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After long years of relative silence on the subject, many clinicians, administrators, and patients finally are talking candidly about the management of chronic pain. The result has been a dramatic shift in attitudes as misconceptions about pain are addressed. In fact, a growing number of health care professionals has followed the lead of the Glenview, IL-based American Pain Society (APS) in recognizing pain as "the fifth vital sign."
At least one significant misconception remains, however. Some clinicians acknowledge that paying heed to the needs of patients in pain can improve quality of care and boost patient satisfaction, but also contend that it can lead to higher costs with the more frequent administration of opiates and other pain medications. But that’s not necessarily the case, says Jane Tollett, PhD, RN, the national coordinator of the Department of Veterans Affairs’ (VA) pain management initiative.
"We have no internal studies in this area, but there are some studies published outside of the VA, in cancer institutions, for example, that showed they were losing a lot of money through unscheduled admissions due to pain," she explains. "One center instituted a pain management program, and in one 12-month period, saved $1 million in unscheduled admissions for pain.
"You can certainly make the case that pain management will most likely be financially helpful," she continues. "Take the average cost of a patient visit. If a patient who has pain makes 10 extra visits, and then gets sent to several specialty clinics, those dollars add up."
"Can proper pain management save money? What we ought to aim at is patient comfort and the preservation of dignity. That should be supreme," says Lofty L. Basta, MD, FRCP, FACC, former chair of the cardiology department at the University of South Florida in Tampa, and a prime mover in Florida’s Project GRACE (Guidelines for Resuscitation and Care at End-of-Life). (See QI/TQM, March 2001, cover story.)
"But by the same token, when we have a system in which more than 50% of patients who die in the U.S. die in a hospital — and that’s the most expensive type of treatment — then something’s wrong," Basta says. "When patients in hospice are resuscitated and sent to a hospital so that mortality rates in nursing homes are made to look better, then there’s something wrong with the system. When a country spends 30% of all medical expenses on the last four months of life and 40% in the last two months, there’s something wrong. When a patient with advanced Alzheimer’s, who cannot comprehend what he sees, undergoes cataract surgery, or receives hip surgery for a hip fracture when we know the majority of them die within six months of hospitalization or surgery, there’s something wrong."
Basta says any patient with a chronic illness must be asked about his or her level of pain. "Sometimes patients are either embarrassed to talk about pain or afraid they may create a burden on their loved ones, or they’re too proud to express that they are suffering."
Staff at the VA ask patients to rank their pain from a level of 0 to 10, notes Tollett. "We usually explain to patients that 0’ is no pain, and ’10’ is the worst pain imaginable," she says. "We’re trying to get people to accept the fact that the patient is the best expert on how much pain he has."
While encouraged by the progress they’ve seen, observers paint a decidedly mixed picture of the current state of pain management. "Things are getting a lot better, but we have a long way to go," says Michael Ashburn, MD, MPH, professor of anesthesiology at the University of Utah in Salt Lake City and current president of the APS. "Physicians must become better educated with regard to understanding techniques for the diagnosis and treatment of pain," he says. "We must also increase awareness among some payers of the necessity of an interdisciplinary approach to pain management."
"There are pockets of wonderful progress, and examples of exactly the opposite; sometimes they even coexist in the same system," says Tollett.
"We’re doing lots of things wrong and few things right," points out Basta. "We have a long, long way to go toward rediscovering the simple, unalterable truth that the core of medicine is to cure sometimes, to palliate often, and to care always. We have trained armies of specialists who are extremely skillful in the use of high technology to restore or repair the ravages of illness, but at the same time, they have been poorly trained to care for the human beings who happen to have the diseases. These are real people with real names, with real identities, with fears and hopes, with defiance and acceptance, with suffering and palliation, with despair and hope, and with a multitude of emotions. The person has been neglected, whereas the treatment of deviation in the function of organs is being perfected.
In order to get somewhere, of course, people must know where they are headed. Exactly what should we be looking for if we want to raise our standards for pain management? "What makes for outstanding pain management is an approach where patients, families, and staff are well-educated; where patients are consistently assessed, treated, and evaluated; and where a multidisciplinary/therapeutic approach is taken," says Tollett. "For example, post-op patients usually receive pain medication, but for people who are chronically ill, with multiple pains, you might need some complementary therapies, such as biofeedback, acupuncture, psychosocial therapeutics, or even spiritual therapy. The term holistic’ may be cliché, but the truth is this is the way we need to look at it."
Ashburn and the APS are strong advocates of an interdisciplinary approach to pain management. "These people have complex diseases that touch many different facets of their lives. It’s not reasonable to expect that one health care provider will have all the necessary skill sets the patients require," he asserts. "Physicians and clinical psychologists with expertise in pain management must certainly be involved, and since rehab is often required, physical therapists and occupational therapists are very important members of the team."
It was precisely the need for standards that helped spur the VA’s pain management initiative, a pioneering venture launched in January 1999. "One of the reasons we put in a national strategy was to try to get some standardization, some continuity for the patients — as well as for the clinicians — to help overcome attitudinal barriers, lack of education, equipment, and an inability of the system to adapt itself for documentation," Tollett explains. With about 1,200 sites, the VA also was "perfectly situated" for such an initiative, she adds.
One of the first clinical guidelines to come out of the initiative, to be published shortly, will deal with post-op pain, says Tollett. "The guidelines committee was multidisciplinary and included people from the Depart-ment of Defense and the community at large. Our goal is to come up with something usable and useful for primary care physicians and others who aren’t pain experts." The guidelines, Tollett notes, will include an algorithm that would take the provider through an "if this, then that," decision-making process. The next study may deal with the long-term use of opioids in the treatment of chronic pain, Tollett says.
There continue to be significant barriers to appropriate pain care, Ashburn notes. "There are still many institutions or medical schools that don’t provide adequate training on the diagnosis of pain," he says. "There are still physicians who have not incorporated good pain care into their practices. In some cases, there may not be good institutional support for development and implementation of a multidisciplinary approach."
Other barriers to access include references written by the Health Care Financing Admini-stration that limit access to certain types of pain care and the fact that some health care companies specifically preclude care.
What can quality managers do? "They must be made aware that there is a growing body of evidence that good pain care in the hospitalized patient improves outcomes — particularly after major surgery," notes Ashburn. "In the oncologic population, appropriate pain care should decrease the rate of readmission for intractable pain, which clearly impacts bottom the line. Also, there appears to be a lot of unnecessary surgery by well-intentioned physicians in the attempt to cure intractable conditions when chances for success are low."
Basta says the process of significantly improving pain care will include the confluence of three forces: political, educational, and technological. "At the national level and in our laws, we have to enable the liberal, appropriate use of drugs and spare physicians the worry about the repercussions," he asserts. "If our role is to relieve pain and to alleviate suffering, and in the process the moment of death is hastened, that should not be an offense. It’s an appropriate, ethical approach."
Education is crucial for both patients and physicians, Basta notes. "For example, patients sometimes feel guilty about their pain," he says. "If they have lung cancer, some may say, I did it to myself.’ Doctors are not trained to routinely and regularly ask their patients about pain. We also have to eliminate the physician’s perpetual lie that It’s not going to hurt.’ We have to become keenly sensitive to the painful effects of our treatment."
As for technology, "We have improved and are continuing to improve our ability to manage pain," Basta says. "Research in this area should continue and should be encouraged."
Quality managers, he adds, should focus on three things when it comes to pain management:
1. Patient and family satisfaction come first. "That’s easily measurable," he says. "Patients will tell you, I don’t want to suffer.’ They will also say, If I am in the process of dying, do not artificially prolong my life through technology.’ They would say they wouldn’t want be a burden to others. And they want to be respected to the end and have a sense of control. These are all measurable."
2. Quality managers must make sure there is a process in place to measure the level of patient pain and what is being done to alleviate it. "They also should research whether there have been high-tech interventions that were not in the patients’ best interest in futile situations. Since life is finite, medicine is finite, and you can impose unnecessarily on the patient and place an unnecessary burden on the family." The patient and family must be an integral part of the decision-making process in these situations, Basta adds.
3. Quality managers should advocate actively the implementation of advanced care planning at their institutions. "I’m not talking about a living will," he asserts. "Living wills talk about terminal illness. But what patients fear most are things like Alzheimer’s, which can last over 10 years, or a massive stroke that renders one wheelchair-bound, which it can do for decades. These are excluded from living wills.
"Second, living wills talk about irreversible’ conditions," he continues. "Let’s say I have Alzheimer’s, and I get pneumonia. Pneumonia is reversible; Alzheimer’s is not. In a living will, I might have wanted to say, If I develop pneumonia and I have Alzheimer’s, I do not want be treated,’ despite the fact that the pneumonia might be deemed reversible by medical standards. (For more about advance directives, visit the Project GRACE web site: www.p-grace.org.)
"If you don’t provide interdisciplinary treatment, patients will continue to suffer and will be desperately seeking care through those individuals who are available. If a patient has intractable back pain, and if interdisciplinary support does not exist, he will seek only surgical options, and surgeons will provide those options," Ashburn warns.
• Michael Ashburn, MD, MPH, Pain Manage-ment Center, University of Utah, Suite 200, 615 Arapeen Drive, Salt Lake City, UT 84108. Telephone: (801) 585-7690.
• Jane Tollett, PhD, RN, National Coordinator, Pain Management Initiative, Department of Veterans Affairs, 810 Vermont Ave. N.W. (114) Washington, DC 20420. Telephone: (202) 273-5700. Web site: www.va.gov.
• Lofty L. Basta, MD, FRCP, FACC. Telephone: (727) 445-1911.
• Marty Ratliff, Executive Director, Project GRACE, 1311 N. Westshore Blvd., Suite 107, Tampa, FL 33607. Telephone: (877) 994-7223.
• Catherine Underwood, Executive Director, American Pain Society, 4700 W. Lake Ave., Glenview, IL 60025-1485. Telephone: (847) 375-4715. Fax: (847) 375-4715. Web site: www.ampainsoc.org.