Note: This is Part 2 of The Hospitalist’s series on pain and hospital medicine. Part 1 appeared on p. 45 of the April issue.
Welcome to Part 2 of our three-part series on managing the pain of hospitalized patients. Last month’s article presented the context for pain management in the hospital—a core competency identified by SHM. It emphasized techniques for assessing patients’ pain, ranging from a zero-to-10 pain score to more complex pain histories addressing type, source, duration, and intensity as well as psychosocial and spiritual factors.
Part 2 delves into some difficult cases and dilemmas of pain management—situations that can take hospitalists out of their comfort zone and challenge their confidence in managing their patients’ pain.
Some of these dilemmas arise from misconceptions about pain and pain treatments and from the fact that, historically, physicians have not been well trained in optimal pain management. General barriers to pain management in the U.S. healthcare system, as identified by the National Association of Attorneys General, include patients’ beliefs, physician and institutional practices, restrictive state polices, and racial and socioeconomic disparities.1
Many of these issues relate specifically to the most common treatments for severe pain, opioid analgesics, which have all sorts of negative associations based on misconceptions about abuse, addiction, and overdose. In other cases, physicians face real challenges in balancing analgesic benefits with side effects and in determining the right medication, dose, and schedule to meet the patient’s need for pain relief.
Hospitalists confronting difficult pain cases work under the added pressure of trying to bring their patients’ acute illnesses under control so they can discharge them to a lower level of care as soon as prudently possible. This time pressure, along with demands arising from the rest of the hospitalist’s caseload, may impose limits on what can be accomplished in difficult situations or with medications that require time to stabilize.
Challenges also arise when the customary approach to pain management—the drug and dosing schedule the hospitalist is most comfortable using for most patients—fails to bring the pain under control. This is often a red flag for the need to try something new, says Stephen Bekanich, MD, a hospitalist at the University of Utah Medical Center in Salt Lake City and a consultant on the medical center’s palliative care service. In some cases, that means calling in a specialist in pain treatment, palliative medicine, psychiatry, or substance abuse.
“You need to work into the equation that there are pitfalls and caveats to everything we say about pain,” Dr. Bekanich observes. “Plus, the common pain treatments are controlled substances, with obvious legal implications and a professional duty for physicians to handle them safely and appropriately.”
When Dr. Bekanich finds himself confronting a difficult pain situation that has caused a conflict with a patient, he often involves one of the hospital’s customer service patient advocates. They are trained to mediate disagreements between patients and the treatment team.
Is This Patient’s Pain Real?
Physicians sometimes wonder if their patients’ reports of pain are accurate. Is the pain really as bad as the patient says it is? “Residents, frequently, are more skeptical of patients’ claims of pain, doubting whether they are truly experiencing that level of pain,” reports Jean Youngwerth, MD, a hospitalist, palliative care consultant, and fellowship associate program director at the University of Colorado Health Sciences Center in Aurora.
“I tell my residents that malingering is rare, and those few cases where it happens really tend to stand out,” Dr. Youngwerth says. “I also tell them that our default position is always to trust the patient, unless given a good reason not to. I have been burned more often when I questioned my patients’ reports of pain than when I didn’t.”
Pain experts emphasize that the patient’s self-report is the most reliable source of information on pain—based on an understanding of pain as a complex, subjective phenomenon associated with actual or potential tissue damage and the patient’s perception of and emotional reaction to that sensation. The phenomenon of pain also includes emotional, social, psychological, even spiritual components and can be mediated by a host of other factors. But that doesn’t mean it isn’t real to the patient.
“Often, younger physicians take the attitude that if the pain is real, then administration of morphine will make it go away,” says Porter Storey, MD, FACP, FAAHPM. “In reality, pain doesn’t always respond to opioids, for all sorts of reasons. Hospitalists value clarity, and they use pain as a screen for all sorts of other problems. Their goal, often, is not so much the comfort of the patient as it is diagnosing, treating, and then discharging the patient from the hospital.” Dr. Storey is a palliative care physician in Boulder, Colo., and executive vice president for Medical Affairs at the American Academy of Hospice and Palliative Medicine (AAHPM).
Physicians need to be reminded, however, that unresolved pain in hospitalized patients has many negative consequences. These range from resistance to rehabilitation to depression to delayed hospital discharge, as well as reduced job satisfaction for the healthcare professionals who care for them.
Will Prescribing Analgesics Cause Addiction?
Fears about causing addiction haunt many pain management discussions. Requests for more medications, obsessing over the next scheduled analgesic dose, and even manipulative or drug-seeking behaviors can be misunderstood by physicians who lack training in the real nature of drug addiction. Actual cases of drug addiction created by appropriate, sufficient, and well-monitored opioid analgesic treatment are rare, pain experts say. There is an important caveat: the patient who brings a prior history of drug abuse to the current acute medical episode.
“There are no good data about iatrogenic addiction,” says Robert Brody, MD, chief of the pain consultation clinic at San Francisco General Hospital and a frequent presenter on pain management topics at clinical workshops for hospitalists. “People who do pain management, certainly including hospice and palliative care physicians, don’t really believe in it. In my own clinical experience, most patients don’t like pain medications and stop them as soon as they can.”
Addiction is more accurately understood as the inappropriate use of a drug for non-medical purposes. It refers to disruptive, drug-seeking behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.2 Addiction experts also describe addiction as a disease syndrome in its own right. Although that concept can sometimes be hard to accept by those who don’t have a lot of experience working with it, it is a useful paradigm to treat addiction as if it were a disease, says Ronald Crossno, MD, Rockdale, Texas-based area medical director for the VistaCare hospice chain.
Pain experts use the term pseudoaddiction for behaviors that are reminiscent of addiction but in fact reflect the pursuit of pain relief. Examples might include hoarding drugs, clock-watching, and exaggerated complaints of pain, such as moaning or crying. If it is pseudoaddiction, once the pain is brought under control, these behaviors cease. The term was coined in 1989 to describe an iatrogenic syndrome resulting from poorly treated pain.3-5
“Pseudoaddiction is a term you need to know,” Dr. Crossno asserted during a presentation on addiction pain at the recent annual conference of AAHPM in Salt Lake City in February. “It is at least as prevalent as addiction—and an indictment of how our healthcare system deals with pain.”
Dr. Youngwerth offers some advice.“We often see pseudoaddiction in response to undertreatment and inadequately managed pain,” she says. “If you treat the pain appropriately, these behaviors go away.” She tries to teach this concept to residents and hospital staff, who sometimes find it hard to put themselves in the shoes of patients experiencing severe pain.
“If you have a 68-year-old patient with no history of addiction or substance abuse who is in the hospital [with the] status post-hip replacement and is now clock-watching and routinely pressing the call button before her next dose of opioids is due, staff may feel that she is displaying addictive behaviors,” Dr. Youngwerth says. “Why would they think that this situation evolved into addiction during her brief hospital stay? It’s more likely that she’s just afraid of having pain.”
The solution to pseudoaddiction is to prescribe opioids at pharmacologically appropriate doses and schedules. Then, titrate up until analgesia is achieved or toxicities necessitate alternative approaches. Use all the techniques described in the first article of this series. It is also important to restore trust and the patient’s confidence in the medical system’s ability to manage his or her pain. Opioid pain regimens in the hospital should also be coordinated with plans for post-discharge medications and with the patient’s primary-care physician.
Two other concepts that often come up in discussions of opioid treatments are tolerance, which is a diminution of the drug’s effects over time, resulting in a need to increase doses of the medication to achieve the same analgesic effect, and physical dependence, in which the abrupt discontinuation of an analgesic after a period of continuous use causes physical symptoms of withdrawal from the drug. Both of these issues can be addressed with proper assessment and management, and neither is diagnostic of addiction.
Pain experts say tolerance, though a real phenomenon of opioids, is not often a serious problem with pain management in the hospital. Instead, the need for escalating analgesic doses may reflect changes in the underlying disease process. Tolerance can also include positive benefits such as its emergence for opioid side effects like nausea or sedation. Physical dependence on opioids is predictable but can be managed if the original cause of the pain is resolved and the analgesic is no longer needed. Most opioids can be gradually reduced, with each day’s dose at 75% of the previous day’s dose, until the drug is tapered off.6
What if the Patient Is an Addict?
Although pain experts believe that drug addiction caused by appropriate and adequate prescribing of opioids for analgesia is rare, this does not mean that hospitalists won’t face the problem of patients who are addicted to pain medications. “You are already treating patients with addiction,” said Dr. Crossno in his presentation at the AAHPM meeting in Salt Lake City.
Given that pre-existing addictions are relatively common in American society (estimates range from 5% to 17% of the population, depending on whether alcohol abuse is included), it is reasonable to expect this segment of the population will be represented among acutely ill, hospitalized patients.7 Sometimes, the substance abuse problem of a friend or family member affects the patient’s care, such as when pain medications are stolen from the patient.
“Some hospitalized patients do abuse opioids,” says Dr. Bekanich. “We catch people with drug paraphernalia or actually shooting up in their rooms.” Providers can exercise some control over what patients do in the hospital, but it is probably not realistic to expect that a hospitalist will be able to resolve long-standing substance abuse problems during the patient’s brief stay in the hospital.
As part of a comprehensive pain assessment, it is appropriate to ask if the patient has a history of drug use. Many patients will freely admit to such a history, may be actively in recovery or on a methadone maintenance program, or may even resist opioid analgesics despite severe pain because of their commitment to recovery. Without the benefit of such candor, however, it will be difficult to reach a conclusive diagnosis of drug addiction during the patient’s acute inpatient stay, because that ordinarily requires observations over time.
“It is not our job as hospitalists to get patients off opioids; there are other institutions and services for that,” Dr. Bekanich adds. “For us to try to do it in a few days in the hospital seems like a hopeless task. That is not to say we shouldn’t be mindful of the issues involved, talking to the patient or even offering a referral to a drug rehabilitation program. But we should not be trying to do drug rehab.”
The basic principles of believing patients’ reports of pain and providing analgesic doses sufficient to relieve the pain still apply—unless side effects or the patient’s problematic behavior demand a modification in this approach. Pain physicians often cite the maxim “trust but verify.” There are various screening tools that can be used for indicating the possibility of substance abuse, and it is imperative the use of controlled substances always be closely monitored.
Urine drug screening tests are easy to order in the hospital and may encourage compliance for patients who have a drug history when presented up front as a routine aspect of pain management. The urine test can detect prescribed medicines that are being taken by the patient as well as non-prescribed opioids, but it is important to be aware of false positives and negatives and opportunities for gaming the system by those who are determined to do so.
“Just as it is a myth that treating pain appropriately leads to addiction, it is also a myth that people with drug histories can’t have their pain treated effectively,” says Scott Irwin, MD, PhD, medical director of palliative care psychiatry at San Diego Hospice and Palliative Care. “The first thing to ask these patients is what are their goals for pain management. Get as much objective information as you can about the pain and the patient’s history. Fully inform the patient about options. Treat the pain just as you would for anyone else.”
Then, if things don’t add up, Dr. Irwin says, it may be necessary to go back and reassess the patient’s pain and history. Is there psychological distress? Perhaps the analgesic dose isn’t adequate. Maybe financial pressures or complicated social relationships are leading to drug diversion.
If the patient is participating in a methadone maintenance program or similar protocol, it is advisable for the hospitalist to speak to the medical director of that program. But effective pain control also supports maintenance. Emphasize long-acting analgesics, add non-opioid adjuvants and, when possible, find alternatives to intravenous administration. But if the patient is addicted, trying to minimize adverse effects from analgesic treatments might be the best the hospitalist can do.
Another approach to managing the patient with a history of drug abuse is the use of a contract or opioid agreement, in which the patient promises to do certain things with a clear understanding of the consequences for not doing so. Establish the rules early and be prepared to enforce them. Explain expectations for the patient and the physician’s role, designate a single pharmacy and a single physician responsible for pain prescribing, and get consent for treatment and drug testing. If a repeat offender breaks the agreement, it may be time to call in an addiction specialist. Such agreements should be negotiated in person by the physician, not delegated to nurses or other professionals, but then make sure other team members are in the loop. For an example of such an agreement, see http://tinyurl.com/y2bbh6.
Will Pain Medications Cause Respiratory Suppression?
Another common fear related to opioid use is that prescribing sufficient analgesic doses for patients with advanced illnesses could lead to toxicities, suppress their breathing, cause an overdose, or even prematurely end their lives. This scenario is often luridly presented as turning up the morphine drip. Pain management experts question the truth of this scenario, arguing that morphine often is falsely credited with deaths that result from advanced disease processes. Morphine is a common treatment for the sensation of dyspnea, while morphine-related toxicity likely will present with drowsiness, confusion, and loss of consciousness before respiratory compromise.8
A main concern of hospitalists is appreciating the need to balance pain relief with the side effects of analgesics, including opioid toxicities, which can be addressed through careful titration and frequent assessments. Respiratory suppression can be a side effect of opioids, and there are special groups of patients for whom any sedation is a major concern. An example is a lung transplant patient, for whom somnolence may suppress the important cough reflex.
Respiratory suppression from morphine is an area without a large evidence base. But a recent study of 725 patients nearing death in 13 hospice programs analyzed those who were receiving opioids and had at least one change in opioid dose prior to death to see if escalating opioid doses was associated with premature death.9 The authors conclude that “final opioid dose, but not percentage change in dose, was one of several factors associated with survival, but the association is very weak … (and explains) only a very small percentage in variation in survival.” They also found support for their conclusion that opioid use is not a major contributor to premature death in the few other published studies on the subject.
“I tell residents that the fear of respiratory suppression is overrated,” Dr. Youngwerth says. “As long as you follow World Health Organization and other recognized guidelines for dosing and titrating opioids, you can safely prescribe pain medications and control the patient’s pain. They get this fear ingrained during residency. In reality, it is not very common. I remind them that there is much more evidence of under-dosing.”
Dr. Bekanich describes a recent patient, a young woman suffering from severe abdominal pain following the birth of her baby. The pain was so difficult to manage that her hospital in rural Idaho transferred her to his medical center in Salt Lake City. She had also experienced respiratory arrest twice secondary to the application of fentanyl analgesic patches. “But she was relatively easy to manage once we tried a different drug, appropriately titrated,” he relates.
Dr. Bekanich spent two hours in the patient’s room adjusting the intravenous analgesic dose and monitoring the patient’s pulse oxygen level and neurological status. “These medicines don’t have to cause respiratory suppression, although it will happen occasionally, especially when there are multiple co-morbidities,” he says. “Hospitalists don’t realize that most of these problems can be avoided if you are meticulous in prescribing.”
Does Regulatory Scrutiny Chill Pain Treatment?
The ubiquitous fear of opioids and their potential side effects, including some unfounded or unrealistic fears, is also reflected in the regulation of controlled substances and physicians’ fears that they will be subjected to oppressive regulatory scrutiny.
Widely publicized cases of physicians being disciplined or prosecuted for over-prescribing opioids have only added to these fears, while the rare case of a physician being sued or sanctioned for under-prescribing pain medications does little to allay them.10
Growing attention to the inadequacies of and barriers to pain management—and the role of controlled substances regulation in those barriers—led to the 1998 promulgation of “Model Guidelines for the Use of Controlled Substances for the Treatment of Pain” by the Federation of State Medical Boards.11 These guidelines, promoting the legitimate role of opioids in relieving pain and acknowledging providers’ concerns about being disciplined, were revised in 2004 and have been adopted by 21 states.12
The effect remains, however. “For decades, physicians have reported being reluctant to prescribe opioids because of the fear of the stress, expense, and consequences of being investigated by licensing agencies or law enforcement,” states a 2006 state report card issued by the Pain & Policy Studies Group at the University of Wisconsin in Madison.13 “Some states—but far from all—have adopted policies which recognize that controlled substances are necessary for public health. … But in some states, pain treatment using opioids is unduly restricted by policies reflecting medical opinions that were discarded decades ago.”
The Pain & Policy Studies Group’s report card, which advocates for a balanced approach to the regulation and prescribing of controlled substances, has given every state a grade for how well it meets this goal. According to the 2006 report card, Michigan and Virginia get top grades for achieving balance in pain policy, while Georgia gets the lowest grade.
“Regulation is a real concern,” says Daniel Burkhardt, MD, associate professor and director of the Acute Pain Service at the University of California-San Francisco. “Every time a prosecutor arrests someone for prescribing too much pain medication, these things travel, adding to the extra regulatory burden on physicians.”
Carol Jessop, MD, a hospitalist and palliative care consultant at Alta Bates Summit Medical Center in Berkeley, Calif., says the burden has lessened somewhat in California because that state eliminated its requirements for triplicate paper prescribing forms for controlled substances.
A related concern involves the potential diversion of controlled substances by impaired healthcare professionals for personal use and abuse. This is another of the fears that have driven archaic pain regulation in many states. In fact, current estimates suggest that a substance abuse-related impairment will affect between 8% and 18% percent of physicians sometime in their lives, and that 2% of physicians are dealing with an active substance abuse problem.14
A recent medical journal letter to the editor from the Wisconsin Pain & Policy Studies Group suggests public policies on opioid diversion should focus more on sources of diversion such as “thefts, including armed robberies, night break-ins, and employee and customer pilferage,” rather than just the doctor-patient prescribing relationship.15
Physician diversion data don’t break out hospital medicine as a category, but some hospitalists say they have not heard of diversion problems involving hospitalist colleagues. That may reflect the fact that hospitalists, unlike some other health professionals, generally don’t administer controlled substances directly to the patient or have ready access to hospital drug storage facilities. TH
Larry Beresford is a regular contributor to The Hospitalist.
- Joranson D, Payne R. Will my pain be managed? In Improving End-of-Life Care: The Role of Attorneys General. National Association of Attorneys General. Washington, D.C. 2003. Available at www.naag.org/end-of-life_healthcare.php. Last accessed April 13, 2007.
- American Pain Society. Definitions related to the use of opioids for the treatment of pain: a consensus document from the American Academy of Pain Medicine, American Pain Society, and American Society of Addiction Medicine. Available at www.ampainsoc.org/advocacy/opioids2.htm. Last accessed April 13, 2007.
- Weissman DE, Haddox JD. Opioid pseudoaddiction. Pain. 1989 Mar;36(3):363-366.
- Weissman DE. Fast Fact and Concept #68: Is it pain or addiction? [The End of Life/Palliative Education Resource Center.] Available at www.eperc.mcw.edu/fastFact/ff_68.htm. Last accessed April 13, 2007.
- Weissman DE. Fast Fact and Concept #69: Pseudoaddiction. [The End of Life/Palliative Education Resource Center.] Available at www.eperc.mcw.edu/fastFact/ff_69.htm. Last accessed April 13, 2007.
- Doyle D, Hanks G, Cherny N, et al, eds. The Oxford Textbook of Palliative Medicine. 3rd ed. Oxford, England: Oxford University Press;2005:336.
- Passik SD, Kirsh KL. Chapter 56: Pain in patients with alcohol and drug dependence. In Bruera E, Higginson I, von Gunten C, et al. Textbook of Palliative Medicine. London, England: Hodder Arnold;2006:517-524.
- Von Gunten CF. Fast Fact and Concept #8: Morphine and hastened death. [The End of Life/Palliative Education Resource Center.] Available at www.eperc.mcw.edu/fastFact/ff_008.htm. Last accessed April 13, 2007.
- Portenoy RK, Siberceva U, Smout R, et al. Opioid use and survival at the end of life: a survey of a hospice population. J Pain Symptom Manage. 2006;32:532-540.
- Warm EJ, Weissman DE. Fast Fact and Concept #63: The legal liability of under-treatment of pain. [The End of Life/Palliative Education Resource Center.] Available at: www.eperc.mcw.edu/fastFact/ff_63.htm. Last accessed April 13, 2007.
- Federation of the State Medical Boards of the United States. Dallas, Texas. Available at www.fsmb.org. Accessed April 13, 2007.
- National Association of Attorneys General. Improving End-of-Life Care: The Role of Attorneys General. National Association of Attorneys General. Washington, D.C. 2003. Available at www.naag.org/end-of-life_healthcare.php. Last accessed April 13, 2007.
- Pain & Policy Studies Group. University of Wisconsin Paul P. Carbone Comprehensive Cancer Center. Available at: www.painpolicy.wisc.edu. Accessed April 13, 2007.
- Blondell RD. Taking a proactive approach to physician impairment. Postgrad Med. 2005 Jul;118(1):16-18.
- Joranson DE, Gilson AM. Drug crime is a source of abused pain medications in the United States. J Pain Symptom Manage. 2005 Oct;30(4):299-301.