Pain after surgery: Why it's not usually smart to 'tough it out'

A week or so ago, I was sitting in a hospital room as a "civilian." That is, my role was not as a physician but as a friend. It was late at night, and my dear friend's husband was slowly waking up after having a hip replacement. He was clearly in pain, but when the nurse came to offer him pain medication, he refused. I was there to help him during these first few hours after surgery and so I gently suggested that he reconsider and take the pain medication as soon as possible. Not long after he swallowed his pills, he got a new roommate. This man had just had major knee surgery. Again, when the nurse came in and offered his roommate pain medication, he declined.

When I thought about this scenario, I realized that many people don't know about the tremendous efforts that are being made by healthcare professionals to better control patients' pain—especially post-operatively. This wasn't always so. One of the most famous accounts of surgical pain comes from a woman named Fanny Burney who endured a mastectomy for presumed breast cancer in 1811. With only a wine cordial (perhaps laced with laudanum, a tincture of opium that was often used to help with pain) to calm her, a group of men dressed in black held her down as the surgeon began the surgery.  Burney screamed and later wrote, "I almost marvel that it rings not in my Ears still…so excruciating was the agony." The mattress, drenched with blood, was discarded.

We've come a long way since Burney's surgery, which was standard protocol for that time period. We now have general anesthesia that makes the actual surgery quite tolerable. Nevertheless, post-operative pain control remains a problem—even in modern times. Doctors and allied health providers recognize this and have adopted pain as the fifth vital sign (after heart rate or "pulse", temperature, breathing rate, and blood pressure). As the fifth vital sign, you may have noticed that nurses now ask about pain every time they check a patient's other four vital signs in the hospital setting.

Hospital administrators, too, must take this fifth vital sign business seriously. When hospitals undergo accreditation, they must show written documentation that during the patient's stay, he or she is asked about pain (usually the nurse will ask a patient to rate his or her pain on a scale of zero to ten with ten being the most severe) and the response is noted in the chart. Also, according to the Comprehensive Accreditation Manual for Hospitals: The Official Handbook, "The following statement on pain management is posted in all patient care areas (patient rooms, clinic rooms, waiting rooms, etc.)…All patients have a right to pain relief."

My friend's nurse and I were chatting about the fact that both men, who had surgery that same day, refused the initial offering of pain medication. Did they do the right thing? The answer is: no. Well, let me qualify that response a bit. There might be legitimate reasons to avoid pain medications, such as if a patient has not tolerated them in the past or has a tenuous respiratory status that might be further depressed by pain medications. However, most people benefit from fairly liberal dosing of pain medications in the first couple of days after surgery.

Keep in mind that after an operation it's really easy to get behind on controlling pain. It's easier to control pain right after surgery than it is to control it later, if that pain becomes even more intense. Moreover, "toughing it out" just leads to a more difficult recovery and often a longer hospital stay. Many people have the idea that it's good to be tough when it comes to pain and that taking medication is not a good thing. Sometimes that's true, but not usually right after surgery. In fact, that's when you really want to control the pain so that you can heal as quickly as possible.

Uncontrolled pain in the first couple of days after surgery can lead to a whole host of medical problems that slow healing. For example, if someone has a lot of pain after surgery and doesn't move around very much, there might be a greater chance of developing a blood clot (deep venous thrombosis) that can travel to the lungs (pulmonary embolism). This is a common problem in people who have orthopedic surgery, and getting up and moving around as soon as possible is the best antidote. Doctors also use other methods to prevent this problem such as blood thinners, but nothing beats moving around.

So, what did I learn from my "civilian" venture into post-surgical care? I learned that despite the tremendous efforts of hospital personnel to improve pain control, many patients refuse the efforts, leading to sub-optimal care and healing. As doctors, we need to do a better job of talking to our patients about the reasons why it's a good idea to take pain medication right after surgery. Sure, there are times to be tough, but right after a major operation is not one of them.

Have you ever had post-surgical pain? Was it well-controlled? What worked and didn't work for you? Let me know what you think about doctors' efforts to control pain.

Julie K. Silver, M.D., is an assistant professor in the Department of Physical Medicine and Rehabilitation at Harvard Medical School. She is also the Chief Editor of Books for Harvard Health Publications.

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