Experiences and perspectives of adults on using opioids for pain management in the postoperative period: A scoping review

BACKGROUND

Opioids play an important role in peri-operative pain management. However, opioid use is challenging for healthcare practitioners and patients because of concerns related to opioid crises, addiction and side effects.

OBJECTIVE

This review aimed to identify and synthesise the existing evidence related to adults' experiences of opioid use in postoperative pain management.

DESIGN

Systematic scoping review of qualitative studies. Inductive content analysis and the Theoretical Domains Framework (TDF) were applied to analyse and report the findings and to identify unexplored gaps in the literature.

DATA SOURCES

Ovid MEDLINE, PsycInfo, Embase, CINAHL (EBSCO), Cochrane Library and Google Scholar.

ELIGIBILITY CRITERIA

All qualitative and mixed-method studies, in English, that not only used a qualitative approach that explored adults' opinions or concerns about opioids and/or opioid reduction, and adults' experience related to opioid use for postoperative pain control, including satisfaction, but also aspects of overall quality of a person's life (physical, mental and social well being).

RESULTS

Ten studies were included; nine were qualitative ( n  = 9) and one used mixed methods. The studies were primarily conducted in Europe and North America. Concerns about opioid dependence, adverse effects, stigmatisation, gender roles, trust and shared decision-making between clinicians and patients appeared repeatedly throughout the studies. The TDF analysis showed that many peri-operative factors formed people's perceptions and experiences of opioids, driven by the following eight domains: Knowledge, Emotion, Beliefs about consequences, Beliefs about capabilities, Self-confidence, Environmental Context and Resources, Social influences and Decision Processes/Goals. Adults have diverse pain management goals, which can be categorised as proactive and positive goals, such as individualised pain management care, as well as avoidance goals, aimed at sidestepping issues such as addiction and opioid-related side effects.

CONCLUSION

It is desirable to understand the complexity of adults' experiences of pain management especially with opioid use and to support adults in achieving their pain management goals by implementing an individualised approach, effective communication and patient-clinician relationships. However, there is a dearth of studies that examine patients' experiences of postoperative opioid use and their involvement in opioid usage decision-making. A summary is provided regarding adults' experiences of peri-operative opioid use, which may inform future researchers, healthcare providers and guideline development by considering these factors when improving patient care and experiences.

Educational needs and preferences of adult patients with acute pain: a mixed-methods systematic review

ABSTRACT

Many patients experience acute pain, which has been associated with numerous negative consequences. Pain education has been proposed as a strategy to improve acute pain management. However, studies report limited effects with educational interventions for acute pain in adults, which can be explained by the underuse of the person-centered approach. Thus, we aimed to systematically review and synthetize current evidence from quantitative, qualitative and mixed-methods studies describing patients' needs and preferences for acute pain education in adults. We searched original studies and gray literature in 7 databases, from January 1990 to October 2023. Methodological quality was assessed with the Mixed Methods Appraisal Tool. A total of 32 studies were included (n = 1847 patients), two-thirds of which were qualitative studies of high methodological quality. Most of the studies were conducted over the last 15 years in patients with postsurgical and posttraumatic pain, identified as White, with a low level of education. Patients expressed the greatest need for education when it came to what to expect in pain intensity and duration, as well how to take the medication and its associated adverse effects. The most frequently reported educational preferences were for in-person education while involving caregivers and to obtain information first from physicians, then by other professionals. This review has highlighted the needs and preferences to be considered in pain education interventions, which should be embedded in an approach cultivating communication and partnership with patients and their caregivers. The results still need to be confirmed with different patient populations.

Movement-evoked Pain versus Pain at Rest in Postsurgical Clinical Trials and in Meta-analyses: An Updated Systematic Review

BACKGROUND

Given the widespread recognition that postsurgical movement-evoked pain is generally more intense, and more functionally relevant, than pain at rest, the authors conducted an update to a previous 2011 review to re-evaluate the assessment of pain at rest and movement-evoked pain in more recent postsurgical analgesic clinical trials.

METHODS

The authors searched MEDLINE and Embase for postsurgical pain randomized controlled trials and meta-analyses published between 2014 and 2023 in the setting of thoracotomy, knee arthroplasty, and hysterectomy using methods consistent with the original 2011 review. Included trials and meta-analyses were characterized according to whether they acknowledged the distinction between pain at rest and movement-evoked pain and whether they included pain at rest and/or movement-evoked pain as a pain outcome. For trials measuring movement-evoked pain, pain-evoking maneuvers used to assess movement-evoked pain were tabulated.

RESULTS

Among the 944 included trials, 504 (53%) did not measure movement-evoked pain (vs. 61% in 2011), and 428 (45%) did not distinguish between pain at rest and movement-evoked pain when defining the pain outcome (vs. 52% in 2011). Among the 439 trials that measured movement-evoked pain, selection of pain-evoking maneuver was highly variable and, notably, was not even described in 139 (32%) trials (vs. 38% in 2011). Among the 186 included meta-analyses, 94 (51%) did not distinguish between pain at rest and movement-evoked pain (vs. 71% in 2011).

CONCLUSIONS

This updated review demonstrates a persistent limited proportion of trials including movement-evoked pain as a pain outcome, a substantial proportion of trials failing to distinguish between pain at rest and movement-evoked pain, and a lack of consistency in the use of pain-evoking maneuvers for movement-evoked pain assessment. Future postsurgical trials need to (1) use common terminology surrounding pain at rest and movement-evoked pain, (2) assess movement-evoked pain in virtually every trial if not contraindicated, and (3) standardize movement-evoked pain assessment with common, procedure-specific pain-evoking maneuvers. More widespread knowledge translation and mobilization are required in order to disseminate this message to current and future investigators.

EDITOR’S PERSPECTIVE

Assessment of post-operative pain management among acutely and electively admitted patients - a Swedish ward perspective

RATIONALE, AIMS AND OBJECTIVES

Swedish health care is regulated to involve the patient in every intervention process. In the area of post-operative pain, it is therefore important to evaluate patient experience of the quality of pain management. Previous research has focused on mapping this area but not on comparing experiences between acutely and electively admitted patients. Hence, the aim of this study was to investigate the experiences of post-operative pain management quality among acutely and electively admitted patients at a Swedish surgical department performing soft-tissue surgery.

METHODS

A survey study design was used as a method based on a multidimensional instrument to assess post-operative pain management: Strategic and Clinical Quality Indicators in Postoperative Pain Management (SCQIPP). Consecutive patients at all wards of a university hospital's surgical department were included. Data collection was performed at hospital discharge.

RESULTS

In total, 160 patients participated, of whom 40 patients were acutely admitted. A significant difference between acutely and electively admitted patients was observed in the SCQIPP area of environment, whereas acute patients rated the post-operative pain management quality lower compared with those who were electively admitted.

CONCLUSIONS

There may be a need for improvement in the areas of post-operative pain management in Sweden, both specifically and generally. There may also be a difference in the experience of post-operative pain quality between acutely and electively admitted patients in this study, specifically in the area of environment. In addition, low levels of the perceived quality of post-operative pain management among the patients were consistent, but satisfaction with analgesic treatment was rated as good.

Patients' experiences and actions when describing pain after surgery--a critical incident technique analysis

BACKGROUND

Postoperative pain assessment remains a significant problem in clinical care despite patients wanting to describe their pain and be treated as unique individuals. Deeper knowledge about variations in patients' experiences and actions could help healthcare professionals to improve pain management and could increase patients' participation in pain assessments.

OBJECTIVE

The aim of this study was, through an examination of critical incidents, to describe patients' experiences and actions when needing to describe pain after surgery.

METHODS

An explorative design involving the critical incident technique was used. Patients from one university and three county hospitals in both urban and rural areas were included. To ensure variation of patients a strategic sampling was made according to age, gender, education and surgery. A total of 25 patients who had undergone orthopaedic or general surgery was asked to participate in an interview, of whom three declined.

FINDINGS

Pain experiences were described according to two main areas: "Patients' resources when in need of pain assessment" and "Ward resources for performing pain assessments". Patients were affected by their expectations and tolerance for pain. Ability to describe pain could be limited by a fear of coming into conflict with healthcare professionals or being perceived as whining. Furthermore, attitudes from healthcare professionals and their lack of adherence to procedures affected patients' ability to describe pain. Two main areas regarding actions emerged: "Patients used active strategies when needing to describe pain" and "Patients used passive strategies when needing to describe pain". Patients informed healthcare professionals about their pain and asked questions in order to make decisions about their pain situation. Selfcare was performed by distraction and avoiding pain or treating pain by themselves, while others were passive and endured pain or refrained from contact with healthcare professionals due to healthcare professionals' large work load.

Postoperative patients' perspectives on rating pain: A qualitative study

BACKGROUND

In postoperative pain treatment patients are asked to rate their pain experience on a single uni-dimensional pain scale. Such pain scores are also used as indicator to assess the quality of pain treatment. However, patients may differ in how they interpret the Numeric Rating Scale (NRS) score.

OBJECTIVES

This study examines how patients assign a number to their currently experienced postoperative pain and which considerations influence this process.

METHODS

A qualitative approach according to grounded theory was used. Twenty-seven patients were interviewed one day after surgery.

RESULTS

Three main themes emerged that influenced the Numeric Rating Scale scores (0-10) that patients actually reported to professionals: score-related factors, intrapersonal factors, and the anticipated consequences of a given pain score. Anticipated consequences were analgesic administration-which could be desired or undesired-and possible judgements by professionals. We also propose a conceptual model for the relationship between factors that influence the pain rating process. Based on patients' score-related and intrapersonal factors, a preliminary pain score was "internally" set. Before reporting the pain score to the healthcare professional, patients considered the anticipated consequences (i.e., expected judgements by professionals and anticipation of analgesic administration) of current Numeric Rating Scale scores.

CONCLUSIONS

This study provides insight into the process of how patients translate their current postoperative pain into a numeric rating score. The proposed model may help professionals to understand the factors that influence a given Numeric Rating Scale score and suggest the most appropriate questions for clarification. In this way, patients and professionals may arrive at a shared understanding of the pain score, resulting in a tailored decision regarding the most appropriate treatment of current postoperative pain, particularly the dosing and timing of opioid administration.

Validation study of the strategic and clinical quality indicators in postoperative pain management questionnaire in Turkish surgery patients

Determining patient satisfaction with postoperative pain management is an important intervention to improve strategies for effective pain control. The aim of this study was to validate an English version of the 14-item Strategic and Clinical Quality Indicators in Postoperative Pain Management questionnaire in Turkish language. The study included 113 patients who underwent elective surgeries at a university hospital in Bursa, Turkey. The data were collected after translation procedures and final adjustments were done on the original instrument. For the total scale, Cronbach's coefficient α was 0.81 and the main score obtained from the scale was 45.8 ± 10.8. Included were three subscales: nursing interventions, pain management, and environments. Of the patients, 40.7% reported more pain than expected in the postoperative period and their satisfaction with pain relief was 7.4 ± 2.5. This instrument is a reliable and valid instrument in Turkish language and can be used to evaluate the effectiveness of postoperative pain management.

Healthcare professionals' perceptions of the use of pain scales in postoperative pain assessments

AIM

To describe how healthcare professionals perceive the use of pain scales in postoperative care.

BACKGROUND

Pain scales are important but not an obvious choice to use in postoperative care. No study has explored how healthcare professionals experience the use of pain scales.

METHODS

An explorative design with a phenomenographic approach was used. The sample consisted of 25 healthcare professionals. Semistructured interviews were performed.

RESULTS

Four descriptive categories emerged - the use of pain scales facilitated the understanding of postoperative pain, facilitated treatment, demanded a multidimensional approach and was affected by work situations.

CONCLUSIONS

Healthcare professionals described that pain scales contribute to the understanding of patient's postoperative pain. It is important to ensure patient understanding and be aware about variations in pain ratings. Dialogue and observations are necessary to be certain what the ratings mean to the patient. The use of pain scales depends on patient's needs and organization.

Numeric rating scale: patients' perceptions of its use in postoperative pain assessments

AIM

The purpose of this study was to describe how patients perceive the use of the numeric rating scale in postoperative pain assessments.

BACKGROUND

There are recommendations to use a pain scale to follow patients' postoperative pain. Most patients prefer the NRS but there is a discrepancy between patients and healthcare professionals how to interpret the ratings from the pain assessments.

METHODS

A descriptive design with a phenomenographic approach was used. Semi structured interviews were held with 25 patients.

RESULTS

Three description categories emerged that illustrate patients' perceptions; use of the NRS facilitated communication of pain, it put demands on healthcare professionals and care routines and it contained interpretation difficulties.

CONCLUSION

The NRS has a place in pain management according to the patients but there is a need for a dialogue to give the patients the opportunity to describe their pain and set a common goal.

Efficacy of the use of evidence-based algorithmic guidelines in the acute care setting for pain assessment and management in older people: a critical review of the literature

AIM

The aim of the literature review was to identify all examples of primary research using an algorithmic approach for the implementation of a clinical practice guideline relating to pain assessment and/or management within acute care, with a specific focus on older people.

DESIGN

Critical literature review.

DATA SOURCES

Inclusion criteria were; English language publications within the past 13 years; peer reviewed; research conducted within a hospital; about adult inpatients. Exclusion criteria; research located outside of a hospital context; quality improvement studies; rehabilitation studies and literature reviews.

REVIEW METHODS

Critical appraisal of the literature by using a qualitative interpretation of a translational approach. The literature was thematically mapped according to the criteria of credibility, transferability, plausibility and applicability.

RESULTS

No clinical practice guideline was found that directly related to both assessment and management of pain using an algorithm in acute care for older people. Five studies were found to have relevance and were critically evaluated.

CONCLUSION

A critique of the literature shows that an algorithmic approach is feasible for translation into a clinical practice guideline for assessment and management of pain in older people within the acute care setting.

IMPLICATIONS FOR PRACTICE

Implementation of any algorithmic approach requires consideration of the environment, culture and availability of resources.

Adolescents' experience with scoliosis surgery: a qualitative study

This article reports a study of adolescents' narrated experiences of undergoing scoliosis surgery. Six adolescents were interviewed. Open and semistructured questions were asked, and a qualitative content analysis of the text was performed. The results are presented in three main categories followed by subcategories. The three main categories of experience were emotional, physical, and social. The emotional aspects that emerged were fear, nightmares, nervousness, and helplessness. These had a great impact on adolescents' well-being before, during, and after the hospital visit. The physical aspects were mobilization, scars, different hip levels, pain, nausea, appetite, and urinary catheter. These aspects caused much discomfort, mostly during the hospital visit. The social aspects were friends, power, coaching and comfort, and sports. Some of the social aspects had a strong negative impact on the adolescents' well-being mostly after the hospital visit. This study suggests that both before and long after the surgery adolescents have strong emotions that they should be better prepared and helped to manage. To optimize perioperative care an interdisciplinary, a holistic approach must be taken that incorporates the complexity and whole of the adolescent's experiences. The findings of this study suggest that perioperative care of adolescents during scoliosis surgery needs to be optimized. To improve patients' psychologic preparation before surgery pediatric nurses should learn more about the individual patient and make care plans from a holistic perspective. Follow-up after discharge should address emotional, social, and physical aspects of the adolescent's health.

Assessment of quality of care in acute postoperative pain management

BACKGROUND/AIM

Managing of acute postoperative pain should be of great interest for all hospital institutions, as one of the key components of patients satisfaction, which indicates quality, as well as the outcome of treatment. The aim of this study was to assess the quality of nursing care in managing acute postoperative pain and to establish factors which influence patients assessment of the same.

METHOD

The investigation was conducted on the sample of 135 patients hospitalized in surgical clinics of the Clinical Centre of Vojvodina in Novi Sad in the form of cross-sectional study, by interviewing patients during the second postoperative day and collecting sociodemographic variables, type of surgical procedure and applied analgesic therapy which were taken from their medical documentation. The modified questionnaire of the Strategic and Clinical Quality Indicators in Postoperative Pain Management (SCQIPP) was used as the instrument of the investigation. The data were processed with suitable mathematical statistics methods such as multivariate analyses of variance (MANOVA), discriminative and other parametric procedures and methods. Roy's test, Pearson's coefficient contingency (X), multiple correlation coefficient (R) were conducted amongst other univariant procedures.

RESULTS

The mean score for the individual items of SCQIPP questionnaire was between 2.0 and 4.7 (scale range 1-5) and the percentage of patients answers "strongly agree" ranged from 4.4 to 77%. The smallest number of positive answers were given by the patients for the item "In order to assess pain intensity, some of the staff asked me at least once in the morning, in the afternoon and in the evening to show the number from 0-10". Most of the patients (57%) evaluated severe pain during the previous 24 hours, as moderate pain, which represents significantly greater number of patients which complain of severe pain and mild pain (p < 0.001). The analysis of patients evaluation (MANOVA p < 0.05 and discriminative p < 0.05) indicates the existence of significant difference between the assessment of nursing care quality in managing acute postoperative pain as regards to clinics as the place for pain management, patient's sex and his expectations. Evaluation from "communication" subscale gives the greatest contribution (24.9%) to the difference between the observed clinics, and the greatest contribution (25.7%) to the difference in evaluation of nursing care quality as regards to patients' sex has the evaluations from "procedure" subscale.

CONCLUSION

The results of this study show a useful evidence and identify aspects of nursing care in postoperative management of acute pain which are still to be improved. According to the patients' answers the priority should be given to a regular assessment of the intensity of postoperative pain and evaluation of the effects of analgesic therapy.

Pain versus bleeding risk following tonsillectomy: do patients and doctors agree?

Objective:

To investigate the differing opinions of patients and medical practitioners regarding the relative priorities of pain relief versus bleeding prevention following tonsillectomy.

Methods:

Questionnaires were mailed out to adult patients, paediatric patients' parents, general practitioners and ENT surgeons.

Results:

A total of 72/112 (64.3 per cent) questionnaires were returned. Adult patients, paediatric patients' parents, general practitioners and ENT surgeons all ranked bleeding as the most important factor when assessing risks related to tonsillectomy. Most adult patients indicated that they would accept a bleeding risk of 2 per cent; however, parents indicated that they would accept a higher bleeding risk (3 per cent) for their children in exchange for better pain control.

Conclusions:

Adult patients, paediatric patients' parents and doctors were slightly more inclined to ‘trade-off’ an increased post-tonsillectomy bleeding risk in exchange for better post-tonsillectomy pain control, although concerns about post-operative haemorrhage remained the main priority for all groups.