Sharon Wrona DNP, RN-BC, PNP, PMHS, AP-PMN, FAAN, Director Comprehensive Pain & Palliative Care Services, Nationwide Children's Hospital
The words pain management may be perceived very differently today than they were 30 years ago. In the 1990s, we realized pain was still being undertreated due to a lack of knowledge and recognizing that quality care means that pain is identified and measured. Early in my career, I recall giving IM injections of pain medications that caused pain to help with managing sickle cell and cancer pain. In the early 2000s, governmental agencies and governing bodies determined it was time to step in to help with doing a better job with treating pain implemented standards on pain assessment and gathering patient satisfaction on their pain management. Many people’s perception of this was the expectation that managing pain meant no pain. While this was not the intention of many of the initiatives to recognize and manage pain, this was the path that many people followed, and the expectation for managing pain was to get a pain score as close to zero as possible. Unfortunately, the words pain management today can be scary and dark words for some people, especially in the midst of an opioid epidemic. Certain people are afraid to appropriately manage their pain if strong medications are necessary due to the fear of addiction, the shame, guilt, and judgment that comes with the stigma of being a pain patient, being labeled as a drug seeker, or even concerns for safety with having needed medications in the home. However, we are fortunate in the current healthcare field as there is a bigger push for providers to use a multimodal approach when managing pain, and there are many more non-pharmacological and pharmacological treatment options for managing pain.
Currently, there is a lot of work being done with healthcare organizations when working with patients with acute pain, especially related to surgery, trauma, or injuries, with opioid stewardship projects and utilizing a multimodal approach when treating pain. Some best practices to help with an opioid stewardship program would be: gathering baseline information regarding healthcare providers’ (physician and nurses) knowledge and clinical practice about opioid prescribing; education on pain management and opioid safety, which is important to determine areas for opportunity for opioid education, as well as to document the change in knowledge and practice after implementing the Opioid Prescribing and Safety Stewardship project. Many states have specific rules for opioid prescribing practices. It is important to identify all the state rules, guidelines, and accrediting organization standards to ensure compliance of your organization. This should be included in educational content developed for your stewardship program. Looking for opportunities to use regional anesthesia approaches with blocks, peripheral nerve catheters, and use of epidural analgesia can be a way to minimize opioid exposure and improve postoperative pain control for patients.
"It is important to identify all the state rules, guidelines, and accrediting organization standards to ensure compliance of your organization"
There are a range of non-opioid medications that can be used for treating various types of pain. Medication such as gabapentin are not only being used to treat chronic neuropathic pain, they can also be beneficial as a prophylactic dose for treating postoperative pain (Doleman, B., et al., 2015). The use of other medications such as ketamine and lidocaine are showing promising outcomes for improving pain in patients in both the postoperative setting, sickle cell vaso-occlusive crisis (VOC), and with refractory chronic neuropathic pain. Puri, Morgan, & Anghelescu (2019) reported studies found that the use of ketamine and/or lidocaine infusions with patients with sickle cell VOCdecreased the opioid consumption when managing the patient’s pain.
In May 2019, the Department of Health and Human Services (HHS) Pain Management Task Force issued a report on best practices of treatment of pain. Dr. Singh, chief medical offer of the HHS office of the Assistant Secretary for Health stated, “Three is a no one-size-fits-all approach when treating and managing patients with painful conditions.”This powerful statement needs to be the gold standard for pain management and needs to be included with any state and federal decision making for implementing rules or laws with treating pain. Pain care needs to be individualized and allow practitioners to practice using an opioid stewardship approach when caring for patients who are suffering from pain. As addressed in the HHS Pain Management Task Force Recommendations, prescribers need to be able to have an important discussion with patients about their history, use screening tools, and work with a patient to develop a multimodal treatment plan with clear set goals for improving the patient’s functioning and quality of life. There needs to be an emphasis on education with patients regarding opioid safe practices with monitoring, storage, and proper disposal of unused medications. Best practice recommendations include the use of restorative and complementary therapies such as therapeutic exercise with all types of trained healthcare providers, including physical therapy, occupational therapy, therapeutic recreation, transcutaneous electric nerve stimulation, massage therapy, traction, cold and heat, therapeutic ultrasound, bracing, and acupuncture for managing pain. Unfortunately, there are challenges with getting many of these services covered or limits for visits set by insurance companies.
In November 2019, a group of national healthcare organizations established the Alliance to Advance Comprehensive Integrative Pain Medicine. This group identified challenges with assessing, diagnosing, and treating pain with barriers between evidenced-based pain management practices and barriers for patients receiving these types of treatment options. This group is currently working on a white paper with strategic policy recommendations and plan to share their recommendations in mid-2020.
With all the work that is being done by many groups and the advocacy work at both state and federal levels, how we manage patients with pain in all settings will look much different than it even does today. In the future, practitioners will have more comprehensive training and education offered on best practices for working with patients of all ages and with all types of pain, and ensure they have a better understanding of the role of a patient’s culture in the pain treatment plan. Coverage of more pain modalities is essential to ensure the words pain management are no longer scary and dark for our patients, and they know there are a variety of options available at their fingertips to help them to manage their pain. The public, patients, and policymakers will be better educated on acute and persistent pain management and best practices as many of them do not have a healthcare degree that has provided any formal education on pain management.
When working with any patient with pain, treat them as an individual and provide the best individualized care that you would want for any of your family members. Take every opportunity to advocate for evidenced-based care and help with changing from managing pain to a holistic functioning approach.