Lessons in Supportive Care VIII: Changing Our Culture About Pain Management
By Thomas J. Smith, MD
Case 1: One of Dr. Xerxes patients calls at 7 p.m. She just can’t take the pain any more. Her family demands that she be admitted. Dr. Xerxes had prescribed long acting morphine and oxycodone/acetaminophen for breakthrough but she had not taken more than a few. Her family did not want her to become addicted.
Case 2: You are one the phone with a nurse from the managed care company. "Whadya mean I can’t admit Mr. Jones for pain control? His pain is an 8 out of 10, and I have him on 20 mg an hour of morphine already!"
Is pain not relieved?
When it has been studied, it is reasonably clear that we don’t do a great job with pain management. Granted, we think we do, we are hopefully getting better, and like the doctors above we might have prescribed the right medicines, but about a half of dying inpatients have pain that was not satisfactorily relieved according to themselves and their families. (JAMA 1995;274:1591-1598.) And about half of cancer outpatients reported the same lack of pain relief. (Cleeland CS, et al. N Engl J Med 1994;330:592-596.) )
What are the consequences of unrelieved pain?
First, it costs real money. This cost is particularly evident in unnecessary hospitalizations for pain control, or readmissions to re-establish pain control. Of 2977 unscheduled admissions in 1989-1990, 255 had a primary diagnosis of uncontrolled pain. (Who among us listed pain back then as a primary diagnosis? I suspect it was much higher.) Over half of these admissions came within two weeks of a prior discharge, and one quarter had a prior admission with the same diagnosis. This was at City of Hope National Medical Center, a good place for cancer treatment, too.
Second, patients who hurt and their families might lower your patient satisfaction scores and lead to lower pay.
Third, there is the pain itself. While there might be some religious benefit to suffering, covering Job with sores to test him is not in most of our job descriptions. Pain can and should be relieved.
Much of this is not my problem. How do I fix it?
Unrelieved pain is our problem. I am not sure that we can avoid fixing it, whether it is our problem or not. Managed care companies are not coming to me and asking how they could help improve the care of the lives they cover. Patients and their families are not experts in pain management. If someone refused CHOP (or ProMACE-CytaBOM, in deference to the Clinical Oncology Alert Editorial Board) for a curable Stage IIA lymphoma because they heard it caused cancer, we would do our best to educate them about competing risks. After all, we educate about complicated cancer issues like genetics, causation, and treatment all the time. It’s the same deal with pain medicines.
The group at City of Hope designed a simple three-part program. (Grant M, et al. Nurs Clin of North America 1995;30:673-682.)
Table 1
Strategies to change culture
Pain resource Nursing staff assumed an active role in pain training program management. Staff pain experts on each shift
and each unit.
Focus of continuous Hospital pain control audit and staff survey
quality improvement to check attitudes and see what educational
(CQI) materials were needed.
Supportive Care Full-time nurse clinical specialist for pain/
Service symptom control, part time physician salary
It worked and saved money by preventing readmissions
Grant and colleagues next audited charts from 1992-1993. There were 1351 unscheduled admissions, out of a total of 4066, with uncontrolled pain listed as the most common reason for 103 (7.6%). Total readmissions decreased as shown in Table 2.
Table 2
Readmissions for pain, after intervention
1989-90 1992-93
Total admissions 5772 4066
Pain admissions 255 (4.4%) 121 (3.0%)
Length of Stay 11.8 days 12.0 days
Total cost @$1,666/day $5,097,960 $2,378,715
Of great importance, the total cost to the system declined by $2,719,245. Even rounding off to $2 million, that’s real money.
I am not sure that all the change can be attributed to the intervention, but some can. For instance, the number of admissions dropped slightly in those years, suggesting that reasons for hospitalization were changing. But the length of stay was higher in the second time period, suggesting that once sick people got into the hospital, they were there until significant problems got fixed. And the flip side of the data is that perhaps there were patients who might have benefited from inpatient stays for pain control, who did not get in thanks to changing admission mores. Luckily, the decrease in the numbers of readmissions suggests that the program was working to help, not keep patients out.
But the real point is that the care was better. Preventing readmissions by relieving pain, and teaching families and patients how to control it, workedand saved money.
Can you fix the problem without doing so much?
Probably not. Just putting pain on the problem list, or assessing the pain with a 0-10 scale, has not shown much effect at all.
What are some practical steps to take?
First, take advantage of their experience. The Mayday Pain Resource Center is at City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA 91010. (818)-359-8111, ext. 2346; fax (818)-301-8941. E mail is mayday_pain.smtplink.coh.org. They have always been terrific at sending inexpensive, useful materials.
Second, share this data or the original articles with your hospital administratorsmoney talks. Depending on your hospital volume, hiring a clinical nurse specialist may be a good deal for the health care system. It does not take too many inpatient days at $1600/day to equal some additional salary money. (Recognize the dilemma of the hospital administrator, though, if you still have a large fee-for-service population . . . keeping the hospital full is good, in that setting. Getting the incentives aligned to reward providing optimal care is a bear.) If this person can also get free drugs from the various programs available for poor people, she or he will make their salary in no time.
Third, use a linear analog scale to assess pain. This may not seem like much, but those who use it are at least paying attention to pain.
Fourth, list pain on the problem listif it’s not written, it’s not important.
Table 3
Practice rules of pain relief
Rule Reason
1. All patients will have their pain Have to start somewhere.
assessed using a 0-10 scale, on the
vital sign sheet.
2. Pain over 8/10 is a medical Just like a fever of 101.5°F and
emergency. Response time to some ANC < 500.
intervention (phone call or visit)
should be less than 15 minutes.
3. Pain over 5/10 is disabling.
Response time should be less
than 30 minutes.
4. All interventions will be assessed Nearly all of this can be done
for effectiveness that same day. with a phone call. If you have
patients rate their pain 0-10,
Fifth, decide how you want your practice to operate. You probably have some written rules indicating what adjuvant regimens, and their dose modifications, that you and your staff can use. (If not, then why not? Since maintaining doses at standard is critical to some regimens, your office staff should not be making it up for each person. Let NSABP do it.) Pain management is the same way. You can set up a simple list like the one shown in Table 3.
Sixth, don’t hesitate to put care management companies on the defensive. If you get turned down for admitting a patient in your office who clearly needs better pain management, get aggressive. Tell them that if the patient had uncontrolled angina and needed intravenous morphine and nitroglycerin, that you would never get an argument. (This despite the fact that all those regimens do is relieve the pain, not fix the blockage.) Clearly document what you have tried as an outpatient and that the pain is still 8 or 9/10, a disabling level. Present a clear plan to increase the morphine to whatever level is needed within two hours, and then convert to an outpatient regimen. Ask the reviewer what he or she would want to happen to their mother in this situation. Fax a note directly to the medical director of the plan. You could even hint about morning newspaper headlines, "Insurer denies dying grandpa pain relief," although I have never had to go that far.
Take home message
Pain is a fixable problem, if we arrange our practices to fix it with the same attention we do to adjuvant therapy. It is better care, and can even save money by preventing admissions and readmissions.
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