Home : Professionals : Pain Reports : Pain Report No. 1
Dannemiller Memorial Educational Foundation
An Update on Issues, Research and Treatment Trends
Volume 1, Number 1

Editorial Board
Neil M. Ellison, MD
Lynn McPherson, Pharm D.
Lora McGuire, RN, MS

Supported by an educational grant from Purdue Pharma L.P.
Accreditation of Healthcare Organizations Tied to New Standards of Pain Management
Starting January 1, 2001, hospitals and other healthcare institutions in the United States must comply with new standards for pain management issued by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to achieve accreditation.

The new standards expressly acknowledge that pain is a co-existing condition with a number of diseases and injuries, and that pain experienced by patients requires appropriate intervention. According to the new standards, a patient with breast cancer, for example, should be treated not only for the malignancy but also for any associated pain.1

Developed by the JCAHO in consultation with a variety of professional associations, pain experts and consumer groups, the standards have been endorsed by the American Pain Society (APS).1

Among the more than 19,500 institutions accredited by the Joint Commission are health care networks, managed care organizations, and healthcare organizations that provide home care, long-term care, behavioral healthcare, laboratory and ambulatory care services.1

The standards are intended to correct serious deficiencies in the way pain is currently managed. Adequate relief of acute pain is provided in only one of four surgical patients, according to C. Richard Chapman, PhD, president of the American Pain Society and a clinical psychologist at the University of Washington. He spoke at a Leadership Summit on Pain Management sponsored by the JCAHO and APS and reported in Journal of the American Medical Association (JAMA).2

Chapman stated that more than half of the Americans with moderate-to-severe chronic pain do not get adequate relief and two out of every three cancer patients fail to obtain satisfactory pain relief.2

The JCAHO standards create new expectations for the assessment and management of pain in accredited hospitals and other healthcare settings. Institutions are being called upon to:
  • Recognize the right of patients to appropriate assessment and management of pain;
  • Assess the nature and intensity of pain in all patients;
  • Record the results of the assessment in a way that facilitates regular reassessment and follow-up;
  • Determine and assure staff competency in pain assessment and management; and address pain assessment and management in the orientation of all new staff;
  • Establish policies and procedures that support the appropriate prescription or ordering of effective pain medications;
  • Educate patients and their families about effective pain management;
  • Address patient needs for symptom management in the discharge planning process."1
In addition, the JCAHO recommends posting a statement of patients' rights and responsibilities in relation to pain care in all health care facilities.

Currently there are serious barriers to pain control, which the JCAHO standards are intended to overcome, according to Perry G. Fine, MD, who addressed the leadership summit on pain management. He is professor of anesthesiology at the University of Utah School of Medicine and associate medical director of the Pain Management Center in Salt Lake City. Barriers he described include:
  • Time constraints that impede physicians from focusing more adequately upon pain control;
  • Inadequate reimbursement and financial incentives;
  • Negative reinforcement during clinical training, in which residents are punished for attending to personal pain [of patients] while being rewarded for measuring potassium levels;
  • Physician fear of regulatory scrutiny and reprisal;
  • "'Opiophobia,' fear of addiction," experienced by some physicians although "crossover in the drug culture world and those in need of medicine is very small;"
  • The fact that pain management is not valued within the established medical culture as a credible or highly respected discipline or specialty;
  • Inadequate knowledge among physicians of how to achieve pain control; and
  • Lack of sufficient practice during residency and training to permit adequate development of pain management skills.2
Suggestions on how institutions might put the JCAHO standards into practice have appeared in such professional journals as American Journal of Nursing and Nursing Management.3-5

The JCAHO is an independent, not-for-profit organization that sets standards for, evaluates, and accredits healthcare organizations in the United States. Pain management standards are available at www.jcaho.org. An overview of the standards, Pain Assessment and Management: An Organizational Approach, has been published by a subsidiary of the JCAHO and may be obtained for $35 from the Web site or by calling (630) 792-5800.

References
  1. JCAHO. Joint commission focuses on pain management. August 3, 1999. [JCAHO Web site] Available at: http:// www.jcaho.org/news/nb207.html Accessed September 4, 2000.
  2. Phillips DM. JCAHO pain management standards are unveiled. JAMA 2000;26:428-429.
  3. Loeb J, Pasero C. JCAHO standards in long-term care. Am J Nurs 2000;100:22-23.
  4. Pasero C, McCaffery M, Gordon DB. Build institutional commitment to improving pain management. Nurs Manage 1999;30:27-33.
  5. Pasero C, Gordon DB, McCaffery M, JCAHO on assessing and managing pain. Am J Nurs 1999;99:22.

Inspanidualized Treatment Optimizes Opioids for Cancer Patients
Physicians and allied healthcare professionals who manage cancer pain have received mixed messages about the use of opioids. On the one hand, the World Health Organization (WHO), the American Academy of Pain Medicine (AAPM), and the American Pain Society (APS) advocate the appropriate use of opioids for cancer pain.1,2 Standard texts, such as The Management of Pain, state that "opioid analgesics represent the mainstay of therapy for cancer pain."3 On the other hand, there remain serious deficits in medical, pharmacy and nursing education on the use of opioids and other pain medications.4,5 Advances in understanding the metabolism of morphine and improved formulations and delivery systems are relatively recent.6 Many healthcare professionals received training before these advances were incorporated into medical curricula. The existence of "opiophobia" in the medical and lay community makes it all the more difficult for many healthcare professionals to offer the benefits of opioid therapy to their patients in pain.

How then should physicians and allied professionals respond when faced with the management of a patient's cancer pain? Here are key elements that should be incorporated into the process of inspanidualizing a treatment plan:
  1. Personally conduct a review of all relevant diagnostic tests in the patient's record.7 If additional diagnostic or therapeutic procedures are needed, be sure the patient's pain is being adequately managed while these are performed.7,8 A trial of opioids or local anesthetics is often useful and indicated.7,8
  2. If the patient has an underlying problem that can be responsive to definitive treatment, focus on that medical condition, but do treat pain symptoms.8
  3. Confer with the patient to establish inspanidual treatment goals for the management of pain. For one patient, the goal may be to resume work; for another, to feel better and relate more fully with family members.7,8
  4. Present the patient, the family, and any caregivers with a pain management plan. This should include a clear statement of the responsibilities of healthcare professionals, information on contacting them if needed, and what should be done if side effects appear.4
  5. Chose a regimen that is easily followed, as this will reinforce good compliance.8 Usually, start with short-acting drugs, and then convert to controlled-release formulations.3 Know the equianalgesic doses of opioid medications—lack of such knowledge has led to inadequate analgesia.7 Seek to achieve round the clock analgesia with the simplest route of administration possible.4 Use prophylaxis to help avoid side effects. Carefully monitor for adverse effects and aggressively address those that appear. Switch to another opioid medication if the patient finds side effects to be intolerable and uncontrollable.3
  6. Consider using not only opioid medications but also adjuvant analgesia, (eg, corticosteroids, antidepressants, anticonvulsants, muscle relaxants, and other drugs).7 Although many patients benefit from receiving opioid analgesia alone, the addition of adjuvant medications can often significantly enhance the effect of opioids or be more effective than opioids alone for certain pain syndromes.8
  7. Incorporate multi-modal approaches to pain management as you inspanidualize therapy for the patient on opioids for cancer pain.9 These could include such techniques as relaxation instructions, music, art and pet therapies, massage, acupuncture, or imagery.
  8. Reevaluate opioid effectiveness as determined by the degree of pain, its expected duration and chronicity. Some patients should be examined within minutes to hours after they start taking opioids. All patients should be evaluated within several days and again at periodic intervals. Each reassessment should include evaluation for new pain reports, a resurgence of earlier pain symptoms, drug toxicities, and improvement of patient function.7,9
  9. Be alert to the patient with special needs. For example, the patient with a recent or current history of having used illicit narcotics may require additional assessments and "opioid contracts," but the use of opioids for these patients should not be ruled out.8 Cognitively impaired inspaniduals, the elderly, children, and minorities are often undermedicated during pain management.
  10. Put in place a plan for addressing breakthrough pain. This usually includes short-acting opioids of the same type as the long-acting opioids being used.3
  11. Some patients do not receive adequate analgesia from medical therapy that includes high doses of opioid analgesics. Other interventions—including neuroablative and anesthetic techniques as well as complementary therapy programs play an important role in these situations.3,7
  12. New pain symptoms should be evaluated along with other therapies. It is often not sufficient to simply raise the dose of the patient’s pain medication.7,9 For example, cancer patients may achieve long-term benefit from radiation therapy or surgery.
References
  1. American Academy of Pain Medicine and American Pain Society. The use of opioids for the treatment of chronic pain: a consensus statement. Available at http://www.painmed.org/html/body_aapm_opioid_ statement.htm. Accessed September 7, 2000.
  2. World Health Organization (WHO). Cancer pain relief and palliative care: report of a WHO expert committee. Technical report series, no. 804. Geneva: World Health Organization, 1990.
  3. Watling CJ, Payne R. Management strategies for pain in the cancer patient. In: Ashburn MA, ed. The Management of Pain. New York, NY: Churchill Livingstone; 1998:473-486.
  4. Paice JA. Pain. In: Yarbro CH, Frogge MH, Goodman M, ed. Cancer Symptom Management 2nd ed. Boston, Mas:Jones and Bartlett; 1999:1218-141.
  5. Phillips DM. JCAHO pain management standards are unveiled. JAMA 2000;26:428-429.
  6. Diamond AW, Coniam SW. The Management of Chronic Pain. 2nd ed. Oxford, England: Oxford University Press, 1997.
  7. Foley KM. Supportive care and quality of life. In: DeVita, VT Jr, Hellman S, Rosenberg SA. Cancer: Principles & Practice of Oncology, 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:2807-2841.
  8. Ellison NM, Lipman AG, Patt RB, Portenoy RK. Opioid analgesia: an essential tool in chronic pain. Patient Care 1998;32:2-11.
  9. Twycross RG. Opioids. In: Wall PD, Melzack R. Textbook of Pain. 4th ed. Edinburgh, England: Churchill Livingstone; 1999:1187-1205.

Management of Nonmalignant Pain in the Nursing Home Setting: An Update
A recent study by Won et al., published in the Journal of the American Geriatric Society reported on an epidemiological investigation concerning nonmalignant pain in nearly 50,000 nursing home residents. A key finding is that no analgesics were administered to approximately one-quarter of the 26% of residents who reported daily pain.1 Residents receiving analgesics at a particularly low rate were those over 85 years of age, males, blacks, Hispanics, and the cognitively impaired. The study does not attempt to document the number of residents who received inadequate analgesia.1

The study found that the effects of nonmalignant pain included impaired activities of daily living and increased likelihood of depression. In addition, nonmalignant pain was associated with less frequent involvement in nursing home activities.1 Previous studies have shown pain to be associated with reduced ambulation, sleep difficulties, and anxiety in nursing home residents.1

The subject of pain management for nursing home residents is a very important one as more than 1.5 million Americans reside in nursing homes and 43% of Americans over 65 years of age will reside in a nursing home at some time.2

Pain can have a great impact upon the quality of life of elderly persons in long-term care facilities. Contrary to common misconceptions, studies have shown that pain tolerance in the elderly is lower than that of the middle-aged population.3

Figure 1 describes factors associated with undertreatment of pain in the nursing home setting. Recommendations formulated by the American Geriatric Society to improve the management of pain in nursing homes are presented in Figures 2 and 3.

It is important to understand that pain is not a normal part of aging. A treatment goal for the elderly is to maintain as close to a pain free existence as possible by using appropriate pain management techniques.3, 4

References
  1. Won A, Lapane K, Gambassi G, et al. Correlates and management of nonmalignant pain in the nursing home. J Am Geriatr Soc 1999;47:936-942.
  2. Ouslander JG, Schnelle JF. Nursing home care. In: Hazzard WR, Blass JP, Ettinger WH, Halter JB, Ouslander JG. Principles of Geriatric Medicine and Gerontology. New York, NY: McGraw-Hill; 1999: 509-521.
  3. Wells N, Kaas M, Feldt K. Managing pain in the institutionalized elderly: the nursing role. In: Mostofsky DI, Lomranz J. Handbook of Pain and Aging. New York, NY: Plenum Press; 1997:129-151
  4. Kwentus JA. Geriatric age group pain treatment. In: Weiner RS. Pain Management: A Practical Guide for clinicians. Boca Raton, FL: St. Lucie Press; 1998: 679-681.
  5. Lynch D. Geriatric pain. In: Raj PP. Practical Management of Pain 3rd ed. St. Louis; Mo: Mosby; 2000: 270-293.
  6. Ferell BA. Pain management. In: Hazzard WR, Blass JP, Ettinger WH, Halter JB, Ouslander JG. Principles of Geriatric Medicine and Gerontology. New York, NY: McGraw-Hill; 1999: 413-433.

FIGURE 1: Factors Associated with Undertreatment of Pain in the Nursing Home Setting
Patient Factors
  • Beliefs that pain cannot be avoided and should simply be tolerated;
  • Reluctance to discuss pain symptoms unless explicitly asked;
  • Misinformation about opioids. (Risks of addiction and side effects should be discussed openly and frankly. Dispelling myths related to opioid use serves to improve the quality of pain management).
Healthcare provider factors
  • Inadequate knowledge of opioid medications;
  • Overestimation of rates of addiction and respiratory depression;
  • Belief that pain is a normal part of aging;
  • Provision of care, on occasion, by nursing assistants with no formal training in pain management;
  • Skepticism as to the value of patients' pain reports.
System factors
  • No inspanidual healthcare provider may feel explicitly accountable for the management of the patient's pain;
  • Screening and prevention not approached systematically;
  • Nurse practitioners and physicians' assistants not used efficiently;
  • Reluctance to send some patients to a multidisciplinary pain center to permit evaluation and establishment of a long-term management plan;
  • Extensive documentation requirements for prescription of opioids leads some healthcare professionals to prefer less effective or inappropriate nonopioid analgesics.
Adapted from references 2, 3, and 5.

FIGURE 2: Principal Recommendations by the American Geriatric Society on the Management of Pain
  1. Pain should be an important part of each assessment of older patients; along with efforts to alleviate the underlying cause, pain itself should be aggressively treated.
  2. Pain and its response to treatment should be objectively measured, preferably by a validated pain scale.
  3. NSAIDs should be used with caution. In older patients, NSAIDs have significant side effects such as GI bleeding and renal toxicity. NSAIDs are the most common cause of adverse drug reactions.
  4. Acetaminophen is the drug of choice for relieving mild to moderate musculoskeletal pain. However, chronic use can cause hepatic and renal problems. Toxic levels of acetaminophen in the elderly can be as low as 3,000 mg/day.
  5. Opioid analgesic drugs are effective for relieving moderate to severe pain from multiple etiologies in the elderly.
  6. Nonopioid analgesic medications may be appropriate for some patients with neuropathic pain and other chronic pain syndromes.
  7. Nonpharmacological approaches (for example, patient and caregiver education, cognitive-behavioral therapy, exercise)—used alone or in combination with appropriate pharmacological strategies—should be an integral part of care plans in most cases.
  8. Referral to a multidisciplinary pain management center should be considered when pain management efforts do not meet the patient’s goals or the health care provider’s goals.
  9. Regulatory agencies should review existing policies regarding access to effective opioid analgesic drugs for older patients in pain.
  10. Pain management education should be improved at all levels for all health care professionals.
Adapted from reference 5.

FIGURE 3: Principles for the Use of Analgesics with Elderly Patients
  • Understand the patient. Focus on treating the patient while managing the symptom.
  • Use lower starting doses of opioid medications than for younger adults and titrate doses more slowly except in acute pain crises.
  • Prefer oral routes of drug administration.
  • Improve compliance by simplifying the regimen as much as possible. This usually entails the use of a long-acting opioid.
  • Anticipate and address prophylacticly and aggressively possible opioid toxicities.
Adapted from references 3, 4, and 6.

Opioids for Managing Patients with Chronic Pain: Community Pharmacists' Perspectives and Concerns
A recent study of community pharmacists' attitudes towards opioids has identified misconceptions and specific areas of inadequate knowledge that hamper the provision of pain relief. The report by Greenwald and Narcessian also indicated, however, that many pharmacies are doing an excellent job for patients with pain.1

One finding of the survey was that the average daily dose of oral morphine the community pharmacists felt comfortable dispensing was 411 mg/day. However, as the investigators point out, several hundred milligrams of morphine every 4 hours are needed for patients with severe pain and no ceiling is recognized for pure agonist opioids.1

Another finding was that only 16.6% of respondents stocked methadone, although the American College of Physicians considers methadone to be extremely useful in the treatment of cancer pain.1

Some pharmacists were frank in acknowledging gaps in their knowledge of opioid analgesics. For example, more than one in three pharmacists (38.9%) responded that they did not know whether it is both lawful and acceptable medical practice to prescribe opioids for pain of nonmalignant origin. Perhaps even more significant is that merely 16.6% of the pharmacists surveyed knew that this is both lawful and acceptable.1

Other findings reported:
  • Slightly more than one-third (13/36) of the pharmacists thought it was illegal for a physician not certified in addiction medicine to prescribe methadone for pain.1
  • Slightly more than one-third (13/36) expressed resistance to filling prescriptions for more than one opioid written by a single physician for an inspanidual patient.1
  • One-third (12/36) of the pharmacists responding expressed the opinion that regardless of diagnosis, the patient who takes opioids every day for a month will become addicted.1
Most community pharmacists expressed little or no concern about how federal or state agencies might view their opioid stocking practices. Yet, 17% were reluctant to stock these drugs because of government surveillance. A particularly interesting finding was that respondents who had experienced a prior federal or state investigation (20%) had only minimal concern about opioid regulatory issues. In contrast, all of the pharmacists concerned about federal or state investigations had never actually been investigated.1

In addition, 14% of community pharmacists surveyed expressed a reluctance to stock opioids because of concerns about robbery. Despite this, "no correlation was found between respondents who had a high degree of concern about robbery and those who had incurred previous robbery."1

Racial, ethnic, and socioeconomic factors may play a role in availability of opioid analgesics for outpatient use. A recent study by Morrison et al., published in the New England Journal of Medicine concluded that "pharmacies in predominantly nonwhite neighborhoods of New York City do not stock sufficient medications to treat patients with severe pain."2

The perspectives and concerns of community pharmacists and other healthcare professionals regarding opioids can be a severe impediment to pain management.3-6 If pharmacists do not carry adequate stocks of opioid drugs, patients may be unable to obtain prescribed medicines. If in counseling patients about opioid drugs pharmacists and other healthcare professionals express hesitation and uncertainty, noncompliance may result. Educational initiatives to dispel myths and encourage rational prescribing, stocking, and dispensing practices are essential to assure access to opioid analgesics for patients who need them.

References
  1. Greenwald BD, Narcessian EJ. Opioids for managing patients with chronic pain: community pharmacists’ perspectives and concerns. J Pain Symptom Manage 1999;17:369-375.
  2. Morrison RS, Wallenstein S, Natale DK, Huang LL. "We don’t carry that" – failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics. N Engl J Med 2000;342:1023-1026.
  3. Weisman DE, Joranson DE, Hopwood MB. Wisconsin physicians’ knowledge and attitudes about opioid analgesic regulation. Wis Med J 1991;90: 671-675.
  4. Elliott TE, Ellott BA. Physician attitudes and beliefs about the use of morphine for cancer pain. J Pain Symptom Manage 1992;7:141-148.
  5. Elliott TE, Murray DM, Elliott BA, et al. Physician knowledge and attitudes about cancer pain management: a survey from the Minnesota Cancer Pain Project. J Pain Symptom Manage 1995;10: 494-504.
  6. Joranson DE, Cleeland CS, Weissman DE, Gilman AM. Opioids for cancer and noncancer pain: a survey of state board members. Fed Bulletin 1992;79: 15-49.
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