Pain Relief - Acute Pain from Injury or Surgery

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Pain Relief - Acute Pain from Injury or Surgery

When the pain becomes too much to bear, or is the result of a serious injury or surgery, relief requires stronger medicine and a doctor's prescription. One class of frequently prescribed pain relievers is nonsteroidal anti-inflammatory drugs, often abbreviated NSAIDs. (The three nonprescription pain relievers are also NSAIDs, according to Love, although acetaminophen is not commonly referred to by that term.)

Prescription NSAIDs are given at higher doses than the nonprescription types, but the mechanism for pain relief is the same--blocking the production of prostaglandins. (For more information on NSAIDs, see "How to Take Your Medicine: Nonsteroidal Anti-Inflammatory Drugs" in the June 1990 FDA Consumer.)

Opiate drugs are another class of pain-relieving prescription drugs. Commonly prescribed opiates include morphine, codeine, hydromorphone (Dilaudid), and meperidine (Demerol). (In some states, some forms of codeine are sold without a prescription in limited amounts.) Most of these drugs are derived from opium, the juice of the poppy flower.

Opiate drugs work by altering the transmission of pain messages in the brain and spinal cord, blocking pain messages or altering their character. The pain-blocking action of the opiates can be enhanced by taking aspirin, ibuprofen or acetaminophen at the same time as the opiate. This hits pain with a "double-whammy." The NSAIDS block the pain at the site of injury, while the opiates suppress in the brain any remaining pain.

Unfortunately, the effect of opiates on the brain isn't limited to pain control. Opiates can cause drowsiness, nausea, constipation, and unpleasant mood changes in some people. However, sometimes simply trying a different opiate may be all that's needed to reduce these side effects.

Tolerance and Addiction

Because doctors are afraid patients may become dependent on opiate drugs, they sometimes hold back on the amount or number of doses, even if this means the patient doesn't get sufficient pain relief. Ronald Dubner, D.D.S., chief of the Neurobiology and Anesthesiology Branch of the National Institute of Dental Research, says those fears are unfounded. But, he explains, "One needs to be very clear about making the distinction between tolerance and addiction."

Tolerance occurs when the body no longer responds as well to the opiate's pain-relieving properties at the current dose. For example, some cancer patients with severe pain may need increasing amounts of morphine to maintain the same level of pain relief. Addiction, on the other hand, is an overwhelming compulsion to continue use of the drug even when pain relief is no longer needed. While some of the addiction is physical, it is mainly considered a psychological dependence that has a detrimental effect not only on the individual, but also on society, because the addicted individual may have to obtain the drug illegally.

Addiction is "really a red herring in the field of pain control," says Dubner. The fear that giving patients opiates will turn them into addicts craving the drugs long after the pain has ended is unfounded, says Dubner. "People who are truly seeking help for their pain and who are in good hands do not have addiction problems," he explains.

In any case, Dubner says, it is very rare for a patient to reach a point where no amount of an opiate will relieve pain and that should never be used as a reason for not increasing the drug's dose. Anesthesiologist Francis Balestrieri agrees. "There's no reason to hold back the drug dose for people in acute pain," says Balestrieri, who is the director of the Woodburn Surgery Center at Fairfax Hospital in Falls Church, Va. However, FDA's Curtis Wright, M.D., warns that the pain relief from higher doses of opiates must be weighed against the side effects these drugs can cause. "It's a balancing act," says Wright, who is a medical review officer for the agency's center for drug evaluation and research. "The amount of pain relief must be weighed against the effects of adverse reactions such as agitation, nausea, confusion, and potentially lethal respiratory depression."

Patients in Control

Frequently, however, the doses of narcotics physicians prescribe are too low, not too high, and the time between doses is too long, according to a book by Barry Stimmel, M.D., Pain, Analgesia, and Addiction: The Pharmacologic Treatment of Pain. Stimmel writes that, "Analgesic medications should be prescribed regularly around the clock in the presence of acute pain. The intervals between administration should be sufficiently close together to avoid swings in pain levels. Both laboratory and clinical studies have shown that the presence of anxiety will result in an increased need for narcotics, thus setting up a vicious cycle whereby escalating doses of analgesics are needed, without adequate pain relief being obtained." The use of analgesics provides more benefits to the patient than just relieving pain.

"Evidence from laboratory experiments has begun to accumulate showing that pain can accelerate the growth of tumors and increase mortality after tumor challenge," writes John C. Liebeskind in an editorial in the January 1991 issue of pain. "It appears that the dictum 'pain does not kill,' sometimes invoked to justify ignoring pain complaints, may be dangerously wrong." Dubner agrees. "Pain is not a passive symptom. We consider pain, in many instances, an aggressive disease in itself. Therefore it becomes very, very critical to control pain as rapidly and as completely as possible."

One solution to inadequate doses of pain relievers is patient-controlled intravenous analgesia (PCA), which is usually used in hospitals for acute pain following surgery. In PCA, the patient is connected to a machine called a PCA pump. When the patient pushes a control button, the machine delivers a dose of narcotic or other pain reliever intravenously. The doses are smaller than what would be given by injection, but because the drug goes directly into the bloodstream, relief can occur within seconds. A patient receiving traditional administration with an injection in the muscle or under the skin, may have to wait anywhere from 5 to 30 minutes for pain relief. Although the pain relief with PCA's small doses may only last for 10 to 15 minutes, the patient can get another dose the second pain begins to return. Injections, on the other hand, may last up to two hours, but since the usual dosage schedule is three to four hours, the pain returns long before the nurse does.

"PCA matches the patients' relief to their pain," says Balestrieri. "It also relieves patients of the worry over their pain relief in the majority of cases." It also helps patients deal with the side effects opiates can cause, says FDA's Wright."A substantial portion of patients don't want complete pain relief," says Wright. "They want as much pain relief as they can get without bad side effects."

Wright says that when the first studies were done on the effectiveness of PCA, "we thought that the pain scores [the patients gave] would be zero." (Patients generally rated pain on a four-point scale with four being the greatest amount of pain and zero, no pain.) "What we found was that patients didn't titrate down to zero, but instead brought the pain down to one or two," he says.

The undesirable side effects of narcotics can be avoided completely with another form of continuous administration--epidural therapy. Epidurals, which inject the narcotics into the membrane surrounding the spinal cord, have been used for many years to block the pain of labor. Now this is being adapted to control pain after some major surgery, especially abdominal. Drugs injected into the epidural space don't travel to the brain like other types of injections, explains Sherry Fisher, R.N., pain management coordinator at Fairfax Hospital. Therefore, complications such as nausea and respiratory depression don't occur.

With epidurals "patients can talk to me, take deep breaths, cough, and even be up and walking around, sometimes 24 hours after surgery," says Fisher. Normally, after the type of major surgery that requires the kind of pain control epidural therapy provides, "the patient would still be on a ventilator after 24 hours," she says.

However, epidurals aren't effective for every type of pain. Besides pain from abdominal surgeries, epidurals are best used for pain following major chest and urologic surgery, according to Fisher. No matter what the form of administration, "I don't think people should be exposed to any more pain than they're willing to tolerate," says Dubner.

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