Sunday, December 12, 2010

Mistreated Acute Pain Still A Dire Problem

Acute PainAs we come to the close of the “Decade of Pain Control and Research” in the United States, it is both surprising and disappointing that acute pain is apparently still widely mismanaged or undertreated, according to a recent review in the journal Pain Medicine. One solution may rest with a greater understanding and application of multimodal pain management therapies.

Raymond Sinatra, MD, PhD, from the Yale School of Medicine, New Haven, Connecticut, comments that millions of patients each year suffer acute pain due to trauma, illness, or surgery. Pain accounts for 40% of the 100 million visits to emergency departments, and most patients report moderate to severe pain following the 73 million surgical procedures performed annually in the U.S. Yet, studies indicate that nearly 50% to more than 70% of those patients have unrelieved acute pain and, in one investigation, 40% of patients did not receive analgesics for their severe pain. The elderly, aged 70 years or older, seem to be particularly undertreated when it comes to providing effective analgesia for acute pain conditions.

Inadequate acute pain management has substantial consequences for patients, including disrupted sleep, impaired physical function, reduced quality of life, and a greater potential for the development of chronic pain conditions. It also is costly: for example, in one study, unresolved acute pain was the most common reason for return to the hospital within 30 days of surgical procedures.

Sinatra discusses numerous barriers, including inadequate physician training in pain management, a lack of patient education on proper and safe analgesic use, and adverse effects of analgesic therapy that contribute to therapeutic noncompliance. A relatively low proportion of patients with moderate to severe acute pain receive opioids — as few as 15% in one study — although these drugs are generally considered the treatment of choice for such pain. Even in postsurgical settings, opioids tend to be underused or underdosed for managing moderate to severe pain, he observes. Particular concerns center on misperceptions regarding the abuse potential of opioids — in actuality, the risks of opioid abuse and addiction are far less than practitioners and patients realize — so greater education is needed despite all the efforts in this regard during the past decade.

For any analgesic therapy, a balance between its effectiveness and tolerability is necessary. Research has shown that patients often are willing to trade analgesic effectiveness for a reduction in side effect severity. Sinatra mentions a study in which, presented with several hypothetical analgesic options, most patients (60%) were willing to settle for fair pain relief with no side effects, rather than good pain relief but moderate nausea (40% chose this option). Yet, such trade-offs should not be necessary with proper analgesic selection and dosing, along with patient education on what to expect and how to manage side effects.

Particularly in the postoperative setting, Sinatra points out that localized analgesic therapies can be effectively combined with systemic analgesics (eg, oral or parenteral agents). As one example, nerve blockade using local anesthetics can provide good acute pain relief with a low incidence of side effects and a high degree of patient satisfaction. As part of a multimodal approach, nerve blocks allow reductions in opioid consumption and related side effects. However, he does caution that nerve blocks are not suitable for all patients, such as those susceptible to bleeding or with systemic disease or infection.

Sinatra observes that, while opioids remain the standard for managing moderate to severe acute pain, polypharmacy incorporating multiple analgesics with different mechanisms of action may have increasing potential in clinical practice. And, multimodal pain management approaches could provide significant benefits for patients while reducing costs in the long term. The implementation of acute pain services in healthcare institutions, involving various medical disciplines, also offers great promise. Currently, such services are focused on surgical patients, including children and outpatients, but it may be appropriate that these are extended in some fashion to serve all patients with acute pain.

COMMENTARY: It seems shameful that any patient should suffer unrelieved acute pain when there are so many analgesic options available to healthcare providers, especially in developed countries. Yet, study after study continues to show that a great many persons — such as minority, economically disadvantaged, elderly, and/or under- or uninsured patients in the U.S. — often do not receive adequate acute-pain care [eg, blogpost here]. Mistreated acute pain may, in part, be contributing to the spreading epidemic of chronic pain that is taking a heavy toll in human suffering and imposing a growing economic burden on society.

Some of the deficits in acute pain management may be attributed to increasing regulatory scrutiny of analgesic prescribing (particularly opioids) and to policy makers who are distracted by other issues (at least in the U.S.). However, healthcare providers also must ask themselves if they have the education and, equally important, the motivation and determination to conquer acute pain in everyday practice by effectively applying available therapies.

REFERENCE: Sinatra R. Causes and Consequences of Inadequate Management of Acute Pain. Pain Medicine. 2010(Dec);11(12):1859-1871 [access article here].