Improving postoperative pain management: what are the unresolved issues?

DESPITE recent advances in our understanding of the physiology of acute pain, the development of new opioid and nonopioid analgesics and novel methods of drug delivery, and more widespread use of pain-reducing minimally invasive surgical techniques, pain after surgical procedures remains a challenge for many practitioners. Not surprisingly, recent surveys in the United States and Europe have emphasized the insufficient quality of postoperative pain management and the need for further improvements. The increasing implementation of standardized pain evaluation and treatment protocols, and the use of multimodal analgesic techniques, are hopeful signs that improvements in pain management are likely to continue in the years ahead. What then are the major unresolved issues in the management of acute postoperative pain, and how should surgical patients be managed based on the available evidence from the peer-reviewed medical literature?