Epidemiology and Critical Factors in Inadequate Acute Pain Control and Effective Strategies for Treatment in Modern Medicine

Alan David Kaye

Chance M. Hebert

Katherine C. Babin

Winston Suh

Taylor Marie Boudreaux

Andrea E. Stoltz

Elyse M. Cornett

Introduction

Pain is a phenomenon that affects many people. While many pain responses act as warning signs for various disease processes or harmful external stimuli impacting the body, uncontrolled pain can be debilitating and predispose individuals to other issues in the future. Despite ever-increasing knowledge regarding the pathophysiology of pain, current pain management standards often fall woefully short in providing patients with adequate relief.

With over 313 million individuals globally undergoing either inpatient or elective surgery as of 2012, this leaves a large population vulnerable to physical, social, and psychological dysfunction as the effects of untreated pain permeate all facets of life. Associations between inadequate acute pain management and increased morbidity, impaired quality of life, and elevated health care costs have been well documented.¹ The impacts of uncontrolled pain also trickle down to affect family members, friends, and coworkers of patients creating far-reaching consequences.² Over 80% of patients endorsed experiencing some degree of postoperative pain, with up to 60% progressing to suffer from chronic pain. Recognizing populations at the highest risk for the development of both severe postoperative pain and chronic pain is imperative to improving outcomes and decreasing the burden on the health care system overall. Such at-risk groups include women, racial minorities, children, and the elderly.¹

Additionally, pain is a major contributory factor for emergency department (ED) visits in the United States. Emergency level visits for exacerbations of inadequately managed chronic pain also proliferate the rising costs of health care.³ As of 2008, the combined annual cost of acute and chronic pain in the United States was estimated to be between $560 and $635 billion when considering the loss of productivity and disability in addition to direct health care costs. Major contributory disorders include arthritis, back pain, and headache, often resulting in permanent disability of many patients.² Promoting proper primary management of these issues could alleviate both undue patient suffering and stress on the already overburdened health system.

Traditionally, surgical pain was managed exclusively as a postoperative entity, with opioids as the primary treatment protocol. Current focus is shifting to an aggressive multidisciplinary approach involving preoperative antiinflammatories and nerve blocks in combination with opioids to target pathways even before the pain begins. Ultimately, this can allow for decreased perceived pain, improved quality outcomes, and shorter hospitalizations.⁴

Risk Factors of Inadequately Controlled Pain

Postoperative Pain

One study conducted a systemic review on the prevalence, consequences, and possible preventions of pain associated with surgical procedures. Specifically, a survey was conducted nationally in the United States to observe how many people who underwent surgery within the past 5 years, also experienced postoperative pain. Of the 300 adults included in the study, 86% experienced postoperative pain, and 75% of those patients experienced moderate to severe pain. Although the sample size of this specific study may be small, it accurately represents the population because, according to the U.S. Institute of Medicine, ˜80% of patients who have surgical procedures will experience some postoperative pain.¹ Since there is such a high prevalence of pain related to inadequately controlled pain in patients, multiple studies have been done to determine if preoperative risk factors existed, which would create a greater chance of experiencing postoperative pain and the development of chronic pain also known as pain chronification. The studies collectively have found that aside from the analgesic/anesthetic involvement and type of procedure, other risk factors included preoperative pain, younger age, female sex, heightened anxiety, and incision size.¹ Related to statewide legislation throughout the country that limits acute pain management with opioids typically to 5-7 days, enhanced recovery after surgery techniques have blossomed. Some of these have included a variety of medications delivered perioperatively such as acetaminophen, gabapentinoid agents, nonsteroidal anti-inflammatory drugs, alpha-2 agonists, ketamine, and others that have been evaluated to reduce postoperative opioid consumption and reduced hospital time for patients as well as ultrasound-guided nerve blocks. In general, patients who have better acute pain management will have a better chance of not developing many of the issues related to chronic pain states. For all of these reasons, excellent manage of acute pain, which did not exist in previous decades, has significantly improved with many physiological benefits, improved patient satisfaction, and the potential for reduced likelihood of the development of chronic pain states and therefore reduced likelihood of opioids. Reduction in long-term use of opioids decreases the potential for addiction, physical dependence, overdose, and death.

Chronic Pain/Cancer

The care of patients with cancer or other diseases that cause chronic pain tends to come with a significant price tag and can overwhelm the patient with the burden of paying for the treatment. Many times, patients diagnosed with cancer will not be able to work, which can result in financial challenges, psychological issues, and stresses in family relationships. Cancer pain management has proven to be inadequate and challenging for many patients and has led to disparities in health care. One study revealed that 7% of the 511 patients reported a negative pain management index at primary and secondary care clinics. This index is calculated by analgesic potency minus the mean pain intensity. The majority of patients reporting a negative pain management index exposed the reality that the current pain management is inadequate.⁵ A second study conducted in Amman, Jordan, was cross sectional in design in order to discover any risk factors in patients that correlated with a higher risk of inadequate pain control. From the total 800 patients surveyed, 56.4% of patients reported having a pain score higher than 4 out of 10 upon movement. Administration of preoperative medications and postoperative opioid/anesthetic significantly decreased the risk of the cancer patient experiencing poor pain control. Specifically, if medications are given solely intravenously, the patient will still have a high risk of inadequate pain control. However, if the medications are given orally and intravenously, the patient experiences a decreased risk of poor pain control.⁶ Another issue that is still being evaluated clinically is the demonstrated effects of opioids causing dose-related inhibition of natural killer cells, which can theoretically increase propagation of cancer cells
allowing for quicker spread of cancer. Therefore, best practice strategies for cancer patients are being studied to determine the best recipes for oncologic surgical procedures and consequent optimal outcomes and longevity from the cancer itself.

Acute Pain

Patients with acute pain often receive poor pain control or no treatment when they visit the ED. A 4-week prospective observational study of 3000 patients was conducted to determine the efficacy of pharmacological intervention on a variety of pain intensities. It was concluded that most patients found relief upon administration of analgesics, such as nonsteroidal antiinflammatory drugs, opioids, or anesthetics. However, the reason for the constantly high prevalence of inadequate pain control is related to inaccuracy of pain reporting and understated pain intensity by nurses.⁷ In this regard, unfortunately patients in ED settings are often questioned whether their acute pain is real and if the reason for coming in for care has more to do with drug dependency issues than real pain states.

Consequences of Inadequately Controlled Pain

Every year, millions of Americans seek treatment in ED for acute pain episodes. It is estimated that pain is the most frequently reported primary symptom, attributing to 45.4% of ED visits, and most patients rate their pain as moderate to severe.⁸,⁹ Acute causes of pain can be generated by various sources, including trauma, illness, or postoperative pain.¹⁰ With the advent of the increased use of surgical interventions, acute pain management is becoming increasingly important. However, it is questionable whether pain is being properly treated.¹¹ There are many barriers to proper pain management including lack of both physician and medical student training on the topic, lack of patient education, pain medication side effects, and the subjectivity of the pain measurement scale.¹² One study showed that pain prevalence in the ED was 70.7%, and only 32.5% of those patients were given pharmacological therapy to treat the pain.⁷ Overall, this lack of pain control in the acute period can have detrimental long-term consequences for the patients.

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