What Is the Problem?

Definition and Impact

Acute pain is awareness of noxious signaling from recently damaged tissue, complicated by sensitization in the periphery
and within the central nervous system (CNS). Its intensity changes with inflammatory processes, tissue healing, and
movement. The rate at which acute pain resolves is one of its key features [3]. Pain by definition is subjective, but for acute
pain the underlying physiological processes involving sensory and autonomic nervous systems, circulating catecholamines
and other stress hormones, and inflammatory responses are key. The inflammatory response to acute tissue injury
sensitizes nociceptors near the injury and sensitizes CNS pathways that process noxious signals.

In nature, acute pain signals tissue trauma, and sensitization inhibits normal behavior in a protective manner to minimize
risk and promote tissue healing. Although unpleasant, acute pain promotes survival. In controlled medical settings such as
recovery from surgery or during invasive procedures, acute pain rarely serves a useful purpose and can prove deleterious.

Individuals vary markedly in the intensity of their pain in response to an identical procedure, injury, or noxious condition.
Genetics, epigenetics, gender, and personal history all contribute to differences in pain sensitivity. Other factors that
enhance individual differences are type of wound or painful condition, phase of wound healing, preexisting stress
responses, comorbidities, and in some cases, age. Marked individual variation also exists in the body’s handling of and
responses to analgesic medications. Psychological factors such as expectations, depression, and anxiety or fear can
exacerbate pain intensity and duration. Personal belief systems and the individual meaning of the painful condition or event
can exacerbate pain. Patients who exaggerate the negative aspects or impact of their injury or situation (“catastrophize”)
may experience more severe pain than others. Cultural background or context can also affect pain severity and expression.

Table 1: Examples of acute pain

Postoperative pain
Trauma, burns, or other injuries and conditions that require emergency department visits
Sports injuries
Overuse injuries and strains
Oral mucositis in cancer patients who undergo head and neck irradiation
Chemotherapy-induced peripheral neuropathy in cancer patients
Diagnostic procedures such as biopsies
Labor and childbirth
Acute headaches
Menstrual cramps
Toothaches

Scope of the Problem

In the United States alone, more than 46 million inpatient and 53 million outpatient surgeries take place annually. Over 80%
of patients who undergo surgery in the United States report postoperative pain [1]. Of these patients, 86% state that the
pain is moderate, severe, or extreme. Most of these patients report worse pain control after discharge from hospital.
Differences exist across countries.

Pain is the most frequent reason why patients visit an emergency department (ED) [8], accounting for over 70% of ED
visits. More than 115 million ED visits occur each year in the United States, and acute headache alone accounts for 2.1
million of these visits [4]. Acute pain is also a common problem in family practice, sports medicine, and especially in
internal medicine.
Despite substantial advances in pain research in recent decades, inadequate acute pain control is still more the rule than
the exception. Numerous studies show that fewer than half of postoperative patients receive adequate pain relief [2].
Patients presenting to the ED with significantly painful conditions fare no better. A large study in the United States revealed
that the median pain score for ED patients was 8 out of 10, and at discharge the median score was 6. About 41% of
patients reported that their acute pain did not change or increased after the ED visit, and almost three quarters reported
moderate or severe pain at discharge [7]. Emergency medicine physicians tend to underuse pain medications.

Consequences of Poorly Managed Acute Pain

Uncontrolled acute pain leads to more than just discomfort. Table 2 illustrates that acute pain has many negative
consequences for the patient, for the clinicians managing the patient, and for those who manage the hospital or clinic that
deals with acute pain. Poor pain management puts patients at risk, creates needless suffering, and increases costs of care.

Table 2: Impact of uncontrolled acute pain

Clinical Perspective
Delayed wound healing due to increased sympathetic tone
Increased rate of anastomotic insufficiency
Increased risk of pulmonary morbidity, including pneumonia due to pain-impaired breathing
Increased risk of thrombosis
Increased mortality risk
Sustained hyperadrenergic stress response with hypertension
Patient Perspective
Needless suffering
Poor sleep
Urinary retention
Limited mobility or breathing and low patient autonomy
Fear and anxiety
Unnecessary partial or total disability with lost work productivity
Slower than necessary recovery of normal function and lifestyle
Reduced quality of life during recovery
Administrative Perspective
Increased length of stay in the intensive care unit or hospital
Higher rates of complication and associated costs
Increased risk of chronic pain development with consequent health care costs
Implication that poor pain control means poor quality of care

The Financial Burden of Poorly Managed Acute Pain

Uncontrolled acute pain results in extended hospital stays following surgery. In 2010, the average U.S. hospital day costs
$2129. If only 20 million U.S. surgery patients stay one extra day in hospital due to poorly managed postoperative pain in
2010, the cost amounts to $42,580,000,000. Other costs include the complications listed in Table 2 and delayed
mobilization of patients after surgery or injury. Slower recovery due to pain means more days of lost work productivity.
Poorly managed acute pain generates unnecessary partial or total disability.

Acute pain often evolves into chronic pain. Persistent pain follows acute postoperative pain in 10–50% of patients who
undergo common surgical procedures [5,6]. Severe chronic pain develops in 2–20% of these patients. Emerging evidence
suggests that poorly controlled acute postoperative pain is a cause of chronic postoperative pain.

References
[1] Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain
continues to be undermanaged. Anesth Analg 2003;97:534–40.
[2] Benhamou D, Berti M, Brodner G, De Andres J, Draisci G, Moreno-Azcoita M, Neugebauer EA, Schwenk W, Torres LM, Viel E.
Postoperative Analgesic THerapy Observational Survey (PATHOS): a practice pattern study in 7 Central/Southern European
countries. Pain 2008;136:134–41.
[3] Chapman, CR, Donaldson GW, Davis JJ, Bradshaw DH. Improving individual measurement of postoperative pain: the pain trajectory.
J Pain; in press.
[4] Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW; American College of Emergency Physicians. Clinical policy: critical
issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann
Emerg Med 2008;52:407–36.
[5] Kehlet H, Jensen TS, Woolf CJ. Persistent surgical pain: risk factors and prevention. Lancet 2006;367:1618–25.
[6] Hinrichs-Rocker A, Schulz K, Järvinen I, Lefering R, Simanski C, Neugebauer EA. Psychosocial predictors and correlates for chronic
post-surgical pain (CPSP): a systematic review Eur. J Pain 2009;13:719–30.
[7] Todd KH, Ducharme J, Choiniere M, Crandall CS, Fosnocht DE, Homel P, Tanabe P; PEMI Study Group. Pain in the emergency
department: results of the pain and emergency medicine initiative (PEMI) multicenter study. J Pain 2007;8:460–6.
[8] Todd KH, Miner JR. Pain in the emergency room. In: Fishman SM, Ballantyne JC, Rathmell JP, editors. Bonica’s management of
pain, 4th edition. Lippincott, Williams and Wilkins; 2010. p 1576–87.
[9] Yaksh TL. Physiologic and pharmacologic substrates of nociception after tissue and nerve injury. In: Cousins MJ, Carr DB, Horlocker
TT, Bridenbaugh PO, editors. Cousins & Bridenbaugh’s neural blockade in clinical anesthesia and pain medicine. Philadelphia:
Wolters Kluwer/Lippincott Williams & Wilkins; 2009. p 693–751.

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© 2010 International Association for the Study of Pain
Interventions: Benefits and Barriers
Benefits of Good Acute Pain Management
Effective prevention or relief of acute pain is cost-effective. Table 1 lists some of the benefits that accrue to institutions that
achieve good pain control. There are no compelling reasons to defend the gap that exists between existing knowledge and
technology for acute pain control and current practice patterns.

Table 1: Benefits of effective acute pain management for institutions

Earlier discharge from intensive care unit or hospital
Lower use of health care resources
Fewer complications that require physician time and health care resources
More efficient use of nursing resources and time
Better patient satisfaction with the hospital, stronger marketing, improved hospital reputation
Reduced costs to insurance providers or other payers
Fewer acute pain patients developing chronic pain syndromes from their persistent acute pain
Fewer days of disability and lost work productivity

Interventions for Acute Pain

Regional anesthesia targets noxious signaling, anti-inflammatory medications target inflammation and related sensitization,
and spinal medications target central sensitization. Opioids target endogenous pain modulation processes. Other agents
such as anticonvulsants influence acute pain by diverse mechanisms. In postoperative settings, many acute pain
management specialists combine several interventions for “multimodal analgesia.” Table 2 lists interventions for
postoperative and other acute pain control.

Table 2: Interventions for acute pain prevention and relief

Preoperative Setup and Treatments for Surgery and Procedures
Patient information and empowerment
Minimally invasive techniques, adequate positioning of patients in the operating room
Medication or nerve blocks prior to surgical incision
Systemic Analgesics
Opioids and intravenous patient controlled analgesia (PCA)
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Ketamine and other agents directed at excitatory amino acids
Anticonvulsants
Alpha-adrenergic medications
Regional Analgesic Techniques
Continuous epidural analgesia
Single-dose neuraxial opioids
Patient-controlled epidural analgesia
Peripheral regional analgesia
Nonpharmacological Interventions
Heat and cold
Massage and stretching
Transcutaneous electrical nerve stimulation
Acupuncture-related therapies
Barriers to Better Acute Pain Management
No one wishes patients to suffer needlessly, and the means for controlling acute pain are readily available. Surgeons
consider acute pain highly relevant to their daily practice and also to their patients [2]. Yet more than half of all patients still
experience severe postoperative pain. Old attitudes dominate daily practice, with clinicians assuming that acute pain is
harmless and inevitable, and patients not knowing that they have a right to effective pain relief. More than half of all
hospitals in Europe have no written guidelines or protocols for pain management [1]. More than half treat pain only when
patients complain. There is a tendency not to accept at face value the pain intensities that patients express. In most
hospitals and practice settings pain assessment and pain therapies are either unknown or not applied.

Organizational Problems Sustain Many Acute Pain Management Deficiencies

Among these problems are:
• Provider and administrator ignorance of the problem and lack of proper pain management protocols;
• Educational deficits in pain management for health care providers: physicians, nurses, physical therapists,
pharmacists;
• Insufficient patient education about pain and the right to pain prevention;
• The complexity of acute pain and its relief;
• Lack of acute pain assessment and documentation (outside of developed countries);
• The belief that acute pain is not important, it will resolve with time, and patients will quickly forget about it;
• Lack of interdisciplinary exchange about pain management concepts and responsibilities.
References
[1] Benhamou D, Berti M, Brodner G, De Andres J, Draisci G, Moreno-Azcoita M, Neugebauer EA, Schwenk W, Torres LM, Viel E.
Postoperative Analgesic THerapy Observational Survey (PATHOS): a practice pattern study in 7 Central/Southern European
countries. Pain 2008;136:134–41.
[2] Neugebauer E, Hempel K, Sauerland S, Lempa M, Koch G. [The status of perioperative treatment of pain in Germany. Results of a
representative and anonymous survey of 1,000 surgical clinics. Chirurg 1998;69:461–6.

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© 2010 International Association for the Study of Pain
Mechanisms of Acute Pain
Introduction
Patients with surgery, injury, childbirth, and acute illness experience pain caused by damage to a variety of tissues.
Commonly injured tissues include skin, muscle, bone, tendons, ligaments, and visceral organs. Symptoms vary depending
upon the type of tissue injured and the extent of the injury. Sensory pathways for pain caused by tissue damage transmit
information from the damaged tissue to the central nervous system (CNS).

Nociceptor Activation, Sensitization, and Hyperalgesia in Acute Pain

• Nociceptors are sensory receptors that respond to tissue damage. Nociceptors respond during and after acute
events such as surgery, injury, childbirth, and acute illness [3].
• Nociceptors have unique response properties that depend on the organ that they innervate. These unique
properties, in part, provide the basis for differences in clinical acute pain states after different organ injuries.
• Sensitization is a characteristic of nociceptors in which responses to stimuli are enhanced at the site of injury [3].
• Nociceptor sensitization produces primary hyperalgesia at the site of injury, which generates ongoing pain at rest
and enhanced pain during and after surgery, injury, childbirth, and acute illness [2,4].

Mediators of Nociceptor Activation and Sensitization in Acutely Injured Tissue

• Substances that are released during acute injury and cause acute pain are not entirely known.
• Prostaglandins released by tissue trauma sensitize nociceptors [1].
• Other mediators of nociceptor activation and sensitization include nerve growth factor, which is increased in
incisions and also sensitizes nociceptors [1].
• Additional factors thought to contribute to acute pain are acidity, interleukins, and cytokines.
• In some cases, nerves may be directly injured and become activated.
Central Sensitization and Acute Pain
• Nociceptive input during and after surgery, injury, childbirth, and acute illness can enhance the responses of pain-
transmitting neurons in the CNS, amplifying clinical pain [5].
• Increased responsiveness of nociceptive neurons in the CNS to normal or subthreshold afferent input is termed
“central sensitization” [3].
• The magnitude of central sensitization depends on many factors, including the type tissue and the extent of the
injury.
• Central sensitization amplifies transmission of input from peripheral tissues and produces secondary hyperalgesia,
an increased pain response evoked by stimuli applied to tissue outside the area of injury [2].
• Central sensitization is expressed in a variety of other forms that include both spinal and supraspinal mechanisms.
References
[1] Carvalho B, Clark DJ, Angst MS. Local and systemic release of cytokines, nerve growth factor, prostaglandin E2, and substance P in
incisional wounds and serum following cesarean delivery. J Pain 2008;9:650–7.
[2] Dahl JB, Kehlet H. Postoperative pain and its management. In: McMahon SB, Koltzenburg M, editors. Wall and Melzack’s textbook of
pain. Elsevier Churchill Livingstone; 2006. p 635–51.
[3] Loeser JD, Treede RD. The Kyoto protocol of IASP basic pain terminology. Pain 2008;137: 473–7.
[4] Pogatzki EM, Gebhart GF, Brennan TJ. Characterization of A-delta- and C-fibers innervating the plantar rat hindpaw one day after an
incision. J Neurophysiol 2002;87:721–31.
[5] Vandermeulen EP, Brennan TJ. Alterations in ascending dorsal horn neurons by a surgical incision in the rat foot. Anesthesiology
2000;93:1294–302.

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© 2010 International Association for the Study of Pain
Acute Pain Medicine: Where Is the Evidence?
Introduction
Evidence supporting acute pain medicine has increased greatly over the last two decades. Knowledge of the physiology and
psychology of acute pain has progressed substantially, methods for acute pain measurement have improved, new drugs and
techniques for acute pain have emerged, and acute pain relief has advanced in numerous clinical situations including
postoperative pain, trauma, burn pain, spinal cord injury, back pain, and acute medical conditions. In addition, the need for
acute pain management has gained recognition in a variety of clinical settings, especially postoperative care, intensive care
units, emergency departments, and prehospital care. With this development, the needs of specific patient populations have
attracted attention—pediatric and elderly patients, pregnant patients, cognitively compromised patients, those with renal or
hepatic disease, and opioid-tolerant patients.

Not only has the quantity of evidence increased, but the quality of that evidence has improved and the scope of the evidence
available has broadened. Practice in acute pain medicine now extends well beyond the management of postoperative pain.
In addition, emphasis has shifted to outcomes that go beyond good pain relief, such as decreases in postoperative morbidity
and reductions in the risk of developing chronic pain after surgery, injury, or an acute medical condition.

Assistance in accessing the evidence

A body of published evidence cannot guide clinical practice unless it is organized, synthesized, and current. Given the
rapidly increasing volume of studies now available on acute pain, extracting knowledge from evidence poses a formidable
challenge. Fortunately, numerous tools exist to facilitate this undertaking, including systematic reviews, evidence summaries,
clinical practice guidelines, and analgesic “league” tables.
• Quantitative systematic reviews (meta-analyses) are the “best” level of evidence available. The most
comprehensive source of systematic reviews related to specific acute pain treatments is the Cochrane Library [2].
• Clinical practice guidelines provide specific evidence-based guides to treatment. Such guidelines may address
specific pain conditions such as postoperative or other trauma-induced pain, back pain, or migraine headache,
patient groups with different needs, or specific settings. Examples are given in Table 1.

Table 1
Group Guidelines Website
PROSPECT Procedure-specific postoperative pain www.postoppain.org/frameset.htm
management
European Society of Regional Anaesthesia and Postoperative pain management: good www.esraeurope.org/PostoperativePainManagement.pdf
Pain Therapy clinical practice
Arbeitsgemeinschaft der Wissenschaftlichen Behandlung akuter perioperativer und www.uni-duesseldorf.de/awmf/ll/
Medizinischen Fachgesellschaften (AWMF) posttraumatischer Schmerzen
(Association of the Scientific Medical Societies (Guidelines on acute perioperative and
in Germany); Deutsche Interdisziplinäre post-traumatic pain) [in German]
Vereinigung für Schmerztherapie (DIVS)
(German Interdisciplinary Association for Pain
Therapy), Germany
Association of Paediatric Anaesthetists, United Good practice in postoperative and www.britishpainsociety.org/book_apa_part1.pdf
Kingdom procedural pain (2008) www.britishpainsociety.org/book_apa_part2.pdf
Society for Anaesthesiology, Analgesia, Postoperative pain treatment SIAARTI www.minervamedica.it/en/journals/minerva-
Reanimation and Intensive Care (SIAARTI), recommendations 2010. Short version anestesiologica/article.php?cod=R02Y2010N08A0657
Italy (2010)
American Academy of Pediatrics Committee on Prevention and management of pain in http://aappolicy.aappublications.org/cgi/content/abstract/
Fetus and Newborn, American Academy of the neonate: an update (2010) pediatrics;118/5/2231
Pediatrics Section on Surgery, Canadian
Paediatric Society Fetus and Newborn
Committee
American Society of Anesthesiologists Practice guidelines for acute pain www2.asahq.org/publications/pc-115-4-practice-
management in the perioperative guidelines-for-acute-pain-management-in-the-
setting perioperative-setting.aspx
• Comprehensive evidence summaries provide an up-to-date and general review of the “best available” evidence for the
management of acute pain from many different etiologies, particularly postsurgical and post-traumatic causes including
spinal injury and burns, as well as acute pain associated with various conditions such as migraine headache, herpes
zoster, hematological disorders, or cancer. Evidence summaries also review and condense specific evidence on a given
drug, analgesic technique, or pain condition. They also facilitate extrapolation of good evidence from one setting to
another where specific high-quality evidence is lacking. Examples include extrapolation of evidence from animal to
human, laboratory to clinical, or acute pain to chronic pain contexts. One example of a comprehensive evidence
summary is Acute Pain Management: Scientific Evidence published by the Australian and New Zealand College of
Anaesthetists and Faculty of Pain Medicine [3]. This document is not a clinical guideline.
• Analgesic league tables summarize evidence from randomized, double blind, single dose studies of individual drugs
compared with placebo given to patients with moderate to severe pain [1]. These tables show the number needed to
treat (NNT) for each drug. The NNT is the number of patients who must receive the active drug in order to achieve at
least 50% pain relief in one patient over a 4- to 6-hour treatment period, compared with a placebo. Interpretation of such
results requires caution.

Applying evidence in clinical practice

“Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about
the care of individual patients”
“Good doctors and health professionals use both individual clinical expertise and the best available external evidence, and
neither alone is enough” [4].

While the best available evidence can and should guide the management of acute pain, current evidence has limited quality,
applicability, and generalizability. Clinical trials focus on the means of patient samples, but practicing clinicians treat one
patient at a time. Few patients approximate the mean of a sample, and individual variation is substantial. Clinicians must
take into account the factors that are unique to each case as well as the published evidence when managing acute pain.

References
[1] Bandolier. Oxford league table of analgesics in acute pain. 2007. Available at:
http://www.medicine.ox.ac.uk/bandolier/booth/painpag/Acutrev/Analgesics/Leagtab.html.
[2] Cochrane Collaboration. Cochrane library. Available at: http://www.thecochranelibrary.com/view/0/index.html.
[3] Macintyre PE, Scott DA, Schug SA, Visser EJ, Walker SM. Acute pain management: scientific evidence, 3rd edition. Melbourne:
Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine; 2010. Available at:
http://www.anzca.edu.au/fpm/resources/books-and-publications.
[4] Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ
1996;312:71–2. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2349778/.

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© 2010 International Association for the Study of Pain
Why the Gaps between Evidence and Practice?
Ample evidence summarized in companion fact sheets shows that optimal treatment of acute pain:
• Improves patients’ quality of life and satisfaction with care;
• Reduces the risk of many complications (e.g., venous thrombosis);
• Permits earlier discharge;
• Facilitates recovery through multiple mechanisms (e.g., reduced stress response);
• Can enhance clinical resource management (e.g., minimize disruptions to the smooth flow of patient care) and
reduce short- and long-term costs of care.

Substantial high-quality evidence attests to the efficacy of multiple classes of medications and modes of their delivery
(including regional anesthesia) and nondrug techniques for patients with acute pain from surgery, injury, or medical illness.
Evidence also points to the importance of individualized care and consideration of the clinical context (e.g., available
resources).

However, abundant evidence also indicates widespread underassessment and undertreatment of acute pain, and failure to
provide proactive pain plans [8]. Gaps between evidence and practice are of several types. Some reflect general barriers to
the implementation of evidence-based and outcomes-driven practice [3,9]. Another type of mismatch between evidence
and practice is the uniform, rigid application of population-based evidence, such as a large randomized controlled trial
(RCT), to individual patients without taking into account their variability, their preferences, or specifics of the clinical context
[4]. Other barriers of particular relevance to optimal acute pain management reflect failure to address long-standing,
prevalent myths about acute pain and the importance of its control [8,12].

Gaps in the quality of pain care delivery reflect:

• Problems related to health care professionals;
• Problems related to patients;
• Problems related to the health care system.
Problems related to health care professionals include:
• Out-of-date or inadequate attitudes and knowledge, e.g., mistaken ideas that:
o Postoperative pain control interferes with prompt recognition of surgical complications;
o Surgery has to be associated with pain;
o Patients who speak up about pain are fussy.
• National differences with respect to professional societies’ differences in interpreting the evidence
• “Clinical inertia” [10], i.e., slowness to update individual practice in light of evolving evidence [1];
• Inadequate staffing of an acute pain service, resulting in ad hoc efforts oriented toward treating pain rather than
preventing it systematically [9,11];
• Incomplete, sporadic, or nonstandard pain assessment;
• Opiophobia;
• Exaggerated concerns about the side effects of pain treatment;
• Limited transferability of RCT-derived results into clinical practice.
Problems related to patients include:
• Out-of-date or mistaken ideas similar to those outlined above for health care professionals;
• Belief that “nice” patients do not complain about pain or do not show suffering (including cultural factors);
• A tendency to be satisfied with inadequate pain control, particularly when health care providers are perceived as
supportive and caring [5];
• Reluctance to take pain medications because of side effects (e.g., nausea, vomiting) and other consequences
(e.g., addiction, tolerance);
• Lack of awareness of the importance of pain control to optimize short- and long-term outcomes (e.g., chronic pain);
• Lack of an organized constituency such as arises among patients (and their families) affected by chronic diseases,
including cancer.

Problems related to the health care system include:

• Low priority given to pain control education for health professionals;
• Low value accorded to patient preferences;
• Regulatory impediments to controlled substance use;
• Income derived from pain treatment is often inadequate to sustain a viable enterprise (often due to fragmented,
flawed cost-effectiveness tracking);
• Cost-shifting to patients (e.g., by insurers);
• Inadequate infrastructure, including knowledgeable personnel to deliver medications and other interventions (e.g.,
patient-controlled analgesia, cognitive-behavioral techniques);
• Practice restrictions, such as regulations that permit nurses to administer injections only intramuscularly or
subcutaneously injections, and not intravenously;
• Failure to capture short- and long-term quality outcomes that might be correlated with the adequacy of acute pain
control [6,13];
• Relative to the burden of acute pain, expenditures for basic, translational, and clinical research funding are all
disproportionately low [2,7].

References
[1] Bernhardt GA, Kornprat P, Cerwenka H, El-Shabrawi A, Mischinger HJ. Do we follow evidence-based medicine recommendations
during inguinal hernia surgery? Results of a survey covering 2441 hernia repairs in 2007. World J Surg 2009;33:2050–5.
[2] Bradshaw DH, Empy C, Davis P, Lipschitz D, Dalton P, Nakamura Y, Chapman CR. Trends in funding for research on pain: a report
on the National Institutes of Health grant awards over the years 2003 to 2007. J Pain 2008;9:1077–87.
[3] Braun BI, et al. Understanding factors that affect organizational improvement. In: Braun BI, et al., editors. Improving the quality of
pain management through measurement and action. Oakbrook Terrace, IL: Joint Commission Resources; 2003. p 59–65.
[4] Carr DB. When bad evidence happens to good treatments. Reg Anesth Pain Med 2008;33:229–40.
[5] Dawson R, Spross JA, Jablonski ES, Hoyer DR, Sellers DE, Solomon MZ. Probing the paradox of patients’ satisfaction with
inadequate pain management. J Pain Symptom Manage 2002;23:211–20.
[6] Gordon DB, Pellino TA, Miaskowski C, McNeill JA, Paice JA, Laferriere D, Bookbinder M. A 10-year review of quality improvement
monitoring in pain management: recommendations for standardized outcomes measures. Pain Manage Nurs 2002;3:116–30.
[7] Lynch ME, Schopflocher D, Taenzer P, Sinclair C. Research funding for pain in Canada. Pain Res Manage 2009;14:113–11.
[8] Macintyre PE, Scott DA. Reasons for undertreatment. In: Chapter 43. Acute pain management and acute pain services. In: Cousins
MJ, Carr DB, Horlocker TT, Bridenbaugh PO, editors. Cousins and Bridenbaugh’s neural blockade in clinical anesthesia and pain
medicine, 4th edition. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; 2009. p 1037–8.
[9] Miaskowski C, Crews J, Ready LB, Paul SM, Ginsberg B. Anesthesia-based pain services improve the quality of postoperative pain
management. Pain 1999;80:23–9.
[10] Phillips LS, Branch WT, Cook CB, Doyle JP, El-Kebbi IM, Gallina DL, Miller CD, Ziemer DC, Barnes CS. Clinical inertia. Ann Intern
Med 2001;135:825–34.
[11] Stamer UM, Mpasios N, Stüber F, Maier C. A survey of acute pain services in Germany and a discussion of international survey
data. Reg Anesth Pain Med 2002;27:125-131.
[12] Uppington J. Implementation of guidelines. In: Chapter 3. Guidelines, recommendations, protocols and practice. In: Shorten G, Carr
DB, Harmon D, Puig MM, Browne J, editors. Postoperative pain management: an evidence-based guide to practice. Philadelphia:
Saunders Elsevier; 2006. p 18–20.
[13] Wu CL, Fleisher LA. Outcomes research in regional anesthesia and analgesia. Anesth Analg 2000;91:1232–42.

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© 2010 International Association for the Study of Pain
How to Implement Change
In spite of high-quality evidence and sophisticated medical and nonmedical treatment options, there is widespread
underassessment and undertreatment of acute pain. Variation in clinical care is largely caused by uncertainty due to
inadequate research or the variable interpretation and dissemination of adequate evidence. Different interventions,
including guidelines and measures of appropriateness, have had little demonstrable impact on clinical practice.

What should be done to facilitate implementation of change?

Future randomized controlled trials as the basis for evidence-based guidelines should:
• Address more realistic clinical situations (e.g., older patients or patients with comorbidities);
• Increasingly focus on functional consequences, side effects of pain management, and quality of life in addition to
reduction of pain intensity as the main outcome criterion;
• Consider cost-utility ratios, and not only efficacy differences between different interventions.
Evidence-based guidelines and recommendations should:
• Be written in a format readable for health care team members not experienced in scientific “language”;
• Be available at point-of-care;
• Be frequently checked to determine whether the recommendations translate into better outcome in clinical
practice;
• Be linked to implementation strategies comprising:
o Reminder, monitoring, and feedback systems;
o Interactive education;
o Auditing;
o Certification/accreditation systems;
o Reward systems (payment for performance);
o Implementation in existing quality management systems.

Evidence-based recommendations should be supplemented by:

• Feedback and benchmarking of quality indicators that are relevant for patient outcomes;
• Set-up of real-life data registries to monitor rare clinical situations and track effectiveness of interventions;
• Clinical decision support systems (both knowledge-based and case-based) to aid clinicians at point-of-care.
Patients, their relatives and the public should be:
• Informed about the importance of adequate pain management and the consequences of insufficient pain
management;
• Advised on the safety and effectiveness of pain management strategies;
• Considered as the most valuable source of feedback on quality of pain management (with preferential use of
patient-reported outcomes);
• Educated and empowered in pain management strategies.
However, no unrealistic expectations should be raised in terms of the degree of pain reduction and the aims of
perioperative management.

Health care professionals should:

• Recognize pain management as an important, but not “stand-alone” part of perioperative care;
• Embed pain management in clinical pathways with the overarching aim of reducing complications, improving
rehabilitation, and optimizing the cost-utility ratio of perioperative care;
• Be supported by a conceptual framework that is accepted and endorsed by hospital administration, governmental
bodies, and society.

Acute pain management should:

• Become obligatory part of teaching in all medical and nursing schools;
• Be taught to medical administrators;
• Be addressed by establishing national strategies and frameworks, involving all those dealing with pain at a
scientific and practical level.

Access to drugs for acute pain treatment should be improved by:

• Changes in drug regulations to allow ready access to inexpensive analgesics
• Changes in government policies regarding controlled substances
References
[1] Anderson T. The politics of pain. BMJ 2010;341:328–30.

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