Managing the pain of hospitalized patients is a fundamental ethical responsibility of hospitalists, enshrined as a core competency by SHM and, according to the Joint Commission on Healthcare Accreditation Organizations (JCAHO), a right for hospitalized patients.
Following last month’s exploration of IV pain medications (“Perfect Pain Control,” p. 40), this month we begin a three-part series on pain management issues in the hospital setting, based on interviews with working hospitalists and other pain experts.
Part one (below) provides a context for pain management and emphasizes assessment as the cornerstone of pain control. Next month, we will explore common dilemmas and difficult cases in pain management that can take hospitalists out of their comfort zone, along with the myths and realities of hot button topics such as addiction. The following month, we will chart the continuum of pain management modalities used in the hospital and discuss how working hospitalists can best utilize them for patients with special needs.
—Steven Pantilat, MD, hospitalist and palliative care physician, UCSF Medical Center
Listen to Your Patient’s Pain
Assessment and follow-up remain key to managing hospitalized patients’ pain. Stephen J. Bekanich, MD, a hospitalist at the University of Utah Medical Center in Salt Lake City and consultant on the medical center’s palliative care service, remembers a hospitalized patient whose pain problem was not what it seemed—although a more careful assessment showed the way to a solution. A woman in her early 80s who resided in a long-term-care facility was admitted to the hospital with out-of-control back pain and mild dementia. House staff fitted her with a patient-controlled analgesia (PCA) pump to treat her pain, with instructions to press the control button whenever she experienced pain. Dr. Bekanich got a call 48 hours later because the patient was still voicing significant pain complaints, despite the PCA.
“I found that her pain scores were taken by the nurses every four hours, which is not often enough when pain is out of control,” he says. “I also looked at a printout of the PCA history, which indicated that she had only pressed the button 10 or 12 times in 48 hours. You would have expected a lot more attempts, given her reports of pain.”
Dr. Bekanich showed the patient the PCA button and asked her, “ ‘What’s this?’ She replied, ‘I can’t see it. I don’t have my glasses here in the hospital.’ When I put it in her hand, she said, ‘This is what I use to call the nurse.’ ”
A small tag on the PCA handle indicated that the patient should push for pain, but the patient was unable to read it. Once Dr. Bekanich understood her functional limitations, he wrote a new order for continuous infusion of an opioid analgesic, which brought the pain under control.
This case illustrates several principles of effective pain management. First is the importance of assessing the various factors that influence pain and the physician’s need to look more deeply if the pain doesn’t respond to initial measures. “That should be a warning flag to ask, ‘OK, what am I missing?’ ” Also, for moderate to severe pain, a component of around-the-clock dosing or continuous infusion to bring the pain under control is just as important as having the availability of a PRN analgesic for responding to breakthrough pain, such as starting the patient on a PCA.
Pain: The Hospitalist’s Responsibility
According to Health, United States, 2006, the federal government’s annual, comprehensive report on America’s health, issued last November by the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics, one-quarter of U.S. adults say they suffered a bout of pain lasting 24 hours or more in the past month. One in 10 says the pain lasted a year or more.
The CDC chose to focus on pain in the latest annual report “because it is rarely discussed as a condition in and of itself; it is mostly viewed as a byproduct of another condition,” says lead study author Amy Bernstein, who also cites the medical costs of pain and pain disparities among different population groups. Other studies have identified physicians’ self-reported discomfort with their training in pain management and with their ability to manage their patients’ pain.
Pain is also the reason many patients end up in the hospital, and treating pain should be the expectation of every hospitalist, says Robert V. Brody, MD, chief of the pain service at San Francisco General Hospital and a frequent presenter on pain management topics at clinical workshops for hospitalists. Effective pain management begins with the pain assessment, but equally important is the follow-up to reassess how the pain responds to initial measures, Dr. Brody says. If initial approaches fail to manage the pain, try again with a new dose, drug, or combination. Then reassess and repeat as often as necessary—viewing the pain challenge as a puzzle to be solved.
Pain is defined by the International Association for the Study of Pain as “an unpleasant experience associated with actual or potential tissue damage to a person’s body.” Key to that definition, notes Dr. Brody, is the recognition that pain is ultimately a subjective phenomenon, reflecting the patient’s perception of and emotional reaction to the unpleasant sensation. Patients are thus the best source of information on how much pain they are experiencing.
In recent years, standardized pain scales (typically ranging from zero—no pain, to 10—the worst pain imaginable) have gained currency in U.S. hospitals and other healthcare settings, thanks to the growing emphasis on pain management by groups such as the Joint Commission. (See “Pain Assessment Scales,” p. 49.) Such pain scales make it possible to quantify, chart, and track over time the patient’s subjective, self-reported pain scores. But while nurses may be regularly charting patients’ pain scores, hospitalists need to review those scores.
“We used to say that treating pain is not rocket science, but clearly there are skills and knowledge that hospitalists should acquire, including how to handle difficult issues around substance abuse or mental health,” explains Dr. Brody. “Certain basic rules of pain management can go a long way if you’re open to the belief that learning those rules is important and if you have an expectation that you will bring the patient’s pain under control.
“Talk to the patient,” he advises. “Ask what are the patient’s goals for pain relief.” The goal is not necessarily zero pain but a balance between pain relief and side effects from analgesics, based on functional status, defined goals, and the patient’s expressed preferences.
With practice, hospitalists can gain comfort with prescribing short-acting and long-acting opioids plus adjuvant treatments sufficient to address the majority of pain cases. They can also learn to convert between oral and intravenous opioid administration. But they must recognize when to call for reinforcements, such as the hospital’s pain service or a palliative care consultant, for assistance with more challenging cases. Ultimately, effective pain management in the hospital is multi-disciplinary, drawing at different times on the complementary perspectives of other team members, including the nurse, pharmacist, social worker, and chaplain.
“The first step to improving pain management is to develop awareness of the problem,” says Steven Pantilat, MD, a hospitalist, associate professor of clinical medicine, Department of Medicine, University of California, San Francisco, and past president of SHM. “But you also have to be comfortable giving adequate doses of these medications. You get comfortable through experience.”
Dr. Pantilat recommends that hospitalists stick with a few familiar opioids, both short-acting and long-acting. “But 90% of pain can be managed by a hospitalist without need for consultation.” He is also the past-president of SHM and the Alan M. Kates and John M. Burnard Endowed Chair in Palliative Care at UCSF.
Start with the Assessment
Pain assessment identifies the location, cause, intensity, duration, and nature of the pain, recognizing that many chronically ill patients may have more than one source of pain. It is important to establish why the patient is in pain because different pain responds to different treatments. It may also be helpful to know how long the patient has experienced the pain, how it was treated prior to the hospitalization, how it responded to treatment in the past, what makes the pain better or worse, and how it affects sleep, appetite, or physical activity.
Have the patient describe what the pain is like—the quality of the pain—using his or her own words, suggests Carol Jessop, MD, a hospitalist and palliative care physician at Alta Bates Summit Medical Center in Berkeley, Calif. There may also be psychological or spiritual elements of the pain—other sources that are not physical but contribute to a pain experience that is very real to the patient. A thorough pain assessment also evaluates the patient’s psychological state, including depression and anxiety, as well as past history of alcohol or drug use. It covers the patient’s and the patient’s family’s attitudes toward the use of opioid analgesics, their cultural context, and the meaning that the patient ascribes to his or her pain.
It can take a long time to gather all of that information as part of a comprehensive pain history, however—time that busy hospitalists may not be able to spare, says Dr. Bekanich. Fortunately, not every hospitalized patient requires this level of detail. But if there is reason to expect complications or difficulties in bringing the pain under control, if the pain doesn’t respond to standard analgesic treatments, or if there are reasons for avoiding opioid analgesics, then it may be worth making the time—or recruiting someone who can take a detailed pain history that would provide a baseline for future assessments.
“The most important thing to remember is that pain is what the patient says it is,” says Dr. Pantilat. “We are challenged by wondering whether the patient is really in pain. The answer has to be yes. You have to trust the patient unless you have specific reasons not to.
“It seems to me the first assessment of the patient’s pain may need to be more complex: Is there something new going on with this patient?” he continues. “If someone comes into the hospital with a new fracture or a kidney stone, you don’t need to spend as much time figuring out the pain’s source. But if it is chronic pain that has been unmanaged for a significant amount of time, that’s when you sit down and say, ‘OK, tell me about your pain.’ There’s no one size fits all in pain assessment.”
A special focus in pain assessment is recognizing neuropathic pain—resulting from injury or damage to the nerves themselves, which is different in nature and treatment from nociceptive pain and is also generally less responsive to opiate analgesics. Roughly 15% of the pain hospitalists see may be neuropathic, which can be suggested by certain words, such as burning, numbing, tingling, or shooting, in the patient’s description of the pain. Certain syndromes also suggest the possibility of neuropathic pain, including diabetes, HIV, alcoholism, radiation or chemotherapy, and amputation and phantom limb pain. Neuropathic pain may be treated with tricyclic antidepressants such as desipramine (Norpramin, Petrofrane) and nortriptyline (Pamelor, Aventyl) as well as with the anticonvulsant gabapentin.1,2
Another key issue in pain management involves side effects. With opioids, constipation is such a common side effect that experts recommend prescribing a laxative and/or stool softener every time an opioid analgesic is initiated. The physician must then stay on top of the issue, prescribing additional laxatives if the desired effect is not achieved. Other side effects of opioids, which must be balanced with their analgesic properties, include nausea, sedation, mental status changes, and respiratory suppression. A number of these side effects will dissipate after a few days on opioids, but constipation remains problematic.
Other basic principles of pain management, gathered from physicians interviewed for this article and from other pain resources (see “Resources and Tools,” p. 49) include:
- There is no absolute maximum dose of opioids; adjust dose based on individual need and response. If initial doses are not effective, titrate up based on percentages of the dose: 25%-50% for mild to moderate pain, 50%-100% for moderate to severe pain.
- Use the right duration in prescribing; short-acting opioids may be more effective when given every four hours than every six hours. PRN prescriptions are not recommended except for breakthrough pain. The World Health Organization’s Pain Ladder suggests an overall approach to dosing based on severity.
- Tailor the pain regimen while the patient is still in front of you, if possible. The patient’s response to intravenous analgesics should start to become clear within 10 minutes of initiation.
- The earlier you treat pain, the easier it will be to bring it under control.
- Oral administration is generally preferable to intravenous unless there is a reason to avoid using the oral route.
- Pain experts do not generally recommend meperidine as an analgesic.3
- Opioids are not recommended for all kinds of pain. Opioids may be avoided for patients with neuropathic pain, for those with existing constipation or nausea problems, or for morbidly obese patients with bad sleep apnea.
Finally, work with primary care physicians to plan for pain needs post-discharge, as well as for potential problems or barriers that may arise, especially if high doses of opioids are involved.
“One of the most difficult issues is addressing what will happen after the patient leaves the hospital,” says Dr. Bekanich. “That’s where the ball often gets dropped.”
He makes a point of calling the patient’s primary physician at the time of discharge and then dictates a letter, including the pain protocol, which is transcribed and faxed to the primary physician. “We don’t let these patients walk out the door without an appointment date already scheduled with a physician,” he says.
Benefits of Pain Relief
Dr. Jessop encourages hospitalists to take advantage of SHM’s core competency in pain management as a guide to improving their skills in this area. Managing patients’ pain is a win/win for the physician, the patient, and the institution. “Nothing feels better than getting a patient out of pain,” she says.
Better outcomes in pain management can help bring down hospital lengths of stay while driving up patient and staff satisfaction, adds Dr. Bekanich. Conversely, unrelieved pain not only leads to unnecessary suffering but also to patients who are depressed, slower to get up and start walking or eating, and reluctant to take deep breaths. “It’s hard to discharge a hospitalized patient whose pain is still out of control,” he says.
Dr. Bekanich reports that his own interest in learning pain management techniques resulted from watching his grandmother experience severe pain while struggling with cancer. “That was the driving force for me to say, ‘We can do so much better at this,’ and then get the training I needed,” he says.
Dr. Bekanich attended conferences offered by the Center to Advance Palliative Care and the American Academy of Hospice and Palliative Medicine. “I started to read a lot more in the pain literature,” he explains. “Initially, I was somewhat self-conscious about putting the new techniques into effect. So I’d call a pharmacist or a mentor to double check. I’m glad I did that.” TH
Larry Beresford is a regular contributor to The Hospitalist.
- Smith TE, Chong MS. Neuropathic pain. Hosp Med. 2000;61(11):760-766.
- Saarto T, Wiffen PJ. Antidepressants for neuropathic pain (review). Cochrane Database Syst Rev. 2005 Jul 20;(3)3:CD005454.
- Weissman DE. Fast Fact and Concept #71: Meperidine for pain—what’s all the fuss? [The End of Life/Palliative Education Resource Center.] Available at: www.eperc.mcw.edu/fastFact/ff_71.htm. Last accessed February 19, 2007.