State of the art in Acute Pain Medicine
ACUTE PAIN MANAGEMENT: SCIENTIFIC EVIDENCE – 2ND EDITION – WHY WAS IT NEEDED?
P E Macintyre
Royal Adelaide Hospital, Adelaide, SA
The aim of evidence-based acute pain guidelines is not to provide global standards or absolute requirements, but to assist decision-making (Walker et al 2005).
The National Health and Medical Research Council (NHMRC) of Australia published Acute Pain Management: Scientific Evidence in 1999. Professor Michael Cousins, current President of ANZCA, chaired the working party responsible for this first edition. At that time the NHMRC and the Agency for Health Care Policy and Research in the US were the only organisations worldwide to have produced evidence-based documents on which to base the treatment of acute pain.
A few years after the first edition was released, it became apparent that knowledge relating to the treatment of acute pain was growing rapidly and that the quality of the evidence was improving. There were also changes occurring in the complexity of acute pain treatments and in the type of patient seen by Acute Pain Services. It was more obvious that comprehensive acute pain management did not just mean care of patients with pain from mainly postoperative, obstetric and trauma-related causes, but included those with acute-on-chronic pain, acute cancer pain or acute pain from a multitude of medical conditions.
However, the progress made in knowledge and quality of evidence had not led to the same degree of progress in patient care. Recent publications have shown that the management of acute pain was often still less than optimal in both surgical and medical patients. While significant advances had been made in the understanding, assessment, and management of acute pain, this had not generally been translated into improvments in clinical practice.
It became clear that the available evidence needed to be updated and then disseminated in a concise and usable form to all health care practitioners.
For some time, the NHMRC had been encouraging development or revision of clinical practice guidelines by external bodies, although such guidelines are still subject to the same rigorous processes and reviews before they can be endorsed by the NHMRC. Therefore, the Australian and New Zealand College of Anaesthetists (ANZCA) and the Faculty of Pain Medicine (FPM) agreed to undertake the revision of Acute Pain Management: Scientific Evidence and appointed a working party to oversee the task
In addition to the working party, a large group of 58 contributors and 38 multidisciplinary panel members helped develop and review the early drafts. The contributors were from the following backgrounds:
| Anaesthesia * | Palliative care | Emergency medicine | * = majority |
| Pain medicine * | Intensive care | Oral surgery | |
| Paediatrics | Psychology | Basic sciences |
The backgrounds of the multidisciplinary panel members are listed in Table 1.
Because of the very large number of papers retrieved during the searches, it was not possible to include them all. Only articles published since 1998 (unless there were no better ones available) were assessed and, if there were a number of papers on the same subject, only those of the highest level of evidence were included (see Table 2 for NHMRC designation of levels of evidence). Fortunately, the Cochrane data base contained a large number of systematic reviews on a large number of acute pain management topics. When appropriate, important information was also obtained from audits, case series and case reports.
The process took 2.5 years, from the first meeting of the working party to final approval by the NHMRC. The document was published by ANZCA in July 2005. As an example of the better information available, while there were just 34 statements made in the first edition for which there was level I, II or III evidence, the second edition now has 108 statements of level I evidence alone. The proportion of citations based on Level I and II evidence also increased (e.g. from 8% to 50%.in the paediatric section).
The second edition has received formal endorsement from the component Colleges and Faculty of the Faculty of Pain Medicine, as well as the Royal College of Anaesthetists in the UK, the International Association for the Study of Pain (IASP) and the Australian Pain Society. The American Academy of Pain Medicine has recommended the document to its members. It also forms the basis for the section on acute and postoperative pain in the IASP Core Curriculum for Professional Education in Pain (3rd edition).
Importantly, international and national bodies have recently highlighted the need for better acute pain management. At a forum held in October 2004, co-sponsored by the IASP, the European Federation of IASP Chapters and the World Health Organization, to launch the Global Day Against Pain, the main message was that ‘the relief of pain should be a human right’. The forum concluded that improvements in the management of pain, including acute pain, require ‘global education of health professionals, patients and their families’. It is hoped that the revised document will provide some support for this educational process. The will also be a companion documents for patients. At a national level, the Victorian Quality Council is promoting its Operational Principles for Acute Pain Management and is undertaking a number of ventures designed to improve the assessment and management of acute pain throughout the state.
Where to from here?
Recommendations made for the management of acute pain will not suit all patients in all situations. The evidence will provide a basis for treatment choices only and the efficacy of any intervention must then be assessed and titrated for each patient.
There are still large gaps in the knowledge available. For example, more information is required about acute pain management in some groups commonly omitted from RCTs (e.g. elderly patients, opioid-tolerant patients, those with a substance abuse disorder or renal or hepatic impairment, patients with obstructive sleep apnoea), those at risk of poor assessment and management (e.g. patients with cognitive impairment), and patients managed in different settings (intensive care, emergency departments, primary care, pre-hospital care). In addition, some information changes rapidly (e.g. COX-2 inhibitors) and frequent updates to the acute pain guidelines will be needed.
The working party will therefore remain and meet on a regular basis to assess new evidence. While a full revision of the document is planned for 2010, it is hoped that updates will be posted on the ANZCA website at 6 to 12 month intervals.
| Table 1: Background of the 38 multidisciplinary panel members | ||
|---|---|---|
| Aboriginal Health Australian Medicines Handbook Basic Sciences Chiropractic Clinical Pharmacology Clinical Psychology Drug and Alcohol and Addiction Medicine Emergency Medicine General Practice General Surgery |
Geriatrics Intensive Care Medicine Neurology Neurosurgery Nursing Obstetrics Oncology Oral Surgery Orthopaedic Surgery Osteopathy |
Palliative Care Paediatrics Pharmacy Physiotherapy Psychiatry Rehabilitation Medicine Rheumatology Rural and Remote Medicine Thoracic Surgery Consumer representative |
| Table 2: NHMRC levels of evidence |
|---|
| I Evidence obtained from a systematic review of all relevant randomised controlled trials. II Evidence obtained from at least one properly designed randomised controlled trial. III-1 Evidence obtained from well-designed pseudo-randomised controlled trials (alternate allocation or some other method). III-2 Evidence obtained from comparative studies with concurrent controls and allocation not randomised (cohort studies), case-controlled studies or interrupted time series with a control group. III-3 Evidence obtained from comparative studies with historical control, 2 or more single-arm studies, or interrupted time series without a parallel control group. IV Evidence obtained from case series, either post-test or pre-test and post-test. |
| Clinical practice points: In addition to the above, information that was considered by the working party to be recommended best practice based on clinical experience was marked with a tick |
Time of Presentation:
Saturday 13 May 2006 - 1030-1200
References
1. Walker SM, Macintyre PE, Visser E, Scott D. Acute pain management: current best evidence provides guide for improved practice. Pain Med 2006;7:3-5
2. Schug SA, Macintyre PE, Power I, Scott S, Visser E, Walker S. The scientific evidence in acute pain management. Acute Pain 2005;7:161-5.
3. Macintyre PE, Walker S, Power I, Schug SA Acute pain management: scientific evidence revisited. Br J Anaesth 2006 Jan;96:1-4.
4. Macintyre PE, Schug SA, Scott DA. Acute pain management: the evidence grows.Med J Aust 2006; 184:101-2.
