CE 1 HOUR

Continuing Education

Managing
Postoperative Pain
Identifying knowledge gaps and putting evidence-based guidelines
into practice.

ABSTRACT: Acute postoperative pain remains undertreated despite the dramatic increase in opioid pre-
scribing in the United States over the past 20 years. Inadequately relieved postoperative pain may be a risk
factor for persistent postoperative pain, chronic pain, and disability. In an effort to promote evidence-based
strategies for optimal postoperative pain management, the American Pain Society published a new postop-
erative pain management guideline in 2016. Its 32 recommendations for interdisciplinary and multimodal
postoperative pain management are stratified according to risks and benefits, based on varying levels of evi-
dence. This article aims to help nurses translate the recommendations into clinical practice, while providing
the historical context in which the guidelines emerged and describing current events that may affect guide-
line implementation.

Keywords: evidence-based guidelines, opioids, pain management, postoperative pain

T
he consequences of widespread opioid misuse Society of Anesthesiologists’ (ASA) Committee on Re-
have focused the nation’s attention on the is- gional Anesthesia, Executive Committee, and Admin-
sue of pain and the limited options for treating istrative Council.12 We explain the strength of guideline
pain. Both our conceptual models for understanding recommendations and the quality of supportive evi-
pain and our efforts to improve pain management dence, point to evidentiary gaps that provide research
through evidence-based approaches have evolved opportunities for nurses, and suggest ways that nurses
over the past five decades and continue to do so (see can implement this guideline. In addition, we provide
Table 11-19). But while public advocacy and legislative the historical context in which the guideline emerged
efforts focus on combating prescription opioid mis- and highlight current health care policy initiatives that
use, nurses must continue providing evidence-based may influence guideline implementation.
care to patients with pain, which includes opioid
administration as part of a multimodal approach THE IMPORTANCE OF ADEQUATE POSTOPERATIVE PAIN
to postoperative pain management. RELIEF
In this article, we review the evidence-based clinical More than 50 million surgeries are performed in
practice guideline on the management of postopera- the United States each year.20-22 Research suggests
tive pain, which was approved by the American Pain that fewer than half of patients undergoing sur-
Society (APS), the American Society of Regional Anes- gery will report adequate postoperative pain relief
thesia and Pain Medicine (ASRA), and the American and more than 80% will report moderate to severe

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 By Renee C.B. Manworren, PhD, APRN, PCNS-BC, AP-PMN, FAAN,
Debra B. Gordon, DNP, RN, FAAN, and
Robert Montgomery, DNP, RN-BC, ACNS-BC

Nurses at the Ann and Robert H. Lurie Children’s Hospital of Chicago manage the postoperative pain of a baby boy following a heart transplant.
Photo courtesy of the Ann and Robert H. Lurie Children’s Hospital of Chicago.

postoperative pain.12, 23 Inadequately controlled THE APS GUIDELINE

postoperative pain is well known to impede func- The clinical practice guideline on the management
tional recovery and reduce quality of life. Several of postoperative pain endorsed by the APS, ASRA,
studies of postoperative pain further suggest an as- and ASA sought to promote safe and effective evi-
sociation between the intensity of pain following dence-based postoperative pain management for
various types of surgery and the subsequent devel- children and adults, including pregnant women.12
opment of chronic pain.24 To develop the guideline, investigators reviewed
Postoperative patients with chronic pain. It may more than 6,500 abstracts published between 1992—
be particularly challenging to manage acute postop- when the Agency for Health Care Policy and Re-
erative pain in patients who have been using analge- search (now the Agency for Healthcare Research
sic opioid therapy to treat their chronic pain. In the and Quality [AHRQ]) ­released the clinical practice
United States, more than 100 million adults have guideline Acute Pain Management: Operative or
chronic pain,25 and those who require surgery may Medical Procedures and Trauma—and December
be at risk for inadequate postoperative pain relief, 2015. The guideline committee also considered ref­
particularly if they have been treating their chronic erence lists of relevant articles, including 107 system-
pain with opioids and are now opioid tolerant. Man- atic reviews and 858 primary studies not included in
aging acute postoperative pain in patients who have the systematic reviews, and suggestions from expert
developed opioid tolerance may require the use of reviewers. The stated goal of the resulting guideline is
higher opioid dosages, with the accompanying dose- “to promote evidence-based, effective, and safer post-
dependent risks.13 operative pain management in children and adults.”12

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Table 1. Historical and Current Events That Have Influenced Pain Care

Year Event
1965 Melzack and Wall articulate the gate control theory.1
1968 Margo McCaffery, MS, RN, defines pain: “Pain is whatever the experiencing person says it is, existing when-
ever he says it does.”2
1979 The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional
experience associated with actual or potential tissue damage or described in terms of such damage.”3
1980 J.D. Loeser, MD, explains pain as a biopsychosocial construct.4
1992 The Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality)
publishes the guideline Acute Pain Management: Operative or Medical Procedures and Trauma.5
1995 James Campbell, MD, president of the American Pain Society (APS), coins the term “fifth vital sign,” suggest-
ing that “quality care means that pain is measured and treated.”6 This idea emphasizes that assessing pain
is as important as assessing the four traditional vital signs (pulse, blood pressure, respiration, temperature)
and that clinicians need to act when patients report pain.
2001 For the first time, hospitals are surveyed by the Joint Commission on Accreditation of Healthcare Organiza-
tions (now the Joint Commission) using standards for pain assessment and management.7
2006 Patient satisfaction with pain management becomes part of the Hospital Consumer Assessment of Health-
care Providers and Systems (HCAHPS) survey.8
2012 •• The HCAHPS survey becomes part of the Hospital Value-Based Purchasing program.8
•• The Joint Commission publishes a Sentinel Event Alert, “Safe Use of Opioids in Hospitals,” urging hospi-
tals to take specific steps to prevent deaths from opioid use.9
2015 •• The U.S. Department of Health and Human Services (HHS) makes the opioid epidemic a top priority,
aiming to reverse opioid overdoses by targeting prescription practices, expanding substance abuse
treatment, and increasing access to naloxone.10
•• The Joint Commission standard PC.01.02.07 EP 4 is revised to clarify that both pharmacologic and
nonpharmacologic approaches, as well as potential patient benefits and risks, may be considered
when determining the most appropriate interventions for pain. When using medications to treat pain,
the risks of dependency, addiction, and opioid abuse should be considered.11
2016 •• Call for reexamination of Joint Commission pain standards
•• Call for the Centers for Medicare and Medicaid Services (CMS) to remove patient satisfaction with pain
management from the HCAHPS survey
February 2016 The APS publishes a clinical guideline on the management of postoperative pain.12
March 2016 The Centers for Disease Control and Prevention publishes a guideline for prescribing opioids for chronic
pain in response to the opioid epidemic, creating controversy among providers and policymakers.13
April 2016 The Joint Commission Statement on Pain Management corrects misconceptions about pain standards.14
November 2016 The CMS begins finalizing removal of the pain management dimension from the scoring formula used in
the Hospital Value-Based Purchasing program, with payment adjustments beginning in fiscal year 2018.
Pain management questions remain on the HCAHPS survey and the pain management measure will con-
tinue to be publicly reported on Hospital Compare.15
June 2017 The CMS publishes newly proposed rules regarding pain in the Hospital Inpatient Prospective Payment
System for Federal Fiscal Year 2020 for public comment by June 13, 2017.16
July 2017 The Joint Commission releases new standards for pain and opioid stewardship.17
October 2017 •• President Trump directs the HHS to declare the opioid epidemic a public health emergency.18
•• The Federal Pain Research Strategy is released.19
January 2018 The Joint Commission begins surveying hospitals using the new pain standards.

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The evidence review and final guideline includes 32 therapies commonly used to treat postoperative pain.
recommendations for the management of postopera- Ice, for example, is often applied to surgical sites to
tive pain, covering preoperative education, periopera- provide local analgesia and reduce swelling. However,
tive pain management planning, use of pharmacologic studies of localized cold therapy have reported incon-
and nonpharmacologic treatment strategies, organiza- sistent results, often finding no differences in postoper-
tional policies and procedures, and transition to out- ative pain or analgesic use among patients who did and
patient care (see Table 212). did not receive cold therapy for pain or swelling.28, 29

Guideline recommendations with low-quality or

insufficient evidence ratings represent research opportunities
for nurses, whose knowledge of pain integrates the behavioral
and biological sciences and is critical for furthering postoperative
pain management.

Strength of recommendations and quality of ev- The application of ice is relatively safe, inexpensive,
idence. The APS guideline development process used and acceptable to most patients, and its recommen-
methods adapted from the Grading of Recommen- dation is within the nurse’s scope of practice in most
dations Assessment, Development and Evaluation states. Nursing studies seeking to clarify the compar-
(GRADE) working group and the AHRQ Effective ative effectiveness of postoperative cold therapy in dif-
Health Care Program to rate each recommendation ferent patient populations undergoing various surgical
based on the strength (strong or weak) and quality procedures could, therefore, fill significant research
(high, moderate, or low) of the evidence.12, 26, 27 Strong gaps. Other areas identified by members of the guide-
recommendations are those that “can apply to most line panel as providing insufficient evidence to inform
patients in most circumstances without reservation,”26 clinical practice include best timing and optimal meth-
or those for which the benefits clearly outweigh po- ods for delivering perioperative patient education,
tential harms.12 Recommendations were rated weak nonpharmacologic interventions, combination or
when the “best action may differ depending on cir- multimodal analgesia, monitoring of patient response
cumstances or patients’ or societal values,”26 or when to postoperative pain management, neuraxial and re-
the evidentiary weight of benefits to risks is smaller.12 gional analgesic techniques, and delivery of organi-
Grading of the evidence “considered the type, num- zational care.30 Further investigation in each of these
ber, size, and quality of studies; strength of associa- areas is needed to advance our understanding of post-
tions or effects; and consistency of results among operative pain management.
studies.”12 Of the 32 recommendations, four were
judged to be based on high-quality evidence and 11 CONCERNS ABOUT LONG-TERM OPIOID USE
on low-quality evidence. Since long-term opioid use to treat chronic pain often
Research opportunities for nurses. Guideline rec- begins with acute pain treatment, some recommenda-
ommendations with low-quality or insufficient evi- tions from the Centers for Disease Control and Pre-
dence ratings represent research opportunities for vention (CDC) guideline for prescribing opioids for
nurses, whose knowledge of pain integrates the behav- chronic pain13 may be relevant in managing acute
ioral and biological sciences and is critical for further- postoperative pain. For example, the CDC guideline,
ing postoperative pain management. The APS, ASRA, which is based on scientific evidence, informed expert
and ASA guideline panel found insufficient evidence opinion, and public input, recognizes that opioids are
to either support or discourage the use of a number of indicated for the treatment of severe acute pain and

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Table 2. Recommendations from the Clinical Practice Guideline on the Management of Postoperative Pain endorsed by
the APS, the ASRA, and the ASA12

Strong recommendation, High-quality evidence

•• Offer multimodal analgesia for the treatment of perioperative pain in children and adults.
•• Provide children and adults who have no contraindications acetaminophen or NSAIDs as part of multimodal analgesia for
the management of postoperative pain.
•• Offer neuraxial analgesia with opioids, local anesthetics, or both for major thoracic and abdominal procedures, particularly
in patients at risk for cardiac complications, pulmonary complications, or prolonged ileus.
•• Consider surgical site–specific peripheral regional anesthetic techniques in children and adults for procedures with evidence
indicating efficacy.
Strong recommendation, Moderate-quality evidence
•• Consider a preoperative dose of oral celecoxib for adult patients without contraindications.
•• Consider gabapentin or pregabalin as a component of multimodal analgesia.
•• Choose oral over iv administration of opioids for postoperative analgesia in patients who can use the oral route.
•• Use postoperative iv patient-controlled analgesia when the parenteral route is needed.
•• Use topical local anesthetics in combination with nerve blocks prior to circumcision.
•• Use continuous, local anesthetic-based peripheral regional analgesic techniques when the need for analgesia is likely to
exceed the duration of effect of a single injection.
•• AVOID using the intramuscular route in the administration of analgesics for the management of postoperative pain.
•• AVOID the neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, and ketamine in the treat-
ment of postoperative pain.
•• NOT RECOMMENDED: routine basal infusion of opioids with iv patient-controlled analgesia in opioid-naive adults
•• NOT RECOMMENDED: intrapleural analgesia with local anesthetics for pain control after thoracic surgery
Strong recommendation, Low-quality evidence
•• Have an organizational structure in place that allows policies and processes for postoperative pain control to be developed
and refined.
•• Provide access to consultation with a pain specialist for patients who have or are at risk for inadequately controlled post-
operative pain.
•• Have policies and procedures that support the safe delivery of neuraxial analgesia and continuous peripheral blocks and
training in the management of these procedures.
•• To guide the perioperative pain management plan, conduct a preoperative evaluation of comorbidities, medications, his-
tory of chronic pain, substance abuse, and prior postoperative treatment and responses.
•• Use a validated pain assessment tool to track postoperative pain treatment response and adjust the treatment plan accordingly.
•• Adjust the postoperative pain management plan based on adequacy of pain relief and adverse events.
•• Provide appropriate monitoring of patients receiving systemic opioids for postoperative analgesia.
•• Provide appropriate monitoring of patients who receive neuraxial interventions for perioperative analgesia.
•• Provide patient- and family-centered, individually tailored education on the management of postoperative pain; document
the plan and goals for postoperative pain management.
•• Provide education to all patients and primary caregivers on the pain treatment plan.
•• Provide instruction to parents (or other adult caregivers) of children undergoing surgery on developmentally appropriate
methods of assessing pain as well as counseling on appropriate administration of analgesics.

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Table 2. Continued

Weak recommendation, Moderate-quality evidence

•• Consider iv ketamine as a component of multimodal analgesia in adults.
•• Consider iv lidocaine infusions in adults undergoing open and laparoscopic abdominal surgery.
•• Consider surgical site–specific local anesthetic infiltration for procedures with evidence indicating efficacy.
•• Consider addition of clonidine as an adjuvant for prolongation of analgesia with a single-injection peripheral neural blockade.
•• Consider TENS as an adjunct to other postoperative pain treatments.
•• Consider using cognitive modalities as part of a multimodal approach.
Insufficient evidence
•• Use acupuncture, massage, or cold therapy as adjuncts to other postoperative pain treatments.
APS = American Pain Society; ASRA = American Society of Regional Anesthesia and Pain Medicine; ASA = American Society of Anesthesiologists’ Committee on Regional
Anesthesia, Executive Committee, and Administrative Council; NSAID = nonsteroidal antiinflammatory drug; TENS = transcutaneous electrical nerve stimulation.

recommends they be prescribed at the lowest effective of Healthcare Providers and Systems (HCAHPS)
dose for no longer than the expected duration of se- survey measure, revising the three questions that
vere pain. The guideline, however, makes no recom- address Communication About Pain During the
mendation for postoperative use of opioids, clearly Hospital Stay to eliminate any perceived financial
stating that opioid treatment for postsurgical pain is pressure to overprescribe opioids. Two of the newly
outside its scope.13 proposed questions focus on the following issues16:
Although the CDC guideline recommends limiting
opioid prescriptions for acute pain that is nonsurgical
and nontraumatic, it does so on the basis of experts’
clinical experience, rather than on scientific evidence— Nurses must be able to distinguish clinical
and the expert opinion cited ranges widely from three
or fewer days to rarely more than seven.13 The expert
opinions expressed in this guideline may have been
practices supported by strong evidence
erroneously applied as evidence for developing health
care policy initiatives regarding acute pain manage- from those with insufficient or weak
ment, including postoperative opioid use. Because of
the lack of evidence supporting any particular practice evidence, as well as evidence-based
for prescribing opioids for inpatient or at-home use
following surgery, the APS guideline provides no rec- recommendations from expert opinion.
ommendation for duration of postoperative opioid
prescribing.
The Centers for Medicare and Medicaid Ser-
vices (CMS) has prioritized the use of evidence- • shared decision making
based practices for managing acute and chronic • discussion of treatment options, including opioid,
pain as a strategy for combating opioid misuse. On nonopioid, and nonpharmacologic pain manage-
April 28, 2017, the CMS proposed new rules for ment strategies
pain management in the Hospital Inpatient Pro- • patient understanding of treatment options
spective Payment System for Federal Fiscal Year • patient engagement in pain care
2020; the proposed rules were open for public com- Analyses of the new Communication About Pain
ment through June 13, 2017.16 The proposed rules composite measure, which includes how often staff
would update the Hospital Consumer Assessment talked about pain and how often staff discussed how to

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 treat pain while in the hospital, reveal that the measure (TENS) is seldom used for postoperative pain,
has strong reliability and validity; however, pain man- though the guideline panel found moderate-quality
agement nurses are calling for evidence to support the ­evidence supporting the use of these small portable
proposed response options—never, sometimes, usually, devices as an adjunct to other postoperative pain
or always—as measures of hospital processes and per- treatments.12, 32 The source for the evidence was a sys-
formance expectations. In the past, “always” has been tematic review of more than 20 randomized trials that
the desired patient response for HCAHPS questions, found that TENS use was associated with 26.5% less
but it is unclear how patient responses to these pro- analgesic consumption than placebo.32 Before using
posed measures will be interpreted going forward. At TENS, nurses should review proper placement of elec-
press time, the new rules had not yet been finalized. trodes, optimal treatment parameters, and patient ed-
ucation guidelines.
A FEDERAL RESEARCH AGENDA Organizational readiness. Assessing an organiza-
The planning committee of the Federal Pain Research tion’s readiness to implement any or all of the APS
Strategy, an initiative of the Interagency Pain Research guideline recommendations is a critical first step. For
Coordinating Committee and the National Institutes each recommendation, an interdisciplinary team of
of Health, Office of Pain Policy, developed an organi- committed clinicians and organizational leaders must
zational and structural plan that fosters a federal re- consider how the change will affect the organization’s
search agenda seeking to improve our understanding people, processes, resources, and systems and ask
and management of pain, including postoperative themselves the following questions:
pain.31 The five key areas that provide the framework • What steps or elements of the recommendations
for identifying research priorities are as follows: are currently in place?
• prevention of acute and chronic pain • What are the institutional strengths for implement-
• acute pain and acute pain management ing the recommendations?
• the transition from acute to chronic pain • Are there any institutional barriers or weaknesses
• chronic pain and chronic pain management to implementing the recommendations?
• disparities in pain and pain care The team should outline strategies and actions
The five work groups of the Federal Pain Research needed to implement specific recommendations. Pa-
Strategy planning committee completed their discus- tient outcomes, quality metrics, and feedback mecha-
sions and posted a draft of research priorities for pub- nisms must be defined in order to measure the practice
lic comment from May 25 through June 6, 2017. change. Targets for change completion and plans to
The Federal Pain Research Strategy was released in measure changes in patient outcomes over time will
October 2017.19 ensure that the change is sustained.
Change often starts with clinical education.
GUIDELINE IMPLEMENTATION In 2012, the U.S. Food and Drug Administration
The Joint Commission has approved revised pain as- (FDA) approved a “Blueprint for Prescriber Educa-
sessment and management standards for its hospital tion for Extended-Release and Long-Acting Opioid
accreditation program. The standards were released Analgesics” as part of a risk evaluation and mitigation
in July 201717 and will become effective January 1, strategy (REMS) for these drugs.33 The goal of the
2018. Revisions will be included in the 2018 hospital voluntary continuing education REMS was to reduce
accreditation manual. The standards stress the need serious adverse outcomes as a result of inappropriate
to focus on evidence-based care. Nurses must be able prescribing, misuse, and abuse of extended-release and
to distinguish clinical practices supported by strong long-acting opioid analgesics while maintaining access
evidence from those with insufficient or weak evi- to opioid analgesics for patients with pain. A recent
dence, as well as evidence-based recommendations version of the blueprint represents a shift from a previ-
from expert opinion. ous focus on risks and the use of opioids to a more
Nurses are in a position to improve the quality of holistic educational focus on acute and chronic pain
acute pain management by advocating for evidence- management that includes pain assessment methods
based strategies. Although many of the APS guideline as well as use of nonpharmacologic interventions, non-
recommendations are not new, some that are well sup- opioid analgesics, immediate-release opioid analgesics,
ported by good quality evidence are still infrequently and extended-release and long-acting opioid analge-
implemented in the clinical practice setting. For ex- sics. The FDA sought public comment on this ver-
ample, transcutaneous electrical nerve stimulation sion through July 10, 2017.33 At press time, proposed

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