New hotlines give docs needed assistance in pain management
Biggest challenge for new program is getting the word out
At 7 p.m., a call comes into the answering service of Maryland’s Emergency Medicine Resource Center. The caller, a physician, tells the operator he is treating a woman with breast cancer and bone metastasis and is having difficulty relieving her pain. Within 15 minutes, the physician receives a call from one of three on-call volunteer physicians with an answer to his question: How can I bring my patient’s pain under control?
The treating physician is advised to use an oral opioid as a replacement for the low-dose anti-inflammatory drug. In addition to that advice, the physician is given guidelines for the opioid’s use and is additionally advised to use a biphosphonate, a bone resorption inhibitor that also helps relieve bone pain for metastatic breast cancer.
The exchange represents a critical step in the education of physicians who lack training in pain management. Instead of adhering to common misconceptions about the use of drugs such as morphine, physicians in certain pockets of the country can now turn to a reliable resource: a pain management hotline.
New efforts to relieve suffering
One of the most criticized elements of end-of-life care has been the lack of pain management by physicians. End-of-life advocates say physicians’ knowledge of palliative care is limited, leading to unnecessary suffering among dying patients.
As part of a statewide effort to improve end-of-life care, Maryland began the first pain management hotline in the United States. Its success has made Physician’s Palliative Care Pain Hotline the model for other states that are interested in providing physicians access to pain management experts. Maryland’s experience with the relatively simple concept — providing a toll-free number for physicians with troubling pain management cases — might offer a solution for other states or communities that want to aid and educate physicians. But how successful are hotlines, and are they a resource that physicians are willing to use?
"I think this is a marvelous thing," says F. Michael Gloth III, MD, FACP, AGSF, president of The Hospice Network of Maryland in Millersville, and associate professor of medicine at Johns Hop-kins University School of Medicine in Baltimore. He is also coordinator of the pain management hotline, and confidently says, "I think every state can do this."
Operators are standing by
The promise of Maryland’s pain hotline has prompted a handful of states to develop their own. Among them is Kentucky’s Journey’s End Project, a Robert Wood Johnson Foundation-funded project to improve end-of-life care in the state. Kentucky physicians began calling for pain management advice in June.
"It’s a good way to provide timely support for physicians faced with difficult cases," says Cynthia Keeney, RN, project director for Journey’s End, which is based in Louisville.
Gloth played a significant role in the development of Maryland’s pain management hotline, which is part of the state attorney general’s initiative, Project on End of Life Care, and is also funded by the Robert Wood Johnson Foundation.
Physicians calling the toll-free number are connected to the answering service of the Maryland Institute of Emergency Medical Service’s Emergency Medical Resource Center (EMRC). EMRC’s telephone personnel also take calls for Shock Trauma, the flight service for trauma patients who need to be airlifted to a facility. Rather than contract with a private answering service firm, pain hotline officials chose EMRC because it had an established statewide answering service.
When a call comes in, EMRC personnel page the physician on call that month, who must respond within 15 minutes. A backup physician is contacted if the on-call doctor doesn’t respond within specified time frames.
As part of the project, Maryland officials measured physician response to the hotline, including the number of calls and physician satisfaction. The study was co-authored by Gloth and published in the January/February issue of the American Journal of Hospice & Palliative Care.
"The concept of a toll-free hotline is practical and feasible," wrote Gloth and Jack Schwartz, JD, Maryland’s assistant attorney general and director of health policy development. "The hotline can help provide information on pain management. Presumably, this will help improve pain management overall."
According to their research:
• Calls averaged one per day for the first week after the toll-free number was announced in two statewide medical publications.
• In the first 10 months, calls averaged three per month.
• Most of the calls (27%) came from Baltimore.
• 90% of calls were considered appropriate, focusing on prescribing pain medications — mostly opioids — or their side effects.
• Although the toll-free number was intended for physician use only, 12% of calls came from nurses and 8% from pharmacists.
• Although the service was staffed 24 hours a day, calls typically were received between 9 a.m. and 7 p.m.
For those contemplating starting their own hotlines, Gloth says that while a call-in service is a relatively simple concept, it is fraught with hurdles. The largest of them is keeping the phone number in the minds of physicians.
He offers these guidelines:
• Identify an interest group to support the program. In this case, it’s the physicians’ branch of the Hospice Network of Maryland. In addition, Gloth suggests, establish an advisory group for the pain management hotline. They can provide insight and help plan for challenges that could arise.
• Identify a source of funding. The Physician’s Palliative Care Pain Hotline is staffed by volunteers, but has a physician outreach grant from Purdue Pharma L.P., a pharmaceutical company in Norwalk, CT, also known as The Purdue Fredrick Co. Maryland officials sought $10,000 in unrestricted grant money from pharmaceutical companies. Purdue Fredrick not only provided money for setup and administration, but also helped promote the hotline by distributing fliers to physicians using local company representatives.
• Identify a source of volunteer doctors to handle the calls and establish an on-call schedule. Maryland’s volunteers are all board-certified in pain and palliative medicine; each is on call for one month. "I expected to have the most trouble recruiting doctors to take calls, but that turned out to be the easy part," explains Gloth. "We have a group of extremely dedicated physicians who are willing to volunteer their time."
But not any physician will do, Gloth says. Of the physicians who were interested, Gloth limited volunteer physicians to those who were certified by the American Board of Hospice and Palliative Medicine.
• Establish a system for answering calls. In Maryland, a schedule of first- and second-call physicians was developed. On any given day, a volunteer physician is designated as the first call the answering service makes. If the first-call physician is unavailable or does not respond within a few minutes, the answering service calls another volunteer physician who is designated as the second-call physician. The hotline administrator is the third-call physician in the rare instance that neither volunteer physician can be reached. The goal, Gloth says, is to have the caller’s question answered within 15 minutes.
• Publicize the hotline. Maryland’s pain hotline founders communicated the existence of the toll-free numbers through articles in physician publications, such as the Board of Physician Quality Assurance newsletter and the Hospice Network of Maryland’s newsletter. "It’s a great service, but not if nobody knows about it," Gloth says.
Remember this number
The real challenge, he says, is keeping the hotline phone number in front of doctors who need it. "When we first announced the service in March 1998 through the medical society and state licensing board newsletters, we received about one call a day," Gloth says. "Since then, calls have dropped to one a week."
To generate renewed interest, Gloth is launching a direct mail campaign to state medical society members. The materials include a sticker with the hotline number that can be posted on telephones or bulletin boards so it is always available.
Kentucky officials are fashioning a call-in service very similar to Maryland’s. The first- and second-physician answering system model will be used, as well as the 15-minute response window. Rather than employing an existing answering service, Kentucky officials have had to contract with a statewide answering service.
Unlike Maryland, physicians are not the only health care professionals targeted. In addition to doctors, their agents, such as nurses, physician assistants, and nurse practitioners will be encouraged to call for help.
"As a former emergency room nurse, I wish I [had] had a number like this to call," Keeney says. "Sometimes, it is late at night when a nurse is left to deal with a patient’s pain. The nurse can call and discuss the options with the physician. We believe we are going to get more calls by allowing physicians’ agents to call."
Both Gloth and Keeney say pain hotlines are an effective way for statewide organizations to help physicians and raise awareness about pain management. Even without any formal, statewide organization like a project to improve end-of-life care, Gloth says a consortium of hospices could also establish a pain management hotline.
The disadvantage hospices face, however, is the appearance of starting the hotline for commercial reasons. "I think a group of hospices can do it," Gloth says. "But it has to be seen as a community resource, not a commercial endeavor."
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