Vol. 284 No. 4,
July 26, 2000
This was the prevailing notion underlying the spring Leadership Summit on Pain Management sponsored by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the American Pain Society (APS). The second such meeting will be held this week in Los Angeles.
Dennis S. O'Leary, MD, president of the JCAHO, said that appropriate pain management is good medicine because it results in quicker clinical recovery, shorter hospital stays, fewer readmissions, and improved quality of life, leading to increased productivity. He said that the "mystique of pain" the long-held notion that because pain is subjective it eludes objective measurementhas given way to evidence-based medicine as newer methods of assessing and controlling pain have emerged.
"Pain control has become a problem because of confusion as to who is responsible [for it], a general lack of knowledge about pain, and misconceptions about drug tolerance and addiction," said O'Learyhence the development of standards that place responsibility for pain management on health care organizations. With the motto "The pain management paradigm is about to shift," the JCAHO says the change will occur in four ways: by making it a patient rights issue as well as an education and training issue, emphasizing the quantitative aspects of pain (placing it on a 10-point scale), encouraging systematic assessment, and emphasizing safe management.
All this adds up to a heightened awareness of pain as the "fifth vital sign" (as originally designated by the Department of Veterans Affairs) that should be monitored with the same vigilance as blood pressure, pulse, temperature, and respiratory rate. It also means a shift from traditional pain control practices, as exercised by individual patient and physician decision making with unspecified follow-up, to a more systematic approach by multidisciplinary teams of individuals with specified responsibilities.
C. Richard Chapman, PhD, a clinical psychologist at the University of Washington and president of the APS, discussed the magnitude of clinical pain. Based on his knowledge of a number of studies, he said that in only about one in four of the 23 million surgical operations done in the United States annually does the patient receive adequate relief of acute pain, he said. In addition, Americans incur about 65 million traumatic injuries, including 2 million burns, each year, and millions more have diseases that produce acute pain.
Of the 50 million people in this country with chronic pain, Chapman said that four in 10 with moderate-to-severe pain cannot find adequate relief. More than 26 million people 20 to 64 years of age have frequent or persistent back pain, and one in six has painful arthritis. Only about 30% of all cancer patients with pain get adequate relief, he said.
BARRIERS TO PAIN CONTROL
Perry G. Fine, MD, professor of anesthesiology at the University of Utah School of Medicine and associate medical director of the Pain Management Center in Salt Lake City, summarized the shortcomings of current pain control. He said they constitute a series of barriers that may reflect physicians' attitudes (interest, open-mindedness or lack thererof, sense of personal priority) or aptitudes (knowledge and skills). Briefly, the barriers are as follows:
Interest. Medical school curriculums spend little time on pain management despite the ethical imperative to relieve pain and suffering. Time constraints cause physicians' interest in helping patients with pain to wane because control procedures are complex and time consuming. Compared with other procedures, pain control offers physicians little in the way of reimbursement and financial incentives.
Open-mindedness. "These include negative reinforcement during clinical training, in which residents are punished for attending to personal pain [of patients] while being rewarded for measuring potassium levels. Cultural biases toward complainers, crooks [such as people seeking drugs for resale rather than pain relief], and drug seekers interfere with prescribing pain drugs. Then there are the hassle factors of documentation, prescription refills, frequency of visits, telephone calls, and so forth. In addition, physicians fear regulatory scrutiny and reprisal and may have 'opiophobia'fear of addiction. The truth," Fine said, "is that crossover in the drug culture world and those in need of medicine is very small."
Priority. During residency training, experience with pain is limited and empathy is not part of the medical culture. Furthermore, medical students have limited positive mentoring experiences with regard to pain control. "Management of pain is not valued within the established medical culture as a credible or highly respected discipline or specialty," Fine said. "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."
Knowledge. There are many of these barriers, including limited undergraduate didactic and preclinical course work, as well as a limited clinical focus. And a universal symptom like pain is not universally addressed in postgraduate training. "We spent many hours memorizing the [blood] clotting cascade, but none on the pain cascade," Fine said, adding, "Half the population may go through a pregnancy, yet 100% of all medical students have to pass boards on obstetrics and gynecology. On the other hand, 100% of the population is at risk for pain, but how many have to pass qualifications for pain management? Zero percent!"
Skills. "People and organizations get good at what they practice and concentrate on."
The elimination of these barriers, Fine said, will require taking several steps. "The first step is recognition of the problems, which is where we are today. But interest alone is not enough. The next step is commitment of resources and alignment of incentive. We're on the verge of taking this step."
Richard S. Frankenstein, MD, an internist in Garden Grove, Calif, and a commissioner of the JCAHO, where he chairs the Standards and Survey Procedures Committee, said the new pain management standards (see sidebar) reflect the consensus of an expert panel of physicians, nurses, pharmacists, therapists, and representatives of other health care organizations. Consistent with pain management guidelines issued by the Agency for Healthcare Research and Quality and the APS, the new JCAHO standardswhich go into effect in Januaryemphasize a collaborative and interdisciplinary approach, individualized pain control plans, assessment and frequent reassessment of pain, use of pharmacologic and nonpharmacologic strategies, and establishment of a formalized approach.
The JCAHO is surveying institutions that have begun programs to assess problems that have emerged. The results of this process will be reviewed this summer, and appropriate recommendations will be made for each accreditation setting. Pain management standards for each manual are posted on the JCAHO's Web site at http://www.jcaho.org.
In addition, Joint Commission Resources, Inc, a subsidiary of the JCAHO, has published an overview of the standards along with examples of implementation from organizations with successful pain assessment and management approaches. The publication, Pain Assessment and Management: An Organizational Approach, is available for $35 from the Web site listed above or by calling (630) 792-5800.
Carole H. Patterson, RN, director of the JCAHO Standards Interpretation Group, described the six standards chapters as follows:
Rights and Ethics. Recognize the right of individuals to appropriate assessment and management of pain. This standard represents the organizational commitment to pain management. Health care organizations may make this commitment explicit through their mission statements, their patient/client bill of rights, or detailed service standards.
Assessment of Persons With Pain. Assess the existence and, if so, the nature and intensity of pain in all patients, residents, or clients. This standard represents the organizational recognition that pain is a common experience and that unrelieved pain has negative consequences. To comply with the standard, the organization incorporates pain assessment into its procedures. It develops procedures for recording assessment results and for ongoing reassessment and follow-up. As part of this standard, the organization also determines and ensures staff competency in pain assessment and management, and incorporates training on pain assessment and management in the orientation of new clinical staff.
Care of Persons With Pain. Establish policies and procedures that support the appropriate prescribing or ordering of effective pain medications. This standard asserts that the goal of care is treating symptoms that may be associated with a disease, condition, or treatment, including pain. In the context of pain management, it focuses on appropriate prescription and administration of patient-controlled analgesia, spinal-epidural or intravenous medications, and other pain management techniques.
Education of Persons With Pain. Educate patients, residents, and clients and families about effective pain management. This standard specifies that the organization is responsible for helping patients, residents, and clients understand the importance of pain management as a part of treatment, as well as the influence that cultural and belief systems have on shaping conceptions of pain and pain control. In particular, organizations must present individuals with balanced and accurate information on pain medication, since many misconceptions exist about them.
Continuum of Care. Address the individual's needs for symptom management in the discharge planing process. This revised standard includes pain as a symptom that should be addressed when considering an individual's needs after discharge.
Improvement of Organization Performance. Incorporate pain management into the organization's performance measurement and improvement program. This revised standard specifies that as the organization collects data to monitor its performance, it should consider the appropriateness and effectiveness of its pain management program.D.M.P.