By Charlotte Huff
February 6, 1998

Pain control specialists say the formula couldn’t be simpler. Ask patients about their level of discomfort, trust what they tell you, and act accordingly.

If only more nurses followed through, said Margo McCaffery, MS, RN. Subjective perceptions, along with an erroneous fear of addiction, too often influence decisions at the bedside, said the nationally known nursing consultant and author of numerous articles on pain. "Pain continues to be extremely under-treated," McCaffery said. "You see no consistency in care. Patients come into the hospital not expecting good pain relief, so the whole thing is a vicious cycle."

Make it second nature

Experts say it’s essential to make pain control part of routine care. Every time a temperature is taken, for example, patients should be asked to rate their pain from 1 to 10, said Judith Paice, PhD, RN, a Chicago-based professor and boardmember of the American Pain Society. A rating of 5 to 6 should be considered moderate pain; anything above is severe. Nursing schools, she said, have begun to place a greater emphasis on pain control. However, she disapproves of rolling the issue into a more general lecture about oncology or surgery. "It’s such a prevalent problem that it needs to be addressed separately."

The Agency for Health Care Policy and Research has done exactly that, publishing a series of clinical guidelines over the past decade focusing on various facets of pain, ranging from cancer to children’s pain. Pain management has spawned numerous medical studies, position papers, and conferences. It was dubbed "the fifth vital sign" by the American Pain Society and has been addressed by other agencies, including the Joint Commission on Accreditation of Healthcare Organizations. The commission cites effective and aggressive pain management in its standards for treatment of the terminally ill and recently began a two-year project with the University of Wisconsin to see if those standards should be further bolstered.

In a medical world of blood tests, X-rays, heart monitors, and other clinical measurements, pain can seem elusive, said Jean Guveyan MSN, RN, co-director of the pain service at Beth Israel Deaconess Medical Center in Boston. But it’s only elusive, she said, if you rely on your personal perceptions of what the patient may be feeling. "Our team builds on the philosophy that we believe the patient," she said. "That is the only reliable source we have—the patient’s report of what they are feeling."

And patients too often are suffering needlessly, say pain specialists, who frequently point to a study of more than 9,000 patients admitted to five hospitals. About half of the terminally ill patients reported moderate to severe pain at least half of the time, according to the November 1995 study published in the Journal of the American Medical Association. The previous year, the New England Journal of Medicine looked at pain control in metastatic cancer patients; 42 percent of those with pain were not given adequate drug therapy. Patients at centers that primarily treat minorities were three times as likely to have insufficient pain control, according to the study.

Get past misconceptions

The biggest obstacle to surmount: fear of addiction. "Patients worry about it," said Karen Kettelman, RN, pain management coordinator at Doctors Medical Center in Modesto, California "The nurses worry about it. The doctors worry about it." A review of 11,882 medical charts, published in 1980 in the New England Journal of Medicine, paints a different picture. Every one of the hospitalized patients had taken at least one narcotic; only four cases of addiction were documented. "We conclude," wrote the authors, "that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addictions."

Paice, who prefers the term opioids to the more pejorative-sounding narcotics, described one paraplegic patient who was shot 20 years ago. The woman, she said, now leads an active life as a mother and even drives a van—and regularly takes morphine. "She never calls and asks me for more medication." Many deeply held beliefs, ranging from personal spirituality to personal tragedy, can influence how a clinician perceives a patient’s pain, Paice added. To bypass those subjective elements, McCaffery believes that each health facility should establish criteria under which medication can be boosted. "Unfortunately," she said, "you cannot leave it up to the individual."

One potential problem—physician resistance—can be remedied if nurses prepare themselves adequately, said Chris Pasero, RN, who writes a pain control column for the American Journal of Nursing. "A lot of times nurses call and don’t have their facts straight." Don’t just ask the physician if you can give the patient something more for pain, she said. Detail the patient’s recent activity level, pain ratings, and medication up to that point.

A dose of reality

Kettelman, who launched a three-hour pain management class soon after she arrived at the Modesto facility five years ago, doesn’t believe nurses worry as much about addiction as respiratory depression. The worry that an opioid may suppress the body’s respiratory system is a real one, she said. But she described it as "not very common" and "very preventable" as long as the patient’s sedation levels are closely monitored.

Addiction isn’t the only fear among patients either, said Paice, also a nursing professor at Rush University in Chicago. In 1996, the university conducted a study among 200 cancer patients. Fifty-six percent feared addiction and 39 percent expressed similar anxiety about becoming tolerant to medication. "They are still very afraid," said Paice, "that if they take morphine now, it won’t work later. So they hold off." In actuality, there is no limit on opioids like morphine, said Paice, as long as they are titrated gradually to allow the body to adjust.

Every hospital should designate a nurse to pain management, in order to assist clinicians through this maze of issues until they gain confidence, said Pasero, who served that role at a Louisiana hospital before moving to Rocklin, California, where she now consults on pain management. Pain can range widely, fluctuating as much as tenfold among post-surgical patients, she said. In Louisiana, nurses would call her for consultation about pain control, but their instincts were usually right. "My first question would be, ‘What do you want to do with the patient?’ They always knew what to do."

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OTHER WEB SITES WITH INFORMATION ON PAIN

American Pain Society

Cancer Pain Page at the Anesthesiology and Critical Care Department in the MD Anderson Cancer Center

Dee's Pain Management Page

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