Guide to Pain
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Pain Control After Surgery
A Patient's Guide

Purpose of this information:

This information talks about pain relief after surgery. It explains the goals of pain control and the types of treatment you may receive. It also shows you hot to work with your doctors and nurses to get the best pain control

Reading this information should help you:

Learn why pain control is important for your recovery as well as your comfort.
Play an active role in choosing among options for treating your pain.

What is pain?

Pain is an uncomfortable feeling that tells you something may be wrong in your body. Pain is your body's way of sending a warning to your brain. Your spinal cord and nerves provide the pathway for messages to travel to and from your brain and the other parts of your body.

Receptor nerve cells in and beneath your skin sense heat, cold, light, touch, pressure and pain. You have thousands of these receptor cells, most sense pain and the fewest sense cold. When there is an injury to your body - in this case surgery - these tinny cells send messages along nerves into your spinal cord and then up to your brain. Pain medicine blocks these messages or reduces their effect on your brain.

Sometimes pain may be just a nuisance, like a mild headache. At other times, such as after an operation, pain that doesn't go away - even after you take pain medicine - may be a signal that there is a problem. After your operation, your nurses and doctors will ask you about your pain because they want you to be comfortable, but also because they want to know if something is wrong. Be sure to tell your doctors and nurses when you have pain.

Treatment Goals

People used to think that severe pain after surgery was something they "just had to put up with." But with current treatments, that's no longer true. Today, you can work with your nurses and doctors before and after surgery to prevent or relieve pain.

Pain Control Can Help You:

Enjoy greater comfort while you heal.
Get well faster. With less pain, you can start walking, do your breathing exercises, and get your strength back more quickly. You may even leave the hospital sooner.
Improve your results. People whose pain is well-controlled seem to do better after surgery. They may avoid some problems (such as pneumonia and blood clots) that affect others.

Pain Control: What are the options?

Both drug and non-drug treatments can be successful in helping to prevent and control pain. The most common methods of pain control are described within this booklet. You with your doctors and nurses will decide which ones are right for you. Many people combine two or more methods to get greater relief.

Don't worry about getting 'hooked' on pain medicines. Studies show that this is very rare - unless you already have a problem with drug abuse.

Pain Control Methods You May Be Using

To get the best results, work with your doctors and nurses to choose the methods that will work best for you.

Your nurses and doctors want to make your surgery as pain free as they can. But you are the key to getting the best pain relief because pain is personal. You are the expert for your pain severity and relief. The amount or type of pain you feel may not be the same as others feel - even those who have had the same operation.

Before Surgery

Drug treatment: Take pain medicine.

Non-drug treatment: Understand what operation the doctor is doing, why it is being done, and how it will be done. Learn how to do deep breathing and relaxation exercises.

During Surgery

Drug treatment: Receive general anesthesia, spinal anesthesia, or nerve blocks, or take a pain medicine through a small tube in your back (called an epidural).

After Surgery

Drug treatment: Take a pain medicine as a pill, shot, or suppository, or through a tube in your vein or back.

Non-drug treatment: Use massage, hot or cold packs, relaxation, music or other pastimes to distract you, positive thinking, or nerve stimulation (TENS).

What can you do to help keep your pain under control? These seven steps can help you help yourself.

Before Surgery

Ask the doctor or nurse what to expect.
- Will there be much pain after surgery?
- Where will it occur?
- How long is it likely to last?
Being prepared helps put you in control. You may want to write down your questions before you meet with your doctor or nurse.
Discuss the pain control options with your doctors and nurses.
Be sure to:
- Talk with your nurses and doctors about pain control methods that have worked well or not so well for you before.
- Talk with your nurses and doctors about any concerns you may have about pain medicine.
- Tell your doctors and nurses about any allergies to medicines you may have.
- Ask about side effects that may occur with treatment and how to control them.
- Talk with your doctors and nurses about the medicines you take for other health problems including over-the-counter medications and vitamin and mineral supplements. The doctors and nurses need to know, because mixing some drugs and some pain medicines can cause problems.
Talk about the schedule for pain medicines in the hospital.
Some people get pain medicines in the hospital only when they call the nurse to ask for them. Sometimes there are delays and the pain gets worse while they wait.

Today, two other ways to schedule pain medicines seem to give better results.
- Giving the pain pills or shots at set times. Instead of waiting until pain breaks through, you receive medicine at set times during the day to keep the pain under control.
- Patient controlled analgesia (PCA) may be available in your hospital. With PCA, you control when you get pain medicine. When you begin to feel pain, you press a button to inject the medicine through the intravenous (IV) tube in your vein.
For both ways, your nurses and doctors will ask you how the pain medicine is working and change the medicine, its dose, or its timing if you are still having pain.
Work with your doctors and nurses to make a pain control pain.
You can use the form at the end of this page to begin planning for pain control with your nurses and doctors. They need your help to design the best plan for you. When your pain control plan is complete, use the form to write down what will happen. Refer to it after your operation. Then keep it as a record if you need surgery in the future.

After Surgery

Take (or ask for) pain relief drugs when pain first begins.
- Take action as soon as the pain starts.
- If you know your pain will worsen when you start walking or doing breathing exercises, or going for rehab therapy, take pain medicine first. It's harder to ease pain once it has taken hold. This is a key step in proper pain control.
Help the doctors and nurses 'measure' your pain.
- They will ask you to rate your pain on a scale of 0 to 10. Zero will represent no pain present and 10 will be the worst pain imaginable. Or you may choose from a panel of happy to sad faces.
- You may also set a pain control goal (such as having no pain that's worse than 2 on the scale.
- Reporting your pain as a number helps the doctors and nurses know how well your treatment is working and whether to make any changes.
- They may ask you to use a 'pain scale' like the one show below.
- They will ask you to describe the pain with words like sharp, dull, burning, constant, intermittent, throbbing, aching, and ask if it radiates to other locations.
Tell the doctor or nurse about any pain that won't go away.
- Don't worry about being a 'bother'.
- Pain can be a sign of problems with your operation.
- The nurses and doctors want and need to know about it.
Stick with your pain control plan if it is working. Your doctors and nurses can change the plan if your pain is not under control. You need to tell the nurses and doctors about your pain and how the pain control plan is working.

Benefits and Risks of Pain Treatment Methods

This information is provided to help you discuss your options with your doctors and nurses. Sometimes it is best to combine two or more of these treatments or change the treatments slightly to meet your individual needs. Your doctors and nurses will discuss this with you.

Pain Relief Medicines

Nonsteroidal anti-inflammatory drugs: (NASIDs)

Acetaminophen (for example, Tylenol), aspirin, ibuprofen (for example, Motrin), and other NSAIDs reduce swelling and soreness and relieve mild to moderate pain.

Benefits:

There is not risk of addiction to these medicines. Depending on how much pain you have, these medicines can lessen or eliminate the need for stronger medicines (for example, morphine or another opioid).

Risks:

Most NSAIDs interfere with blood clotting. They may cause nausea, stomach bleeding, or kidney problems. For severe pain, an opioid usually must be added.

Opioids:

Morphine, codeine, and other opioids are most often used for acute pain, such as short-term pain after surgery.

Benefits:
These medicines are effective for severe pain, and they do not cause bleeding in the stomach or elsewhere. It is rare for a patient to become addicted as a result of taking opioids for postoperative pain.

Risks:
Opioids may cause drowsiness, nausea, constipation, itching, or interfere with breathing or urination.

Local anesthetics:

These drugs (for example, bupivacaine) are given, either near the incision or through a small tube in your back, to block the nerves that transmit pain signals.

Benefits:
Local anesthetics are effective for severe pain. Injections at the incision site block pain from that site. There is little or no risk of drowsiness, constipation, or breathing problems. Local anesthetics reduce the need for opioid use.

Risks:
Repeated injections are needed to maintain pain relief. An overdose of local anesthetic can have serious consequences. Average doses may cause some patients to have weakness in their legs or dizziness.

Methods Used to Give Pain Relief

Tablet or liquid

Medicines given by mouth (for example, aspirin, ibuprofen, or opioid medications such as codeine).

Benefits:
Tablets and liquids cause less discomfort than injections into muscle or skin and they can work just as well, They are inexpensive, simple to give, and easy to use at home.

Risks:
These medicines cannot be used if nothing can be taken by mouth or if you are nauseated or vomiting; sometimes these medicines can be give rectally (suppository form). There may be a delay in pain relief, since you must ask for the medicine and wait for it to be brought to you; also, these medicines take time to wear off.

Injections into skin or muscle

Benefits:
Medicine given by injection into skin or muscle is effective even if you are nauseated or vomiting.

Risks:
The injection site is usually painful for a short time. Medicines given by injection are more expensive than tablets or liquids and take time to wear off. Pain relief may be delayed while you ask the nurse for medicine and wait for the shot to be drawn up and given.

Injections into vein:

Pain relief medicines are injected into a vein through a small tube, called an intravenous (IV) catheter. The tip of the tube stays in the vein.

Benefits:
Medicines given by injection into a vein are fully absorbed and act quickly. This method is well suited for relief of brief episodes of acute pain. When a patient controlled analgesia (PCA) pump is used, you can control your own small, frequent doses of pain medicine.

Risks:
A small tube must be inserted in a vein. If PCA is used, there are extra costs for pumps and supplies. You must want to use the pump and learn how and when to give yourself doses of medicine.

Injections into spine:

Medicine is given through a small tube in your back (called an epidural or intrathecal catheter).

Benefits:
This method works well when you have chest surgery or an operation on the lower parts of your body.

Risks:
Staff must be specially trained to place a small tube in the back and to watch for problems that can appear hours after pain medicine is given. Extra supplies are needed.

Non-Drug Pain Relief Methods

These methods can be effective for mild to moderate pain and to boost the pain-relief effects of drugs. There are no side effects. These techniques are best learned before surgery.

Patient teaching:

Learning about the operation and the pain expected afterwards (for example, techniques when coughing or getting out of bed or a chair).

Benefits:
These techniques can reduce anxiety; they are simple to learn, and no equipment is needed.

Risks:
There are no risks; however, patient attention and cooperation with staff are required.

Relaxation:

Simple techniques , such as abdominal breathing and jaw relaxation, can help to increase your comfort after surgery.

Benefits:
Relaxation techniques are easy to learn, and they can help to reduce anxiety. After instruction, you can use relaxation at any time. No equipment is needed.

Risks:
There are no risks, but you will need instruction from your nurse or doctor.

Physical agents:

Hot and cold packs, massage, acupressure, music therapy, and TENS therapy are some of the non-drug pain relief methods that might be used following surgery.

Benefits:
In general, physical agents are safe and have no side effects. TENS, which stands for transcutaneous electrical nerve stimulation, is often helpful; it is quick to act and can be controlled by the patient.

Risks:
There are no risks related to the use of physical techniques for managing pain. If TENS is used, there is some cost and staff time involved for purchasing the machine and instructing patients in its use. Also, there is only limited evidence to support the effectiveness of TENS for pain relief in certain situations.

Example of Non-drug Pain Relief-Slow Rhythmic Breathing Relaxation

Breathe in slowly and deeply.
As you breathe out slowly, feel yourself beginning to relax; feel the tension leaving your body.
Now breathe in and out slowly and regularly, at whatever rate is comfortable for you. You may try abdominal breathing. If you do not know how to do abdominal breathing, ask your nurse for help.
To help you focus on your breathing and breathe slowly and rhythmically:
- Breathe in as you say silently to yourself, "in, two, three."
  Breathe out as you say silently to yourself, "out, two, three."
  or
- Each time you breathe out, say silently to yourself a word calming word such as peace or relax.
You may imagine that you are doing this in a place that is very calming and relaxing for you, such as lying in the sun at the beach.
Do steps 1 through 4 only once or repeat steps 3 and 4 for up to 20 minutes.
End with a slow deep breath. As you breathe out say to yourself "I feel alert and relaxed."

Additional points: If you intend to do this for more than a few seconds, try to get a comfortable position in a quiet place. You may close your eyes or focus on an object. This breathing exercise may be used for only a few seconds or for up to 20 minutes.

Resources: Acute Pain Management Guideline Panel. Pain Control After Surgery, A Patient's Guide. AHCPR Pub. No. 92-0021. Rockville, :Agency for Healthy Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. Feb. 1992.
River Oaks Health System; River Oaks Hospital and Woman's Hospital
Clinical Practice Guideline for Acute Pain Management: Operative or Medical Procedures for Trauma. The guideline was developed by a private sector, expert panel made up of doctors, nurses, other health care providers, an ethicist, and a consumer representative. It was sponsored by the Agency for Health Care Policy and Research (AHCPR), an agency of the U.S. Public Health Service.

Pub. No. AHCPR 92-0068