The expert consensus on pain assessment recommends [11] using the Digital Rating Scale (Numerical Rating Scale, NRS) or Visual Analog Scale (Visual Analogue Scale, VAS) to evaluate pain intensity. For children and elderly individuals with communication difficulties, the Facial Expression Scale (Faces Pain Scale, FPS) is recommended for pain assessment. For those who cannot self-assess, the Adult Pain Behavior Assessment Scale is recommended. Pain assessment is the foundation of pain management, accurate pain assessment enables targeted pain management measures. Controlling resting pain ensures patient comfort post-surgery, while managing active pain promotes recovery and reduces postoperative complications. Guidelines from institutions such as the American Pain Society (American Pain Society, APS) and the Swedish Medical Association (Swedish Society of Medicine, SSM) all emphasize that a comprehensive postoperative pain assessment should include both resting and active pain assessments. Currently, the scoring of postoperative active pain primarily combines subjective pain evaluation tools with objective pain assessment tools, such as the numerical rating scale (Number Rating Scale, NRS) [12], and functional activity scoring sheet (Functional Activity Score, FAS) [13].

According to the World Health Organization (WHO) “Three-Step Analgesic Treatment for Cancer Pain” principle, analgesics should be selected based on the patient’s pain intensity. For patients with mild pain, nonsteroidal anti-inflammatory analgesics such as ibuprofen, diclofenac, acetaminophen, indomethacin, and celecoxib can be used; for moderate pain, weak opioids like codeine and tramadol can be prescribed, or low-dose strong opioids can also be used, in combination with nonsteroidal anti-inflammatory analgesics and adjuvant analgesics; for severe pain, strong opioids such as morphine and fentanyl are preferred, and can be combined with nonsteroidal anti-inflammatory analgesics and adjuvant analgesics [14]. The concept of postoperative analgesia has been updated from conventional analgesia to preemptive analgesia and then to preventive analgesia. Opioid analgesics are an important part of modern anesthesia and analgesia, but their high efficacy and specific pharmacokinetic characteristics are also more likely to induce acute tolerance and/or allodynia, which may be the cause of postoperative pain aggravation [15]. The management of post-CRC active pain is an important clinical issue, and a large number of studies have explored the efficacy of different drugs and regimens. Currently, multimodal analgesia is widely considered to be the best practice [16]. This multi-modal approach aims to optimize analgesic effects and reduce opioid use by blocking peripheral and central pain pathways through different mechanisms of action，local infiltration analgesia, regional nerve block analgesia techniques, and intravenous lidocaine infusion have demonstrated favorable analgesic effects in patients undergoing colorectal cancer surgery. Additionally, elderly individuals exhibit lower pain sensitivity compared to younger people, while women demonstrate higher pain sensitivity than men, necessitating personalized medication regimens [17].

Non-drug therapy, such as psychological care, music therapy, acupuncture, transcutaneous electrical stimulation, nutritional support and relaxation training, can help relieve pain. Studies have shown that non-drug intervention has a good effect on postoperative pain relief in patients undergoing abdominal surgery, and ear acupressure can relieve abdominal pain in patients [18]. Studies have shown that pain in patients undergoing abdominal surgery can be improved by psychological intervention, among which cognitive behavioral therapy and relaxation therapy are more commonly used [19]. Psychological care can help improve pain in patients with CRC after surgery. In the study of graded psychological nursing intervention for CRC patients, it is mentioned that graded psychological nursing can alleviate patient pain [20]. Relaxation techniques such as deep inhalation and slow exhalation, progressive muscle relaxation, and meditation to shift attention can help relieve physical and mental tension, thereby reducing the perception of pain in cancer patients. Demonstrated that music therapy can help reduce pain in CRC patients. Music therapy helps patients enhance their personal strength, interrupt the cycle of suffering, and improve pain [21]. In summary, non-pharmacological interventions have a positive regulatory effect on postoperative pain; however, physical therapy, psychological support, and other non-pharmacological methods have not been fully utilized in the treatment of active pain after CRC surgery.

4.1.1. Lack of Pain Knowledge among Patients and Primary Caregivers

A large cross-sectional study [22], showed that more than 50% of patients with pain refused to use analgesics due to fear of opioid addiction and adverse effects of analgesics. Due to the lack of understanding of pain, patients and their families are worried about increasing the dosage of drugs and drug addiction, so they do not report pain or deliberately reduce the subjective score [23], leading to postoperative pain assessment deviation and poor effect of pain control management. Some patients think that they only need to take medication when the pain symptoms are obvious, and do not follow the doctor’s instructions to take painkillers [24]. The study indicates [25] that 52.6% of patients did not have medical staff introduce pain relief methods, and as high as 79.9% of patients did not have medical staff introduce pain assessment methods, causing 48.5% of patients to choose not to receive postoperative analgesic treatment. Studies show that the use of painkillers, lack of pain knowledge, negative beliefs, attitudes and psychological distress of patients and their primary caregivers lead to obstacles in pain management [26]. Patient and primary caregiver concern about the use of pain medication, lack of knowledge about pain, negative beliefs, attitudes, and psychological distress lead to barriers to pain management, while health care providers lack adequate explanation and information. Therefore, in order to carry out postoperative active pain management smoothly, it is necessary to conduct training and health education on rest and active pain assessment for patients and their families, improve their pain knowledge and self-efficacy, and change the concept of pain relief for patients and their caregivers.

4.1.2. Lack of Pain Knowledge among Medical Staff

Active pain can more sensitively reflect the effect of postoperative analgesia than resting pain. However, active pain is often not well controlled. For example, after major thoracic surgery, the use of opioid drugs can make patients feel comfortable and fully relieve their resting pain, but it can’t well relieve severe active pain. The results of a cross-sectional survey on nurses’ cognition of pain intervention in China showed that only 57.9% of nurses had received special training in pain intervention, but 100% of nurses believed that they needed to strengthen their knowledge of pain intervention. Among them, nurses had a high demand for non-pharmacological pain intervention and pain assessment, accounting for 84.2% and 57.9% respectively [27]. The training in pain assessment for doctors and nurses is not sufficient [28]. The pain assessment is made by observing the facial expressions of patients and working experience, ignoring the complaints of patients, resulting in an objective pain assessment with subjective judgment [29], leading to a deviation of pain assessment, which is not conducive to the formulation of pain control plans for patients. In addition, clinicians may not fully realize the importance of postoperative active pain management in clinical practice, focusing on cancer treatment rather than pain treatment, and failing to provide targeted treatment for active pain in CRC patients after surgery [30]. According to the results of a study by Tong Yingge [31]et al., nurses believe that lack of knowledge about pain assessment, fear of patient addiction to analgesics, and fear of adverse drug reactions are the main obstacles to the effective implementation of pain management. Similarly, Alsaiari [32]et al. also found that many doctors and nurses have a negative attitude towards pain management, lack of knowledge about opioid analgesics, and worry about drug addiction and side effects of analgesics. Research shows that [33], nurses “knowledge of pain is below the recommended 80% level. Pain knowledge is positively correlated with previous pain training, so continuing education initiatives are needed to improve healthcare providers” knowledge of active pain assessment, medication selection, and non-pharmacological pain treatment.

At present, in the field of pain management, the formation of multidisciplinary pain management team has become a widely adopted practice mode. This mode, through the collection of experts from different medical specialties, is committed to the comprehensive evaluation and effective management of patients’ pain. Its superiority has been fully verified by many studies, and it has achieved remarkable results in improving analgesic effect. Despite the numerous theoretical advantages of multidisciplinary pain management teams, existing research has also revealed a series of challenges in their practical implementation. Poor communication among team members is one of the key factors limiting their effectiveness. Differences in professional background, work habits, and communication styles can lead to poor information flow, affecting decision-making efficiency and treatment outcomes [34]. In addition, the irrationality of the multidisciplinary team organizational structure is also an urgent issue to be addressed [35]. Some pain management teams failed to adequately consider the complementarity and collaboration needs among members during their initial formation, leading to a loose organizational structure that hinders the establishment of an efficient work system. Unclear division of labor further exacerbates this problem, blurring the boundaries of responsibilities among members, making it easy for overlapping or omissions in work to occur, thus affecting overall work efficiency [36].

The CRC treatment guidelines [30] and expert consensus [37] address issues such as the diagnosis, treatment principles, and postoperative nutritional therapy for CRC, but do not cover specific management plans for postoperative active pain in CRC. Although some healthcare providers pay attention to postoperative pain in CRC patients, the lack of specific management plans for postoperative active pain has led to inadequate relief of postoperative pain. Accurate assessment is the foundation of pain management. According to research by Sun Jing [38]et al., standardized pain assessment reduces pain perception, improves quality of life and satisfaction. However, 54% of nurses underestimate patients’ pain levels, while 13% overestimate them. In recent years, despite the introduction of new drugs and analgesic techniques, overall postoperative pain treatment has not truly improved [39]. Improper choice of analgesic drugs, insufficient or excessive dosage, and improper timing of administration can lead to poor pain control [40]. Opioids play an important role in postoperative pain, but their adverse reactions such as drug dependence and respiratory depression increase the incidence and mortality of postoperative patients. Although opioids can relieve pain well, their adverse reactions delay recovery, so they are strictly controlled in clinical practice [41]. Currently, different guidelines both domestically and internationally provide vague descriptions of non-pharmacological pain interventions. In clinical practice, providers often adopt only one method, lacking specific approaches tailored to the characteristics of post-CRC active pain. There is also a lack of targeted non-pharmacological analgesic measures based on patient assessment results. Additionally, health education is limited to basic knowledge dissemination, lacking individualized and continuous counseling. Although recent years have seen deeper understanding of postoperative pain and the development of methods for its prevention and treatment, the incidence of moderate to severe acute postoperative pain remains as high as 30%, with 10% to 50% of patients progressing to chronic pain [28].