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  1. Analgesia, as distinct from hypnosis, is a vital and integral component of anesthesia.

  2. Anesthesiologists must plan for the continuum of intra- and postoperative pain.

  3. The principles of "opioid sparing" or "multimodal analgesia" are central to the goal of rapid recovery because opioid side effects delay recovery.

  4. Patient-controlled analgesia (PCA) has greatly facilitated acute pain management at both provider and institutional levels.

  5. Epidural analgesia continues to play an important role in the treatment of pain after major intra-abdominal and thoracic surgery, although the benefit versus risk should be reexamined in an era of potent thrombosis prophylaxis.

  6. Chronic opioid use and abuse are emerging as prominent challenges during acute pain treatment.

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After the first public demonstration of ether anesthesia at the Massachusetts General Hospital in 1846, the news that "We have conquered pain" spread around the world. What was not understood at the time is that the potent hypnotics merely suspend pain perception but do little to change pain transmission. The addition of neural blockade or strong analgesics (notably opioids) is needed to halt the pain processes that excite the nervous system, trigger neuroendocrine stress responses, and produce pain once it can be perceived. The provision of analgesia, during and after surgery, is now considered a vital and integral part of anesthesia, and its central goal to reduce the stress and derangements of surgery. Anesthesiologists apply their knowledge of pharmacology, anatomy, physiology, pathophysiology, surgery, and medicine toward optimizing pain relief. Whether by means of an informal relationship with surgical colleagues or a more structured service—an acute pain service—they play a key role in managing postoperative pain.1 As experts, they help educate others in the tools of pain management and teach the importance of pain control in terms of postoperative recovery.

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Institutional Considerations

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The Role of the Acute Pain Service

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The idea of the acute pain service arose during the 1980s when "walking" epidurals made epidural analgesia suddenly more feasible for postoperative patients and when the microchip made patient-controlled analgesia (PCA) pumps small enough to have wide applicability. Initially, pain services ran both these modalities, developed treatment protocols, and taught nurses and others how to manage these new therapies. Soon, surgeons and nurses became familiar with the use of PCA, so that this component of postoperative management, at least for routine cases, is largely being managed by them. Epidurals remain the province of anesthesiologists, and the core function of the acute pain service is to manage postoperative epidural analgesia. The acute pain service is also available to help with complex cases, notably cases that cannot be managed using routine measures. Naturally, each institution will structure its pain service differently, according to institutional and local factors. Smaller hospitals and ambulatory facilities may not have a service as such.

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Acute pain services are usually staffed by a mixture of attending physicians (sometimes pain trained and commonly anesthesiologists), nurses, physician assistants, pain fellows, and anesthesia ...

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