pain relief, particularly if they have been treating their chronic pain with opioids and are now opioid tolerant. Managing acute postoperative pain in patients who have developed opioid tolerance may require the use of higher opioid dosages, with the accompanying dose-dependent risks.13
THE APS GUIDELINE
The clinical practice guideline on the management of postoperative pain endorsed by the APS, ASRA, and ASA sought to promote safe and effective evidence-based postoperative pain management for children and adults, including pregnant women.12 To develop the guideline, investigators reviewed more than 6,500 abstracts published between 1992—when the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality [AHRQ]) released the clinical practice guideline Acute Pain Management: Operative or Medical Procedures and Trauma—and December 2015. The guideline committee also considered reference lists of relevant articles, including 107 systematic reviews and 858 primary studies not included in the systematic reviews, and suggestions from expert reviewers. The stated goal of the resulting guideline is “to promote evidence-based, effective, and safer postoperative pain management in children and adults.”12 The evidence review and final guideline includes 32 recommendations for the management of postoperative pain, covering preoperative education, perioperative pain management planning, use of pharmacologic and nonpharmacologic treatment strategies, organizational policies and procedures, and transition to outpatient care (see Table 2 12).
Strength of recommendations and quality of evidence. The APS guideline development process used methods adapted from the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group and the AHRQ Effective Health Care Program to rate each recommendation based on the strength (strong or weak) and quality (high, moderate, or low) of the evidence.12, 26, 27 Strong recommendations are those that “can apply to most patients in most circumstances without reservation,”26 or those for which the benefits clearly outweigh potential harms.12 Recommendations were rated weak when the “best action may differ depending on circumstances or patients’ or societal values,”26 or when the evidentiary weight of benefits to risks is smaller.12 Grading of the evidence “considered the type, number, size, and quality of studies; strength of associations or effects; and consistency of results among studies.”12 Of the 32 recommendations, four were judged to be based on high-quality evidence and 11 on low-quality evidence.
Research opportunities for nurses. Guideline recommendations with low-quality or insufficient evidence ratings represent research opportunities for nurses, whose knowledge of pain integrates the behavioral and biological sciences and is critical for furthering postoperative pain management. The APS, ASRA, and ASA guideline panel found insufficient evidence to either support or discourage the use of a number of therapies commonly used to treat postoperative pain. Ice, for example, is often applied to surgical sites to provide local analgesia and reduce swelling. However, studies of localized cold therapy have reported inconsistent results, often finding no differences in postoperative pain or analgesic use among patients who did and did not receive cold therapy for pain or swelling.28, 29 The application of ice is relatively safe, inexpensive, and acceptable to most patients, and its recommendation is within the nurse's scope of practice in most states. Nursing studies seeking to clarify the comparative effectiveness of postoperative cold therapy in different patient populations undergoing various surgical procedures could, therefore, fill significant research gaps. Other areas identified by members of the guideline panel as providing insufficient evidence to inform clinical practice include best timing and optimal methods for delivering perioperative patient education, nonpharmacologic interventions, combination or multimodal analgesia, monitoring of patient response to postoperative pain management, neuraxial and regional analgesic techniques, and delivery of organizational care.30 Further investigation in each of these areas is needed to advance our understanding of postoperative pain management.
CONCERNS ABOUT LONG-TERM OPIOID USE
Since long-term opioid use to treat chronic pain often begins with acute pain treatment, some recommendations from the Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids for chronic pain13 may be relevant in managing acute postoperative pain. For example, the CDC guideline, which is based on scientific evidence, informed expert opinion, and public input, recognizes that opioids are indicated for the treatment of severe acute pain and recommends they be prescribed at the lowest effective dose for no longer than the expected duration of severe pain. The guideline, however, makes no recommendation for postoperative use of opioids, clearly stating that opioid treatment for postsurgical pain is outside its scope.13
Although the CDC guideline recommends limiting opioid prescriptions for acute pain that is nonsurgical and nontraumatic, it does so on the basis of experts’ clinical experience, rather than on scientific evidence—and the expert opinion cited ranges widely from three or fewer days to rarely more than seven.13 The expert opinions expressed in this guideline may have been erroneously applied as evidence for developing health care policy initiatives regarding acute pain management, including postoperative opioid use. Because of the lack of evidence supporting any particular practice for prescribing opioids for inpatient or at-home use following surgery, the APS guideline provides no recommendation for duration of postoperative opioid prescribing.
The Centers for Medicare and Medicaid Services (CMS) has prioritized the use of evidence-based practices for managing acute and chronic pain as a strategy for combating opioid misuse. On April 28, 2017, the CMS proposed new rules for pain management in the Hospital Inpatient Prospective Payment System for Federal Fiscal Year 2020; the proposed rules were open for public comment through June 13, 2017.16 The proposed rules would update the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey measure, revising the three questions that address Communication About Pain During the Hospital Stay to eliminate any perceived financial pressure to overprescribe opioids. Two of the newly proposed questions focus on the following issues16:
- shared decision making
- discussion of treatment options, including opioid, nonopioid, and nonpharmacologic pain management strategies
- patient understanding of treatment options
- patient engagement in pain care
Analyses of the new Communication About Pain composite measure, which includes how often staff talked about pain and how often staff discussed how to treat pain while in the hospital, reveal that the measure has strong reliability and validity; however, pain management nurses are calling for evidence to support the proposed response options—never, sometimes, usually, or always—as measures of hospital processes and performance expectations. In the past, “always” has been the desired patient response for HCAHPS questions, but it is unclear how patient responses to these proposed measures will be interpreted going forward. At press time, the new rules had not yet been finalized.
A FEDERAL RESEARCH AGENDA
The planning committee of the Federal Pain Research Strategy, an initiative of the Interagency Pain Research Coordinating Committee and the National Institutes of Health, Office of Pain Policy, developed an organizational and structural plan that fosters a federal research agenda seeking to improve our understanding and management of pain, including postoperative pain.31 The five key areas that provide the framework for identifying research priorities are as follows:
- prevention of acute and chronic pain
- acute pain and acute pain management
- the transition from acute to chronic pain
- chronic pain and chronic pain management
- disparities in pain and pain care
The five work groups of the Federal Pain Research Strategy planning committee completed their discussions and posted a draft of research priorities for public comment from May 25 through June 6, 2017. The Federal Pain Research Strategy was released in October 2017.19
The Joint Commission has approved revised pain assessment and management standards for its hospital accreditation program. The standards were released in July 201717 and will become effective January 1, 2018. Revisions will be included in the 2018 hospital accreditation manual. The standards stress the need to focus on evidence-based care. Nurses must be able to distinguish clinical practices supported by strong evidence from those with insufficient or weak evidence, as well as evidence-based recommendations from expert opinion.
Nurses are in a position to improve the quality of acute pain management by advocating for evidence-based strategies. Although many of the APS guideline recommendations are not new, some that are well supported by good quality evidence are still infrequently implemented in the clinical practice setting. For example, transcutaneous electrical nerve stimulation (TENS) is seldom used for postoperative pain, though the guideline panel found moderate-quality evidence supporting the use of these small portable devices as an adjunct to other postoperative pain treatments.12, 32 The source for the evidence was a systematic review of more than 20 randomized trials that found that TENS use was associated with 26.5% less analgesic consumption than placebo.32 Before using TENS, nurses should review proper placement of electrodes, optimal treatment parameters, and patient education guidelines.
Organizational readiness. Assessing an organization's readiness to implement any or all of the APS guideline recommendations is a critical first step. For each recommendation, an interdisciplinary team of committed clinicians and organizational leaders must consider how the change will affect the organization's people, processes, resources, and systems and ask themselves the following questions:
- What steps or elements of the recommendations are currently in place?
- What are the institutional strengths for implementing the recommendations?
- Are there any institutional barriers or weaknesses to implementing the recommendations?
The team should outline strategies and actions needed to implement specific recommendations. Patient outcomes, quality metrics, and feedback mechanisms must be defined in order to measure the practice change. Targets for change completion and plans to measure changes in patient outcomes over time will ensure that the change is sustained.
Change often starts with clinical education. In 2012, the U.S. Food and Drug Administration (FDA) approved a “Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics” as part of a risk evaluation and mitigation strategy (REMS) for these drugs.33 The goal of the voluntary continuing education REMS was to reduce serious adverse outcomes as a result of inappropriate prescribing, misuse, and abuse of extended-release and long-acting opioid analgesics while maintaining access to opioid analgesics for patients with pain. A recent version of the blueprint represents a shift from a previous focus on risks and the use of opioids to a more holistic educational focus on acute and chronic pain management that includes pain assessment methods as well as use of nonpharmacologic interventions, nonopioid analgesics, immediate-release opioid analgesics, and extended-release and long-acting opioid analgesics. The FDA sought public comment on this version through July 10, 2017.33 At press time, proposed additions and changes to the REMS are with the FDA for review. The release date has not been announced, but the FDA has sent formal letters to all manufacturers of immediate-release opioid analgesics, requiring them to participate in the FDA opioid REMS once it is approved.
CONCLUSION AND ACTION
Optimal postoperative pain management requires evidence-based guidance from published guidelines and clinical experts, and must consider individual patient values and preferences. We encourage nurses to use the information provided by the expert interdisciplinary panel that developed the APS guideline on the management of postoperative pain to help their patients and health care institutions navigate changing standards and regulations. Nurses can advocate for their patients by promoting evidence-based practice, implementing the recommendations of the APS guideline panel, ensuring appropriate resources are available to safely translate this guideline into practice, and further developing the scientific basis for postoperative pain management clinical practices.
We encourage readers to share their feedback. Which APS guideline recommendations would you, could you, or did you implement in your clinical setting? What barriers to implementation were difficult or insurmountable? What new challenges to postoperative pain management were not addressed by these clinical practice guideline recommendations? Please e-mail your response to AJNPOP@luriechildrens.org
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For more than 70 continuing nursing education activities on pain management topics, go to www.nursingcenter.com/ce.
Keywords:Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
evidence-based guidelines; opioids; pain management; postoperative pain