Teresa Keane , on pain management

By Bree LeMaire, MS, RN
June 28, 2004

How did you get into nursing? Pain management?

I always wanted to be a nurse. While a student, I came upon a New York Times story on Dr. Herbert Benson from Harvard College and his work at the Mind-Body Clinic at Deaconess Hospital in Boston. Several years earlier, I had studied meditation in India and was seeking a way to incorporate what I had learned into my clinical practice. I had an epiphany and my future plans took shape. I went to study with Dr. Benson in Boston.

Upon my return to Oregon, I asked my physician colleagues for assistance in opening a clinic. They said it sounded interesting but not for them, personally. I returned to school and became a psychiatric nurse practitioner and opened a stress reduction clinic at OHSU.

My main referral base was patients with pain, so I moved the clinic into the department of neurosurgery. As a nurse practitioner with full and independent prescribing privileges, my role expanded to management of the medical and psychiatric care of pain patients.

What does a regional nurse liaison for a drug company do?

I offer support and education to health care professionals and others in providing appropriate pain management strategies.

What assessment skills can a nurse use to monitor for pain?

Since pain is a subjective symptom, assessment relies on the patient’s self-report and the use of the nursing art of therapeutic communication and trust.

Our culture has a long history of undertreating pain. Many patients have learned that our health care system has been negatively responsive to pain complaints. Consequently, there are a whole slew of names for pain sufferers such as drug seekers, addicts, doctor shoppers, and clock-watchers.

Many pain patients also don’t understand the language necessary to report pain symptoms. When asked about pain, a patient may say, “It just hurts.” Nurses need to educate patients on the descriptors and components required for a full pain assessment. The patient’s description of pain is a key piece of information for treatment plan development.

Intuition is also important. Nurses often sense when a patient may underreport or overreport pain using a pain scale. This is where education and communication are essential.

What’s the difference between physical dependence, tolerance, and addiction?

Misunderstanding and confusion between physical dependence and addiction is one of the biggest barriers to adequate pain control.

Physical dependence is an expected physiological consequence from prolonged use of several classes of drugs including steroids, opioids, some antidepressants, and antihypertensives.

Addiction, on the other hand, is a disease with genetic, psychosocial, and environmental factors. Clinicians can detect the development of addiction by observing for such behaviors as lack of control over medication use or continued use despite harm, and craving, among other things.

Pseudoaddiction is another important concept in pain management. This occurs when a legitimate pain patient is undertreated for pain and behaves in ways that may be mistaken as drug seeking. This includes such behaviors as requesting increased strengths or doses of medicine.

Tolerance describes a physiological response when continued use of a drug may result in a lower therapeutic effect, whereby an increased dose may be required.

Are the protocols for controlled substances adequate?

I like to ask health care professionals to name a chronic symptom that we treat only when reported as moderate or severe. I have yet to get an answer to this question other than pain. The guidelines suggest that we need to treat chronic pain as we treat diabetes or hypertension. The goal of disease state management is to keep symptoms under control 24 hours a day to reduce pain and improve function. It is especially important to remember the component of suffering with pain.

A successful treatment plan improves both well-being and quality of life.

We have many guidelines and consensus statements on how we should be treating pain and reducing suffering. We also have the tools to treat pain, but we are not using them effectively.

Anything you’d like to add?

I’d like nurses to think of prn as meaning power resides in nurses. Nurses are patient advocates and first-line health care providers and we powerfully influence patient pain outcomes. I encourage nurses to learn the fundamentals of pain management so that when an applied treatment plan is inadequate, the nurse can call the person prescribing. The nurse can make a clinically sound recommendation based on that reassessment.

We can and do play a huge part in relieving the suffering of people in pain. I believe we can continue to do a better job.