Overall, proportionately more patients experienced pain after discharge (from the hospital or physician office) than before discharge. Approximately 75% of patients reported pain after discharge, compared with 58% of patients who reported pain before discharge. Almost half of all patients experienced severe to extreme pain before discharge. After discharge, the percentage of patients who experienced severe pain was relatively unchanged, but the percentage of patients who experienced extreme pain was substantially reduced.
Approximately 82% of all patients received pain medications in the hospital, doctor’s office, outpatient clinic, or surgery center. The most commonly administered medications were morphine (33%) and meperidine (27%) for inpatients and acetaminophen with codeine (23%) and ibuprofen (15%) for outpatients. Overall, one third of patients requested their first one to two doses of pain medication while in the surgical setting. Of these, 37% were inpatients and 25% were outpatients. After discharge, 76% of all patients received pain medications. The most frequently prescribed medications were acetaminophen with codeine (17%) or acetaminophen alone (17%) for inpatients and acetaminophen with codeine (21%) or oxycodone with acetaminophen (20%) for outpatients.
Of the patients who received pain medications, 23% reported experiencing adverse effects (Table 5). In the hospital, doctor’s office, outpatient clinic, or surgery center, 15% experienced adverse effects; 17% of patients experienced adverse effects after discharge. The most common side effects were drowsiness, nausea, and constipation.
When patients who received pain medications before discharge were asked about satisfaction with their medications, 88% of them reported that they were either “very satisfied” or “satisfied” (Table 6). Despite reporting intense pain, only 3% of patients were “dissatisfied” or “very dissatisfied” with pain medications. A similar trend was noted for surgical inpatients and outpatients; however, outpatients were slightly less satisfied. Approximately 90% of inpatients and 85% of outpatients were satisfied with their pain medications, compared with only 2% of inpatients and 4% of outpatients who were dissatisfied with their pain medications. The percentage of patients reporting “very satisfied” or “satisfied” was 90% in the inpatient group, compared with 84% in the outpatient surgical group while in the hospital or outpatient surgical center. The rates for patients postdischarge home (up to 2 wk) were 87% vs 76%, respectively.
When patients were asked about their satisfaction with pain medications during the first 2 wk after discharge, 83% reported being “very satisfied” or “satisfied,” 10% “slightly satisfied,” 3% “slightly dissatisfied,” and 4% “dissatisfied” or “very dissatisfied” (Table 6). After discharge, patients who had outpatient surgery were slightly less satisfied with their pain medication than were patients who had inpatient surgery. Findings were similar for outpatient and inpatient surgical settings.
Approximately two thirds of patients reported that a health care professional talked with them before surgery about how their pain would be treated (Table 7). Overall, nurses were more likely than other health care professionals to educate patients about pain and pain management. Among surgical outpatients, surgeons were as likely as nurses to provide patient pain education, but nurses were more likely to provide this service for surgical inpatients. After surgery, two thirds of patients reported being asked by a health care professional about their pain, most frequently by a nurse.
When asked about attitudes regarding pain and pain medications, 75% of patients believed that it was necessary to experience some pain after surgery, and 8% of patients had postponed surgery because they were worried about the possibility of experiencing pain. Approximately 94% of patients thought that some pain medications prescribed after surgery caused adverse effects, and, if given a choice of pain relievers, 72% of patients would choose a nonnarcotic drug. The main reasons for this choice were that nonnarcotic drugs are less addictive (49%) and have fewer adverse effects (18%).
With current standard postoperative care, approximately 80% of all patients in our survey experienced acute pain after surgery. Alarmingly, most of these patients had moderate, severe, or extreme pain. Both inpatients and outpatients experienced postoperative pain. Ambulatory patients experienced more pain after discharge than when they were in the facilities.
When assessing the severity and effect of pain experienced after day surgery, Beauregard et al. (14) found that 40% of patients reported moderate to severe pain during the first 24 hours after discharge. Pain decreased over time but was severe enough to interfere with daily activities, even several days after surgery. Chung et al. (15) found that >25% of ambulatory patients reported experiencing moderate to severe pain after discharge. Another study, conducted by Lynch et al. (16), used a 1–10 numerical rating scale to assess the severity of pain among patients who had noncardiac inpatient surgery. The mean maximum pain score on postoperative Day 1 was 6.3 (moderate pain) and decreased only slightly to 5.6 by postoperative Day 3. The findings demonstrated that patients experienced intense pain after inpatient and outpatient surgery, which is consistent with the findings from our study.
A national study similar to ours assessed the status of acute pain management and attitudes toward postoperative pain in a random sample of patients (4). Although this study was performed approximately a decade ago, it provided a baseline against which later studies could be compared to assess improvement in pain management. In this study of 500 patients, 77% experienced pain after surgery, 23% experienced severe pain, and 8% experienced extreme pain. Similarly, we found that 82% of patients experienced pain after surgery: 21% of patients experienced severe pain, and 18% of patients experienced extreme pain. The percentage of patients with overall pain increased slightly in our study; however, the percentage of patients with extreme pain more than doubled as compared with the results from Warfield and Kahn (4) (Fig. 1). Patients seem just as concerned about experiencing postoperative pain today (59%) as they were almost a decade ago.
Adverse effects can occur after pain medications. Of those patients who received analgesia, 23% experienced adverse effects in our study, which was similar to the results reported by Warfield and Kahn (4). Interestingly, almost 90% of these patients reported satisfaction with their pain medications. This finding is similar to results in studies that focused on overall pain management rather than specific satisfaction with the actual pain medication. This could be related to patients’ expectation of postoperative pain and little awareness of the efficacy of current analgesics (17,18). Satisfaction with pain care is also challenging to understand because patients often base their response on sympathetic reactions and friendliness of staff rather than the outcomes of pain relief.
We were surprised to find that more than half of the patients surveyed were concerned about experiencing pain after surgery and that this caused some of them even to postpone surgery. Although most patients claimed to receive preoperative education on postoperative pain management, our findings suggest that a patient’s real concern is not adequately addressed. Despite the increased focus on pain management over the last several years and the development of formal standards and guidelines for the management of acute pain, a significant number of patients continue to experience unacceptable levels of pain after surgery and after discharge. This fact is alarming, considering the trend toward ambulatory surgery and shorter hospital stays. Aggressive management could prevent complications that result from postoperative pain. The intense pain experienced after surgery and side effects from pain medications may explain why patients continue to fear postoperative pain.
Guidelines have been designed to improve treatment outcomes for patients with acute pain. In 1995, the American Pain Society’s Quality of Care Committee published a set of guidelines recommending quality improvement programs for acute pain, which include five key elements: 1) recognition and prompt treatment of pain, 2) provision to clinicians of information about analgesics, 3) promise to patients of attentive analgesic care, 4) implementation of policies for using modern analgesic technologies, and 5) assessment and continuous improvement of pain management (19). Such recommendations have the potential to improve patient satisfaction with medical care and remove some of the obstacles to optimally manage pain. However, as the results of this study show, postoperative pain is still not adequately managed. Recognizing the importance of the issue of undertreatment of pain, the JCAHO implemented new pain standards, which require that all patients be assessed for pain and then be appropriately treated and monitored. In 1999, the National Health and Medical Research Council of Australia published evidence-based guidelines on management of all forms of severe pain (20).
Other factors also may explain the inadequate management of acute pain after surgery. The pressure to discharge patients after surgery could limit the pain medications health care professionals are willing to prescribe. In our study, inpatients had more pain and were more likely to receive morphine and meperidine before discharge than outpatients, who were more likely to receive acetaminophen with codeine or ibuprofen before discharge. Both patient groups received similar medications after discharge. Physicians may be unwilling to discharge a patient medicated with potent, long-acting opioids from a supervised setting because of potential safety concerns. Also, patients may not have someone at home who can assist them during the first 24 hours after discharge, when the pain may be greatest, adverse effects can be common, and analgesia administered at the hospital is wearing off.
Although there is still some risk, when opioids are used for a medical purpose for a short time, the risk of addiction is small (21). Fearful of the addictive potential of opioids, many patients may prefer a non-opioid or a less potent opioid medication. Also, some patients may be so distressed by the adverse effects of opioids that they may prefer to experience pain rather than opioid adverse effects. Efforts toward multimodal analgesia with the combination of opioid and non-opioid medications, including nonsteroidal antiinflammatory drugs, cyclooxygenase-2 inhibitors, or local anesthetics, may result in more optimal pain management (22). Our findings suggest that greater awareness of the importance of managing pain and the dedication of resources to pain control are needed to improve postoperative pain management.
There are some weaknesses in this study. A retrospective survey of an event or an experience is likely to be influenced by the events occurring after the event in question, as well as by the time interval. Although many people are able to recall past events or experiences with reasonable accuracy, over long periods of time, the effect of recall bias and passage of time should be considered when interpreting a retrospective analysis. However, we believe that postoperative events are unique and significant enough that patients may be able to recall their general pain experience, even when it took place several years previously. Approximately 50% of patients who responded to this survey had had surgery within the year before the survey. In addition, these data should be interpreted in the context of 250 patients, with just slightly more female respondents (60%), because there can be some difference in pain experience between sexes. Finally, it is acknowledged that these results are based on a survey of only 250 randomly selected patients, spanning both inpatient and outpatient procedures. Nonetheless, these findings are consistent with previous reports and provide a current understanding of the potential challenges we still face in adequately managing pain.
In summary, most patients experience moderate to severe pain sometime during their postoperative recovery. The results from this study are even more relevant with the increasing attention to pain management in the hospital setting. Changes in medical practice patterns, continued research, development of newer analgesics with potent efficacy and minimal adverse effects, and use of balanced analgesia should enhance the potential to treat postoperative pain more successfully.
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