PAIN MANAGEMENT PROTOCOL
Introduction:
Pain unrelieved by the analgesics aspirin, acetaminophen and
Ibuprofen, is estimated to affect 30 to 40 million Americans annually.
Further, according to American Medical Association, 13 to 15 million
Americans suffer from chronic, intractable and severe pain, most of which is
inadequately treated. Under treatment occurs in both hospital and out patient
settings. The principal reasons treatment is inadequate for both short term
and chronic pain are thought to be
1) Pt. Reluctance to take medications out of fear of addiction
2) Pt. Reluctance to report pain
3) Physician concerns about the side effects of the opiate derived
Medications.
4) Poor physician assessment of pain.
5) Physician fear of patient addiction
6) Inadequate physician knowledge of pain management
7) Unavailability of pain treatment programs and facilities
8) Inadequate third party reimbursement for pain treatment
9) Low priority for pain treatment
10) Restrictive regulation of controlled substances
Considering that modern pain management techniques are
available which would be effective in relieving virtually every pain case, the
under treatment of pain and its lethal consequences, presents one of the most
urgent issues in contemporary medicine. The recent announcement of
clinical trials by Abbott Pharmaceuticals of its drug ABT-5945, derived
from epibatidine, obtained from the skin of the Ecuadorian frog
Epilbpedoates tricolor, represents a critical change in the history of the
treatment of pain. It is said to be 200 times more potent than Morphine and
has none of the deleterious side effects of Morphine like tolerance,
constipation, and cholinergic effects. Clinical trials are underway.
Nevertheless it is conservative to conclude that drugs specifically designed
to singularly effect cellular pain receptor sites are in the near horizon.
Despite that the phenomenon of opioid phobia in the prescriptive practices
of North American Physicians is not likely to disappear without extensive
educational activities among both physicians and patients.
To achieve that goal and review the critical factors involved in the safe
and effective use of opiate derived medications we undertook this task of
writing a pain management protocol for the successful treatment of pain
without iatrogenic complications.
Diagnosis:
Foremost among the factors essential in the successful
treatment of pain is accurate diagnosis. A careful history of the course and
cause of the pain must first be obtained. To achieve this adequate diagnostic
studies when appropriate are essential. In this direction the availability of
computer assisted tomography, Magnetic resonance Imaging and
Electromyography, makes highly specific diagnosis universally possible.
Especially the etiology of the pain needs to be determined.
Assessment of Chronic Pain:
The importance of proper pain
management cannot be overstated. It is the essential first step in ensuring
appropriate treatment. Patients have the right to appropriate assessment and
management of pain. Patients will be taught that pain management is a part
of treatment. We should emphasize that the single most reliable indicator of
the existence or the intensity of acute pain is the patient’s self report. There
are a number of commonly used self assessment tools, however we will use
the 0-10 numeric pain intensity scale as it has been shown to one of the valid
and reliable and one that is easily understood by almost all patients. We will
make sure that the patient understands the scale each time he/she fills it out.
We believe that the self reporting of pain scale allows each patient to
identify his or her own level of pain regardless of how the nurse/medical
assistant is influenced by other factors like the patient’s behavior and coping
mechanisms.
A comprehensive initial pain assessment will be done for all
patients presenting with significant pain as well as a physical exam.
Neurological assessment if appropriate and desired. Regular reassessment
once treatment has been initiated or when there is a new report of pain. A
pain diary was also developed to assess the ongoing pain control at home
when the patient is under treatment as well as side effects noticed during the
treatment period and interference with daily activities and functions during
the week before the visit. Also the patient will sign a pain management
agreement restricting him/her to a single pharmacy and a single provider.
An in service for educating the staff at Downriver medical
center and Newhaven medical center was separately conducted making sure
that all staff were educated in proper assessment and management of pain.
Further the appropriate pain assessment tools will be given to the patient at
the time the nurse or medical assistant meets the patient. As the patient
awaits the arrival of the provider he/she will fill the forms and hand them to
the provider.
Adequate Treatment:
The pharmacological treatment of pain will follow
the principles of treatment of any condition. The correct medicine will be
selected, the proper dose prescribed and the risks and side effects will be
carefully monitored and weighed against the benefits. With pain medications
utilized for intractable pain, the most serious considerations are for excessive
sedation, severe constipation and under dosage. Adequate pain relief
throughout the day needed through long acting pain medications when
needed. Additional PRN doses for break through pain should be provided.
Psychological Factors:
Careful attention to psychological sequel of chronic
intractable pain is necessary. Pain patients consistently complain of
depression because they no longer do the things that made their lives
satisfying. Relief of pain without relief of depression is clearly inadequate
medicine. Second opinion- The physician might want to get a second
opinion to confirm a diagnosis and safeguards against pitfalls of the
treatment of intractable pain. It also guarantees that comprehensive
treatment is provided.
Patient Education/Therapeutic Alliance:
Patients should be educated
about the nature of pain, its treatment, and their role in pain control. They
are encouraged to report pain as active participants in their own care. A
strong therapeutic alliance is a significant predictor of success. A positive
transference between the treating physician and the patient is essential. By
firm policy the prescription of pain medication should be consistently
limited to a single physician and a single pharmacy. Inclusion of families
and significant others in the education process is encouraged.
Important patient education topics include
1) Proper dosage and schedule for pain medications
2) The difference between tolerance and addiction
3) Realistic expectations of pain medications
4) Management of adverse effects (e.g: constipation)
5) Use of numeric rating scale
Patient Requirements:
Inform staff and physicians when experiencing
pain and quantify pain intensity on a numeric rating scale provided.
Communicate to providers when an acceptable/unacceptable pain relief
exists. Participate in care to achieve an optimal level of function and quality
of life. Ensure appropriate follow up appointment is made.
Documentation:
Careful record keeping of treatment is essential. A plan
for pain management should be documented. Complete records should be
maintained of all therapeutic interventions including medications, dosages,
results, and quantities prescribed for each patient visit. Patient reports of
initial pain assessment, pain intensity, ongoing pain assessment, pain
management agreement should all be in the record. All significant adverse
effects and subsequent interventions associated with pain management
should be recorded. Patient education given should also be recorded.
Summary: JCAHO STANDARDS
RI. 1.2- Patients to be involved in all aspects of their care.
RI.1.2.8- Patients have the right to appropriate assessment
and management of pain
PE.1.4- Assessment of pain in all patients, including identification
of patients in pain, reassessment and follow up.
PF.1.7- Patients should be taught that pain management is a part of
treatment
Ramesh C. Kilaru MD, Medical Director, Down River
Community Services