maharashtra is one of the largest states in india which has been in the forefront of healthcare and boasts of health - care indices above the national average
. however , there is inadequate literature on acute pain management in hospitals in the state  government or private . less than 30% of patients in india receive adequate pain management .
undertreated pain leads to increased post - operative morbidity and mortality , prolonged hospital stay , overcrowding of wards which consequently adversely affects the quality of health care .
therefore , a questionnaire survey was undertaken to assess the current practice of post - operative pain management in the tertiary hospitals in maharashtra .
the availability of the pain service for non - surgical cases , the roles , attitudes and perceptions of health - care professionals and the hurdles faced by them in delivering pain services were also surveyed .
this non - interventional , descriptive , cross - sectional , multi - centre survey was undertaken ( december 2013february 2016 ) after taking the ethics committee approval from the parent institution .
out of the 47 government and private medical colleges and 10 corporate hospitals ( teaching hospitals with more than 100 beds ) that were approached , 35 agreed to participate in the survey .
the procedures like taking permission from the dean / head of department or the ethics committee of the participating centre were completed as per the norms of each institute .
one questionnaire for the anaesthesiology department and one each for various surgical specialties was sent to each institute in printed form by post or in an electronic version by e - mail .
if there was no response within 3 weeks , four telephonic reminders were given at weekly intervals after which follow - up was not done .
the questionnaires for anaesthesiologists and surgeons were identical and consisted of 24 questions with 4 questions having likert scale responses as options , 3 open - ended questions , and the remaining had multiple choices or yes / no responses [ annexure i ] .
the questions sought information about the respondents ' pain management policies , clinicians ' attitudes , perceptions and beliefs about pain management , and hurdles faced by them in providing optimal pain management . before the study
a small pilot study initially was done in the parent institute to confirm face validity .
the data were analysed using the statistical package for the social sciences ( ibm corp . released 2015 ,
ibm spss statistics for windows , version 23.0 , armonk , n.y . , u.s.a ) and percentages , mean and standard deviation
we got one response each from the anaesthesiology departments of thirty institutes , while 15 institutes sent the responses of forty surgeons of different specialties such as general surgery , orthopaedics , obstetrics and gynaecology , and oncosurgery ( one response from each department of an institute ) .
the demographic profiles of the hospitals and the respondents are depicted in table 1 . out of the 30 hospitals ,
7 had an operational acute pain service ( aps ) , 2 had a formal pain management program and 4 had a chronic pain clinic .
the surgeons played a major role in pain management throughout the patients ' stay in the hospital while the role of most of the anaesthesiologists was confined to treating pain primarily in the operation theatre and post - operative recovery room .
however , anaesthesiologists from 17 centres agreed that they managed pain , even in wards for a selected group of patients or if requested by the surgeons [ table 2 ] .
dedicated staff for acute pain management was available in 7 centres and 6 hospitals provided round - the - clock pain services .
the facility for treating acute pain in non - surgical patients was available in 13 hospitals on demand . written protocol for pain management was developed in 4 hospitals .
five institutes had on - going pain education for the health care professionals out of which 2 centres were also providing training for nursing staff .
intermittent non - steroidal anti - inflammatory drugs ( nsaids ) , opioids and epidural analgesia were used most commonly for treating post - operative pain , while patient - controlled analgesia ( pca ) was the least commonly used modality .
nine institutes claimed to use non - pharmacological methods such as physiotherapy , psychological counselling , and change in position which were resorted to more frequently by the orthopaedic surgeons [ table 2 ] .
current post - operative pain management practices in various tertiary hospitals in maharashtra anaesthesiologists and resident doctors were responsible for the follow - up of the patients with epidural catheters and peripheral nerve blocks . in patients receiving potent analgesics ,
pain scores at rest were measured routinely in 23 hospitals , and dynamic pain scores were routinely measured in only 7 hospitals [ table 2 ] .
there were significant differences in pain management practices of anaesthesiologists and surgeons [ table 3 ] .
while surgeons ( 92.5% ) used nsaids more frequently , ( p = 0.046 ) , the anaesthesiologists ( 83.3% ) used opioids more frequently ( p = 0.000 ) . furthermore , other modalities such as epidurals , nerve blocks , intrathecal additives and multimodal approach were used more frequently by the anaesthesiologists .
comparison of pain management practice by anaesthesiologists and surgeons : drugs used for post - operative pain management with the existing pain management strategies , about 40% of anaesthesiologists and an equal percentage of surgeons believed that they had succeeded in bringing a moderate degree of pain relief in the post - operative patients . regarding the benefits of pain management and aps ,
ninety - four per cent of anaesthesiologists agreed that optimal pain management in the form of aps would bring down the post - operative complications as against 85% of surgeons who concurred ( p = 0.039 , p < 0.05 ) .
there was a consensus between the anaesthesiologists ( 43.3% ) and surgeons ( 42.5% ) that treating post - operative pain prevented chronic post - operative pain ( p = 0.793 ) [ figure 1 ] .
knowledge / perception of clinicians about the goals of acute post - operative pain management .
a  anaesthesiologists ; s  surgeons thirty per cent of the anaesthesiologists and 47.5% of surgeons believed that patients should ' expect to have some amount of pain ' after surgery .
all surgeons ( 100% ) and 96.7% of anaesthesiologists agreed that the patients should be counselled preoperatively about post - operative pain .
all the anaesthesiologists ( 100% ) agreed that they should have a role in managing pain even in the wards while 80% of surgeons agreed to this .
most of the clinicians accepted that a multidisciplinary approach and an aps would be required for optimal pain management [ figure 2 ] .
attitudes and beliefs of clinicians about acute post - operative pain management . a  anaesthesiologists ; s  surgeons in spite of having the willingness to run an aps , they were faced with many hurdles .
the biggest hurdle , as cited by both anaesthesiologists ( 83.3% ) and surgeons ( 72.5% ) was a lack of pain education at all levels of health - care professionals .
the other obstacles were lack of equipment and workforce and lack of priority from hospital administration [ figure 3 ] .
the 24-item questionnaire was designed on the basis of the questionnaire surveys done before , to get a comprehensive idea about the existing acute pain management practices and availability of aps .
an aps is a rapidly evolving health - care service for managing post - operative pain which may also be tasked with consultation related to non - surgical pain like trauma , burns and other cases . besides the post - operative pain , treatment for non - surgical pain
was provided by anaesthesiologists in 13 hospitals out of 30 , on request by surgeons , irrespective of the presence of aps .
many guidelines have been issued by the pain medicine associations of different countries , but no such guidelines exist in india .
the 2005 american pain society recommendations for post - operative pain management suggest that an interdisciplinary process should be used to improve pain management .
the association of anaesthetists of great britain and ireland has recommended that all hospitals performing major surgeries should have a multidisciplinary pain team with an anaesthesiologist in charge .
anaesthesiologists are a logical choice to provide pain relief because of their knowledge and technical expertise in managing pain .
the results of our survey showed that the surgeons played a key role in post - operative pain management with the help of anaesthesiologists . in most of the institutes , leadership on the part of the anaesthesiologists and involvement of nursing staff , physiotherapist and pharmacists was limited .
our survey showed that the role of nurses in almost all the hospitals was limited mostly to administering the analgesics as per clinicians ' orders .
this scenario must change , and nurses should play a more active role as they have the most frequent contact with patients .
this can be done by training them adequately and giving them responsibilities of pain assessment , counselling the patients , adjusting the drug infusions , pca , etc .
as early mobilisation and less post - operative pulmonary complications are proven benefits of treating pain , the physiotherapists should also be involved . however , only 7 ( 23.3% ) hospitals take the help of a physiotherapist for pain management .
the personnel like pharmacists and clinical psychologist should also be recruited as a part of the pain management team to provide better pain relief . besides the multidisciplinary approach , the other recommendations include good physician - patient communication to encourage patients ' involvement in decision - making in their treatment , on - going pain education of health providers with interventions in the health - care system like use of synergistic analgesia , minimally invasive surgery , 24 hours / day pain service , pain protocols , increased use of patient reported outcomes and patient education regarding prompt reporting of pain .
however , our survey showed that there was a paucity of organised pain services , written protocols , round the clock services and training programs .
there are five recognised quality criteria for an aps : dedicated personnel , 24 hours / day service , written protocols , regular assessment / documentation of pain scores and on - going pain education .
although 7 centres claimed to have an aps , only 2 hospitals had an organised aps according to the set criteria .
the observation that there is a paucity of aps in maharashtra is a reflection of a previous national level survey by jain et al .
the advantages of having an aps are an improvement in the quality of pain management and lower incidence of side effects .
in addition , with an aps in place , patients are more likely to receive pain education , are more satisfied , are discharged earlier and perceive fewer barriers to pain management .
a written protocol ensures a more consistent standard of care and provides detailed instructions on when and whom to call for unrelieved pain , treatment of special groups of patients and standard orders for pca pumps , epidurals , nursing care and so on .
analgesics like nsaids and opioids given by intramuscular and intravenous routes were widely used , but they may not provide optimal analgesia unless the intermittent analgesics are tailored according to individual patient 's needs with regular pain scoring .
the use of epidurals was observed in 26 out of 30 institutes , and pca pumps were used in only 2 institutes .
non - pharmacological methods which are cost - effective and useful adjuncts for pain management were used by 43.3% of anaesthesiologists and 60% of surgeons [ table 2 ] .
regular pain assessment was lacking in many hospitals , which is an important tool to individualise treatment .
our questionnaire had no direct question about the awareness about pain as a 5 vital sign .
furthermore , we have not asked about the frequency of pain assessment , which is a limitation of our study .
the perception in the anaesthesiologists ( 30% ) and surgeons ( 47.5% ) that the patients should ' expect to have some pain ' after surgery may contribute to suboptimal pain management .
however , a positive finding was that many of them were aware of the benefits of optimal pain management and were convinced of the need for a multidisciplinary approach and special pain services for post - operative pain management . despite this , aps is not available in most of the medical centres .
the frequently cited reason for this by both anaesthesiologists ( 83.3% ) and surgeons ( 72.5% ) was lack of pain education at all levels of health - care professionals .
the other reasons were lack of equipment ( 86.7% ) , workforce ( 83.3% ) , concerns regarding affordability of patients ( 80% ) , difficulty in procuring opioids ( 76.6% ) , lack of priority from hospital administration ( 63.3% ) , etc .
, this is a very important take - home message of this study as it provides directions for improvement in the area of post - operative pain management . in the national survey by jain et al .
, lack of initiative and funds were the major reasons cited by the anaesthesiologists . in this study , '
however , it has been cited as one of the biggest hurdles in pain management in our study .
in the italian survey by coluzzi et al . , the inadequate training of nurses and surgeons , poor organisation and lack of equipment were the biggest hurdles . in a canadian survey by zimmerman and stewart , ' time commitment ' and financial constraints
have been cited as the top reasons for failure to institute aps . in another study ,
jain and chatterjee have described several barriers which were overcome while implementing aps in a tertiary hospital in india . these were lack of workforce , pain education , and administrative problems .
the information gathered may be skewed and there may be a recall bias and a social desirability bias , which means the responders , may give responses which appear more desirable socially .
however , clinicians in other sectors may have a different perspective on post - operative pain management and aps .
thus , still larger scale surveys are needed to evaluate the practices and attitudes of the clinicians in other sectors .
the study shows that the tertiary hospitals in maharashtra face many challenges in acute post - operative pain management . to improve it , on - going education programs , policy changes at government as well as institutional levels , procuring funds , equipment ,
improving accessibility to opioids , continued research and establishment of aps needs to be done .
in addition , procedure - specific , evidence - based , acute post - operative pain management guidelines - based practice must be promoted in all the tertiary hospitals .
 background and aims : undertreated pain can have negative consequences on patients ' health as well as the health - care system 
 . the present study was aimed at identifying the current trends in post - operative pain management and availability of acute pain services ( aps ) . in addition , it is also an attempt to assess the availability of analgesia for non - surgical cases , and the attitudes , beliefs , and perceptions of clinicians regarding acute pain management in the tertiary hospitals in the state of maharashtra ( india).methods : this was a cross - sectional , multicentre questionnaire survey involving the anaesthesiologists and surgeons . 
 percentages , median , interquartile ranges were calculated and compared by employing a wilcoxon sign rank test.results:data from thirty centres revealed that the surgeons played a major role in treating pain , while most of the anaesthesiologists treated pain primarily in the operation theatre and recovery room . 
 an aps was operational in seven hospitals . 
 the most frequently employed techniques to achieve analgesia were the administration of non - steroidal anti - inflammatory drugs , opioids and epidural analgesia . 
 the majority of the centres had no written protocol and dedicated staff for pain management , pain assessment was not adequately stressed , and only five out of the thirty centres included in the study provided ongoing pain education to health professionals even when the hospitals claimed to provide aps . 
 the major hurdles in providing optimal analgesia and implementing aps were a lack of pain education , equipment and administrative problems.conclusion:thus , the tertiary centres in maharashtra fall short of providing optimal acute post - operative pain management . 
INTRODUCTION
METHODS
RESULTS
DISCUSSION
CONCLUSION
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Conflicts of interest