The Role of Intravenous Acetaminophen in Acute Pain Management

A Case-Illustrated Review

Chris Pasero, MS, RN-BC, FAAN; Daphne Stannard, PhD, RN, CCRN, CCNS, FCCM

Disclosures

Pain Manag Nurs. 2012;13(2):107-124. 

In This Article

The Need for Improved Acute Pain Management

Effective treatment for pain is essential to achieve and maintain patient comfort and good clinical outcomes (Pasero, Quinn, Portenoy, McCaffery, & Rizos, 2011). Inadequate acute pain management can result in shortened or missed rehabilitation sessions and delayed mobilization (Morrison, Magaziner, McLaughlin, Orosz, Silberzweig, Koval, & Sui, 2003), and delayed ambulation can increase the risk for venous thromboembolism (Agnelli, Bolis, Capussotti, Scarpa, Tonelli, Bonizzoni, … Gussoni, 2006; Geerts, Bergqvist, Pineo, Heit, Samama, Lassen, … American College of Chest Physicians, 2008; Pasero & Portenoy, 2011). The psychologic effects of uncontrolled pain, such as insomnia, depression, and anxiety, may contribute to decreased quality of life, poor patient outcomes, and decreased patient satisfaction (Joshi & Ogunnaike 2005; Pasero & Portenoy, 2011; Wu, Naqibuddin, Rowlingson, Lietman, Jermyn, & Fleisher, 2003). Ineffective pain management also results in increased health care costs. In one study of patients undergoing surgical repair of a hip fracture, patients with higher postoperative pain scores had significantly longer hospital stays (Morrison et al., 2003). Another study found that the primary reason for unanticipated postoperative hospital admissions or readmissions was not due to surgical complications, medical complications, or bleeding, but was due to poorly controlled pain (Coley, Williams, DaPos, Chen, & Smith, 2002).

Despite improvements in analgesic delivery, including new analgesic options and the use of patient-controlled analgesia (PCA) by a variety of routes of administration (Pasero 2011), postoperative pain remains undertreated (Wu & Raja, 2011). The continued undertreatment of acute pain worldwide led the International Association for the Study of Pain (IASP) to designate 2011 as the Global Year Against Acute Pain (Vijayan, 2011). A comparison of two studies investigating the epidemiology of acute pain in postoperative patients—one conducted in 1995 and another in 2003—illustrates that pain control did not improve during that period. Warfield and Kahn (1995) reported the results of a study using telephone surveys of patients who had undergone surgery in teaching or community hospitals. They found that ~77% of patients reported experiencing postsurgical pain, and 80% of those patients rated their postsurgical pain as moderate to extreme (Warfield & Kahn, 1995). Apfelbaum, Chen, Mehta, & Gan (2003) reported similar results from their study using telephone surveys of 250 adults who had had recent surgical procedures. They found that ~80% of patients reported having acute postsurgical pain, and 86% of those patients reported that the pain was moderate, severe, or extreme (Apfelbaum et al., 2003).

Undertreatment of acute postoperative pain also increases the risk of progression from acute to chronic (persistent) pain (Joshi & Ogunnaike, 2005; Pasero, 2011). Kehlet, Jensen, and Woolf (2006) examined the incidence of persistent pain after common surgical procedures, such as coronary artery bypass surgery, breast and thoracic surgery, groin hernia repair, and leg amputation, and found that chronic (often disabling) pain can persist for months or years after the surgical wound has healed (Kehlet, Jensen, & Woolf, 2006).

Disadvantages of Opioid Monotherapy

Opioids have been used as analgesics for more than 2,000 years and continue to be a key element in moderate to severe acute postoperative pain management. However, opioid-only treatment plans can result in intolerable and dangerous adverse effects, including constipation, nausea and vomiting, excessive sedation, and respiratory depression (Jarzyna Jungquist, Pasero, Willens, Nisbet, Oakes, … Polomano, 2011; Pasero, 2009). Concerns are also being raised about a possible link between opioid-only treatment plans and a paradoxic clinical situation in which increasing doses of opioid result in increasing sensitivity to pain, a condition referred to as opioid-induced hyperalgesia (Angst & Clark, 2006; Lee, Silverman, Hansen, Patel, & Manchikanti, 2011; Pasero & McCaffery, 2012; Pasero 2011).

Adverse effects associated with opioids commonly occur and can prevent patients from experiencing satisfactory analgesia (Oderda, Said, Evans, Stoddard, Lloyd, Jackson, … Samore, 2007; Wheeler, Oderda, Ashburn, & Lipman, 2002). In a systematic review analyzing opioid-induced adverse effects among postoperative patients in 45 randomized-controlled studies, 31% of patients experienced an adverse gastrointestinal (GI) event (ileus, nausea, vomiting, constipation), 30.3% of patients reported an adverse central nervous system (CNS) event (somnolence, sedation), 18.3% of patients reported pruritus, 17.5% of patients experienced urinary retention, and 2.8% of patients had respiratory depression (Wheeler et al., 2002). These adverse effects, especially nausea and vomiting, can be so unpleasant that some patients are willing to accept less-than-adequate pain relief to avoid them (Eberhart, Morin, Wulf, & Geldner, 2002; Gan, Lubarsky, Flood, Thanh, Mauskopf, Mayne, & Chen, 2004). CNS effects associated with opioids also increase the risk for major postoperative complications, such as aspiration, respiratory failure, decreased mobility, and falls (Jarzyna et al., 2011; Oderda et al., 2007; Wheeler et al., 2002).

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