Editorial Views  |   July 2007
Improving Pain Management: Are We Jumping from the Frying Pan into the Fire?
Author Affiliations & Notes
  • Paul F. White, MD, PhD
  • Henrik Kehlet, MD, PhD
  • From the *Department of Anesthesiology and Pain Management, University of TX Southwestern Medical Center at Dallas, Texas, †Section for Surgical Pathophysiology, The Juliane Marie Centre, Rigshospitalet, Copenhagen, Denmark.
Article Information
Editorial Views / Pain Medicine
Editorial Views   |   July 2007
Improving Pain Management: Are We Jumping from the Frying Pan into the Fire?
Anesthesiology 7 2007, Vol.107, 10-12. doi:10.1213/01.ane.0000268392.05157.a8
Anesthesiology 7 2007, Vol.107, 10-12. doi:10.1213/01.ane.0000268392.05157.a8
The review article by Brennan, Carr, and Cousins (1) is a laudable effort to discuss the ethical, political, cultural, and legal challenges involved in trying to improve the management of both acute and chronic pain. Unfortunately, this largely philosophical review fails to provide convincing scientific arguments to support the authors' strongly held beliefs that many physicians fail to provide adequate pain relief because of a lack of concern and/or because of misconceptions regarding the use of analgesics in the management of pain (1–3). Although there is a clear need for improved techniques for controlling acute and chronic pain, we have serious concerns about the authors' seemingly narrow focus on the alleged under-use  of opioid analgesics and their suggestion that more liberal use of opioids can solve the problem. We would strongly argue for a more balanced view when considering approaches to improving acute and chronic pain management.
Brennan et al. (1) are appropriately critical of the myths perpetuated by misinformed physicians. However, in characterizing individuals who advocate against more liberal use of opioid (narcotic) analgesics as “opioidphobic and/or opioignorant,” they demonstrate a disconcerting lack of insight into the recent literature relating to the frequent adverse effects associated with the use of opioid analgesics in the management of acute and chronic pain. Not only are opioid-related adverse drug events common in hospitalized patients, they increase the length of stay and total hospital cost (4,5). In reviewing the critical outcomes related to the use of opioids in the management of chronic noncancer pain, Eriksen et al. (6) recently concluded that long-term use of these compounds in the treatment of noncancer pain failed to improve the patients pain relief, quality of life or functional capacity. A recent study by Chu et al. (7) suggested that opioid tolerance and hyperalgesia develop within one month of initiating therapy with oral morphine in patients with chronic pain. Even short-term use of potent opioid compounds for acute pain can produce clinically significant hyperalgesia (8–10).
Brennan et al. (1) state that the “under-treatment of pain is a poor medical practice that results in many adverse effects” and “is an abrogation of a fundamental human right.” Yet, they fail to provide scientific evidence from the peer-reviewed medical literature to support many of their statements regarding the alleged benefits of more aggressive approaches to acute and chronic pain management for patients, their families and society. Interestingly, in a recent issue of Anesthesia & Analgesia  , Liu and Wu (11) performed a systematic review of the pain literature and concluded that evidence supporting improved outcomes due to better postoperative pain management is lacking. Although the methodology used by these investigators has been questioned (12), we would also strongly disagree with the conclusions of Brennan et al. (1) regarding the purported benefits of liberalizing the use of opioid analgesics in the management of pain. In fact, some clinical studies have suggested that use of large doses of opioid analgesics may contribute to increased morbidity and mortality in the acute care setting (13). Brennan et al. (1) have also completely ignored the obvious psychosocial concerns related to the “excessive use” of opioid analgesics in the management of chronic (nonmalignant) pain (6,14).
In 2000, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) introduced new standards that mandated pain assessment fifth vital sign and treatment as part of routine patient care (15,16). Most medical institutions have interpreted this mandate as requiring that treatment of pain must be guided by patient reports of pain intensity indexed to a numerical pain scale (17). After the implementation of a routine numeric pain scoring system in their postanesthesia care unit, Frasco et al. (18) reported a significant increase in the use of opioid analgesics. Vila et al. (19) recently reported that as a result of the JCAHO-mandated policy for pain management, the incidence of opioid-induced adverse reactions increased from 11 to 25 per 100,000 inpatient days at their medical center. The majority of adverse drug reactions were preceded by a documented decrease in the patient's level of consciousness due to opioid-related sedation.
The Institute for Safe Medical Practices released a report asking the question “Has safety been compromised in our noble efforts to alleviate pain?” (20). This Institute concluded that more aggressive pain management has lead to an increase in adverse events (including deaths) related to “over-sedation” and respiratory depression. Opioid-related sedation seems to be highest within the first 4 h after discharge from the postanesthesia care unit (21). Taylor et al. (22) further demonstrated that the first 24 h after surgery represents “a high-risk period for a respiratory event as a result of narcotic use.”
At a recent Anesthesia Patient Safety Foundation workshop (October, 2006) on safety concerns related to the use of patient-controlled analgesia in the postoperative period, one of the participants argued that JCAHO's emphasis on pain as “a fifth vital sign” had the unintended adverse consequence of setting patient expectations to be “no pain after surgery” and that, as a result, more patients are receiving excessive amounts of opioid analgesics (23). In our opinion, the JCAHO recommendation regarding the use of a one-dimensional pain score (e.g., an 11-point visual analog scale from 0 = none to 10 = severe pain) to insure adequate pain relief after surgical procedures is inappropriate, and cannot be reliably achieved using opioid analgesics without a high risk of adverse effects (e.g., ventilatory depression, sedation, pruritis, nausea, vomiting, constipation, urinary retention, constipation and/or ileus).
At the risk of being labeled “opioidphobic” (1), we strongly disagree with these authors' statement that there is a pressing need to “liberalize national policies on opioid availability” in the treatment of acute and chronic pain syndromes. It is gratifying that other experts in pain management are also urging caution in the use of opioids for chronic pain (24,25). The recommendation by Brennan et al. (1) that failure to alleviate pain “is negligent, a breach of human rights and professional misconduct” might well lead to increased morbidity and mortality, as well as more frequent medical legal conflicts for physicians and health care facilities. In contrast to these authors, we would encourage our colleagues in anesthesia and surgery to avoid using opioids for “maintenance” analgesic therapy in patients with chronic noncancer related pain, and use opioid-sparing analgesic techniques to improve pain management and facilitate the recovery and rehabilitation processes after surgery (26–28). The treatment should not be worse than the disease! 
Brennan F, Carr BD, Cousins MJ. Pain Management as a fundamental human right. Anesth Analg 2007;105:205–21.Brennan, F Carr, BD Cousins, MJ
Cousins MJ. Relief of acute pain: basic human right? Med J Aust 2000;172:3.Cousins, MJ
Cousins MJ, Brennan F, Carr DB. Pain relief: a universal human right. Pain 2004;112:1–4.Cousins, MJ Brennan, F Carr, DB
Philip BK, Reese PR, Burch SP. The economic impact of opioids on postoperative pain management. J Clin Anesth 2002;14: 354–64.Philip, BK Reese, PR Burch, SP
Oderda GM, Evans RS, Lloyd J, Lipman A, Chen C, Ashburn M, Burke J, Samore M. Cost of opioid-related adverse drug events in surgical patients. J Pain Symptom Manage 2003;25:276–83.Oderda, GM Evans, RS Lloyd, J Lipman, A Chen, C Ashburn, M Burke, J Samore, M
Eriksen J, Sjogren P, Bruera E, Ekholm O, Rasmussen NK. Critical issues on opioids in chronic non-cancer pain: An epidemiological study. Pain 2006;125:172–9.Eriksen, J Sjogren, P Bruera, E Ekholm, O Rasmussen, NK
Chu LF, Clark DJ, Angst MS. Opioid tolerance and hyperalgesia in chronic pain patients after one month of oral morphine therapy: a preliminary prospective study. J Pain 2006;7:43–8.Chu, LF Clark, DJ Angst, MS
Zarate E, Sa Rego MM, White PF, Duffy L, Shearer VE, Griffin JD, Whitten CW. Comparison of adenosine and remifentanil infusions as adjuvants to desflurane anesthesia. Anesthesiology 1999;90:956–63.Zarate, E Sa Rego, MM White, PF Duffy, L Shearer, VE Griffin, JD Whitten, CW
Guignard B, Bossard AE, Coste C, Sessler DI, Lebrault C, Alfonsi P, Fletcher D, Chauvin M. Acute opioid tolerance: intraoperative remifentanil increases postoperative pain and morphine requirement. Anesthesiology 2000;93:409–17.Guignard, B Bossard, AE Coste, C Sessler, DI Lebrault, C Alfonsi, P Fletcher, D Chauvin, M
Angst MS, Koppert W, Pahl I, Clark DJ, Schmelz M. Short-term infusion of the mu-opioid agonist remifentanil in humans causes hyperalgesia during withdrawal. Pain 2003;106:49–57.Angst, MS Koppert, W Pahl, I Clark, DJ Schmelz, M
Lui SS, Wu CL. Effect of postoperative analgesia on major postoperative complications: a systematic update of the evidence. Anesth Analg 2007;104:689–702.Lui, SS Wu, CL
White PF, Kehlet H. Postoperative pain management and patient outcome: time to return to work¡ Anesth Analg 2007; 104:487–9.White, PF Kehlet, H
Myles PS, Daly DJ, Djaiani G, Lee A, Cheng DC. A systematic review of the safety and effectiveness of fast-track cardiac anesthesia. Anesthesiology 2003;99:982–7.Myles, PS Daly, DJ Djaiani, G Lee, A Cheng, DC
Devulder J, Richarz U, Nataraja SH. Impact of long-term use of opioids on quality of life in patients with chronic, non-malignant pain. Curr Med Res Opin 2005;21:1555–68.Devulder, J Richarz, U Nataraja, SH
Phillips DM. JCAHO pain management standards are unveiled. JAMA 2000;284:428–9.Phillips, DM
Huang N, Cunningham F, Laurito CE, Chen C. Can we do better with postoperative pain management? Am J Surg 2001;182:440–8.Huang, N Cunningham, F Laurito, CE Chen, C
Burgess FW. Pain scores: are the numbers adding up to quality patient care and improved pain control? J Pain Med 2006;7:371–2.Burgess, FW
Frasco PE, Sprung J, Trentman TL. The impact of the joint commission for accreditation of healthcare organizations pain initiative on periooperative opiate consumption and recovery room lengths of stay. Anesth Analg 2005;100:162–8.Frasco, PE Sprung, J Trentman, TL
Vila H Jr, Smith RA, Augustyniak MJ, Nagi PA, Soto RG, Ross TW, Cantor AB, Strickland JM, Miguel RV. The efficacy and safety of pain management before and after implementation of hospital-wide pain management standards: is patient safety compromised by treatment based solely on numerical pain ratings? Anesth Analg 2005;101:474–80.Vila, H Smith, RA Augustyniak, MJ Nagi, PA Soto, RG Ross, TW Cantor, AB Strickland, JM Miguel, RV
Medication Safety Alert Pain scales don't weigh every risk. Huntington Valley, PA: Institute of Safe Medications Practices, 2002. Huntington Valley, PA Institute of Safe Medications Practices
Taylor S, Voytovich AE, Kozol RA. Has the pendulum swung too far in postoperative pain control? Am J Surg 2003;186:472–5.Taylor, S Voytovich, AE Kozol, RA
Taylor S, Kirton OC, Staff I, Kozol RA. Postoperative day one: a high risk period for respiratory events. Am J Surg 2005;190:752–6.Taylor, S Kirton, OC Staff, I Kozol, RA
Weinger MB. Dangers of postoperative opioids. APSF Newsl 2007;21:61–3.Weinger, MB
Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Engl J Med 2003;349:1943–53.Ballantyne, JC Mao, J
Ballantyne JC. Opioids for chronic pain: taking stock. Pain 2006;125:3–4.Ballantyne, JC
Kehlet H. Postoperative opioid sparing to hasten recovery: what are the issues? Anesthesiology 2005;102:1083–5.Kehlet, H
White PF. The changing role of non-opioid analgesic techniques in the management of postoperative pain. Anesth Analg 2005; 101:S5–22.White, PF
White, PF, Kehlet H, Neal JM, Schricker T, Carr DB, Carli F, Fast-track Surgery Study Group. The role of the anesthesiologist in fast-track surgery: from multimodal analgesia to perioperative medical care. Anesth Analg 2007;104:1380–96.White, PF Kehlet, H Neal, JM Schricker, T Carr, DB Carli, F Fast-track Surgery Study Group,