Helen Askitopoulou Department of Anaesthesiology. Medical School, University of Crete

Over the past years the development of anaesthesia-based services for acute and chronic pain has highlighted the involvement of anaesthesiologists beyond the operating theatres in challenging new fields or disciplines that have changed the practice of contemporary surgery and medicine. Although pain. a common symptom of acute and chronic illness, has been targeted as an area of improvement across settings and populations, its relief has not reached the required level. M. Cousins in his Rovenstine Memorial Lecture, entitled "Pain : The Past, Present, and Future ofAnesthesiology," stated that post-surgical, post-trauma and cancer pain can now be relieved in more than 90% of patients, yet world-wide 50% or fewer patients have access to this type of relief [5]. The situation is even worse in chronic, non-cancer pain, for which, despite the fact that recent advances now make it possible to relieve pain in perhaps 70 to 80% of patients, fewer than 10% of patients with these difficult problems obtain pain relief [5].

Realising that achievement in pain treatment was not satisfactory, a wide variety of national and international organisations, devoted to the management of pain, have issued guidelines, produced by an army of international experts [1,2,8,11]. Despite these guidelines in many countries or hospitals a significant number of surgical or medical patients still experience an unacceptable level of acute or chronic pain. It is disturbing that although the information regarding pain management is widely published, it is rarely adopted in clinical practice. John Bonica stated very elegantly in 1990 : "for nearly thirty years I have studied the reasons for inadequate management of postoperative pain, and they remain the same, inadequate or improper application of available information and therapies is certainly the most important reason for inadequate postoperative pain relief [3]. It is no wonder that leaders in the field of pain management ask : "Is education enough ? " "Will guidelines make a difference ? " "Why more attention has not been paid to this phenomenon ?

Until the last decade pain following surgery had received little attention from the medical profession. Despite an unprecedented interest in understanding pain mechanisms and pain management, a significant number of patients continue to experience unacceptable pain after surgery. It has become increasingly clear that the development of an organisation to exploit existing expertise rather than the development of new techniques is the solution to the problems of postoperative pain management. Anaesthesia-based pain services are facilitating improvements in the quality of care of surgical patients by developing and directing institution-wide peri-operative analgesia programs that include interdisciplinary collaborations |7J. However, although Anaesthesiologists are in a unique position to provide leadership in pain management they have not taken up this challenge f9].

A recent European survey found that although the majority of European Anaesthesiologists were dissatisfied with pain management on surgical wards, only one third of the 105 selected hospitals studied from 17 nations during 1993 had some kind of organisation to provide Acute Pain Services (APS) [9]. Similar results were found in a nation-wide survey of 354 hospitals in the UK [15]. Of those hospitals that claimed to have a pain service, less than 65% had formally organised APS with daily ward rounds, development of protocols, quality assurance measurements, use of non-conventional techniques and nurse teaching [9]. A joint report of the Royal College of Surgeons and the College of Anaesthetists of Great Britain has led to a proliferation of "acute pain teams" in UK but the extent of medical cover and designated sessions vary f2,4J. It is time that the medical profession realises that the management of pain must become an important part of a health professional's role and that postoperative pain management must be approached as an integral part of the peri-operative care.

The introduction of acute pain services that exploit existing or new expertise is bound to optimise postoperative patient care and might well prove to be a significant factor in reducing postoperative morbidity. Although the impact of anaesthesia-based pain services has not been evaluated in a systematic fashion, the findings of clinical trials demonstrate that the care provided by these services has a significant impact on patient outcomes [7]. However, more concrete information from outcome studies coupled with further clinical practice is needed on the benefits of analgesia methods and on meaningful outcome improvements [12]. The demonstrated advantages need to go further beyond simply showing that pain relief is improved or that patients needed less morphine [12]. Successful pain management requires knowing the type of surgical procedure that has been performed as well as patient characteristics that may influence the choice of analgesic. The risk of morbidity is increased in patients with certain underlying conditions such as unstable angina if they do not receive adequate post-operative analgesia. The use of multimodal analgesia improves the effectiveness of pain relief after surgery than a single medication or administration route [8], while a team approach can lessen the amount of postoperative pain. Although pain is difficult to assess because of its unique nature, adequate and repeated assessments using techniques such as visual analogue scales are vital for good results and optimisation of pain control.

Chronic pain is recognised as a major health care and social problem [3] that causes much suffering and disability and is frequently mistreated or under-treated. Chronic pain has been regarded as the disease of the 21st century, a silent epidemic [3]. Patients with chronic pain often suffer silently. Relatives and others are silent : they hope it won't happen to them. Society is silent : mostly it is unaware of the enormous human and financial cost of this illness [5]. There is a huge gap between knowledge and practice, and this gap is, in fact, widening as the knowledge increases almost exponentially [5J. Although cure is possible, it is also infrequent. Many pain clinics have insufficient designated consultant sessions, support staff and premises [2]. Patients with chronic pain frequently require a multidisciplinary model of care to allow care givers to address pain on a multidimensional perspective, which defines pain simultaneously as a physical and psychological experience. For patients in whom conventional procedurally based treatments are ineffective and in those who have not found success in traditional pain clinics, the biopsychosocial model that recognises the complexity of chronic pain has been advocated [6]. Therapy is provided with the aim of decreasing pain and suffering while improving physical and mental functioning. The challenge is how best to train anaesthesiologists in biopsychosocial chronic pain management to complement their regional anaesthesia skills [6].

The field of pain management is rapidly changing requiring professional knowledge and experience in order to ensure pain management of good quality. Advances in the treatment of pain have created a standard of care by which quality can be assessed. The challenge for clinicians is to balance pain control with concern for side effects of pain treatments and patient safety. Effective strategies to increase the visibility of pain and the accountability of health-care professionals for the treatment of pain are needed to improve the quality of pain management [13]. In choosing a method for pain management, various factors need to be considered including physician skill, knowledge of analgesics and routes of administration, patient-related and clinical circumstances, the availability of an environment supportive of effective pain management, and the knowledge and skill of staff to assess and monitor patients. These factors need to be considered along with the risks and benefits and cost-benefit of the various drugs and techniques. Protocols describing strategies of pain management should be written and surveys and audits should be carried out regularly to check their efficacy. Moreover, patients should be fully informed of the range of treatments available and their adverse effects. Education of patients regarding the aims and risks of pain therapy is an essential pan of pain control and can lead to an improvement of both chronic and postoperative pain [14]. NB Scott has recently concluded that widespread public and professional education is required before further improvements can be made to such a universal and basic clinical problem [10]. Anaesthesiologists have the responsibility to educate themselves and also to educate others in the rapidly evolving field of pain management.

Pain management is already an integral and important component of anaesthesia practice and the speciality of anaesthesiology is committed to its management. Anaesthesiologists have the knowledge and expertise to relieve most post-surgical and cancer-related pain, and encouraging advances are being made in chronic pain management and in pain research. As anaesthesia for surgery and obstetric pain relief have been accepted world-wide as virtually a human right, at least it is morally and ethically unacceptable not to treat post-surgical pain [10]. This challenge should be taken up by Anaesthesiologists, who should lead a societal debate that pain relief is a basic human right. They must highlight the salience of pain and suffering for the public health and focus attention on the under-treatment of this epidemic of suffering. In the future, anaesthesiology can play the key role in the management of what will undoubtedly be the disease of the new millennium [5].

References

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Pain in Europe III. EFIC 2000, Nice, France, September 26-29, 2000. Abstracts book, p. 172 - 174.