Tyranny of the pain score question after surgery
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* Vivian C. McAlister

Some surgeons are concerned that their efforts for the patient to have a good experience of surgery may be subverted in the post–anesthesia care unit (PACU). Once the patient is awake and extubated, I usually assist in their transfer to the stretcher. While they are being covered with a warm blanket, I ask if they enjoyed the operation, confirming that it went well. My purpose is to counter the effect of the question that will dominate their experience of the PACU: “What is your pain, out of 10?” I don’t know of any business that greets their customers with a query about the level of their dissatisfaction. Imagine then, my reply when I found myself waking up from an anesthetic, with a strange face looking down on me, asking loudly the dreaded question.

Only recently did I discover the reason why the “pain out of 10” question is so resistant to modification. In 2000, lobbying by the American Pain Society (APS) succeeded in having the pain score included in the initial postoperative check demanded by the Joint Commission for Accreditation of Healthcare Organizations, which certifies hospitals in the United States.1 Physicians specializing in pain management were concerned that pain was undertreated; their campaign conflated chronic pain with postoperative pain. The APS said that the new, stronger opiates would deal with the pain without a risk of addiction, and we moved from meperidine and codeine to fentanyl and oxycodone to treat the same conditions, without an apparent improvement.2

The Canadian Pain Society (CPS) is continuing this campaign. Activists lobbied the Senate in 2004 for the first week of November to be designated National Pain Awareness Week. The examples used to convince the politicians all concerned chronic conditions.3 Purdue Pharma (Canada) promoted National Pain Awareness Week with a news release that highlighted chronic pain.4 The news release referred to a CPS fact sheet.5 It is not clear who wrote the “Pain in Canada” fact sheet. Its first four bullets highlight dissatisfaction with postoperative surgical care, including the following claims: “Although we have the knowledge and technology, Canadians are left in pain after surgery, even in our top hospitals”; “Only 30% of ordered medication is given, 50% of patients are left in moderate to severe pain after surgery and the situation is not improving”; and “Acute postoperative pain is followed by persistent pain in 10%–50% of individuals after common surgical procedures (groin hernia repair, breast and thoracic surgery).”5

Drug companies in the United States and Canada have used national pain societies, nursing organizations and regulators to promote their message that opiates are underprescribed. Despite a string of lawsuits regarding their marketing practices that have resulted in fines and settlements totalling more than $600 million,6 companies continue to profit from long-acting super-opioids, such as OxyContin, to the tune of approximately $30 billion a year. Dr. David Kessler, who was the US Food and Drug Administration (FDA) commissioner when OxyContin was approved, now believes its approval was a mistake.7 It is with trepidation, therefore, that we welcome their approval of sublingual sufentanil, a drug with 500 times the potency of morphine.

In the current opioid crisis, many examples of dependence are believed to have started with the intended short-term use of opioids after surgery or trauma. In addition, unused prescribed opioids are considered to be a significant source of inappropriate access. Surgeons are not unaware of the problem. Several studies have looked at ways to limit opioid use after surgery. Mitchell and colleagues8 of Halifax have shown that a nonsteroidal anti-inflammatory drug (NSAID) is equivalent to codeine when used with acetaminophen after general surgery. Hartford and colleagues9 of London encouraged patients to take acetaminophen and an NSAID after outpatient surgery, giving them a prescription for a short course of tramadol, to be filled for breakthrough pain. Less than 30% of the patients filled the prescription, and many of them used only a few pills. These studies strongly suggest that overprescription of opioids after surgery is a problem.

There are lessons available to us from the military. The road to mental readiness program of the Canadian Armed Forces is designed to build resilience against operational stress by anticipating the conditions of deployment and controlling expectations.10 We could modify this program to prepare our patients for surgery. Total absence of postoperative pain is not a realistic expectation. Rather, understanding expected discomfort and knowing countermeasures will permit patients to recover with minimal use of opioids. Unnecessary restrictions regarding exercise and lifting give the impression of fragility and cause anxiety. Patients can be reassured if they understand what is unexpected pain after surgery and have easy access to return to hospital.

I had a benign tumour expertly removed from the spinal canal, requiring a spinal fusion. The anesthesia, surgery and nursing teams were so good that I used the experience to learn how to improve care that I give. I was determined to be a patient and not use medical knowledge or access for special favour. I had not anticipated that I would have to rate my pain out of 10 within moments of waking up from the operation. I considered the matter quickly and broke my vow not to use my knowledge of postoperative care. I answered “zero.” Acetaminophen and ibuprofen were sufficient to allow a speedy and enjoyable recovery.

## Footnotes

*   The views expressed in this editorial are those of the author and do not necessarily reflect the position of the Canadian Medical Association or its subsidiaries.

*   **Competing interests:** None declared.

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