Physicians have a poor track record for relieving pain. A deplorably large number of studies during the past few decades document our persistent failure to adequately relieve pain in many patients, particularly in those undergoing surgery and those with cancer-related pain. There are many reasons for this failure, including simply prescribing inadequate dosages of appropriate analgesics.1 Obviously, though, our patients would certainly be grateful to us if they received adequate pain control after surgery.
However, in this issue of American Family Physician, Gottschalk and Smith2 take the concept of postoperative pain control one step further, or should I say one step back. They describe an innovative approach to relieving predictable pain, such as that which occurs following surgery, by the preemptive administration of analgesia before the procedure starts. They also review the theoretic mechanisms by which preemptive analgesia might desensitize the nervous system and thereby reduce pain perception and other untoward effects that can persist far beyond the recovery period. To work best, it seems that painful stimuli should be blocked as much as possible throughout the perioperative period.
Regardless of the mechanism, preemptive analgesia has been shown to be effective in a variety of surgical procedures. One notable success story was the enhanced ability of preemptive analgesia to reduce phantom limb pain and stump pain as long as one year after lower extremity amputation.3 Studies of analgesia used in circumcision have shown lasting beneficial effects on an infant's subsequent response to painful stimuli (in the form of vaccinations).4,5 Although not all studies of preemptive analgesia show positive effects, there seems to be little downside to controlling pain before it starts and following the intriguing promise of enhanced and persisting beneficial effects.
If preemptive analgesia stands up to further study, it will join the ranks of two other proven therapies that work best when given before an operation begins—low-dose heparin and prophylactic antibiotics. Family physicians can help ensure that their patients undergoing painful procedures receive adequate pain control not only after but, perhaps, also before.