Fortnightly review: Treating acute pain in hospital

Introduction

In treating acute pain, tradition and ill informed prejudice sometimes hold sway over evidence and common sense. In this review we concentrate on simple, clinically appropriate, and evidence based treatments.

Methods

Whenever possible we based our recommendations on systematic reviews of randomised trials. A citation database of systematic reviews of pain relief can be found at http://www.jr2.ox.ac.uk/Bandolier/painres/MApain.html. 1 We chose reviews for their relevance and quality. Poor quality reviews are significantly more likely to make positive conclusions.1 We collected over 12 000 randomised trials of analgesic interventions from 1950 onwards2; these are available on the Cochrane database. We used trials from this database when there was no relevant systematic review.

What is pain?

The neurophysiology of acute pain may be complex, with sensory, affective, cognitive, and behavioural dimensions intertwined (fig 1). Although pain is influenced by all the factors in figure 1), the subjective measurement of pain has proved to be robust. At its simplest the patient reports pain, and this report is the yardstick against which doctors measure the effects of treatment. The message is “believe the patient.” Doctors cannot measure pain objectively, so the management of pain in patients who cannot report pain, such as babies and those who are unconscious, may pose problems.

Effective pain management is fundamental to the quality of care. We believe that good control of pain also speeds recovery, but there is still no compelling evidence that this is so. Advantage can be shown with proxy measures such as mobility or coughing, but evidence …