Poorly controlled postoperative pain: prevalence, consequences, and prevention

Abstract

This review provides an overview of the clinical issue of poorly controlled postoperative pain and therapeutic approaches that may help to address this common unresolved health-care challenge. Postoperative pain is not adequately managed in greater than 80% of patients in the US, although rates vary depending on such factors as type of surgery performed, analgesic/anesthetic intervention used, and time elapsed after surgery. Poorly controlled acute postoperative pain is associated with increased morbidity, functional and quality-of-life impairment, delayed recovery time, prolonged duration of opioid use, and higher health-care costs. In addition, the presence and intensity of acute pain during or after surgery is predictive of the development of chronic pain. More effective analgesic/anesthetic measures in the perioperative period are needed to prevent the progression to persistent pain. Although clinical findings are inconsistent, some studies of local anesthetics and nonopioid analgesics have suggested potential benefits as preventive interventions. Conventional opioids remain the standard of care for the management of acute postoperative pain; however, the risk of opioid-related adverse events can limit optimal dosing for analgesia, leading to poorly controlled acute postoperative pain. Several new opioids have been developed that modulate μ-receptor activity by selectively engaging intracellular pathways associated with analgesia and not those associated with adverse events, creating a wider therapeutic window than unselective conventional opioids. In clinical studies, oliceridine (TRV130), a novel μ-receptor G-protein pathway-selective modulator, produced rapid postoperative analgesia with reduced prevalence of adverse events versus morphine.

Keywords: acute pain; analgesics; chronic pain; opioid; surgical procedures.

Figure 1

Proportion of patients with postoperative pain in inpatient and outpatient settings by pain severity. Note: Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey. Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL.Current Medical Research and Opinion. Jan 2014. Reprinted by permission of the publisher (Taylor & Francis Ltd, http://www.tandfonline.com).

Figure 2

Incidence of chronic pain at 4, 12, and 24 months after surgery. Note: Reprinted with permission from Montes A, Roca G, Sabate S, et al., Genetic and Clinical Factors Associated with Chronic Postsurgical Pain after Hernia Repair, Hysterectomy, and Thoracotomy: A Two-year Multicenter Cohort Study. Anesthesiology. 122(5):1123–41. http://anesthesiology.pubs.asahq.org/Article.aspx?articleid=2135169.