Managing the fifth vital sign: your patients’ pain
By learning to use drugs and other therapies wisely, residents can bring patients needed relief
From the April 2001 ACP-ASIM Observer, copyright © 2001 by the American College of Physicians-American Society of Internal Medicine.
By Christine Kuehn Kelly
Carcinoma of the head and neck had brought the Russian immigrant to a Chicago-area nursing home, where he spent his days in his room, rocking and drooling. The nursing staff had classified him as demented. “I initiated opioid analgesics,” said Martha L. Twaddle, ACP–ASIM Member, a Northwestern Memorial Hospital internist who specializes in pain and palliative medicine and is president-elect of the American Academy of Hospice and Palliative Medicine.
“I was shocked the next time I visited him,” she said. “He was seated in the lounge, dressed, with his hair combed. The person had emerged! It was truly one of the most striking changes I had ever seen in a patient.”
Not all patients have a physician who effectively manages their pain. For many Americans, pain is chronic—and uncontrolled. According to an Arthritis Foundation survey, 37% of all men and 46% of all women experience daily, long-standing pain.
Up to 50% of cancer patients in routine practice settings report inadequate pain relief, and 25 million cancer patients worldwide die in pain each year, according to Michael Ashburn, MD, a Utah anesthesiologist who is president of the American Pain Society (APS). In an APS survey of adults suffering from noncancer-related pain, 56% reported having pain for more than five years—pain that 41% of sufferers called “out of control.”
Because nearly 70% of all patients present with painful conditions, from residency onward you will be treating acute pain as well as chronic pain at the end of life and from conditions such as arthritis, cancer, diabetes, fibromyalgia and migraines. But while barriers to adequate pain management remain, new therapies and a shifting regulatory environment are making it easier to bring your patients relief.
Pain specialists have long called for more pain-management education in medical schools. Scott Fishman, MD, an anesthesiologist who is chief of the division of pain management at the University of California, Davis, believes that doctors are not learning enough about pain in medical school and residency. In part, this is because it is hard to teach what pain is, he said, and because there are no hard and fast pharmacological rules. And despite what he calls a “revolution” in pain medicine, physicians still need to have their consciousness raised. “We need to recognize that pain is treatable.”
Schools are beginning to make pain management an important part of learning. Institutions such as the University of Colorado School of Medicine have begun revising the curriculum to include more pain-management education. Memorial Sloan-Kettering Cancer Center and Weill Medical College of Cornell University/New York Presbyterian Hospital are among those that provide pain management and palliative care training during residency.
State licensing boards also have begun requiring physicians to demonstrate knowledge of pain assessment and evaluation. California recently passed legislation making it necessary to evaluate and record pain as a “fifth vital sign,” after temperature, pulse, respiration and blood pressure. It also made license renewal contingent upon completing pain management CME.
New Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards require providers to ask patients about pain. The new pain management standards are included in the 2000-2001 standards manuals, and JCAHO surveyors will assess compliance starting this year.
Although pain is a complex medical, social and even legal issue, internists can effectively treat it. “Primary care physicians can effectively use a variety of pain treatment modalities without the assistance of a pain expert,” Dr. Ashburn pointed out.
To begin, physicians need to understand how to properly use the narcotic substances that are a mainstay of pain treatment—and stay abreast of changing prescribing guidelines.
Because of fears about fraudulent opioid prescribing and use, federal and state regulators have created laws and regulations that may seriously affect a physician’s ability to provide adequate pain control and may inhibit ongoing prescribing practice. However, as understanding of pain management grows, this heavy-handed approach to controlling physician prescribing practices is slowly being replaced. More than 40 states have enacted pain management guidelines or legislation. An equal number have created laws or regulations that protect physicians who prescribe therapeutic doses of oral narcotics for long-term, chronic, disabling pain. However, experts advise residents to familiarize themselves with their state’s controlled substances laws and keep adequate documentation.
As a resident, you also need to be aware of logistical barriers to adequate pain control. Insurance companies may limit reimbursement for pain management, and pharmacists may be reluctant to fulfill prescriptions. Studies show that some patients have difficulty accessing narcotics at their local pharmacies.
Holly Mattix, ACP–ASIM Associate, a renal fellow at Massachusetts General Hospital and Chair of the College’s Council of Associates, recalled treating a patient who was in extreme pain from calciphylaxis. She had been using oxycodone so frequently her insurance company refused to pay. Dr. Mattix prescribed morphine. But five pharmacies in the woman’s inner city neighborhood told her they didn’t carry the opioid.
“I finally had to call her primary pharmacy and tell them to make sure the patient received the morphine,” Dr. Mattix said. Once the patient’s pain was under control, she also was able to better tolerate dialysis.
Physicians say that your pain control efforts will pay you back many times with those kinds of results, whether you’re treating acute or chronic conditions. “It’s exciting to see a patient emerge from a blanket of uncontrolled pain,” said Dr. Twaddle.
For many patients, pain control allows them to return to daily activities. For others, it can simply enable them to sleep through the night.
Experts give the following tips to effectively manage pain:
Learn the basics. Although pain control techniques are well established, physicians often do not apply them. Evidence-based guidelines and comprehensive reviews of pain assessment and management show that the right combination of nonpharmacologic techniques and therapeutic agents can control pain in up to 95% of patients.
It’s important to know a few opioids well, particularly morphine, hydromorphone and methadone, according to Dr. Twaddle. Dr. Ashburn pointed out that opioids are not the answer for every patient. Pharmacologic therapy also includes nonopioids, including NSAIDs and acetaminophen; adjunct drugs, such as tricyclic antidepressants, anticonvulsants and corticosteroids; and local anesthetics. Nonpharmacologic approaches include cognitive-behavioral techniques and invasive procedures.
Learn when to refer. Complex conditions requiring intense, interdisciplinary care often necessitate referring a patient to a specialty center, according to Dr. Ashburn. These patients include those with disorders such as postherpetic neuralgia, cancer pain or long-lasting pain that has led to severe disability. Interventions provided by a pain specialist may include nerve block therapy, multi-modal therapy (a combination of medical management, pain psychology and activating physical therapy with block therapy) and implantation therapy, such as a dorsal column stimulator, or an intrathecal or electronically controlled infusion pump.
Talk about pain. Patients with chronic pain do not demonstrate the symptoms of acute pain: tachycardia, elevated blood pressure and facial grimaces. In order to determine patients’ pain intensity, you need to talk to them. In particular, patients over age 60 may be less likely to report pain for fear of taking time from discussing their primary medical problems or appearing to be complainers.
You can choose from well-known pain assessment scales that use verbal-numerical, word or visual-analog scales, such as the pain anxiety symptoms scale (PASS). And because pain is an individual experience, experts stress the importance of believing your patients.
Be aware of biases. Studies reported in Cancer have shown that patients from lower socioeconomic groups—particularly if they are Hispanic or African-American—receive insufficient levels of analgesic medications. A study in the Nov. 1, 1997, issue of Annals of Internal Medicine showed that 65% of minority patients did not receive guideline-recommended analgesic prescriptions, compared with 50% of nonminority patients. Physicians also underestimate pain in their female patients and may be unaware that estrogen levels affect how opioids are metabolized.
Be part of a team. “Chronic pain frequently doesn’t respond to one type of treatment,” said Dr. Ashburn. It requires integrated, interdisciplinary care. While primary care physicians would not be expected to develop and implement an interdisciplinary pain program, they should understand how chronic pain is diagnosed and treated, and be able to implement basic measures.
Be open to complementary therapies. Residents should stay abreast of complementary therapies for pain, including exercise, nutrition, chiropractic, acupuncture and mind/body techniques such as biofeedback, imagery and visualization. Nutrients such as bioflavonoids, anti-inflammatory herbs (including Devil’s claw), glucosamine, vitamin B6 or bromelin may also be useful.
Len Wisneski, FACP, medical director for LifePath Health Center in Bethesda, Md., and a clinical professor of medicine at George Washington University Medical Center, said he sees a changing trend in pain management that involves the relatively new field of integrative medicine. Dr. Wisneski reviewed acupuncture while serving on a 1997 NIH panel that ultimately found the technique effective in treating certain types of chronic pain from conditions including tennis elbow, fibromyalgia and low back strain.
Dr. Wisneski incorporates acupuncture into his practice and said he has been impressed by results with both acute and chronic pain. He also said he believes that integrating empirical Western medicine with traditional Chinese therapies brings humanism and personal caring back to the practice of medicine.
Christine Kuehn Kelly is a Philadelphia-based freelance writer specializing in health care.
Agency for Healthcare Research and Quality, “Acute Pain Management Clinical Guide,” http://hstat.nlm.nih.gov/ftrs/tocview.
World Health Organization three-step analgesic ladder, http://www.mcm ahonmed.com/wworks/CHARTS/3step/text/intostep.html.
Pain management series, The Lancet, volume 353, issue 9167.
New guidelines on managing chronic pain in older persons, JAMA, http://jama.ama-assn.org/issues/v280n4/ffull/jmn0722-1.html.
American Academy of Hospice and Palliative Medicine, http://www.aahpm.org/links.htm #Doctors'Resources.
American Pain Society, http://www.ampainsoc.org.
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