Pain, 41 (1990) 303-307 Elsevier
303
PAIN 01596
Clinical Note
Postoperative pain therapy: a survey of patients' expectations and their experiences Harry Owen, Virginia McMillan * and Dianne Rogowski * Department of Anaesthesia and Intensive Care, and * Department of Nursing, Flinders Medical Centre, Bedford Park, S.A. 5042 (Australia) (Received 6 October 1989, revision received 22 December 1989, accepted 24 December 1989)
Summary For 2 months elective surgical patients (n = 259) were asked preoperatively about their expectations of pain and pain relief. At both 24 and 72 h after their surgery they were asked about their pain and pai~l control. The analgesics they received were monitored for the first 72 h. The survey revealed that patients do not have the necessary knowledge about pain relief to contribute effectively in their own pain management. Analgesics administered intermittently were generally effective when given, however, the dosing interval was too long for the agents used resulting in frequent reports of poor pain relief. We conclude that patients need better education on postoperative pain control therapy. Medical staff could prescribe, and nursing staff administer, analgesics more effectively. Key words: Postoperative pain therapy; Pain expectations; Pain relief; Pain management
Introduction
A comprehensive audit of perioperative care should include the measurement of the quality of pain relief. Medical audits have tended to coneentrate upon complications and resource utilization [8] and have often omitted the issue of effective pain relief in the postoperative period. Where postoperative pain control has been surveyed it was generally found to be inadequate. At our institution 'on-demand' (PRN) intermittent intramuscular injection of an opioid (IMI) is
Correspondence to: Dr. H. Owen, Department of Anaesthesia and Intensive Care, Flinders Medical Centre, Bedford Park, S.A. 5042, Australia.
still the mainstay of postoperative pain control. This technique requires a nurse to interpret both a doctor's prescription and the patient's response to the administered drug. Hence, ~he frequent therapeutic failure of IMI is attributed to nursing staff [4-6,14,20,21], medical staff [13,14,18,20,21] and to the inherent properties of the technique [2-4,9]. Little is known of how much pain patients expect after their surgery or of what leads them to verbalize theh~paiii and request pain relief. However, with most methods of postoperative pain control, including IMI, efficacy is dependent on the patient communicating and the nursing and medical staff interpreting just these details. This study was designed to identify expectations of patients regarding postoperative pain and pain relief and to determine when administration of an analgesic agent would be requested.
0304-3959/90/$03.50 © 1990 Elsevier Science Publishers B.V. (Biomedical Division)
304
Patients and methods This investigation was approved by the Flinders Medical Centre Committee on Clinical Investigations. All adult patients admitted to the Centre for Elective Surgery in July and August, 1988, and who were expected to remain in hospital for more than 48 h after their surgery were considered eligible. These months were chosen as representative of the institution's activities. There were no public holidays during this time and there was no industrial action which could distort results. Nurse and medical staffing were within tiormal limits. The Centre has an operating theatre suite in which approximately 10,500 operations are carried out annually.
TABLE I RESULTS: PREOPERATIVE PATIENT QUESTIONNAIRE
Q1. How much pain do you expect to have after your operation?
No pain Mild pain Moderate pain Severe pain
4 12 42 13
Unbearable pain Don't know
1 27
Q2. If you are given medicinefor your pain after y o u r operation, do you want it to giveyou:
No relief Littlerehet Moderaterelicf A lot of relief Completerelief
0 3 26 44 27
Q3. If you have pain after your operation, whenwould you most likelyask for pain relieving medicine?
When havingsome pain 21 When pain becomessevere 65 Not ask. Wait until it is offered 5 Ask, regardlessof the amount of pain 6 Rather put up with the pain than have medicine 3
Q4. If you asked for pain relieving medicine,when would you expect it to be given?
Immediately,havingput up with the pain for as long as possible Immediately,unless the nurse was interrupted by an emergency When the nurse isn'i busy The next time the nurse is givingout medicine
31 45 21 3
Patients who met the survey criteria were asked to complete 3 questionnaires: one preoperatively, the other administered at both 24 and 72 h postoperatively. In the preoperative questionnaire, patients were asked how much pain they expected after surgery, how much relief from pain they wanted, when they would request analgesia (i.e., to what stimulus), and when, having made a request, they expected to receive pain relief. In the postoperative questionnaires, patients were asked how much pain had been present in the previous 24 h, for what length of time pain had been relieved and how much relief had been olztained from administered analgesics. The postoperative questionnaires were administered as close to 24 and 72 h as possible. The actual questions asked are reported in Tables I and III. The survey incorporated a pain rating scale of none, mild, moderate, severe, and unbearable in the questionnaires. It has a good correlation with visual analogue scales (VAS) and an acceptable degree of variation between individuals [17]. Whilst the VAS is most efficient for monitoring the progress of an individual patient, the pain rating scale has advantages in inter-individual assessment. In addition, at each postoperative visit, the method of pain therapy prescribed and frequency of analgesic administration was recorded. All data were collected by the authors with the help of a specially employed registered nurse.
Results Informed written consent was obtained from 262 patients; due to rescheduling of surgery, transfers and discharges 259 patients filled in the first, 213 the second and 186 the third questionnaires. The responses to the preoperative questions are shown in Table I. Of note, few patients expected little or no pain (Q.1) although most wanted effective analgesia (Q.2). The majority of patients would wait until they had severe pain before askh~g for analgesic medication (Q.3) and expected it to be administered promptly (Q.4). The majority of patients (77%) were prescribed analgesics to be admimstered 'on demand' (prn) and this was usually (57%) intermittent intramus-
305 TABLE II ROUTES OF ANALGESIA ADMINISTRATION n
% experiencing severe or unbearable pain
Intermittent intramuscular opioid 121 57 37 Continuous intravenous opioid 49 23 26.5 infusion Intermittent epidural pethidine 9 4 Not calculated Intermittent oral non-opioid 34 16 Not calculated Total
.-
213
cular (IMI) morphine or pethidine (Table II). The IMI prescriptions usually stipulated a dose range, although the maximum dose was never more than 10 nag morphine (sulphate) or 100 mg pethidine. The stipulated interval between injections was 3-4 h. The mean rate of administration for both pethidine and morphine was identical: 2.7 injections in the first 24 h after surgery, with a wide dosing range noted (0-775 mg pethidine and 0-60 mg for morphine).
TABLE III RESULTS: POSTOPERATIVE (24 and 72 h) PATIENT QUESTIONNAIRE 24 h
72 h
(~)
(~)
6 20
9 26
amount of pain you have had in the past 24 h?
Moderatepain 37 Severepain 28 Unbearable pain 9
39 21 5
Q2. Whichof the following best describes the length of time your pain has been relieved?
Noneof the time 2 Some of the time 40 Most of the time 8 All of the time 8
4 37 9 9
Q3. In the last 24 h how much help have you got from painkillers?
No relief Little relief Moderaterelief A lot of relief Complete relief No analgesics received in previous 24 h
1 12 34 37 8
1 10 27 41 9
8
12
Q1. Which of the following No pain best describes the Mild pain
A quarter of patients received continuous infusion of an opioid. Bolus doses were prescribed in just over half of these and received by one-third of patients. Oral analgesics were prescribed for 16% of patients and epidural opioids administered to 9 patients. After surge~ (Table III) one quarter of patients had effective pain control (Q.1) and more than half of patients had pain for most or all of the time (Q.2). Patients receiving continuous infusion of opioid had similar pain control to those receiving IMI. There was little difference between reports of pain at 24 and 72 h. With either therapy, patients generally reported that analgesics were effective when administered (Q.3).
Discussion
This survey has confirmed the continuing failure to control pain after surgery. We do not believe that our institution is unique [4,7,11,14,15]. Although reliable pain relief is theoretically attainable, it is fortunat:: that most patients do not expect this outcome. The largest number of postoperative analgesic prescriptions were for intermittent 'on demand' (prn) drug administration (IMI). Since over twothirds of patients said they would wait until they were in severe pain before requesting analgesia, or not ask at all, it is not surprising that so many patients experienced severe, unrelieved pain postoperatively. Further, 75% of patients expected that when analgesics were requested they would be obtained immediately. The lag between demand and response is a failing of intermittent 'on demand' administration techniques. Nursing staff apparently underestimate this lag time between request and response [11] although it contributes significantly to poor pain management and, to compound the issue further, many nurses wait for the patient to be in severe pain before administering analgesia. When administered, analgesics were generally effective, suggesting that the dose chosen was appropriate, but that the dosing interval, as evidenced by the small number of doses, was a fault.
306
Since the mean frequency of injection (2.7 in 24 h) was so far short of the known duration of action, it is not surprising that patients were in pain for so much of the time. A previous survey of postoperative pain had concluded that the introduction of continuous intravenous infusions could improve pain control [11]. We found that patients receiving continuous intravenous administration of opioid had fewer complaints of severe or unbearable pain than IMI. However, there were still a quarter of patients in the continuous infusion group who described their pain as either severe or unbearable. It is likely that because patients wait until in severe pain before requesting analgesia they contribute to the inadequate dosing and, therefore, therapeutic failure. Direct comparison of the effectiveness of IMI and continuous infusion of opioid cannot be drawn from these results because the variables of operation type and criteria for choice of analgesic were not controlled. The tendency was for patients having more major surgery to be prescribed continuous intravenous infusion of opioid. Whilst there has been a focus on the development of new drugs or new technology to provide better pain control, education on the appropriate use of traditional methods could be more cost effective. Most research on postoperative pain therapy concentrates on the first day or two after surgery, even though pain may persist for much longer [9,16]. A quarter of patients in this survey recalled severe or unbearable pain in the 48-72 h postoperative period. The calls for special wards where patients can receive special analgesic care for 2448 h after their surgery [12] may therefore be too simplistic and unnecessary. Another approach is to develop a skilled team or 'acute pain service' [191. Such a resource could best select patients for the advanced techniques of patient-controlled and epidural analgesia. In terms of affecting the largest number of patients, an 'acute pain service' could provide a core of educators to teach the effective use of traditional pain therapies. The need for better education in postoperative pain therapy has been reported previously [5]. The authors suggest the most appropriate venue for this to be in the
surgical ward where the results of decisions can be evaluated. In spite of the advances in health care in the last 100 years, including the growth in knowledge about pain and analgesics, the transfer of that knowledge into clinical practice has not advanced. The patient plays a major part in determining the effectiveness of both IMI and continuous infusion methods of postoperative pain control. This aspect, we believe, has generally been understated. Unrelieved pain after surgery is still expected by all parties involved. Surgeons, nurses and anaesthetists can help address the problem by teaching patients preoperatively to communicate about their pain more effectively [1]. Of course, as a corollary to this, a higher priority must be attached to effective pain control by health professionals [1,6]. It would be disastrous to raise patients' expectations if the logistics for providing quality postoperative pain therapy are not in place. The solution may not require new technology but instead be based upon more effective communication and skill in utilizing the traditional systems.
Acknowledgements The authors wish to acknowledge the support of Aileen Monck, Director of Nursing, who made the survey possible by employing a research nurse. Jill Mitchell, RN, collected and organized much of the data. Prof. M.J. Cousins and Prof. J.D. Loeser gave helpful advice on this paper.
References 1 Al~.onymous, Postoperative pain, Br. Med. J., ii (1978) 517. 2 Anonymous, Postoperative pain, Br. Med. J., ii (1976) 664. 3 Austin, K.L., Stapleton, J.V. and Mather, L.E., Multiple intramuscular injections: a major source of variability in analgesia response to meperidine, Pain, 8 (1980) 47-62. 4 Cartwright, P.D., Pain control after surgery: a survey of current practice, Ann. Roy. Coll. Surg. Engl., 67 (1985) 13 -16. 5 Champman, P.J., Ganendran, A., Scott, R.J. and Basford, K.E., Attitudes and knowledge of nursing staff in relat.ion to management of postoperative pain, Aust. NZ J. Surg., 57 (1987) 447-450.
307 6 Cohen, F.L., Postsurgical pain relief: patients' status and nurses medication choices, Pain, 9 (1980) 265-274. 7 Cousins, M.J. and Mather, L.E.M., Relief of postoperative pain: advances awaiting medication, Med. J. Aust., 150 (1989) 354-356. 8 Devlin, H.B., Professional audit; quality control; keeping up to date, Clin. Anesthesiol., 2 (1988) 299-324. 9 Donovan, B.D., Patients' attitudes to postoperative pain relief, Anaesth. Intens. Care, 78 (1983) 125-129. 10 Donovan, M.~ Dillon, P. and McGuire, L., Incidence and characteristics of pain in a sample of medical-surgical inpatients, Pain, 30 (1979) 69-78. 11 Gibbs, J.M., The need for patient education on analgesic drug treatment, Curr. Ther., 25 (1984) 65. 12 Hull, C.J., Control of pain in the perioperative period, Br. Med. Bull., 4 (1988) 341-356. 13 Marks, R.M. and Sachar, E.J., Undertreatment of medical inpatients with narcotic analgesics, Ann. Intern. Med., 78 (1973) 173-181. 14 Mather, U and Mackie, J., The incidence of postoperative pain in children, Pain, 16 (1983) 427. 15 Mather, L.E. and Owen, H., The scientific basis of patientco,trolled analgesia, Anaesth. Intens. Care, 16 (1988) 427.
16 Melzack, R., Abbott, F.Z., Zackon, W., Mulder, D.S. and Davis, M.W.L., Pain on a surgical ward: a survey of the duration and intensity of pain and the effectiveness of medication, Pain, 29 (1987) 67. 17 Mitchell, R.W.D and Smith, G., The control of acute postoperative pain, Br. J. Anaesth., 63 (1989) 147-158. 18 Morgan, J.P., American opiophobia: Customary underutilization of opioid analgesics, Adv. Alcohol Subst. Abuse, 5 (1986) 163-173. 19 Ready, L.B., Oden, R., Chadwick, H.S., Benedetti, C., Rooke, G.A., Caplan, R. and Wild, L.M., Development of an anesthesiology-based postoperative management service, Anesthesiology, 68 (1988) 100-106. 20 Sriwantanakul, K., Weis, O.F., Alloza, J.L., Eelvie, W., Weintraub, M. and Lasagna, L., Analysis of narcotic analgesic usage in the treatment of postoperative pain, JAMA, 250 (1983) 926. 21 Weis, O.F., Sriwantanakul, K, Alloza, J.L., Weintraub, M and Lasagna, L., Attitudes of patients, housestaff, and nurses towards postoperative analgesic care, Anesth. Analg., 62 (1983) 70-74. 22 Wilson, P.R., Postoperative analgesia, Med. J. Aust., 150 (1989) 399.
303
PAIN 01596
Clinical Note
Postoperative pain therapy: a survey of patients' expectations and their experiences Harry Owen, Virginia McMillan * and Dianne Rogowski * Department of Anaesthesia and Intensive Care, and * Department of Nursing, Flinders Medical Centre, Bedford Park, S.A. 5042 (Australia) (Received 6 October 1989, revision received 22 December 1989, accepted 24 December 1989)
Summary For 2 months elective surgical patients (n = 259) were asked preoperatively about their expectations of pain and pain relief. At both 24 and 72 h after their surgery they were asked about their pain and pai~l control. The analgesics they received were monitored for the first 72 h. The survey revealed that patients do not have the necessary knowledge about pain relief to contribute effectively in their own pain management. Analgesics administered intermittently were generally effective when given, however, the dosing interval was too long for the agents used resulting in frequent reports of poor pain relief. We conclude that patients need better education on postoperative pain control therapy. Medical staff could prescribe, and nursing staff administer, analgesics more effectively. Key words: Postoperative pain therapy; Pain expectations; Pain relief; Pain management
Introduction
A comprehensive audit of perioperative care should include the measurement of the quality of pain relief. Medical audits have tended to coneentrate upon complications and resource utilization [8] and have often omitted the issue of effective pain relief in the postoperative period. Where postoperative pain control has been surveyed it was generally found to be inadequate. At our institution 'on-demand' (PRN) intermittent intramuscular injection of an opioid (IMI) is
Correspondence to: Dr. H. Owen, Department of Anaesthesia and Intensive Care, Flinders Medical Centre, Bedford Park, S.A. 5042, Australia.
still the mainstay of postoperative pain control. This technique requires a nurse to interpret both a doctor's prescription and the patient's response to the administered drug. Hence, ~he frequent therapeutic failure of IMI is attributed to nursing staff [4-6,14,20,21], medical staff [13,14,18,20,21] and to the inherent properties of the technique [2-4,9]. Little is known of how much pain patients expect after their surgery or of what leads them to verbalize theh~paiii and request pain relief. However, with most methods of postoperative pain control, including IMI, efficacy is dependent on the patient communicating and the nursing and medical staff interpreting just these details. This study was designed to identify expectations of patients regarding postoperative pain and pain relief and to determine when administration of an analgesic agent would be requested.
0304-3959/90/$03.50 © 1990 Elsevier Science Publishers B.V. (Biomedical Division)
304
Patients and methods This investigation was approved by the Flinders Medical Centre Committee on Clinical Investigations. All adult patients admitted to the Centre for Elective Surgery in July and August, 1988, and who were expected to remain in hospital for more than 48 h after their surgery were considered eligible. These months were chosen as representative of the institution's activities. There were no public holidays during this time and there was no industrial action which could distort results. Nurse and medical staffing were within tiormal limits. The Centre has an operating theatre suite in which approximately 10,500 operations are carried out annually.
TABLE I RESULTS: PREOPERATIVE PATIENT QUESTIONNAIRE
Q1. How much pain do you expect to have after your operation?
No pain Mild pain Moderate pain Severe pain
4 12 42 13
Unbearable pain Don't know
1 27
Q2. If you are given medicinefor your pain after y o u r operation, do you want it to giveyou:
No relief Littlerehet Moderaterelicf A lot of relief Completerelief
0 3 26 44 27
Q3. If you have pain after your operation, whenwould you most likelyask for pain relieving medicine?
When havingsome pain 21 When pain becomessevere 65 Not ask. Wait until it is offered 5 Ask, regardlessof the amount of pain 6 Rather put up with the pain than have medicine 3
Q4. If you asked for pain relieving medicine,when would you expect it to be given?
Immediately,havingput up with the pain for as long as possible Immediately,unless the nurse was interrupted by an emergency When the nurse isn'i busy The next time the nurse is givingout medicine
31 45 21 3
Patients who met the survey criteria were asked to complete 3 questionnaires: one preoperatively, the other administered at both 24 and 72 h postoperatively. In the preoperative questionnaire, patients were asked how much pain they expected after surgery, how much relief from pain they wanted, when they would request analgesia (i.e., to what stimulus), and when, having made a request, they expected to receive pain relief. In the postoperative questionnaires, patients were asked how much pain had been present in the previous 24 h, for what length of time pain had been relieved and how much relief had been olztained from administered analgesics. The postoperative questionnaires were administered as close to 24 and 72 h as possible. The actual questions asked are reported in Tables I and III. The survey incorporated a pain rating scale of none, mild, moderate, severe, and unbearable in the questionnaires. It has a good correlation with visual analogue scales (VAS) and an acceptable degree of variation between individuals [17]. Whilst the VAS is most efficient for monitoring the progress of an individual patient, the pain rating scale has advantages in inter-individual assessment. In addition, at each postoperative visit, the method of pain therapy prescribed and frequency of analgesic administration was recorded. All data were collected by the authors with the help of a specially employed registered nurse.
Results Informed written consent was obtained from 262 patients; due to rescheduling of surgery, transfers and discharges 259 patients filled in the first, 213 the second and 186 the third questionnaires. The responses to the preoperative questions are shown in Table I. Of note, few patients expected little or no pain (Q.1) although most wanted effective analgesia (Q.2). The majority of patients would wait until they had severe pain before askh~g for analgesic medication (Q.3) and expected it to be administered promptly (Q.4). The majority of patients (77%) were prescribed analgesics to be admimstered 'on demand' (prn) and this was usually (57%) intermittent intramus-
305 TABLE II ROUTES OF ANALGESIA ADMINISTRATION n
% experiencing severe or unbearable pain
Intermittent intramuscular opioid 121 57 37 Continuous intravenous opioid 49 23 26.5 infusion Intermittent epidural pethidine 9 4 Not calculated Intermittent oral non-opioid 34 16 Not calculated Total
.-
213
cular (IMI) morphine or pethidine (Table II). The IMI prescriptions usually stipulated a dose range, although the maximum dose was never more than 10 nag morphine (sulphate) or 100 mg pethidine. The stipulated interval between injections was 3-4 h. The mean rate of administration for both pethidine and morphine was identical: 2.7 injections in the first 24 h after surgery, with a wide dosing range noted (0-775 mg pethidine and 0-60 mg for morphine).
TABLE III RESULTS: POSTOPERATIVE (24 and 72 h) PATIENT QUESTIONNAIRE 24 h
72 h
(~)
(~)
6 20
9 26
amount of pain you have had in the past 24 h?
Moderatepain 37 Severepain 28 Unbearable pain 9
39 21 5
Q2. Whichof the following best describes the length of time your pain has been relieved?
Noneof the time 2 Some of the time 40 Most of the time 8 All of the time 8
4 37 9 9
Q3. In the last 24 h how much help have you got from painkillers?
No relief Little relief Moderaterelief A lot of relief Complete relief No analgesics received in previous 24 h
1 12 34 37 8
1 10 27 41 9
8
12
Q1. Which of the following No pain best describes the Mild pain
A quarter of patients received continuous infusion of an opioid. Bolus doses were prescribed in just over half of these and received by one-third of patients. Oral analgesics were prescribed for 16% of patients and epidural opioids administered to 9 patients. After surge~ (Table III) one quarter of patients had effective pain control (Q.1) and more than half of patients had pain for most or all of the time (Q.2). Patients receiving continuous infusion of opioid had similar pain control to those receiving IMI. There was little difference between reports of pain at 24 and 72 h. With either therapy, patients generally reported that analgesics were effective when administered (Q.3).
Discussion
This survey has confirmed the continuing failure to control pain after surgery. We do not believe that our institution is unique [4,7,11,14,15]. Although reliable pain relief is theoretically attainable, it is fortunat:: that most patients do not expect this outcome. The largest number of postoperative analgesic prescriptions were for intermittent 'on demand' (prn) drug administration (IMI). Since over twothirds of patients said they would wait until they were in severe pain before requesting analgesia, or not ask at all, it is not surprising that so many patients experienced severe, unrelieved pain postoperatively. Further, 75% of patients expected that when analgesics were requested they would be obtained immediately. The lag between demand and response is a failing of intermittent 'on demand' administration techniques. Nursing staff apparently underestimate this lag time between request and response [11] although it contributes significantly to poor pain management and, to compound the issue further, many nurses wait for the patient to be in severe pain before administering analgesia. When administered, analgesics were generally effective, suggesting that the dose chosen was appropriate, but that the dosing interval, as evidenced by the small number of doses, was a fault.
306
Since the mean frequency of injection (2.7 in 24 h) was so far short of the known duration of action, it is not surprising that patients were in pain for so much of the time. A previous survey of postoperative pain had concluded that the introduction of continuous intravenous infusions could improve pain control [11]. We found that patients receiving continuous intravenous administration of opioid had fewer complaints of severe or unbearable pain than IMI. However, there were still a quarter of patients in the continuous infusion group who described their pain as either severe or unbearable. It is likely that because patients wait until in severe pain before requesting analgesia they contribute to the inadequate dosing and, therefore, therapeutic failure. Direct comparison of the effectiveness of IMI and continuous infusion of opioid cannot be drawn from these results because the variables of operation type and criteria for choice of analgesic were not controlled. The tendency was for patients having more major surgery to be prescribed continuous intravenous infusion of opioid. Whilst there has been a focus on the development of new drugs or new technology to provide better pain control, education on the appropriate use of traditional methods could be more cost effective. Most research on postoperative pain therapy concentrates on the first day or two after surgery, even though pain may persist for much longer [9,16]. A quarter of patients in this survey recalled severe or unbearable pain in the 48-72 h postoperative period. The calls for special wards where patients can receive special analgesic care for 2448 h after their surgery [12] may therefore be too simplistic and unnecessary. Another approach is to develop a skilled team or 'acute pain service' [191. Such a resource could best select patients for the advanced techniques of patient-controlled and epidural analgesia. In terms of affecting the largest number of patients, an 'acute pain service' could provide a core of educators to teach the effective use of traditional pain therapies. The need for better education in postoperative pain therapy has been reported previously [5]. The authors suggest the most appropriate venue for this to be in the
surgical ward where the results of decisions can be evaluated. In spite of the advances in health care in the last 100 years, including the growth in knowledge about pain and analgesics, the transfer of that knowledge into clinical practice has not advanced. The patient plays a major part in determining the effectiveness of both IMI and continuous infusion methods of postoperative pain control. This aspect, we believe, has generally been understated. Unrelieved pain after surgery is still expected by all parties involved. Surgeons, nurses and anaesthetists can help address the problem by teaching patients preoperatively to communicate about their pain more effectively [1]. Of course, as a corollary to this, a higher priority must be attached to effective pain control by health professionals [1,6]. It would be disastrous to raise patients' expectations if the logistics for providing quality postoperative pain therapy are not in place. The solution may not require new technology but instead be based upon more effective communication and skill in utilizing the traditional systems.
Acknowledgements The authors wish to acknowledge the support of Aileen Monck, Director of Nursing, who made the survey possible by employing a research nurse. Jill Mitchell, RN, collected and organized much of the data. Prof. M.J. Cousins and Prof. J.D. Loeser gave helpful advice on this paper.
References 1 Al~.onymous, Postoperative pain, Br. Med. J., ii (1978) 517. 2 Anonymous, Postoperative pain, Br. Med. J., ii (1976) 664. 3 Austin, K.L., Stapleton, J.V. and Mather, L.E., Multiple intramuscular injections: a major source of variability in analgesia response to meperidine, Pain, 8 (1980) 47-62. 4 Cartwright, P.D., Pain control after surgery: a survey of current practice, Ann. Roy. Coll. Surg. Engl., 67 (1985) 13 -16. 5 Champman, P.J., Ganendran, A., Scott, R.J. and Basford, K.E., Attitudes and knowledge of nursing staff in relat.ion to management of postoperative pain, Aust. NZ J. Surg., 57 (1987) 447-450.
307 6 Cohen, F.L., Postsurgical pain relief: patients' status and nurses medication choices, Pain, 9 (1980) 265-274. 7 Cousins, M.J. and Mather, L.E.M., Relief of postoperative pain: advances awaiting medication, Med. J. Aust., 150 (1989) 354-356. 8 Devlin, H.B., Professional audit; quality control; keeping up to date, Clin. Anesthesiol., 2 (1988) 299-324. 9 Donovan, B.D., Patients' attitudes to postoperative pain relief, Anaesth. Intens. Care, 78 (1983) 125-129. 10 Donovan, M.~ Dillon, P. and McGuire, L., Incidence and characteristics of pain in a sample of medical-surgical inpatients, Pain, 30 (1979) 69-78. 11 Gibbs, J.M., The need for patient education on analgesic drug treatment, Curr. Ther., 25 (1984) 65. 12 Hull, C.J., Control of pain in the perioperative period, Br. Med. Bull., 4 (1988) 341-356. 13 Marks, R.M. and Sachar, E.J., Undertreatment of medical inpatients with narcotic analgesics, Ann. Intern. Med., 78 (1973) 173-181. 14 Mather, U and Mackie, J., The incidence of postoperative pain in children, Pain, 16 (1983) 427. 15 Mather, L.E. and Owen, H., The scientific basis of patientco,trolled analgesia, Anaesth. Intens. Care, 16 (1988) 427.
16 Melzack, R., Abbott, F.Z., Zackon, W., Mulder, D.S. and Davis, M.W.L., Pain on a surgical ward: a survey of the duration and intensity of pain and the effectiveness of medication, Pain, 29 (1987) 67. 17 Mitchell, R.W.D and Smith, G., The control of acute postoperative pain, Br. J. Anaesth., 63 (1989) 147-158. 18 Morgan, J.P., American opiophobia: Customary underutilization of opioid analgesics, Adv. Alcohol Subst. Abuse, 5 (1986) 163-173. 19 Ready, L.B., Oden, R., Chadwick, H.S., Benedetti, C., Rooke, G.A., Caplan, R. and Wild, L.M., Development of an anesthesiology-based postoperative management service, Anesthesiology, 68 (1988) 100-106. 20 Sriwantanakul, K., Weis, O.F., Alloza, J.L., Eelvie, W., Weintraub, M. and Lasagna, L., Analysis of narcotic analgesic usage in the treatment of postoperative pain, JAMA, 250 (1983) 926. 21 Weis, O.F., Sriwantanakul, K, Alloza, J.L., Weintraub, M and Lasagna, L., Attitudes of patients, housestaff, and nurses towards postoperative analgesic care, Anesth. Analg., 62 (1983) 70-74. 22 Wilson, P.R., Postoperative analgesia, Med. J. Aust., 150 (1989) 399.
