A patient’s response to painis multi factorial and is influencedby emotional, cognitive,behavioral, cultural, sensory andphysiological components. Paincontrol after surgery can be complicated,but it needs to be one ofthe primary concerns in the postoperativeperiod. Pain decreaseshemodynamic parameters, relievesstress on cardiovascular systems,decreases stress on surgical sites,and improves perfusion of surgicalsites.
Beyond the scope of themedical advantage of pain control, it is an ethical duty to providepain relief to each patient recovering from surgery. Unfortunately,pain control after surgery can be especially difficult to achieve inchronic pain patients. In addition to their frequently increased requirementfor opioid analgesics, chronic pain patients require specialconsideration from a psychological standpoint. Furthermore,they are often labeled as drug seeking, thus preventing physiciansfrom providing an adequate amount of pain medication.
Very few investigations exist that give scientifically based recommendationsfor the treatment of acute postoperative pain in chronicpain patients. One study found that 83% of chronic pain patientsreferred to pain centers were being treated by general practitionersinstead of being properly managed by pain specialists, 47% beingtreated with strong opioids. The increase in the use of narcotics isdue to increased physician education, knowledge of under treatment,and better synthetic drugs with less side–effect. Furthermore,the number of patients who receive opioid analgesics as a chronicpain patient has increased significantly over the past decade.
The prevalence of patients taking strong opioids can only beexpected to increase as general practitioners continue to becomemore familiar with the treatment of pain. When planning postoperativecontrol of pain in opioid dependent patients, the physiciansmust start with a preoperative evaluation. Types of medicines,length of treatment, effect of treatment, and progression rate ofdosages are among the basic preoperative evaluations. Also of importanceis the psychological aspect of the patients: pain control.Chronic pain patients are usually familiar with surgical procedures.If a patient has had poor post–operative pain control previously, heor she will be likely to have anxiety to overcome when preparingto enter another surgical procedure. The importance of discussingthe plan for pain control with the patient can’t be overemphasized.These patients deal with pain on a daily basis and they need to be involvedin post–operative pain control plans. Once the preoperativeassessment and plan has been made and discussed with the patient,the next step occurs on the day of surgery. Patients should be toldto continue taking their normal regimen of pain medicines on themorning of surgery, making sure there will not be a contraindicationto taking these medications the morning of surgery. The fundamentalconcept is to have the patient receive his normal daily dose ofpain medicine before surgery is started.
Pain control can present a problem for any postoperative patient.The psychological overlay which is frequently present in thepatient with chronic pain can make the pain control in the post–operativeperiod more difficult to achieve. Obtaining pain control inthese patients is more difficult but none the less as fundamental andethical as in any patient. The basic strategy for pain control in postsurgicalchronic pain patients requires a comprehensive approach.Studies have shown that much higher doses of opioids can be expectedacutely after surgery and should not be withheld due to thefear of addiction, side effects, or lack of experience with higher dosagesof narcotics. Cognitive behavioral approaches to pain controlhave been shown to aid in postoperative pain control and should beutilized. Hill stated that “under conditions which promote anxietyand fear of pain, patients can be expected to overestimate the effectof painful stimuli” which can lead to depression if under treatment ispresent, leading to more anxiety and less pain control, causing a spiralingcycle that further exacerbates the pain. Therefore, the psychologicalaspect of pain is just as important as the physiologic aspect.
Patients should receive their daily baseline doses of pain medicinebefore surgery. They should be closely monitored intra–operativelyfor increasing pain and should be expected to have a highertolerance, requiring 30–100% more opioid analgesic than the naivepatient. Post–operative evaluation should include stringent pain assessmentto include pain scores, coughing ability, mentation, ambulation,etc. adjusted for the needs of each individual patient. Eachchronic pain patient should be expected to have higher pain scores,require more pain medications, have better side effect profiles dueto tolerance, and a longer need for post operative pain medications.Finally, tapering should be performed at a slower rate than in a regularpatient to prevent withdrawal symptoms. Throughout the postoperativeperiod, patients with histories of abuse should be closelymonitored for signs of addiction such as craving and continuallyreassured that the recurrence of addiction is unlikely if they followthe preoperative plan. Although post–operative pain control is moredifficult in the chronic pain patient, it is possible and likely. The paincan be controlled if stringent evaluation and monitoring are done toassure the patient is receiving the proper dose of medication, no lessand no more.
