American College of Physicians: Internal Medicine — Doctors for Adults ®

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When patients know more

Dealing with pain management

From the May 1997 ACP Observer, copyright © 1997 by the American College of Physicians.

By Deborah Gesensway

Internists taking care of patients in pain face a dilemma, one that compounds the generally poor job doctors do in this field: The patient always knows more than the doctor.

"We can know more about our patients' hearts or lungs or even their brains than the patients do, and we are very comfortable with that fact," explained Robert V. Brody, MD, of San Francisco General Hospital. "The existential dilemma of pain management, however, is that we can never know more about our patient's pain than our patient does."

Accepting this premise can be a first step for physicians looking to improve their pain management skills. "Never get into an argument with a patient about whether there is pain or not," Dr. Brody said. "It's self-defeating. The question about whether that patient will get the Tylenol with codeine is a separate decision."

Dr. Brody was joined by Zail S. Berry, ACP Member, an internist at Aesculapius Medical Center in South Burlington, Vt., and a hospice physician, in describing ways internists can manage pain specifically for patients at the end of life. The lessons, they said, apply to all patients with pain.

The primary way to improve the care of patients in pain is to accept the reality of their pain. Dr. Brody said that at his hospital, nurses are now asked to regularly check a fifth vital sign—pain as rated by the patient on a scale of 0 to 10—and enter that information on the vital sign sheet.

A second principle has to do with committing yourself to erasing the patient's memory of pain, thereby reducing the patient's expectation of pain. This is done by providing analgesic treatments around the clock, not just waiting for the pain to return before giving the next dose.

"You need more medication to control pain in somebody who is already in pain than you need to prevent the reoccurrence of pain," Dr. Berry said. Moreover, she said, a patient should always have access to a breakthrough dose for those times when pain returns unexpectedly.

"After you have done something for a patient's pain, we want to know several things," Dr. Brody said. "Where [on the 0 to 10 scale] was the pain before you gave the drug or the massage or whatever? Where did the pain go on the scale after the treatment? How long did the relief last? And if the relief lasted five hours, we're going to repeat what we did in four hours."

And equally important is making sure the patient is asked if what was done was good enough "because the goal of pain management is not necessarily zero. It's the maximally functional patient," Dr. Brody said. "For a lot of people, four or five out of 10 is fine, because in order to get below that they begin to feel drugged."

It's also important for internists to understand the difference between different kinds of pain: somatic, visceral and neuropathic. Although somatic and visceral pain can usually be treated with conventional analgesics, neuropathic pain is more likely to respond to other types of drugs such as tricyclic agents or anticonvulsants.

Once neuropathic pain is ruled out and physicians are sure they are dealing with somatic or visceral pain, it is essential for doctors to lead the way out of our cultural "opiophobia"—fear of narcotics—and a general misunderstanding of the difference between physical dependence and abuse and addiction.

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