New understanding, new treatments

Experts say it’s about time the healthcare community gives pain – and people suffering from it – their due

Pain is sometimes called the “fifth vital sign,” but identifying and managing it are more difficult than the first four. Nevertheless, a lot of attention has been paid to pain management and treatment in the past 10 to 20 years, and Journal of Healthcare Contracting readers may soon see the results in their facilities, if they aren’t already doing so.

Over the past 10 years, laypeople and professionals have become much more focused on pain than in the past, says Theresa Grimes, RN-BC, MN, FNP, BC, CCRN, president of the American Society for Pain Management Nursing, and associate vice president for nursing and nurse practitioner in pain management at John T. Mather Memorial Hospital, Port Jefferson, N.Y. In fact, 2010 marks the end of the Congressionally designated Decade of Pain Control and Research. “People in pain now have the ability to say ‘I have pain,’ and expect adequate and balanced pain management,” she says.

The cost of pain
The economic cost of pain, including medical bills and lost workdays, is estimated at $100 billion per year in the United States, according to the American Pain Society, a Glenview, Ill.-based multidisciplinary organization of basic and clinical scientists, practicing clinicians, policy analysts and others who research and treat pain and advocate for patients with pain. Back pain alone produces chronic disability in 1 percent of the U.S. population and is the leading cause of disability in Americans under 45 years old, according to the society. As the population ages, chronic pain in the elderly will most likely increase.

According to the American Pain Society:

  • 40 million Americans have arthritis.
  • More than 26 million Americans, ages 20 to 64, experience frequent back pain.
  • Among cancer patients, it is estimated that 70 percent have significant pain during their illness, but fewer than half receive adequate treatment for their pain.
  • More than 25 million Americans suffer migraine headaches.
  • 20 million Americans have jaw and lower facial pain (TMD/TMJ) each year.
  • Nearly 4 million Americans, mostly women, suffer from fibromyalgia, a complex condition involving widespread pain and other symptoms.
  • Half of all hospitalized patients have moderate to severe pain in the last days of their lives.

The vocabulary of pain
Despite the ubiquity of pain, the topic hasn’t always been discussed or treated head-on. Some elderly people as well as some cultural groups don’t even use the term “pain,” says Grimes. What’s more, people who have suffered from chronic pain for years might long ago have stopped acknowledging the problem. Yet a dialogue about pain has definitely begun.

Hospitals are expected by the Joint Commission to have a pain protocol in place, says Grimes. At some facilities, patients are asked about pain at least once a shift. The difficulty, of course, is that pain is inherently subjective, unlike, say, blood pressure or pulse rate. That raises the question, how does the provider determine what intervention – if any – is necessary to address the person’s pain?

One common standard was established about 40 years ago by Margo McCaffery, RN, MS, FAAN, whom Grimes and others acknowledge as a guru of pain management. According to McCaffery, pain is defined as “whatever the experiencing person says it is, existing whenever he or she says it does.”

When adults are asked to describe their pain, they are generally asked to do so on a zero-to-10 scale, with 10 being the worst they can imagine. Children are usually asked to rank their pain on a zero-to-five scale, since they can find it difficult to discriminate 10 different numbers, says Grimes. Some providers use pictures of faces to help children communicate the level of pain they are experiencing.

When people in pain are unable to provide such a ranking (such as infants or people who are cognitively impaired), providers may use a behavioral scale to indicate that pain is present. Is the patient grimacing, groaning, guarding or exhibiting behavior that is non-typical for him or her? For babies, providers may use a tool called the FLACC scale, an acronym that refers to facial (e.g., grimacing), leg movement, arm movement, crying and consolability.

Responding to pain
“In the past 10 years, many practitioners have become convinced that pain is multifaceted, and that the best approach is to treat the person, not just the pain,” says Chuck Weber, spokesperson for the American Pain Society. “So the multidisciplinary approach to pain management is gaining favor, because it helps patients with myriad elements of chronic pain – physical, medical, psychological, personal and social. The goal for pain treatment, therefore, is to optimize functionality, so patients can pursue their everyday life activities – school, work, family time, relationships, recreation, etc.”

Says Grimes, “There’s a need for a coordinated effort to manage pain.” The pain management team might be quarterbacked by an anesthesiologist, neurologist, neurosurgeon, physiatrist (rehabilitation physician), psychiatrist, or primary care physician; working in tandem with nurse practitioners, physician assistants and others.

They practice in a variety of settings. Ninety-four outpatient interdisciplinary pain rehabilitation programs are certified by the Commission on Accreditation of Rehabilitation Facilities, or CARF. Some are freestanding, others are located in hospitals. In addition to the outpatient programs, CARF reports four accredited inpatient programs.

“A lot of pain management has moved to the physician’s office setting,” adds Grimes. “We’ve seen a movement from the inpatient setting to the outpatient setting.”

Tools at their disposal
Providers have a number of tools at their disposal to help people in pain. Opioid pain medications, such as morphine, oxycodone, oxymorphone and fentanyl, are potent analgesics that may be used within a multimodality approach to managing pain. Once used primarily to relieve pain following surgery or cancer, or at the end of life, opioids today are used widely to relieve severe pain caused by chronic low-back injury, accident trauma, arthritis, sickle cell, fibromyalgia and other conditions, according to the American Pain Society.

With the increase in opioid usage, however, concerns have grown about abuse, addiction and diversion. In response, the American Pain Society guidelines call for clinicians to continually assess patients on chronic opioid therapy by monitoring pain intensity, level of functioning and adherence to prescribed treatments. The society recommends periodic drug screens for patients at risk for aberrant drug behavior.

Additional treatments for managing pain include interventional treatments such as injections of local anesthetics, nerve blocks (numbing of groups of nerves), electrical stimulation of nerve fibers, and acupuncture; physical modalities such as physical and aquatic therapy; cognitive- behavioral modalities such as psychological support; and, when necessary, surgery. Medical devices typically used by pain management specialists include intrathecal drug devices (which pump medication into the spinal fluid), various needles and catheters for epidural procedures, pumps to drip local anesthetics inside incisions, and TENS (transcutaneous electrical nerve stimulation) units.

“The Decade of Pain was successful in increasing professional and public awareness about pain,” says Weber. “Its crowning achievement was passage of federal legislation that recognizes pain as a medical condition and not just a complication of certain diseases.”

Indeed, the discipline received a shot in the arm in the Patient Protection and Affordable Care Act, or healthcare reform law, signed by President Obama in March 2010. Section 4305 includes a number of provisions related to pain, including:

  • Authorization of an Institute of Medicine Conference on Pain Care to increase awareness of pain as a significant public health problem; evaluate the adequacy of pain assessment, treatment and management; and identify barriers to appropriate pain care.
  • Establishment of the Interagency Pain Research Coordinating Committee to track advances in federally supported pain research, identify critical research gaps, and coordinate research across the National Institutes of Health, the Veterans Administration, the Department of Defense and other agencies.
  • Establishment of a “Program for Education and Training in Pain Care, to be housed in the Health Resources and Services Administration of the Department of Health and Human Services, which would authorize training grants and contracts to health professions schools and other entities; emphasize training on comprehensive, interdisciplinary approaches to pain care, including attention to access and regulatory issues as well as clinical components; and require HRSA to evaluate the effectiveness of federally supported pain care training programs.

“We now have the avenue to reduce barriers to care, the research to quantify the science of pain, and a means to educate and train clinicians across multiple specialties and disciplines,” said American Academy of Pain Medicine President-Elect Perry Fine, M.D., when the legislation was passed.

Still, there’s much to do, according to experts. “Unfortunately, very little time in medical school is devoted to studying pain and pain management, despite the fact that an overwhelming majority of doctor’s office visits are attributed to pain,” says Weber.

“The American Pain Society and other organizations are trying to rectify this deficiency, especially among primary care clinicians. Much has been accomplished in increasing physician awareness about pain, but we have a long way to go to help clinicians obtain the knowledge they need to treat chronic pain.”