A special focus in pain assessment is recognizing neuropathic pain—resulting from injury or damage to the nerves themselves, which is different in nature and treatment from nociceptive pain and is also generally less responsive to opiate analgesics. Roughly 15% of the pain hospitalists see may be neuropathic, which can be suggested by certain words, such as burning, numbing, tingling, or shooting, in the patient’s description of the pain. Certain syndromes also suggest the possibility of neuropathic pain, including diabetes, HIV, alcoholism, radiation or chemotherapy, and amputation and phantom limb pain. Neuropathic pain may be treated with tricyclic antidepressants such as desipramine (Norpramin, Petrofrane) and nortriptyline (Pamelor, Aventyl) as well as with the anticonvulsant gabapentin.1,2
Another key issue in pain management involves side effects. With opioids, constipation is such a common side effect that experts recommend prescribing a laxative and/or stool softener every time an opioid analgesic is initiated. The physician must then stay on top of the issue, prescribing additional laxatives if the desired effect is not achieved. Other side effects of opioids, which must be balanced with their analgesic properties, include nausea, sedation, mental status changes, and respiratory suppression. A number of these side effects will dissipate after a few days on opioids, but constipation remains problematic.
Other basic principles of pain management, gathered from physicians interviewed for this article and from other pain resources (see “Resources and Tools,” p. 49) include:
- There is no absolute maximum dose of opioids; adjust dose based on individual need and response. If initial doses are not effective, titrate up based on percentages of the dose: 25%-50% for mild to moderate pain, 50%-100% for moderate to severe pain.
- Use the right duration in prescribing; short-acting opioids may be more effective when given every four hours than every six hours. PRN prescriptions are not recommended except for breakthrough pain. The World Health Organization’s Pain Ladder suggests an overall approach to dosing based on severity.
- Tailor the pain regimen while the patient is still in front of you, if possible. The patient’s response to intravenous analgesics should start to become clear within 10 minutes of initiation.
- The earlier you treat pain, the easier it will be to bring it under control.
- Oral administration is generally preferable to intravenous unless there is a reason to avoid using the oral route.
- Pain experts do not generally recommend meperidine as an analgesic.3
- Opioids are not recommended for all kinds of pain. Opioids may be avoided for patients with neuropathic pain, for those with existing constipation or nausea problems, or for morbidly obese patients with bad sleep apnea.
Finally, work with primary care physicians to plan for pain needs post-discharge, as well as for potential problems or barriers that may arise, especially if high doses of opioids are involved.
“One of the most difficult issues is addressing what will happen after the patient leaves the hospital,” says Dr. Bekanich. “That’s where the ball often gets dropped.”
He makes a point of calling the patient’s primary physician at the time of discharge and then dictates a letter, including the pain protocol, which is transcribed and faxed to the primary physician. “We don’t let these patients walk out the door without an appointment date already scheduled with a physician,” he says.
Benefits of Pain Relief
Dr. Jessop encourages hospitalists to take advantage of SHM’s core competency in pain management as a guide to improving their skills in this area. Managing patients’ pain is a win/win for the physician, the patient, and the institution. “Nothing feels better than getting a patient out of pain,” she says.