Postoperative Pain Management: New Rules, New Tools for PACU Nurses
By Jennifer Mitchell, contributor
Opioids play an important role in the management of postoperative pain, but as any PACU nurse knows, these drugs come with serious risks. In the United States, opioid overdoses claim the lives of more than 130 people every single day, according to the National Institute on Drug Abuse. This national crisis has led to changes in the way opioids are prescribed, and even if you don't have prescribing authority, these changes still affect you and your patients.
The latest pain management guidelines
The opioid crisis has prompted changes in pain management guidelines. In its most recent pain management guidelines, the Centers for Disease Control and Prevention recommends prescribing the lowest effective dose of opioids for no longer than the amount of time a patient is expected to be in severe pain. The CDC notes that it's rare to need opioid treatment for more than 7 days. The American Pain Society reports that severe post-surgical pain tends to rapidly improve in the first few days of recovery and that most patients can tolerate tapering their opioid dose as their pain improves.
Accurately assessing patients' pain levels
PACU nurses are responsible for managing patients' pain levels after surgery, and to do that, they need to accurately assess those levels. Numeric pain rating scales are familiar to both nurses and patients, but some facilities use other methods to measure pain. The APS explains that other validated pain assessment tools include pain thermometers and faces rating scales.
Experienced PACU nurses also know to pay attention to objective signs of pain, such as pain behaviors or vital signs. However, since pain is subjective, and pain behaviors vary from one patient to another, the APS cautions against relying only on these objective signs. Instead, use them to supplement your patients' self reports.
Opioid prescribing trends
According to a study recently published in the New England Journal of Medicine, doctors in the United States are writing fewer prescriptions for opioids. Using administrative-claims data from Blue Cross-Blue Shield, the authors estimated that the monthly incidence of initial opioid prescriptions decreased by a whopping 54 percent between July 2012 and December 2017.
Doctors didn't just write fewer prescriptions for opioids; they also wrote shorter prescriptions. The incidence of opioid prescriptions of more than three days dropped by 57 percent, while prescriptions of more than seven days dropped by 68 percent.
These changes in opioid prescribing may be having a positive effect. According to the most recent provisional drug overdose death counts from the CDC, reported drug overdoses dropped by 2.8 percent between April 2018 and April 2019.
Other useful pain management methods PACU RNs can champion
During the postoperative period, opioids aren't the only available pain management method. In its pain medication guidelines, the APS explains that many drugs can be part of multimodal anesthesia, including ketamine, lidocaine, gabapentin and pregabalin. The APS also notes that when acetaminophen and non-steroidal anti-inflammatory drugs are used alongside opioids, patients need less opioids and have less postoperative pain.
Various nonpharmacologic therapies may be used to supplement opioids and other drugs. According to the APS, studies have found that patients who receive transcutaneous electrical nerve stimulation require about 25 percent less pain medication. Cognitive modalities, like guided imagery, music or relaxation techniques, may also be helpful, though right now, there isn't enough evidence to support specific techniques.
State-by-state opioid prescribing rules PACU nurses should understand
According to the National Conference of State Legislatures, at least 33 states have passed laws that put limits on opioid prescriptions. These limits vary significantly from one state to another, and as a PACU travel nurse, it can be hard to keep track. In New Jersey, for example, initial opioid prescriptions for acute pain are limited to just five days. Several states, including Indiana, Louisiana and New York, set their limits at seven days. In Arizona, doctors can prescribe up to 14 days of opioids after a surgical procedure, while Utah allows for 30 days. When you're traveling to a new state as a PACU RN, turn to your assignment facility for information about best practices for pain management.
All healthcare professionals are affected by new rules that aim to slow down the opioid crisis, but these rules are especially important for PACU nurses. To put your pain management expertise to work, visit Travel Nursing to find a rewarding PACU travel nurse position.