Acute Pain Management PDF Free Download
It is a delight and an honor to be asked to write the foreword for this text on acute pain management.We have an impressive array of different options for acute pain management (Figure F.1), and not all of them were available in the late 1970s. As a simple example of the improvement in knowledge, compare the analgesic efficacy work ofMoertel and colleagues1 with that available to us now (Figure F.2). We can use these league tables of relative efficacy to say with some authority how well on average the different analgesics compare. This leaves us, of course, with the real-world issues of, for example, how the individual patient will react, prior experience, and drug-drug interactions. Yet, we have the continued embarrassment of surveys that show that a substantial number of patients still endure severe pain after their surgery or trauma. This “unmet need” is a mixture of our failure to implement effective analgesic strategies and the inadequacy of those strategies. Acute pain teams date back to the early 1980s, and their policies and education of both patients and caregivers have made a difference. There is little excuse now for the failure to provide adequate analgesia for straightforward cases, but we need to acknowledge that there are also difficult cases. Many of the patients whose care causes problems for the teams seem, locally for us at least, to be the patients with chronic pain problems who are already on substantial analgesic therapy (e.g., chronic gastrointestinal disease) or substance abusers. Things the teams can do well include the education and patient advocacy roles within the institution.Things they may struggle with include changing behavior and provision of seamless care across nights and weekends. Since the late 1990s there has been a flurry of interest in the extent to which acute pain can become chronic pain and how we might reduce the incidence of such chronicity. Perhaps the most important thing this foreword points out is the sheer scale of the problem. From the chronic pain perspective, it appears now that surgery may be the most common cause of nerve damage pain and should perhaps be something that patients are warned about as a possibility in the consenting process. Mechanistically, one can ask what happens to cause this surgical pain to become chronic. I have always been skeptical that there is some psychological factor, pejoratively some weakness, that causes some patients to have the problem and others not. As an example, take a patient who had an inguinal herniorrhaphy 3 years ago: the procedure was performed perfectly and result was perfect. This year he had the other side done, and the same procedure was performed by the same surgeon. The patient described very severe postoperative pain, qualitatively and quantitatively quite different from the first operation, and this severe pain persisted. Something happened to cause the pain, and one cannot invoke a psychological explanation because of the perfect result the first time. What can we do about this?We still have no strong evidence that analgesia delivered before the pain does anything radically different from the same analgesia given after the pain, let alone that it preempts the development of this type of chronicity. It may be that unexpected severe pain is a red flag, but that is not easy to spot given the huge variations in pain intensity experienced after a given procedure. But it might be something we could pursue. Teasing apart precisely what happens during surgery would be another approach.
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