CMs must develop clear pain policies
JCAHO turns the spotlight on pain assessment
Pain is often called the fifth vital sign, but too often routine pain assessment is overlooked in treatment plans. Lack of routine assessment and adequate education about effective pain management leads to undertreatment of pain symptoms in many patients.
The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, recently addressed the need for more effective pain management by revising its standards for managing pain in all settings, including the acute, ambulatory, home care, long-term care, health plan, and health system settings.
"Unrelieved pain causes needless suffering and delays healing. Case managers have a vital role in improving pain management. One of the largest barriers to managing pain effectively is that nurses, doctors, and pharmacists receive little formal education in this area," says Carol P. Curtiss, RN, MSN, OCN, clinical nurse specialist consultant in Greenfield, MA, and past president of the Oncology Nursing Society in Pittsburgh.
"We make decisions every day as part of our practices," she explains, "but we haven’t learned enough about good methods of pain assessment and management."
The first step in a pain management plan is an honest appraisal of the patient’s pain, adds Mark A. Young, MD, FACP, associate chairman of physical medicine and rehabilitation at New Children’s Hospital and the Bennett Institute for Sport’s Medicine and Rehabilitation and associate co-director of rehabilitation at Maryland Rehabilitation Center, all of Baltimore. "Every patient is different. At the very onset, the physician must establish a clear and accurate picture of the pain."
Young recommends case managers look for the following elements in a thorough pain evaluation:
• a chronological history of the pain;
• activities, treatments, or events that make the pain better;
• activities or events that make the pain worse;
• ability to perform activities of daily living;
• underlying disease processes that cause or contribute to pain or the perception of pain;
• the quality of the pain,such as sharp, dull, radiating or localized;
• therapies tried in the past for pain relief;
• a complete list of medications taken for pain and other conditions.
"There also must be a clear understanding of the psychosocial issues that go along with the patient’s pain," he says. "The physician and the case manager must be very directed and targeted and even obsessive at times in obtaining a good pain history. The history guides the future treatment plan and sets the tone and stage for an effective pain management regimen."
Young says these psychosocial issues should be included in a pain evaluation:
• family dynamics;
• work situation;
• emotional cycles;
• history of treatment for depression or other psychiatric disorders.
Show me where it hurts
A pain diary and body mapping diagrams, which chart the areas affected by pain, also are crucial elements of a pain management evaluation and treatment plan, note Curtiss and Young.
"Patients generally come in for initial evaluation and then are typically seen again by the physician a week or two weeks later. A pain diary helps the physician see patterns of pain and pain relief throughout the week and develop a more effective pain management plan," Young says.
Even many cognitively impaired patients can be taught to use a simple pain severity scale, body diagrams, or visual analog scales, say Curtiss and Young. These scales usually use a number range from zero to 10 to rate pain severity, where zero is no pain and 10 is the worst possible pain. Analog scales use faces with expressions ranging from smiling to severely distorted to demonstrate pain severity.
"Once a client is taught how to use a pain severity scale, it’s an easy task for the case manager and the treating physician to determine when pain is a problem for the patient," Curtiss says. "Patient self reports of pain and of pain relief go hand-in-hand. If you are only asking your patients to measure their pain, you are only receiving a piece of the picture. You must also evaluate the effectiveness of the interventions that are in place."
If your patient has difficulty understanding how to rate pain on a severity scale, try using an analogy, she suggests. "I have a friend who works in the long-term care setting. She has her cognitively impaired patients pretend they are driving a car. She tells them to imagine their pain as a speedometer. She instructs them to imagine zero as no pain and 100 miles an hour to be the worst pain possible. Then she tells them push down on the gas pedal and tell her where the speedometer stops."
Even case managers who work exclusively or predominately with patients via telephone can and should effectively assess pain symptoms, Curtiss says. She suggests that case managers ask patients the following questions about their pain symptoms:
• What is the worst your pain has been today?
• What is the best your pain has been today?
• What have you done that made your pain worse?
• What have you done to manage your pain? Has it made a difference? How much relief did it provide on a scale of one to 10?
• What is your pain preventing you from doing?
• What are your goals for pain management? On a scale of zero to 10, what level of pain would let you go about your daily business?
"Asking questions over the phone and assessing the outcomes of your patient’s pain management efforts gives the case manager a decent picture of whether the patient’s pain symptoms need further investigation," Curtiss says.
She also suggests case managers instruct patients to call them to report the following:
• any experience of new pain;
• any worsening of pain;
• any pain above level five on a zero to 10 rating scale;
• any level of pain unacceptable to the patient;
• lack of bowel movements for two or more days in patients who are using opioids.
"This last bullet gives patients permission to call you for other reasons, including I’m afraid to take this medicine," says Curtiss.
Often the biggest obstacle case managers must overcome in advocating for more effective pain management is the fear common to both physicians and patients that use of certain pain medications may lead to addiction, say Young and Curtiss. " I could just beat my head against the wall sometimes over that one issue," Curtiss says. "There is a fear of use of opioids when, in truth, appropriately used, the risk of addiction with these drugs is less than 1%."
The important thing is for case managers to explain to patients, families, and, if necessary, physicians, the differences between physical dependence, tolerance, and the psychological drug-seeking behavior associated with addiction, she says. (For more on appropriate opioid use, see Case Management Advisor, Sept. 1998, pp. 151-155.)
"There are a number of physicians uncomfortable using more heavy-duty medications due to lack of information about proper prescribing habits," Young says. "They fear subjecting patients to addiction potential."
However, there is little danger of addiction to pain medications if physicians follow guidelines established by the Agency for Health Care Policy and Research in Silver Spring, MD, which outlines a disease management approach to chronic pain, Young says. "It’s a stepped-up approach which starts at the safest and least addictive options and progresses to more powerful drugs, only as needed."
Setting standards for care
She adds that it’s important for both payer- and provider-based case management programs to have a clear pain management policy. "It’s difficult to know if you are managing pain well if you don’t have a written standard of care that defines pain management. In addition, most health insurers have no clear-cut policies for reimbursement for pain relief. This leads physicians to err on the side of caution and leaves patients undertreated."
"The nice thing about developing a pain management policy is that the standards are clear among organizations about how to assess and manage pain," she notes. (See insert for a list of resources you may use to develop a pain management policy. Also, see story on acupuncture for pain management, p. 65.)
Curtiss recommends case managers include these elements in their own pain management policies:
• systematic and ongoing assessment of pain symptoms;
• minimum required assessment frequency of once each visit in the home care setting and once each shift in the inpatient setting;
• standard for the level of pain that requires a review of the pain management plan;
• systematic use of appropriate pain medications;
• evaluation of the effectiveness of pain medications;
• combining pain medications with non-drug therapies, such as heat, cold, relaxation, and imagery;
• measuring pain management outcomes;
• ongoing quality improvement assessments.
Curtiss has given presentations on pain management in 41 states and nine countries. She often shares a quote from a pain patient who came forward to talk to her after one presentation. "I had shown a slide with a quote from a terminal cancer patient who said, When you treat my pain, you help me forget I have cancer.’ The patient who came up to me was also a cancer patient, but not considered terminal, he said, You have to tell the other side of the story. When you treat my pain, you free me to fight my cancer.’"
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