A Guide to Post-Surgery Pain Management

Pain management is an incredibly important topic for surgery patients. Prior to surgery, patients are often concerned that their pain needs will not be met and they will suffer needlessly after their procedure. Post-surgery pain management must find a common ground between the safety of the patient and reducing pain to a reasonable and tolerable level during recovery.  

The process is often the responsibility of the surgeon.

Their expertise and experience in performing specific procedures guides them in properly providing pain medication that is adequate for the typical patient. Other areas of specialization, such as hospitalist medicine and anesthesiology, often play a role in appropriate pain management as well. For the patient who has pain that is difficult to control, a specialist in the area of pain management may be involved as well.

Understanding the Term "Pain Management"

The term pain management can be a used in many ways. You may hear someone say, "we will make pain management a priority during your stay in the hospital," meaning they plan to pay close attention to your pain needs. You may also hear, "we are going to consult pain management to help manage your pain," which means a pain management specialist is going to be asked to participate in your care. Some patients may be told they will need a referral to pain management, which means they are being instructed to see a pain management specialist as an outpatient.

Acute Pain Versus Chronic Pain

Pain is classified as acute pain or chronic pain. Acute pain is described in multiple ways, but is generally pain that is not expected to last for more than six months. Acute pain is usually brief and when the injury heals the pain is gone. A broken leg is an excellent example of acute pain.

The pain is severe at the time of the injury, and may be excruciating while the bone is being set, but improves once the cast is on. The pain may be present while the bone is healing, but after the cast is off the pain is nearly or completely gone.

Acute pain may also be a headache, a toothache, or the pain that a person feels in the weeks following a surgical procedure. Acute pain is expected to go away, and to go away fairly quickly.

Chronic pain is long-term pain. It is pain that is expected to be present for six months or longer, and may never go away completely. This is pain that will be an ongoing issue and may require pain treatment by a specialist. In some cases, there is an end to the pain, whether through physical therapy, surgery, or an improvement in the disease that is causing the problem. For others, such as patients diagnosed with certain types of pain, or with cancer, there may be an expectation that the pain will worsen over time.

How Acute Pain and Chronic Pain Are Treated Differently

Pain management has changed dramatically in the last several years, largely because of the dramatic increase in the rate of accidental deaths due to prescription drug overdose and the unprecedented rates of prescription drug addiction.

In some states, prescriptions for pain medications are limited to three days worth of medication when the prescription is provided by an emergency room provider. The expectation is that the emergency room will provide you with enough medication to allow you to make an appointment with your primary care provider or a specialist.

As an example, let's say that somebody breaks their leg. The leg is set and casted in the ER. The patient is given a prescription for pain medication for three days, and are given an appointment to follow up with the orthopedic surgeon (bone specialist) in three days. The expectation is that you will keep your appointment, and the orthopedic surgeon will manage your pain after that.

Chronic pain, or pain that is longstanding, should be treated on an outpatient basis. That means your primary care provider, your disease specialist or a pain management specialist provides your pain medication. Unless your chronic pain has dramatically increased and you need assistance controlling that new and increased pain—and potentially a new diagnosis or an explanation of why the pain is worsening—the emergency room will no longer be willing to provide weeks or months worth of prescription pain medication in most cases.

Understanding the Pain Scale

If you are having pain, expect to be asked what your pain is on a scale of 0 to 10. For children, a scale that uses sad faces and happy faces is used, especially in children under the age of 5.

A pain scale rating of 0 means that you are not experiencing pain. A pain scale rating of 10 means that you are having such horrific pain that you cannot imagine that it could be worse than it currently is. Be realistic when using this pain scale. Stating that you are having 10 out of 10 pain when it is really a 5 may sound like a good idea, or a way to get more pain medicine, but nurses and physicians are very good at observing the signs of pain. Rating your pain a 10 out of 10 while sitting in the emergency room talking on your phone or eating a snack is an excellent way to prove that you are not to be trusted when reporting your pain level. People who are having 10 out of 10 pain truly are in agony. This type of pain typically means an immediate trip to surgery or to an MRI or CT scan, because something is very wrong, often life-threatening. 

When I ask patients to rate their pain and they tell me they are experiencing 10 out of 10 pain, I simply say this, "ten out of ten pain means that it hurts so bad that your pain couldn't be made worse, that you would rather have me cut your ____ off than to continue to feel the pain there." Sometimes the pain is that bad, but the vast majority of the time the patient indicates that is closer to a 5 or 7. True 10 out of 10 pain is uncommon, and, unfortunately, often means the patient is extremely sick or injured and might require emergency surgery such as in the case of an "acute abdomen."

Pain Is What the Patient Says It Is

In the 1990s a new philosophy of pain management was adopted. Nurses and physicians were taught that pain is the fifth vital sign and that pain is what the patient says it is. The idea was that if the patient said their pain was 10 out of 10, then we would treat them for 10 out of 10 pain. This type of pain management led to significant increases in the amount of pain medications that were prescribed and dispensed to patients.

The more modern idea of pain management is that it is often impossible or unrealistic for some patients to have no pain. Currently, the goal for the management of acute pain is not to remove pain, but to treat pain until it is a tolerable level. This means that your broken leg will ache in the weeks following the injury, but you won't suffer intolerable pain. Most people find a 2 to 3 on the pain scale an acceptable level of pain control that allows them to get through their day, to sleep, to cough well enough to avoid pneumonia, and to function well enough to take care of their basic needs.

Chronic pain, when properly managed, is often done with a goal of good to excellent function in mind. For example, chronic low back pain can prevent people from working and taking care of their day to day needs. The goal for their pain management might be to control the pain well enough to allow them to return to work, take a shower and take care of light household tasks such as washing dishes or doing laundry. The goal isn't to make the patient pain-free, but to allow them to perform important daily tasks.

Key Goals in the Proper Management of Acute Pain After Surgery

The management of pain has several key concepts that help a patient experience good pain control with a low risk of complications and better quality of life.

• Don't take more than you need.  If your pain is well controlled by over the counter medication, don't take the stronger prescription medication. If your pain is improving, your dose should be decreasing or become less frequent.
• Control your pain well enough to function. Able to function typically means able to walk, cough effectively, and complete simple tasks like showering.
• Aim for tolerable pain, not zero pain.  No pain is unrealistic and can lead to too much medication being taken, which increases the risk for serious complications like decreased breathing and overdose.
• Do not increase your dose without your physician's blessing. It may seem like a good idea to take more medication when you are hurting more, but the risks often outweigh the rewards. If your pain medication isn't controlling your pain effectively, talk to your surgeon or primary care physician. Taking your pain medication in a way that it isn't prescribed can lead to serious issues with breathing, addiction and being discharged from the care of your physician for failure to follow the rules.
• Try to find steady pain control.  A patient who waits until their pain is an 8 to take medication, has a pain level of 3 for a few hours, then lets the pain rise again to an 8 before taking more medication is going to have a far more challenging time with pain management than the individual who works to keep their pain at a 4-5 at all times.
• Prevent or anticipate side effects. Constipation is a well-known side effect of opioid medications and can cause discomfort or actual pain and can be prevented with stool softeners and ample water intake. Pain medication can cause drowsiness, so anticipate not driving after taking medication. Preparing for these types of issues can improve your quality of life and prevent further problems.

If your prescribed dosing schedule has you bouncing around from a 3 to a 5 to an 8 back to a 3 through the day, you may need to talk to your doctor about more frequent dosing. You may not need a higher dose, but more frequent doses.

Alternatives to Prescription Pain Medication

When people think of pain management, they are often thinking of prescription pain medications. Prescription medications are just one of the many ways pain can be managed on a daily basis, whether the pain is acute or chronic.

While prescription pain medications are a significant part of pain management, most professional pain management providers use many types of pain relief to help their patients function.

There are many procedures that are designed to help reduce pain, and often simple changes with diet, exercise, physical therapy, over the counter medications and other interventions can provide effective pain relief.

A Few Words About Addiction to Pain Medication

When pain medication is used properly, the risks of addiction are low. There are two types of addiction: physical and emotional. Physical addiction happens when your body becomes accustomed to the medication after taking it for an extended period of time. This is often true of patients who have chronic pain and have been taking their medication as prescribed and is normal when taking pain medications for months or even years. For these people, when and if they are able to stop taking their medication, it is often decreased over days or weeks to prevent withdrawal.

Emotional addiction happens when a person abuses pain medication and takes pain medication they do not need. These individuals will take pain medication that isn't theirs, take more medication than prescribed, visit multiple doctors or emergency rooms to get more medication and even buy medication on the black market. These people are typically treated with a rehabilitation stay to help them stop abusing pain medication.

In reality, most people who are addicted to pain medication have a mixture of emotional and physical addiction. They have an emotional need to take pain medication, even when pain is absent or mild enough that prescription narcotics are not necessary. They also have a physical addiction, and experience physical withdrawal symptoms when medication is not available. Recovery typically requires professional help, with counseling and medical intervention.

Who Might Need Ongoing Pain Management?

After surgery, most individuals experience acute pain that is easily controlled with common pain medications. They are able to recover from their procedure and return to their normal lives and normal level of activity, and over time no longer need pain medication. This process may happen over the course of days, weeks or months.  

Pain management is appropriate for individuals who are expected to have pain that is difficult to control, could be helped by an outpatient procedure such as a nerve ablation, or will need more treatment than the average patient after surgery. For these people, a provider who specialized in the treatment of pain may be a godsend, and will help reduce pain to a manageable level.  Individuals with a diagnosis of a condition known to be very painful, such as bone on bone arthritis that cannot be treated with surgery, cancer, or back pain that did not respond well to surgery are also good candidates.

If you think you might need pain management after surgery, it is a good idea to request a referral from your surgeon to a pain provider that they recommend.

Identifying Good Pain Management Practitioners

A good pain management provider is a wonderful thing. They are skilled at helping reduce pain, and they are also very good at minimizing the risk associated with taking narcotic pain medications on a daily basis. Many pain management providers are initially trained as anesthesia providers, and some are board certified in the practice of pain management or have completed a fellowship for additional training.

When you are looking for a pain management provider, you are looking for someone with the appropriate training to provide excellent pain management. A pain management provider who is trained as a plastic surgeon but is working in pain management would be very unusual and should be investigated, just as it would be odd for a heart doctor to be working in pain management.

In general, to avoid a pain management clinic that is not reputable, avoid the following things:

• Cash only pain management providers. Legitimate clinics accept insurance, and often many types of insurance including Medicare.
• Avoid pain management clinics that focus exclusively on pain medications. There should be a well-rounded approach to pain management, which should include therapies other than prescriptions.
• Avoid clinics that frequently change locations, or have a location that doesn't seem like a doctor's office. There should be medical equipment in the office.
• Avoid clinics that advertise in unusual places, such as roadside signs at intersections.
• Avoid clinics that do not include a physical examination and possibly a medical record review to start your treatment.
• Avoid clinics that seem to have little interest other than seeing the patients as quickly as possible and dispensing prescriptions.

Many legitimate clinics require drug screening at every visit, require a pain management contract that indicates you cannot take pain medication other than what is prescribed at the pain management center, and may require you to participate in random pill counts where you must present your prescription bottle within 24 hours of being notified to have your pills counted. These policies and procedures are all normal and acceptable when being treated at a pain clinic, and are in place to help prevent abuse of prescription medications.

Source:

The Specialty of Chronic Pain Management. https://www.asra.com/page/44/the-specialty-of-chronic-pain-management