Federal Panel Backs Higher Drug Doses to Control Pain : Health: Under-medication of post-surgery patients can slow recovery. Guidelines recommend use of morphine.

Federal health officials recommended Thursday that surgery patients be given more drugs to control pain than they now typically receive, saying that under-medication results in unnecessary suffering, slower recovery and prolonged hospital stays.

In a series of guidelines that are expected to change the way the medical community treats post-surgical pain, the federal government said that both adults and children typically need higher and more frequent doses of painkillers delivered earlier than currently is standard practice.

The guidelines also recommended that morphine become the drug of choice for pain relief.

“We can do more and better to control pain after surgery,” Health and Human Services Secretary Louis W. Sullivan said in a press conference called to announce the recommendations. “We need to plan ahead for pain control.”

The guidelines, which were released by the department’s Agency for Health Care Policy and Research, are the result of two years’ work by a panel of pain management experts. The recommendations will be widely distributed to physicians, nurses, medical and nursing societies, medical and nursing schools, insurers, consumer groups and others.

While they are not binding, the guidelines are expected to become the standard of care for the nation’s physicians. The department estimated that more than 23 million surgeries are performed annually in this country.

The same panel is expected to announce guidelines for the control of cancer-related pain in December.

Dr. James O. Mason, assistant secretary for health and head of the U.S. Public Health Service, said that about half of those treated in the conventional manner for pain following surgery are under-medicated and experience “unacceptable” levels of pain. Typically, physicians prescribe painkillers “as needed” after surgery, a practice that results in too-little, too-late pain relief, he said.

“This means the patient is already in pain, often very severe pain, before the nurse is called, goes to the medication cabinet, prepares the injection, returns and gives it,” he said. “It means the patient goes in and out of pain. . . . The report calls for regular medication before the pain emerges or re-emerges.”

The report said that unmanaged pain actually can harm patients. It can impair the immune system, delay the return of normal stomach and bowel functions and make patients reluctant to cough and breathe deeply, which in turn places them at greater risk of complications such as pneumonia and blood clots, the report said.

“Pain is not just uncomfortable, it can be dangerous,” the agency said.

In recommending morphine as the drug of choice--instead of the more popularly used Demerol--the agency said that it is extremely unlikely that a brief post-surgical dose of morphine will result in addiction.

They said Demerol--or meperidine--is ineffective at the usual doses used. At higher doses that would make it more effective as a painkiller, it can have toxic side effects, causing kidney failure, irritability and seizures. At lower doses it can cause kidney failure in patients who already have impaired kidney function.

The guidelines also dismissed as “myths” several popular notions regarding pain, such as that infants do not feel pain, that elderly patients have a higher pain tolerance and that “pain is necessary and builds character.”

Children experience moderate to severe pain in as many as 60% of procedures, and many receive no post-operative pain medication, the report said. Painkillers frequently are withheld from infants because of the belief that the drugs could depress breathing. Recent studies, however, “show that careful pain treatment of infants reduces surgical stress and postoperative deaths,” the panel said.

The guidelines were endorsed by a range of medical organizations, including the American Medical Assn., the American Nurses Assn., the American Assn. of Critical Care Nurses, the American Academy of Pain Management and others.

“We’ve been scaring people into the arms of the euthanasia movement because they fear they won’t get adequate pain relief,” said Art Caplan, director of the Center for Biomedical Ethics at the University of Minnesota.

“We’ve made people terrified of words like ‘cancer,’ because it sounds like a sentence to suffer. Across the board, we’ve had too many people frightened of too many treatments because they worry that they’re going to hurt--and that is intolerable at a time when we’ve got the means to prevent it.

“We’ve had a puritanical attitude that says not only does pain build character but that pain is redemptive. . . , that pain is deserved,” Caplan added. “It’s time to separate our morality from our medical response to pain. So I think this is all to the good. And I think it should have an immediate impact on practice.”

Dr. James Todd, executive vice president of the American Medical Assn., explained that most physicians probably have been cautious about administering pain medication because they tended to “err on the side of giving too little, rather than too much,” he said.

Dr. Daniel Carr, director of the division of pain management of the anesthesia department at Massachusetts General Hospital, who was co-chairman of the panel, said that the new guidelines could result in reducing health care costs by preventing expensive post-surgical complications.

“If one assumed a hospital stay shortened by even a half-day in just 50% of the 23 million operations . . . each year, that would mean savings in the billions of dollars,” he said.

Carr and Ada K. Jacox, professor of nursing at the Johns Hopkins University School of Nursing, the other co-chairman, predicted that the guidelines would be used by courts in evaluating malpractice cases.

The guidelines also suggested the use of self-relaxation techniques, such as deep breathing or peaceful imagery, and non-drug aids, such as heat, cold and massage, to reduce pain.

And they said that when patients are allowed to “self-medicate” themselves with small intravenous doses of drugs using a metered infusion pump, they tend to be discharged earlier and may have fewer chronic pain problems.