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Heal the Whole Hurt


 

Note: This is Part 3 of The Hospitalist’s series on pain and hospital medicine. Part 1 appeared on p. 45 of the April issue, and Part 2 appeared on p. 33 of the June issue.

Hospitalists face demands for pain care every day. Usually, the general pain principles described in the first two articles in this series and the use of a few opioid analgesics with which the hospitalist has become familiar can supply relief.

But what about the more difficult cases in which psychosocial influences or a history of substance abuse complicates the patient’s pain? Perhaps it is a chronic pain case that has never been adequately addressed, or the patient keeps turning up in the emergency department (ED) complaining of out-of-control pain. Other examples of difficult-to-manage pain include complex regional pain syndrome, post-herpetic neuralgia, other neuropathic pains, sickle cell anemia, and patients at high risk of opioid toxicity.

These cases are like a leaky bucket for the hospital—costly, frustrating, unsatisfying to the patient, and prone to bad outcomes, says Jerry Wesch, PhD, director of the pain service for the Alexian Brothers Health System in greater Chicago. “These are the patients who tend to bedevil everybody in the hospital,” he says.

Dealing with such patients is a demanding task.

“You don’t have chronic pain without a psycho-social-spiritual overlay,” adds Scott Fishman, MD, chief of the Division of Pain Medicine at University of California-Davis in Sacramento. “Their emotional lives are deteriorating. They can’t sleep, they’re depressed, and their physical functioning is also deteriorating. There are all kinds of situations that demand use of a full spectrum of bio-psycho-social interventions in addition to opioid analgesics.”

These complex, unresolved cases are likely to have emotional, social, or spiritual manifestations. But what does that mean to a busy hospitalist with a short window of opportunity to address patients’ pain before pointing them toward discharge? A psychologist, social worker, or chaplain may have something to contribute to pain management. Meanwhile, the rest of the caseload is clamoring for the hospitalist’s attention.

The hospitalist is charged with responsibility for the whole person during a patient’s brief hospital stay. But there are limits to what the hospitalist can accomplish. A palliative care team or an acute pain service can make important contributions to hospitalized patients’ pain. So can social workers, psychologists, pharmacists, and chaplains.

Make Pain Management Multidisciplinary

A dizzying array of pain modalities can be brought to bear on complex pain cases. These range from opioid analgesics to a variety of adjuvant non-opioid medications to interventional techniques involving surgery, spinal injections, nerve blocks, nerve stimulation, and nerve destruction techniques.

There are also complementary methodologies (e.g., acupuncture) that have been shown to reduce the volume of narcotics needed for pain control, even though how they work is not well understood.

But how many hospitalists call on acupuncturists, hypnotists, or teachers of guided-imagery meditation for their patients? Many of these techniques are more appropriately initiated in the outpatient setting, but the hospitalist still has a responsibility to make sure “frequent fliers” with complex pain complaints get connected post-discharge to a pain service that can offer long-term relief. The challenge is applying the acute treatment models of the hospital to chronic pain syndromes that are not optimally addressed in crisis mode.

Jonathan Weston, MD, a hospitalist at Penrose Hospital in Colorado Springs, Colo., says these difficult, chronic pain cases are the bane of the hospitalist’s working life. These patients show up at night in the ED saying, “ ‘I’m in so much pain, please don’t send me home,’ ” he says. “The emergency physician puts them on an IV drip and their pain is relieved for the moment, but only one facet of that pain has been addressed.”

The emergency physician—also under caseload pressure— decides the easiest disposition is to admit the patient and dump the problem on the hospitalist. “They’re out of their pain medications at home, and when you call the attending you are told that they are drug seekers,” Dr. Weston relates. “These patients take a lot of energy. They can be manipulative. We can’t do right for them. It’s not satisfying. We don’t want to round on them. The way we hospitalists manage these patients sometimes reflects not only the patient’s personality, but our personality as well.”

Hospitalists don’t just treat these patients’ pain, they also address their suffering, he says.

High-quality pain management is multidisciplinary, Dr. Weston notes, because pain is multifactorial. The hospitalist occupies an important coordinating position and is charged with responsibility for the whole person during that patient’s brief hospital stay. But there are limits to what the hospitalist can accomplish. A palliative care team or an acute pain service can make important contributions to hospitalized patients’ pain. So can social workers, psychologists, pharmacists, and chaplains. But it is the hospitalist’s responsibility to coordinate these pieces of the pain puzzle for patients on service.

In many hospitals, the palliative care service has been set up to consult on pain, suffering, and clarification of treatment goals for patients nearing the end of life. These services vary from institution to institution in terms of whether they prefer to focus on end-of-life issues or are comfortable fielding other kinds of chronic pain questions. Acute pain services equally vary in terms of whether their focus is primarily on surgical pain “interventions” or on a multidisciplinary approach to pain management.

Ideally, Dr. Weston says, a major hospital would have both services available as resources to the hospitalist. Or, if there is only one of them, it should have a broad approach to pain management. Otherwise, it is up to the hospitalist to pull together a virtual pain team to provide a multidisciplinary response to complex pain.

“I am also board certified in hospice and palliative medicine,” Dr. Weston says. “I can use my medical knowledge to try to get the patient comfortable on oral meds so that they can go home. And I can personally make an appointment for them within 48 hours of discharge with their attending physician or a pain specialist. But for too many patients, this connection never happens.”

“Pain management in general is a hard thing to deal with,” adds Lauren Fraser, MD, regional chief of the department of hospital medicine for Kaiser Permanente Colorado in Denver. “It’s frustrating because you want to do the right thing,” she says. “We need first of all to rule out anything we can fix that might be causing the pain. Then we’re dealing with the patient’s quality of life and the disabling effects of pain. Each patient and family has a different need, and when you meet with them one-on-one you’re dealing with all of it.”

Dr. Fraser doesn’t have access to an acute pain service in her current setting, “although we have interventional folks to put in the PCAs and epidurals. We generally are able to get the services we need, although there would be an advantage to having an identified multidisciplinary pain service to provide the coordination.”

Tips to Manage Pain

  • Investigate all inpatient and outpatient pain resources in your community. Collect business cards and brochures and develop personal relationships with pain specialists. A multidisciplinary outpatient pain clinic can be a huge resource. Ask someone from the local integrative medicine center to speak at a brown bag presentation for hospital staff. Sometimes other specialists (neurologists, obstetricians/gynecologists, surgeons) may have insights on underlying pathology for a pain case that isn’t responding as expected.
  • Develop effective communication links with attending physicians and find ways to make sure they receive specific communications by telephone and fax about how their patient’s pain problem was treated in the hospital, what medications are in your discharge orders, and what you recommend in terms of ongoing pain treatment. If possible, make an appointment for the patient’s next visit to the primary physician or the pain clinic before the patient leaves the hospital.
  • Ascertain the extent of the palliative care and/or pain service at your hospital, if it exists, and find out the extent of its services. Learn when to call for help with difficult cases, such as when pain doesn’t respond as expected to first-line treatments. Learn from the anesthesiologist when certain interventions are called for and gain comfort in requesting them.
  • Find ways to participate on the palliative care or pain service at your hospital, such as by attending team meetings or serving on an advisory committee. Qualified hospitalists may be able to play a larger role by rotating through the service as attendings.
  • Create a virtual pain team in the hospital if there is no formal pain service. Find a nurse, social worker, pharmacist, chaplain, physical therapist, and other professionals who have an interest in pain management and will meet regularly to solve difficult cases. Consider the availability of and institutional receptivity to complementary modalities such as acupuncture.
  • Collect data to show the extent of the pain problem, particularly for patients who keep recycling through the ED with chronic pain complaints. How much do they cost the hospital? How much would the hospital willingly spend on a pain service that could help manage these cases better and faster? Work with other hospitalists to bring attention to these issues.
  • Make pain management a formal focus for institutional quality improvement activities. Involve multiple disciplines on a pain management task force charged with suggesting improvements for the difficult pain challenges seen in your hospital and applying evidence-based pain management to the hospital’s routines. Does the hospital have a pain policy, pain protocols, and standardized order sets? Is there a pharmacy and therapeutics committee or other body that could spearhead the development of such policies?

A “Pain Hospitalist”

Jerry Wesch, director of the pain program at Alexian Brothers Hospital Network in Arlington Heights, Ill., recently posted a job listing on the Internet seeking a pain management physician. He is looking for a doctor with an interest in comprehensive, interdisciplinary team management of chronic pain who is “able to function as a pain hospitalist.”

Although the details of this new position are still being finalized and a pain hospitalist would function with a different focus than a generalist hospitalist, Wesch suggests the role has important analogies with what hospitalists like Dr. Weston face in coordinating a virtual team of multidisciplinary pain resources.

Wesch is building an inpatient pain service comprising the pain physician, two nurse practitioners, and a part-time psychologist with full-time presence in two Alexian Brothers acute hospitals. This team would work closely with hospitalists, the palliative care service, and ancillary services such as physical therapy and chaplains.

“This should make us ideal collaborators with the hospitalists, who can just walk down the hall and initiate a pain consult,” he explains. “We’re all working toward the same goal, which is to improve efficiency, medical management, quality of care, and patient satisfaction. A good hospitalist is also my best ally in building a multidisciplinary pain service.”

In other settings, however, it will be the hospitalist’s responsibility to build the relationships that bring these pain resources together.

Deb Gordon, RN, MS, FAAN, senior clinical nurse specialist at the University of Wisconsin Medical Center in Madison, also sees herself functioning like a hospitalist in addressing pain issues. “I manage a clinical pain consultation service. I see patients every day,” she says. “I’m also in staff development, helping professionals in the hospital learn to manage pain better, and using quality improvement techniques to take what we know about pain management to support people like hospitalists at the bedside.”

Since 1990, an interdisciplinary quality improvement pain management group has been meeting at the UW medical center to improve the institution’s response to pain patients. Gordon believes pain is a natural target for hospital quality-improvement activities because it touches on the domains of quality identified by groups such as the Institute of Medicine in Washington, D.C., and the Institute for Healthcare Improvement in Cambridge, Mass.

Limits in the Hospital Setting

Even with a vast array of pain modalities, hospitalists face inherent limitations in addressing pain challenges within the hospital, starting with caseload pressures and short lengths of stay. Many of the approaches that might offer long-term solutions to the patient’s chronic pain syndrome belong in the outpatient setting, adds John Massey, MD, president and medical director of Nebraska Pain Consultants in Lincoln.

Dr. Massey sees chronic pain cases that have been refractory to treatment, both at his clinic and as a consultant in the hospital. Inevitably there is a psychological overlay to these cases, he says. That doesn’t mean the patient’s pain isn’t real, but if high doses of analgesics have failed to bring the pain under control, then a different approach is needed—one that includes behavioral techniques and involves the patient not as a passive recipient of treatment, but an active participant in his or her own pain management and coping strategies.

“There are ways to treat, for example, back pain that require finding a specific nerve in the spine responsible for the pain,” says Dr. Massey. “If I can locate that nerve, there are things that I can do, like radio frequency neuro-ablation. But this requires three separate visits to the pain clinic to make an accurate diagnosis. I’m often consulted by hospitalists and there are things I can do to put a finger in the dike. But I try to add another perspective to my discussion with the hospitalist, pointing out that many of the best pain management modalities are done on an outpatient basis.”

What can be achieved in the hospital often is more of a Band-Aid, sometimes even a step backward in terms of the lifestyle changes necessary to get patients out of their passive response to their chronic pain, Dr. Massey says.

The hospitalist’s job is to see what can be done to make patients more comfortable and then send them home with a referral to the pain service, if that is indicated. “I’m happy to help with an intervention in the hospital but, ultimately, we’d like the patient to be less dependent on opioids to treat their pain,” says Dr. Massey. “I know that nothing I can do will really change the situation until I get them out of the hospital and can initiate physical therapy and behavioral interventions.”

There are no shortcuts to permanent pain relief, which can be long, slow, hard work using evidence-based medicine, Dr. Massey says. But it also involves a frank discussion with the patient, which may be hard in the hospital.

“One of the questions we ask patients is: How many times have you visited the emergency room for pain?” says Dr. Massey. “If the answer is more than four in a year, there are likely to be psychological co-morbidities. The challenge for the hospitalist is, ‘How can I arrest this acute pain episode, and then what can I contribute to helping the patient find the help he or she needs to prevent the next episode?’ That means trying to establish rapport and pointing the person to appropriate follow-up pain resources. If you go too hard too fast, the patient may reject what you’re offering. But if you do nothing, you’re facilitating a continued passive approach that doesn’t lead to meaningful solutions.”

Dr. Massey recently saw a woman who had been in the ED 48 times in the previous year for pain that had a major behavioral component. The hospital hired him after the 48th visit to find a different approach to controlling the patient’s pain.

Make Pain a Priority

“My hospitalist group meets regularly to discuss difficult topics, and pain often comes up,” says Stephen Bekanich, MD, hospitalist and palliative care physician at the University of Utah Medical Center in Salt Lake City. “The more you can focus on pain, the more time you spend making it a priority, you are sending a message: This is important to me. You communicate to nurses and other staff that you take pain seriously.”

Dr. Fishman concurs. “Ultimately, it is an issue of priorities and how to prioritize what gets done in the hospital,” he says. “Why would a health professional ever categorize pain relief as a lower priority? We have wandered far from our compassionate mission as doctors when that happens.

“In the real world, when there is no one else to do it, and no pain clinics available, the responsibility for pain management falls on the provider at the front lines, often the emergency physician and the hospitalist. Hospitalists are becoming de facto pain specialists for patients with chronic and terminal conditions. These patients are looking for support, comfort, and redirection. This can also be one of the most rewarding aspects of hospital practice. It really brings you back to the roots of medicine.” TH

Larry Beresford is a regular contributor to The Hospitalist.

Pain Treatment Modalities

This chart categorizes and summarizes the variety of pain treatment modalities that might be available to the hospitalist. Because there are so many, we have not included specific doses or instructions for use.

  • Non-opioid analgesics for mild to moderate pain: Analgesics such as acetaminophen, aspirin, and non-steroidal anti-inflammatory drugs (NSAIDs) are fundamental in managing acute and chronic pain from a variety of causes. They may be combined in commercial formulations with codeine or other opioids. They often are recommended—even when stronger opioids are being used. Take care not to exceed recommended daily maximums. No NSAID is a priori more effective than another in the general population, although there is great inter-patient variability in their response.
  • Opioid analgesics: These drugs are the mainstay of managing moderate to severe pain and the types of pain challenges hospitalists face every day. Experts say opioids typically offer the best approach to short-term pain management in the inpatient setting and, when used correctly and closely monitored, provide effective pain relief with limited risk. Oral administration is preferred. There are situations where other routes are indicated, including intravenous, which is the quickest and most precise route for titration, intramuscular and transdermal, as well as sustained-release pills. Opioids can be long-acting or short-acting. Hospitalists should be familiar with equi-analgesic dosing conversion and able to substitute equivalent doses between methods of administration. Pain experts also recommend becoming familiar with a few short- and long-acting opioids and their use for the majority of pain cases.
  • Patient-controlled analgesia (PCA): The PCA pump is a boon for treating acute pain in the hospital setting, offering patients the opportunity to control how much analgesia they get, and when, by pressing and releasing a control button connected to the computerized infusion pump. PCAs can be prescribed with a basal rate of analgesia administration plus an incremental dose, typically equal to 50% to 100% of the basal rate over a 24-hour period, with safety features to prevent receiving more than the recommended dose and lock-out intervals between doses, defined in minutes. A digital history can be generated, and the PCA can free nurses from frequent requests for analgesics from the patient. It is recommended that hospitals establish criteria for which patients are appropriate for PCAs because they can be overused, especially for chronic pain exacerbations that could be managed orally.
  • Adjuvant analgesics: A diverse list of adjuvant analgesics is also used to treat pain. In some cases they may allow a reduction in the total dose of opioids required to achieve pain relief. They may also be used to address types of pain not well managed by opioids, such as neuropathic pain. Patients with severe chronic pain often experience anxiety or depression, which can be treated by the appropriate adjuvant drug in order to achieve optimal pain management. Classes of analgesic adjuvants include:
    • Anticonvulsants, including gaba-pentin, pregabalin, lamotrigine, and carbamazepine;
    • Select antidepressants (e.g., tricyclic antidepressants, duloxetine, citalopram venlafaxine, bupropion, and paroxetine;
    • Local anesthetics;
    • Alpha-2 adrenergic agonists;
    • NMDA receptor antagonists;
    • Corticosteroids;
    • Muscle relaxants; and
    • Hypnotics and anxiolytics
  • Interventional pain treatments: Interventional pain techniques in a variety of mechanisms can be used to address pain problems resistant to the usual oral analgesics. Most often these interventions are provided by a pain specialist in the anesthesia department or acute pain service, although hospitalists are encouraged to start learning which techniques are appropriate for which kinds of hospitalized patients. Interventional pain techniques refer to surgical interventions to block, stimulate, modulate, ablate, or otherwise deaden the nerves transmitting pain messages to the brain. Other interventional techniques include fluoroscopy technology, radio-frequency ablation, and cryoanalgesia.
  • Non-pharmacological pain treatments: Non-pharmacological pain techniques are even more varied, although they may not be readily accessible in the hospital. Non-pharmacological techniques can be used as adjuvants to morphine, helping to reduce the total analgesic dose required. Or, when pain is not responsive to the usual techniques, these alternatives may be utilized to help the patient gain control over their pain. They include:
    • Cognitive/behavioral therapies;
    • Psychological counseling;
    • Support groups;
    • Meditation/relaxation/guided imagery;
    • Distraction;
    • Music therapy;
    • Heat and cold;
    • Exercise;
    • Biofeedback;
    • Hypnosis;
    • TENS (trans-electrical nerve stimulation); and
    • Complementary/alternative therapies such as acupuncture, acupressure, aroma therapy, and therapeutic touch
  • Other: Other pain techniques include radiation or chemotherapy to alleviate pain from intruding cancer tumors, along with physical therapy and other applications of rehabilitation medicine for different kinds of pain.

—LB

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