Taking the Pain Out of Pain Management

At a symposium held in conjunction with the American Academy of Physician Assistants Annual Conference, two leaders in emergency medicine and pain management presented an overview of the current issues in pain management. Topics included overcoming attitudinal barriers to pain management, and choosing the appropriate pain management agents and regimens in the clinical setting.

This program was supported by an educational grant from Purdue Pharma, L.P.

Dilemmas, Decisions, and Disparities: Paradoxical Pain Management Issues

Pain management has advanced tremendously in recent years, and physician assistants will play a key role in facilitating further progress in this area. “In providing optimal patient care, providers need to focus on their shared base of scientific knowledge rather than relying on societal, personal, or moral attitudes about pain and its treatment,” said Knox H. Todd, MD, MPH, Director, Pain and Emergency Medicine Initiative, in Atlanta, Georgia. According to Dr. Todd, achieving effective pain management in the practice setting requires overcoming the attitudinal barriers and biases associated with the assessment and treatment of pain.

Naming the Barriers
According to the International Association for the Study of Pain, pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or is described in terms of such damage (www.iasp-pain.org). “Importantly, pain is a subjective sensation; therefore, an appropriate amount of pain cannot be defined for a given injury. We need to trust our patients’ report of their own pain, because it is the best measure available to us,” Dr. Todd noted.

Pain management is an important part of patient care in a number of clinical settings, including specialties such as oncology and emergency medicine. Indeed, a 1997 report showed that pain medications represent one third of all medications used in the emergency department (NHAMCS, 1997 ED summary). Unfortunately, a variety of factors can interfere with adequate pain management.

In an early study of pain management at Akron City Hospital, only 44% of patients presenting to the emergency room with acute pain received analgesics (low dose)—and almost 50% of these waited 2 hours for treatment (Wilson, Am J Emerg Med 1989). Similarly, at the Cincinnati Children’s Hospital, only 62% of children with isolated fractures received an analgesic (Friedland, Ann Emerg Med 1994).

Other early research explored the barriers that prevented effective pain management, particularly in the emergency setting. Todd and colleagues investigated pain management in all patients seen at the UCLA Emergency Medicine Center for extremity fractures in 1991 and 1992. The findings revealed that only two thirds of these patients received an analgesic. Moreover, astounding ethnicity-related differences emerged, with 45% of Hispanic persons compared with 74% of whites receiving an analgesic. Severity of injury, insurance status, primary language, and physician characteristics appeared unrelated to whether or not patients received an analgesic. “These were striking findings, showing greater undertreatment of pain in the Hispanic community. Whether this was an issue of ethnicity bias or of cultural differences, such as how different individuals express pain, warranted further study,” Dr. Todd said.

To investigate the issue of ethnicity in pain management further, Todd and colleagues conducted a follow-up study, analyzing the pain management practice in 217 patients who presented to an Atlanta emergency department with extremity fracture. According to Dr. Todd, pain was described similarly in the patient medical charts for African-American and white patients; however, 74% of white patients versus only 57% of African-American patients received analgesic for their pain. “This finding could not be explained by income, insurance status, injury type, or other patient factors. Since the presence of pain was well documented, cultural difference in expressing pain appeared not to be a factor. Thus, perception about ethnicity appears to be a barrier, not to the assessment of pain, but to the treatment of pain,” Dr. Todd explained (Figure 1).

Another issue of disparity in pain management involves the drug supply carried in different neighborhood pharmacies. For example, in a study by Morrison and colleagues, a random sample of New York City pharmacies showed that 72% of pharmacies in predominately white neighborhoods and only 25% of those in minority neighborhoods carried an opioid supply adequate to treat severe pain (Morrison et al, N Engl J Med 2000). “This is a serious issue in pain management. Even when clinicians prescribe adequate pain medication, patients may be unable to fulfill the prescription in their own neighborhood,” Dr. Todd commented.

One further barrier to effective pain management, particularly in the emergency setting, is that of time until treatment. An analysis of Emory University and University of Chicago emergency department pain management practice showed that time to treatment of pain is approximately 2 hours, regardless of whether pain is moderate or severe (Todd et al, Can J Emerg Med 2002).

“Together, these data indicate the need to continue to provide education and promote awareness in pain management among health professionals. Issues of ethnicity and access to care must be addressed in order to change attitudes and provide effective pain management for all persons in need,” Dr. Todd said.

Addressing Abdominal Pain
A common myth about providing opioid treatment to persons with severe abdominal pain is that the medication will interfere with the clinician’s ability to provide a diagnosis, Dr. Todd noted. Some of the rationale in support of this myth include: 1) the belief that a patient cannot provide informed consent (for surgery) while receiving an opioid agent; 2) the fear that alleviation of pain will mask abdominal symptoms; and 3) the need to wait for surgeon consultation before providing pain relief.

Indeed, in one survey of surgeons regarding the treatment of acute abdominal pain, 93% reported that they will not give opioids before their examination, 53% said opioid use may compromise informed consent, 78% said this concern influences their decision to withhold pain medication until after examination, and 67% reported that opioids reduce diagnostic accuracy (Graber et al, Am J Emerg Med 1999).

However, in a survey of emergency medicine physicians, 86% of physicians reported no change in diagnostic examination for abdominal pain with opioid use. Although they did not believe opioid use masks underlying illness, most also reported that they wait until after the surgeon’s examination to treat the patient’s pain (Wolfe et al, Am J Emerg Med 2000).

According to Dr. Todd, these beliefs are based on personal and societal attitudes rather than on science. “The appropriate dosage of medication to relieve pain can, in fact, enhance a patient’s ability to give informed consent. One could argue that a patient in unbearable pain is in no position to provide consent. In addition, several research studies clearly show no compromise in diagnosis with the treatment of acute abdominal pain,” Dr. Todd noted.

McHale and colleagues conducted a review of all prospective trials investigating the safety and ultimate outcome in emergency room patients who had acute abdominal pain and received opioids. The results showed no adverse outcomes or delays in diagnosis attributable to use of analgesia. These researchers concluded that administering narcotic pain relief to persons with acute abdominal pain in the emergency setting is both safe and humane (McHale et al, Eur J Emerg Med 2001).

In addition, Thomas and associates performed a randomized, double-blinded trial of morphine versus saline administered to emergency department patients with undifferentiated abdominal pain. These data showed no difference in examination or diagnostic accuracy between the morphine and placebo groups (Thomas et al, Ann Emerg Med 2002 abstract; Attard et al, BMJ 1992; Kim et al, Acad Emerg Med 2002; Pace & Burke, Acad Emerg Med 1996).

Confronting Fear of Addiction
In overcoming the fear that pain medications cause addiction, an understanding of the definitions of addiction, dependence, and tolerance is essential (Table 1). While many patients who receive a long-term intravenous opioid agent may require a gradual dose tapering before complete withdrawal, this is evidence for tolerance rather than addiction. Although the question of addiction is an active area of investigation, the research that does exist indicates that addiction is a rare complication of chronic opioid therapy. As a sequelae for acute therapy in the emergency department, it should be vanishingly rare, the speaker noted (Aronoff, Curr Rev Pain 2000). Indeed, in an early prospective trial, Porter and colleagues studied 11,882 hospitalized medical patients. Only four of these patients could be documented as having an addiction to opioid agents (Porter et al, N Engl J Med 1980).

Dr. Todd emphasized that “clinicians need to be aware of the current data and pain management guidelines—as well as the myths about addiction—to provide the best care to their patients. Physician assistants can play a key role in ensuring that pain management guidelines become practice.”

Exposing the Realities: Cases of Everyday Pain Management

It is estimated that 48 million Americans have chronic pain, accounting for 40 million medical appointments and $100 billion in healthcare cost and lost productivity each year. Despite new JCAHO pain standards, pain remains undertreated in the cancer and non-cancer patient populations, said Allan Platt, Jr., PA-C, Georgia Comprehensive Sickle Cell Center, Atlanta. “By partnering with patients and health professionals, we as physician assistants can play a pivotal role in ensuring optimal pain management for the patients we see in our practice settings every day,” Mr. Platt said.

Importance of Pain Assessment
According to Mr. Platt, effective pain management begins with a thorough and comprehensive assessment. As part of this process a complete history, physical examination, and appropriate laboratory and imaging tests are critical. “When taking a patient history, the LOCATES approach is often helpful,” Mr. Platt said. LOCATES signifies a description of pain, wherein:
L = Location
O = Other associated symptoms
C = Characteristics
A = Alleviating and aggravating factors
T = Timing
E = Environment
S = Severity
To rate severity, multiple pain assessment instruments are available. “The Visual Analog Scale allows patients to make a mark between 1 and 10, with 10 representing the greatest pain. The FACES scale is a second option, and one that works particularly well for children,” Mr. Platt explained (Bijur et al, Acad Emerg Med 2001; Pasero, Am J Nurs 1997; Bieri et al, Pain 1990). Ultimately, said Mr. Platt, effective pain management can be achieved using the ABCDE method, for which:
A = Ask and assess the pain
B = Believe the patient
C = Choose the appropriate therapy (safest dose and route for pain level)
D = Deliver therapy in a timely manner (dose according to half life)
E = Empower and enable the patient.
“In believing our patients’ report of pain and offering effective treatment options, physician assistants can partner with the patients and allow them to participate in their own care,” Mr. Platt said.

Pain Treatment Options
Current therapy allows for the attack of pain at three anatomic levels (Table 1) and with many options, including pharmacologic agents (disease-specific, opioids, and non-opioids), surgical and anes- thesia methods, adjuvant agents, non-pharmacologic approaches, and vocational rehabilitation (Table 2) (Brookoff, Hosp Pract 2000, Hartmann et al, Postgraduate Med 2000; Foley, Hosp Pract 2000). The World Health Organization’s Analgesic Ladder provides the following recommendations for the treatment of pain: mild pain (score 1-3), a non-opioid and adjuvant agent; moderate pain (score 4-6), an opioid for moderate pain plus non-opioid plus adjuvant agent; and severe pain (score 7-10), opioid for moderate-to-severe pain plus non-opioid plus adjuvant agent.

“Many non-opioid agents are available for relief of mild pain. Clinicians need to consider their effectiveness against pain as well as other drug effects. For example, acetaminophen is not anti-inflammatory, does not block platelets, and does not erode the stomach lining. In contrast, aspirin is anti-inflammatory, does block platelets, and may erode the stomach lining,” Mr. Platt said. In addition, non-steroidal anti-inflammatory drugs (NSAIDs) may be associated with renal impairment, gastro- intestinal bleeding, and platelet dysfunction. However, misoprostol or a proton pump inhibitor may provide gastroprotection with NSAID use. Clinicians need to note that, each agent has its own efficacy and safety profile. “If one agent does not work for any given patient, another may be effective,” said Mr. Platt.

Opioid agents are recommended for use in patients presenting with moderate or severe pain, along with a non-opioid and adjuvant agent. When choosing an opioid agent, clinicians need to consider the effectiveness and safety of each route of administration, including oral, rectal, transdermal, and intravenous methods. For example, oral or transdermal administration allows ease and convenience, but may not be preferred for a rapid response. If intravenous options are needed, a PCA system may help relieve pain quickly and allow the patient some control. Epidural and intrathecal methods are also options, when appropriate. “Importantly, clinicians need to avoid PRN dosing when dealing with pain because too often the severity of pain increases before the analgesic effect begins,” Mr. Platt cautioned.

A number of measures can provide patient comfort when administering an opioid agent. First, opioids can slow gut motility; therefore, a laxative agent may help prevent and treat constipation. In addition, antiemetic therapy can be used to treat any nausea that may occur. An antihistamine can help control itching, which may occur particularly with morphine use. According to Mr. Platt, health professionals need to watch for respiratory depression, although this is uncommon in patients treated for pain. The respiratory rate should always be monitored, but respiratory depression can be avoided with careful medication titration. “Finally, addiction to opioid agents is extremely rare. However, patients need to be tapered off opioid medications slowly to avoid withdrawal symptoms,” Mr. Platt explained.

Adjuvant agents are helpful for treating side effects of other medications (eg, laxatives, antiemetics, antihistamines), but also for their direct effects on pain. Use of an antidepressant, for example, can address depression as well as provide an analgesic effect. Anticonvulsant agents may be useful in the treatment of neuropathic pain. In addition, a number of non-pharmacologic techniques are frequently used to manage pain. These range from a TENS unit to acupuncture to relaxation. According to Mr. Platt, effective pain management can be achieved through comprehensive assessment and careful selection of the appropriate management options for each patient.

Conclusion
Mr. Platt emphasized the importance of identifying pain management resources and providing a multidisciplinary approach to care. “Physician assistants can play a critical role in forging partnerships with patients and other health professionals. By being proactive in initiating collaborations with a number of other health disciplines—including social work, physical therapy, and vocational counseling—physician assistants can help ensure the best outcomes for patients experiencing acute or chronic pain,” he concluded.