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It Hurts

The patient’s pain started on an otherwise normal day—another day of hard work as a certified nurse assistant who frequently does more physically demanding work than she should. She woke up with excruciating pain in her back. When she called her family physician, she was told that she didn’t need to be seen, that she just needed to rest and use NSAIDs for a day or so.

Fast forward a few years. The patient, still in the same job, injured her back again, overexerting herself at work. This time, the pain didn’t go away. The patient was seen by multiple physicians, none of whom could alleviate the pain to the patient’s satisfaction.

Does this patient seem familiar to you? She represents your patient in the ED who hears the nurse say quietly, “There’s another ‘seeker’ in bed two.” She is the patient in the exam room who cries in disbelief when you tell her that she is being overly emotional and needs to see a psychiatrist. She is the customer in the pharmacy being lectured about the dangers of addiction to narcotics. Treating the chronic pain patient can be difficult and frustrating, not only to the patient but also to you.

Facts and Figures
The American Pain Foundation tells us that pain affects more Americans than diabetes, heart disease, and cancer combined. A National Center for Health Statistics Report found that more than one-quarter of Americans (26 percent) age 20 and over, an estimated 76.5 million Americans, reported problems with pain of some sort that lasted for more than 24 hours. More than half of all hospitalized patients experienced pain in the last days of their lives and, although therapies are present to alleviate most pain for those dying of cancer, research shows that 50 to 75 percent of patients die in moderate to severe pain. An NIH survey indicated that low back pain was most common type of pain, followed by severe headache or migraine pain, neck pain, and facial ache or pain.¹

Not Everyone Is Treated the Same
Disparities in health care are also evident in pain management. African Americans and Hispanics are affected by racial profiling for diversion and under-treatment by some physicians. This is compounded by a lack of research on pain across racial and ethnic differences, as well as cultural attitudes toward pain management. In the elderly population, 25 to 50 percent can expect to suffer pain. Under-treatment in the pediatric population is even worse. The FDA has only recently required that new medications be evaluated for efficacy and safety in the pediatric population. Gender is also a bias in pain management. Women seek help more frequently than men but are less likely to receive treatment. They are often viewed as hysterical or oversensitive.²

The Barriers
Patients with untreated pain often feel that the physicians they consult are unfeeling, paternalistic, judgmental gatekeepers. The pressures on physicians that may contribute to this perception include poor training in pain management or training against the use of opioids for chronic pain, feedback from pharmacists about over-prescribing, pressure from reimbursement channels to hold down costs, bad experiences with other opioid patients, and the knowledge that honest physicians have been unfairly indicted for their prescribing habits. In order to meet patient and physician needs, several guidelines need to be in place.

Guidelines
Physicians who treat chronic pain need to be comfortable and secure in their competency. Many times pain is under-treated because of lack of training. The California Society of Anesthesiologists provides online CME on pain management and end-of-life care that includes preventive measures to help reduce the practitioner’s risk of suffering a medical-legal action.³

Physicians and surgeons may have to deal with breakthrough pain (BTP) in patients with cancer and noncancer-related pain. Treatment regimens can incorporate nonpharmacologic and pharmacologic treatment that include opioids. Because different treatment approaches are possible, additional education may enhance the provider’s ability to tailor BTP treatment by matching pharmacology of the drug to: the subtype of BTP, the patient’s risk for abuse, and the capacity to monitor the patient. Medscape, a free resource for physicians and nurses, provides more information on BTP management.⁴

Because narcotic prescriptions are aggressively monitored by multiple agencies, physicians may worry that prescribing narcotics can cost them their license. The Medical Board of California, which provides guidelines for prescribing controlled substances for pain, assures California physicians and surgeons that they need not fear disciplinary or other actions for the mere fact of having prescribed opioids in the course of treatment of a person for intractable pain. The appropriate use of opioids has been recognized in the California Intractable Pain Treatment Act (Section 2241.5 [c] of the California Business and Professions Code). The board expects physicians and surgeons to follow the standard of care in managing pain patients.⁵

The fear of addiction is another barrier to opioid pain management—the result can be under- or nontreatment of moderate-to-severe pain. Douglas L. Gourlay, MD, MSc, FRCPC, FASAM, and Howard A. Heit, MD, FACP, FASAM, have advocated the use of a “universal precautions” approach to all pain patients, especially those who are considered for a therapeutic trial of opioids to improve quality of life. These universal precautions are standardized assessments and management approaches to chronic pain that include a substance use assessment, a stratification of patients into three groups to determine a particular setting to manage the pain, and applying 10 steps of precautions.⁶ Following these precautions may prevent another bad experience with managing the pain patient.

Clinical Pearls

• All patients deserve to be thoroughly assessed for pain and to have their pain managed appropriately to increase the quality of life.
• BTP is a common and frequently debilitating experience for patients with noncancer-related pain.
• Because of the risk for misuse and/or abuse of opiate agents, patients with chronic pain should be evaluated and supported according to their level of risk.
• Pain patients need to be listened to, receive validation of symptoms, have their fears calmed, be treated with respect and belief, and have a medical partner for dealing with their pain. Pain, although not objective, is real. Don’t fail to treat the pain.
• Understand the barriers to effective pain management.
• Prescribe only to your patients.
• Educate and provide informed consent.
• Document—use a flow sheet to help monitor prescription refills.
• Don’t hesitate to get help.

J4271 4/08

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