Vol. 17 Issue 16
The 'Fifth Vital Sign'
We are living in the Decade of Pain Control and Research
Pain is easy for physicians to recognize but hard for them to deal with.
Caught in the gap between physiology and human behavior, doctors have to weigh patients' personal testimony of discomfort with what the physicians know of a particular disease process or what they can find in a physical examination or observe in affect.
It is perhaps no wonder that doctors long have overlooked pain as a primary concern. They see it as secondary to something else, and treat the condition they can identify as the underlying cause. It's also part of early American stoicism that pain is an inevitable part of life and should be suffered with grace, not complaint.
Yet pain often causes more dysfunction in individuals than the disorders with which it is associated, greatly reducing quality of life. In the next 10 years, pain will come out of the closet to be subjected to intense research, as Congress makes better pain management a medical priority of the decade.
An addendum to the Violence Protection Act of 2000 (HR 3244), Sec. 1603, passed Oct. 31, 2000, names this the Decade of Pain Control and Research. The initiative became effective last Jan. 1. Though it carries no funding mandate, it was enacted in response to a documented need.
According to C. Richard Chapman, PhD, a clinical psychologist at the University of Washington and president of the American Pain Society (APS), studies show that fewer than 6 million of the 23 million surgical patients that American hospitals see each year get adequate relief from acute pain. Other conditions that cause severe pain are burns and trauma. Statistics unveiled at the spring Leadership Summit on Pain Management in Chicago, co-sponsored by APS and the Joint Commission on Accreditation of Health Care Organizations (JCAHO), show that more than 26 million Americans between the ages of 20 and 64 have persistent back pain, and one in six has painful arthritis. Only 40 percent of chronic pain patients get the relief they need, as do only 30 percent of all cancer patients with pain.
While it might not seem as though an unfounded declaration would accomplish much, it can actually give impetus to a scientific groundswell of research.
"If you remember, the 1990s were declared the 'Decade of the Brain,'" said Dr Philipp Lippe, a California neurosurgeon and executive medical director of APS. "It resulted in considerable benefit to research, clinical practice and education," all summarized in a recent report to the American Medical Association.
"Our hope is that this will promote the same type of advances in science, research and education. We would like to get a presence at the NIH (the National Institutes of Health)," he said–something that did happen during the Decade of the Brain.
From there, it would be easier to secure funding. A Pain Care Coalition among APS, the American Academy of Pain Medicine and the American Headache Society is likely to be the prime mover for whatever happens next.
Why is it important to study and treat pain?
For starters, of course, there are the general medical benefits. "(Easing pain) promotes healing and recovery," said Dr. Lippe. "Pain can actually cause other medical problems."
But in a larger sense, pain is a player in what has become one of the biggest ethical dilemmas of the age: assisted suicide. A few years ago, Dr. Jack Kevorkian was imprisoned in Michigan for injecting a willing ALS patient with a lethal concoction because the man did not want to live with the horror of his future. Kevorkian, a suicide advocate for terminally ill patients, had provided the means to people to kill themselves in several other cases, but in this case he actually injected his patient.
In 1999, the U.S. Congress passed the Conquering Pain Act, an amendment to the Public Health Service Act, in part to try to stem that growing counterculture.
But changing pain treatment protocols will take more than a declaration.
Seven months ago JCAHO "went live" with six new pain treatment standards that it now requires for accreditation of its facilities. Called simply Pain Standards for 2001, the "rules" were actually adopted in 1999 and already appear in the standards manuals that JCAHO-accredited health care organizations use. Their establishment was the result of a two-year effort by the joint commission and the University of Wisconsin-Madison Medical School. Last summer, based on its assessment of its accredited organizations to comply with the rules, JCAHO announced that full compliance with them would be expected beginning Jan 1, 2001, by all its organizations except laboratories. JCAHO observed treatment models in place at various facilities, and has included examples of how its facilities might orchestrate compliance with the standards. Dennis O'Leary, president of JCAHO, said at the Chicago meeting earlier this year that "pain control has become a problem because of confusion as to who is responsible, a general lack of knowledge about pain, and misconceptions about drug tolerance and addiction."
Current pain treatment reaches out in many directions. Basically, medications involve various strengths of topical/injectable/ingestible analgesics from creams to pills to lollipops that either deaden sensory receptors to pain or reduce the brain's response to the stimulus. Tranquilizers, muscle relaxers and certain anti-depressants also control pain that erupts from various disorders.
TENS units and electro-acupuncture devices that have come into vogue over the past 10 years may carry the best clue as to the nature of physical pain and its future treatment. These machines use electrical impulses to change the chemical reactions of irritated nerve fibers so that they carry normal impulses instead of pain impulses.
But pain is much more complex than that.
A case in point is phantom limb, a phenomenon that amputees often experience when they still "feel" their missing limbs as though they were still there. In a striking experiment at the University of California-San Diego in 1993, neuroscientist Vilaynur Ramachandran asked a man who had had his right arm amputated 10 years earlier to reach out and "grab" a cup that was on a nearby table. The man gestured his stump toward the table and acknowledged that he was "holding" the cup. The man was asked to repeat the task; but this time, as the subject reached for the cup, Dr. Ramachandran quickly moved it, to see if the stump would follow the motion.
Suddenly the man cried out in pain. He said it felt as though the cup had been wrenched out of his hand.
Dr. Ramachandran told ADVANCE at that time that the reaction suggested that this particular pain involved "an act of judgment and observation. It may be a kind of illusion or a memory image in the brain."
Because pain is perceptual, it cannot be measured. So rather than recording neurological data, pain assessments really probe patients' attitudes toward their own discomfort, which can change dramatically over short periods of time, depending on states of mind.
Medical students spend little time on pain management because control procedures are too time-consuming and offer no reimbursement or financial incentives. Physicians learn to beware of "druggies" out looking for fixes through legitimate means, and of getting their patients addicted to painkillers, some of which are under regulatory scrutiny. Perhaps the best statement about the situation came from Perry G. Fine, a professor of anesthesiology at the University of Utah School of Medicine and associate medical director of the Pain Management Control Center in Salt Lake City: "Pain control is not respected in the medical community, and we are told that if we get involved in the pool of suffering, we will lose our objectivity," he told Donald Phillips of the Journal of the American Medical Association (JAMA) last month.
There is a very limited clinical focus on pain, and so medical students gain little experience in treating it; therefore, doctors are not skilled in pain management.
JCAHO has been using data from several demonstration models among its facilities to begin turning these stats around. Included with some of the six pain standards are examples of how they are being put into effect successfully.
To meet the standards, JCAHO-accredited institutions must:
• recognize the right of individuals to appropriate assessment and management of pain;
• assess the existence and, if so, the nature and intensity of pain in all patients, residents or clients;
• establish policies and procedures that support the appropriate prescribing or ordering of effective pain medications;
• educate patients, residents, and clients and families about effective pain management;
• address the individual's need for symptom management in the discharge planning process; and
• incorporate pain management into the organization's performance measurement and improvement program.
A suggested (not required) protocol for meeting JCAHO's pain assessment requirement is to screen all patients upon admission by asking a general question: "Do you have pain now? Have you had pain in the last several months?" If the answer is yes, the patient should be further assessed with a pain intensity rating scale that is appropriate for the diagnosis population. (The scale should be one the facility consistently uses and one that is used between disciplines.) The scale should measure current pain, pain at worst and pain at best, and its effects on daily life activities such as function, sleep, appetite, relationships with others, emotions, concentration, etc. The assessment tool should be able to cover more than one site, because people often have pain in several places. And the hospital should use more than one intensity measure if it serves both children and adults, and those who are cognitively impaired (see related story page 37).
Staff should be educated about pain assessment and treatment, including the barriers to reporting pain and using analgesics.
Pain intensity scales might be enlarged and displayed in all areas where assessments are conducted. Pain assessment would be incorporated, in some way, into every clinical pathway.
The JCAHO rules require that when appropriate, patients and their families be educated about pain management and the assessment process. Health care facilities may prove their involvement in such education with examples of educational materials, organization-wide policies and procedures that define pain management responsibilities for patients and families, progress notes, flowcharts, referral and consultation notes and testimony from clinical staff.
To meet JCAHO's safe medication guidelines (pain standard 4), one hospital really did its homework before instituting patient-controlled analgesia (PCA) for surgical patients. According to the standards document, "an interdisciplinary team of physicians, pharmacists and nurses reviewed the literature on PCA, drafted policies, procedures and standing orders, obtained approval from the pharmacy and therapeutics committee and medical staff, oriented all staff and conducted a pilot test on the general surgery patient care unit."
The goal behind these directives and examples is simple: to bring pain management into the forefront of medicine. If physicians like Dr. Lippe have their way, pain assessment will really become, as it has already been designated by the Department of Veterans Affairs, "the fifth vital sign."
E.J. Brown is editor of ADVANCE.