Pain management after bowel (colorectal) cancer surgery

It is normal to experience some pain or discomfort for a few days after surgery, but with the variety of drugs and drug delivery systems available pain can be very effectively managed.

Some drugs can cause side effects like sickness or occasionally hallucinations, in some people and it may be necessary to try a different method of pain relief if one is unsatisfactory. Pain relief may be delivered by epidural (a small needle inserted into the spine) by PCA (patient-controlled analgesia, a machine which releases controlled doses of medication at the push of a button), by injection, or in tablet form.

Chris recalled that his pain was well controlled by using a morphine pump which he could control…

Age at interview 46

Gender Male

Age at diagnosis 45

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What was your pain relief like? Pain control.

What I do remember is I had morphine which I was able to sort of manage that myself. I think in the first day or two I was probably, I remember other people commenting, this was something that you could administer yourself through a little sort of clicky thing, and I think I was at times clicking it rather a lot, although the machine itself regulated to ensure that you didn’t overdose or whatever.

But I don’t have any recollection of being in significant pain, despite you know, well I suppose the keyhole sort of helps there aren’t major incisions going on. But no, I don’t have any recollections of being uncomfortable, in pain, following that. I think the pain relief was perfectly adequate for me.

So how long did you have a morphine pump?

It wasn’t the whole time I was in, as I said I was in sort of six days. It probably was the first two, possibly three. And when they withdrew it I wasn’t suddenly aware of the fact that you know things hurt. I think they, you know the timing was obviously about right.

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Only a few people we interviewed remembered any sort of discussion about pain management with a medical professional before their operation. Many people were not given any choices and a considerable number didn’t even realise that there were different choices available. Some people were reluctant to use pain relief because they worried about becoming dependent on it. Others were reluctant to tell nurses when they were in pain because they didn’t want to be a nuisance. People whose pain management had broken down often had difficulty getting the situation resolved.

Some people experienced highly effective pain management after their operations and were amazed at how pain free their hospital experience was. One man was so impressed with his epidural that he asked for “a bucketful to take home”. Other people found that their pain control medication was effective but caused unpleasant side effects like sickness or hallucinations.

Others found their pain management to be uneven. People who experienced difficulty at night or at weekends often faced long delays before their problem was dealt with. One woman remembers what it was like having to wait for pain relief at night.

Remembers waiting for pain relief at night.

Age at interview 62

Gender Female

Age at diagnosis 48

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I remember the pain control was slightly spasmodic and you’re not allowed to swallow anything at all so you have to have the pain in injections and they were so busy very often and only a Sister who’s in charge of the drugs cupboard can actually do that and sometimes you did have to wait a long time, you didn’t get them as regularly as you should have done.

In the daytime it didn’t matter too much but sometimes at night you’d be waiting. Everybody else had had their pills, you had to wait for that injection and it would be sometimes a couple of hours late. And I remember thinking oh I wish shed hurry up and come with my injection.

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Several people had been given PCAs without adequate explanation of how to use them. One woman recalls what happened when her PCA failed to relieve her pain. Some people had epidurals which didn’t work, leaked or fell out. A woman whose epidural had leaked and then fallen out explains the difficulty she had in getting the situation resolved.

She was given a PCA but not told how to use it effectively.

Age at interview 54

Gender Female

Age at diagnosis 52

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You were given a choice for pain relief before you have the op. You could either have epidural or you could have a little machine and you’re wired up to that, you had a button which you pressed when you felt pain and that was supposed to relieve the pain. Or you could have painkillers from the trolley.

I actually opted for the one where I thought I would be in control, that’s pressing the button when I felt pain.

But in actual fact it didn’t work for me, it probably worked a bit, I don’t know how bad I would have been without it but that really was quite a bad experience because I was just told to press the button when I had pain and I kept on pressing the button and I still had a lot of pain.

And I can remember the man who was obviously in charge of pain control, I can remember him coming in and shouting at me and saying “You can’t expect this to work if you keep on pressing that button. You’re pressing it too often.”

And I didn’t actually say anything to him. It upset me a lot because I was, I was feeling so low and it was so soon after the operation. If it had been now I jolly would have, I would have shouted back at him and given him what for, because I’m that sort of person.

But you know, I realised at the time I didn’t do it because I was feeling very weak and I wished really that I’d gone for pain-relieving tablets from the trolley.

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Her epidural fell out and she had difficulty getting the situation resolved.

Age at interview 33

Gender Female

Age at diagnosis 28

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It was really difficult actually because I remember I kept on having to wait for top-ups of the epidural. And the anaesthetist kept being somewhere else so it was taking ages to get this thing topped-up and in the end I suppose because I told people I was in excruciating pain even though they were topping up, that’s when they realised and had a look and saw that it had come out, by the end, it had actually come out and it was at night time and it was night staff and it was really difficult to get somebody to come.

I suspect part of it’s down to me, part of it’s down with how much fuss I didn’t want to make basically, I didn’t, you know I didn’t want to scream, I didn’t want people to sort of get really upset about me and, and that sort of thing, that I think I would do differently another time.

Once the problem was discovered how was the pain management then?

And then it was much better because then it was, it was changed to pethidine injections and, and they were effective. I mean that’s what should have been, you know it should have been effective pain management from the beginning. I don’t think you have to go through a lot of pain after surgery like that.

So I suppose it was, it was about three days after my operation before I had really good pain control.

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A lack of consultation with patients about their pain was also sometimes a problem. One woman, whose pain was being reasonably well managed, explains what happened when a junior doctor decided to reduce her pain relief without consultation.

A junior doctor reduced her pain relief without consulting her.

Age at interview 54

Gender Female

Age at diagnosis 52

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The medical staff were very good apart from a resident junior doctor who decided on the second night that he would reduce my medication in the epidural without saying anything and he reduced the level of the drugs and so, I think that’s the one night I spent in great pain and I couldn’t understand it.

It was very distressing, the night nurses were very reluctant to wake the doctor and kept trying to jolly me along until a reasonable hour in the morning.

And I think in retrospect I should have been more assertive and I should have kind of thumped and said “Get the doctor” because I felt as if my insides were falling out, it was a really unpleasant and painful burning sensation.

And I, afterwards, the next day they said “Oh doctor so-and-so reduced the level of the pain killers, he didn’t think you needed them because you were doing so well.”

And I think you know, that was, that stands out as the sort of the big down period of being in hospital. And he was you know, not particularly apologetic, he said “Oh I didn’t think you needed it. You looked as if you were doing fine.” But I think I did express to him that he should have actually discussed it with me rather than just taking action.

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On occasion, pain management broke down completely, leaving the patient in a terrible state. One man started off with an epidural that didn’t work and “woke up screaming” with pain. It was a full 10 hours before he received a morphine injection which finally provided some relief. He explains what happened in the meantime:

His pain management broke down completely.

Age at interview 60

Gender Male

Age at diagnosis 60

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What they’d done is in the meantime they’d tried putting me on the one where you have a little button and you can apply the morphine yourself.

Yes.

It started off, I mean me pressing a button like mad but it will only give you what it will give you.

It’s programmed. The switch or button failed and I could, I didn’t turn my head much but I could hear and I could hear a number of nurses to my right discussing how to make it work and then I heard one young lady say well if I had a book of instructions I could work it and I thought well if I had the book of instructions I could work it but you just had to lay there and it was I suppose the worst 12 hours of my life (laughs) looking back.

Did they not have another machine to bring you?

Yes that came along and that was broken.

Looking back that was really bad. My surgeon wasn’t there so he didn’t see what I had to put up with.

Why do you think they waited so long before they did anything?

I don’t know, I think they kept hoping something else would work, these machines and things.

At that moment in time was in so much pain I couldn’t care less if I lived or died at that time.

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