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Acute Pain Management:  Operative or Medical Procedures and Trauma 
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Clinical Practice Guideline
**Panel Co-chairs:  Daniel B. Carr, M.D., Massachusetts General Hospital's Divisionof PainManagement, and Ada Jacox, Ph.D., R.N., Johns Hopkins University School of Nursing.Guideline Release Date:  March 5, 1992.**

*In February 1992, AHCPR released a clinical practice guideline to help surgeons, nurses, andanesthesiologists manage acute postoperative pain more effectively.  The guideline was developedby an18-member private-sector panel of pain experts.  The multidisciplinary panel reviewed theresearch literature onpain management to develop the scientific base for the guideline*.

**Acute Pain Management Guideline Contents (Summer 1994)**
- Introduction
- Findings
- Dissemination
- Implications
- Bibliography
Introduction
Unrelieved pain causes suffering, can lead to other healthproblems, and delaysrecovery, thereby adding unnecessarily to health care costs.  The acute pain management guidelinehad fourmajor goals:
- To reduce the incidence and severity of acute postoperative or posttraumatic pain.
- To educate patients about the need to communicate about their unrelieved pain.
- To enhance patient comfort and satisfaction.
- To reduce postoperative complications and, in some cases, shorten stays after surgicalprocedures.

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Findings
After analyzing the results of more than 7,000 published studies, the panel concluded thefollowing:
- Half of all patients given conventional therapy for their pain—most of the 23 millionsurgical cases each year—do not get adequate relief.  These patients continue to feel moderate to severe pain.
- Giving patients pain medicine only "as needed" can result in prolonged delays because patientsmay delay asking for help.
- Aggressive prevention of pain is better than treatment because, once established, pain is moredifficult to suppress.
- Patients have a right to treatment that includes prevention of or adequate relief from pain.Physicians need to develop pain control plans before surgery and inform the patient what to expect in terms of pain duringand after surgery.
- Fears of postsurgical addiction to opioids are generally groundless.
- Patient-controlled medication via infusion pumps is safe.

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Dissemination
Following release of the acute pain guideline at a press conference in Washington, D.C., news of the guideline was carried nationwide by CBS, NBC, CNN, and Univision, a Spanish-language network serving the United States and Latin America.  Radio also carried the news. 

The acute pain guideline release made the front pages of the *New York Times*, *WallStreet Journal*, *Washington Post*, *Los Angeles Times*, *Chicago Tribune*, *Chicago Sun Times*, *Boston Globe*, *Detroit News*, and other major dailies.  Other publications that have written about or mentioned the guideline include *Time* magazine, *U.S. News and World Report*, *Ladies Home Journal*, *McCall's*, *Good Housekeeping*, *Family Circle*, *Working Mother*, *Parenting*, *Consumers Report on Health*, and the *Bulletin of the American Association of Retired Persons*.  This coverage helped put more than 645,000 patient versions of the guideline in the hands of consumers.

Physicians, nurses, and other health care professionals have been made aware of the pain guideline through many means.  They include popular and trade media, professional journals (9 of which reprinted the guideline), AHCPR exhibits at professional meetings, and dissemination through research reports in peer-reviewed journals and by professional societies and hospitals.  AHCPR mailed 20,000 copies of the guideline to the hospitals that are members of the American Hospital Association, and to freestanding ambulatory surgery centers, managed care organizations, national- and State-level medical and nursing societies, medical and nursing schools, health insurance companies, peer review organizations, and otherorganizations.
Dissemination Summary: Acute Pain Management GuidelinePresentations:44Professional Articles:43Health Industry Articles:42Editorials/Mentions:135Consumer Print:892Consumer Broadcast:103Total:1,259
Overall, AHCPR has disseminated nearly 2.4 million copies of the acute pain guideline (all versions).  The guideline has been translated into Spanish, French, Turkish, Hebrew, Chinese, Korean, and other languages.

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Implications
It is too early to know if the acute pain guideline is improving pain management in the United States, but the demand for the guideline has continued to be strong.  Hospitals ordering copies include:
- The University of California's Davis Medical Center ordered 1,000 copies for attending physicians and incoming house staff.  The hospital also gave copies to pharmacists and nurses, and it encouraged them to discuss pain management issues with physicians.  In addition, a pain management committee was formed, and this group developed pain monitors (standardized tools for measuring patients' pain and indicating the appropriateintervention).
- The National Hospital for Orthopedics and Rehabilitation of Arlington, VA, ordered copies ofthe pain guideline and formed a pain management task force.  According to the hospital's Director ofProfessional Services, several activities have been initiated with the help of the guideline.  These include designating appropriate pain medication for the day of surgery and the day after, starting round-the-clock dosing (rather than as needed), training staff nurses to recognize pain, and revising a form used by the physical therapy department to reflect greater awareness of pain management.
- In Madison, the University of Wisconsin Hospitals and Clinics distributed 700 copies of the pain guideline's quick reference guide to attending surgeons and staff nurses.  It also assembled a 50-member multidisciplinary pain management team, incorporated pain management techniques in some of the 75 critical paths developed and used by the hospital, and carried out other activities inspired by the pain guideline.

To reflect important new research findings, AHCPR established a new panel to update the acute pain guideline.

Nine other guidelines have been issued since the publication of the acute pain guideline.Guidelines have been issued on urinary incontinence, pressure ulcers, cataract, depression, sickle cell disease, early HIV infection, benign prostatic hyperplasia, management of cancer pain, and unstable angina.  Guidelines on other topics will be issued this year.

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Bibliography
*Acute Pain Management:  Operative or Medical Procedures and Trauma.*(Clinical Practice Guideline.)  Publication No. AHCPR 92-0032.  Rockville, MD:  Agency forHealthCare Policy and Research, Public Health Service, U.S. Department of Health and Human Services, February 1992.  

*Acute Pain Management in Adults:  Operative or Medical Procedures and Trauma* (Quick Reference Guide for Clinicians). Publication No. AHCPR 92-0019.  Rockville, MD:  Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, February 1992.

*Acute Pain Management in Infants, Children, and Adolescents:  Operative or Medical Procedures and Trauma* (Quick Reference Guide for Clinicians).  Publication No. AHCPR 92-0020.  Rockville, MD:  Agency for Health Care Policy and Research, PublicHealth Service, U.S. Department of Health and Human Services, February 1992.

*Pain Control After Surgery*  (A Patient's Guide). Publication No. AHCPR 92-0021.  Rockville, MD:  Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, February 1992.

*Pharmacologic Management of Acute Pain:  Dosing Data*.  Publication No. AHCPR 92-0086.  Rockville, MD:  Agency for Health Care Policy and Research, PublicHealth Service, U.S. Department of Health and Human Services, February 1992.

*Formas de Controlar el Dolor Despues de una Operación:  Guía Para elPaciente*  (Spanish Version of Patient's Guide).  Publication No. AHCPR 92-0068.  Rockville, MD:  Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, February 1992.

Acute Pain Management Guideline Panel  (1992).  Clinicians' quick reference guide to postoperative pain management in adults.  *Journal of Pain and Symptom Management* 7(4), 214-228.

Acute Pain Management Guideline Panel  (1992).  Clinicians' quick reference guide to acute pain management in infants, children, and adolescents:  Operative and medical procedures.  *Journal of Pain and Symptom Management* 7(4), 229-242.

Acute Pain Management Guideline Panel, AHCPR (1993).  Acute pain management:  Operative or medical procedures and trauma.  *Journal of the American Academy of Physician Assistants* 6(2), 94-105.

Acute Pain Management Guideline Panel  (1993).  Acute pain management in adults:  Operative procedures, quick reference guide for clinicians.  *Journal of Pharmaceutical Care in Pain and Symptom Control* 1(1), 63-84.

Acute Pain Management Guideline Panel  (1993).  Acute pain management in infants, children, and adolescents:  Operative and medical procedures, quick reference guide for clinicians.  *Journal of Pharmaceutical Care in Pain and Symptom Control* 1(1), 85-108.

Agency for Health Care Policy and Research  (1992).  Acute pain management:  Operative or medical procedures and trauma, part 1.  *Clinical Pharmacy* 11, 309-331.

Agency for Health Care Policy and Research  (1992).  Acute pain management:  Operative or medical procedures and trauma, part 2.  *Clinical Pharmacy* 11, 391-414. 

Agency for Health Care Policy and Research  (1992).  Acute pain management in adults:  Operative procedures.  *American Family Physician* 46(1), 128-138. 

Agency for Health Care Policy and Research  (1992).  Acute pain management in infants, children and adolescents:  Operative and medical procedures.  *American Family Physician* 46(2), 469-479. 

Agency for Health Care Policy and Research  (1992).  Acute pain management in adults:  Operative procedures.  Quick reference guide for clinicians.  *Oncology Nursing Forum* 19(7), 29-40. 

Ballantyne, J. C., Carr, D. B., Chalmers, T. C., Dear, K. B. G., Angelillo, I. F., and Mosteller, F.  (in press).  Comparative effects of postoperative analgesic therapies upon reparatory function:  Meta-analyses of initial randomized control trials.  *Anesthesia and Analgesia*. 

Ballantyne, J. C., Carr, D. B., Chalmers, T. C., Dear, B. G., and Mosteller, F  (1993).  Patient controlled analgesia in the postoperative patient: Meta-analyses of initial randomized control trials.  *Journal of Clinical Anesthesia* 5, 182-193. 

Ballantyne, J. C., Carr, D. B., Ulmer, J., Jacox, A., and Mahrenholz, D.  (in press).  The control of postoperative pain.  In F. Mosteller and H. Frazier (Eds.), *Benefits of Medicine*. 

Carr, D. B  (1993).  Pain control:  The new "whys" and "hows."  *Pain:  Clinical Updates*1, pp. 1-4. 

Carr, D. B., and Aronoff, G. M  (1992).  The future of pain management.  In G. M. Aronoff (Ed.), *Evaluation and Treatment of Chronic Pain* (2nd edition, pp. 507-521). Baltimore:  Williams and Wilkins. 

Carr, D. B., and Jacox, A. K. (1991).  Pain management guideline:  A status report.  *American Society of Anesthesiologists (Newsletter)* 55(4), 12-16. 

Carr, D. B., and Jacox, A. K  (1993).  New federal guidelines on the management of pain.  *Journal of Pharmaceutical Care in Pain and Symptom Control* 1(2), 5-7.

Carr, D. B., and McPeek, B  (1993).  Pain control.  In E. M. Copeland III, B. A. Levine, R. J.Howard, H.Sugerman, and A. L. Warshaw (Eds.), *Current Practice of Surgery* 3 (pp.4.1-4.17).  New York: ChurchillLivingstone. 

Carr, D. B, and McPeek, B  (1993).  Management of an acute pain unit.  In J. Chrubasik, M.Cousins, and E.Martin (Eds.), *Advances in Pain Therapy II* (pp. 1-13).  Berlin:  Springer-Verlag.

Carr, D. B., and Song, S. O  (1993).  So you want to set up an acute pain treatment unit. *Current Review inClinical Anesthesia* 14(Lesson 7), 53-64. 

Dauber, A., and Carr, D. B  (1993).  Pain management in the ICU.  *Pulmonary and CriticalCare UpdateLesson* 18(8), 1-9.  Park Ridge, IL:  American College of Chest Physicians. 

Ferrell, B. R  (1993).  Challenge for Leadership in the National Agenda for Relief of Cancer Pain(Commentary). *Journal of the National Cancer Institute* 85(13), 1034-1037. 

Ferrell, B. R., Curtiss, C. P., McCaffery, M., and Schmitt, R  (1992).  Introduction. *Oncology Nursing Forum* 19(7), 3-4. 

Ferrell, B. R., McCaffery, M., and Ropchan, R  (1992).  Pain management as a clinical challengefor nursingadministration.  *Nursing Outlook* 40(6), 263-268.  

Fishman, S. M., and Carr, D. B  (1992).  Clinical issues in pain management.  *ContemporaryInternal Medicine* 4, 92-103. 

 Hester, N. O., Jacox, A., Miaskowski, C., and Ferrell, B  (1992).  Excerpts from guidelines forthe managementof pain in infants, children, and adolescents;  undergoing operative and medical procedures. *MCN, American Journal ofMaternal/Child Nursing* 17(3), 146-152. 

Jacox, A  (1993).  Developing clinical practice guidelines:  An interview with Ada Jacox. *ANNA Journal* 20(2), 121-126. 

Jacox, A  (1993).  Improving quality through clinical practice guidelines.  *AmericanNurse* 12. 

Jacox, A  (1992).  Pain management: A health policy perspective.  *Oncology NursingForum* 19(7), 27-28. 

Jacox, A., and Carr, D. B.  (1991).  Clinical practice guidelines.  *Nursing Economics* 9(2), 118-20. 

Jacox, A., Ferrell, B., Heidrich, G., Hester, N., and Miaskowski, C  (1992).  A guideline for theNation: Managing acute pain.  *American Journal of Nursing* 92(5), 49-55. 

Jacox, A., Mahrenholz, D., and Ulmer, J  (1993).  Development of interdisciplinary guidelines forthe management of acute pain.In D. Fishman and O. Strickland (Eds.), *Nursing Issues in the 1990's*.  Delmar. 

Jacox, A., Carr, D. B., and Payne, R.  (in press).  Toward effective pain management.  *Journalof Pain andSymptom Management*. 

Lipman, A. G  (1993).  Clinical guideline for symptom control (Editorial).  *Journal ofPharmaceutical Care inPain and Symptom Control* 1(2), 1-3. 

Lipman, A. G., Carr, D. B., and Jacox, A. K.  (in press).  The need for improved acute painmanagement:  Newfederal clinical guideline defines the problem and some solutions.  *Drug Therapy*. 

Miaskowski, C  (1993).  Current concepts in the assessment and management of acute pain. *Medsurg Nursing* 2(1), 28-32. 

Miaskowski, C.  (1994, in press for January).  Acute pain guidelines:  Implications for orthopedicnursing. *Orthopedic Nursing*. 

Miaskowski, C., Jacox, A., Hester, N. O., and Ferrell, B  (1992).  Interdisciplinary guidelines forthe management of acute pain:Implications for quality improvement.  *Journal of Nursing Care Quality* 7(1),1-6. 

Mulder, D. S  (1993).  Pain management principles and anesthesia techniques for thoracoscopy. *Annals ofThoracic Surgery* 56, 630-632. 

Ready, L. B., Carr, D. B., Del Guercio, L. R. M., and Fischer, W. B  (1992).  Symposium:  Painmanagement. *Contemporary Orthopaedics* 24, 737-759. 

Ready, L. B., Carr, D. B., Del Guercio, L. R. M., and Fischer, M. D  (1992).  Symposium:  Painmanagement. *Contemporary Surgery* 40, 45-75. 

U.S. Department of Health and Human Services, Public Health Service, Agency for Health CarePolicy andResearch  (1992).  Pain control after surgery:  A patient's guide.  *Decubitus* 5(6),50-52. 

Youngstrom, P.  (in press).  Obstetric Anesthesia.  In J. P. O'Grady, M. Gimovsky, and C.McIlhargie (Eds.),*Operative Obstetrics*. 

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