Let's Talk About Pain

Added on Mar 6, 2017

pain puzzle

Two pain-related public health issues occupy prominent positions on the health care industry’s radar screen: effective pain management and opioid abuse. 

Although opioid abuse receives the lion’s share of media attention because of its increasing scope and devastating consequences—the Centers for Disease Control and Prevention estimates that 91 Americans die every day from an opioid overdose—the statistics around poorly managed, under-recognized and undertreated pain are also staggering. The Institute of Medicine estimates that more than 116 million Americans suffer from chronic pain, and that pain frequently remains unrecognized and poorly managed.

As the media continue to focus on the very real opioid epidemic, we as care providers must stay ever mindful of the fact that our patients’ pain is also very real, and that we cannot subjugate one to fix the other. It is our job to better understand and help manage our patients’ pain. But how?

Certainly, we can assess pain in terms of functional status or pain scale scores, but in the end, the patient is the only person who can tell us what he or she is feeling. It is our job to listen to what our patients tell us, keeping an ear open to certain verbal cues. We must also ask the right questions, watch for nonverbal cues and body language, and provide choices for pain management. 

We have to remember that when patients are in the health care system, they are very often anxious and afraid. They worry about what is happening to them, what it may do to their lives and livelihood, and how it might affect their families. This fear is consuming. When coupled with pain, it can result in a lack of clarity around whether and how quickly the pain—and the fear—can be fixed. Often, they believe the solution will come in a pill or a shot and that we, as providers, can eliminate their pain.  Unfortunately, that is not always possible.

I followed a nurse into the room of a first-day postoperative total knee replacement patient. The nurse did everything right in terms of her interaction with and clinical care for the patient. However, when I looked at the whiteboard it said, “Pain Goal: 0”. Now, as most providers will attest, total elimination of pain on the first day postop after a total knee replacement is impossible. So, from a pain management perspective, the nurse set herself up to fail from the very beginning. Worse, by not managing expectations appropriately, she set her patient up to fail. 

We must have honest and transparent conversations with our patients to make them feel safe and to assure their success in their health care journey. First, we need to connect with the patient. Our research has shown that it takes less than one minute—56 seconds, on average—to make a meaningful human connection. We all have 56 seconds to ask our patients, “When you are not in the hospital, what do you like to do?” They will talk about a hobby or family or work. They might mention children or grandchildren, or a sport. With this information, we can strike up a conversation that has nothing to do with the reason they are in the hospital.

This connection builds trust, so that when we have discussions about pain, patients know we are being open with them about what they can expect. For example, we can say prior to surgery, “Mrs. Smith, I see you are going to have your knee replaced tomorrow. Now, you are going to have some pain after surgery.  We are going to do everything we can to help you manage that pain but we won’t be able to eliminate it entirely. So, when you’re at home and have a headache or your knee hurts, what is a reasonable amount of pain that you can deal with—is it a 3 or a 5 out of 10?  Once we know that, we can be sure to manage your pain to that level.” 

Having this conversation around pain further strengthens the caregiver-patient connection and ensures that patients’ expectations around pain are in line with reality, which increases the likelihood that they will comply with treatment. For caregivers this also means time savings, as patients are less likely to use the call light to ask for pain medication before it’s time for their next dose. Thanks to the connection that has been made, they trust that you will be back when you said you would and that you have their best interests in mind. This makes them feel safe. Nothing we do in health care is more important than that.

Giving patients some choice in their pain management is also an effective practice. It provides them with a sense of control, rather than feeling powerless. There are many ways to alleviate pain: Listening to music, repositioning, walking, reading, aromatherapy, massage, and pet therapy are some examples. These things are not top of mind to patients when they’re frightened, vulnerable and in pain. Reminding them is a way to provide compassionate and connected care.

Sisters of Charity Leavenworth Health System developed a “Pain Menu” that patients receive upon admission. On the back of the laminated fold out card is a pain scale and on the inside are all the ways that pain can be alleviated. During purposeful rounding, nurses assess the patient and ask them to identify their pain level and to choose options from the menu that might help with the pain. The practice makes patients feel like active participants in their own care and it helps them feel acknowledged by their caregiver. It has also been shown to reduce narcotics usage.

Acknowledging our patients’ pain, providing realistic expectations and dialogue around pain, managing pain by providing choice and evaluating effectiveness with ongoing conversation will allow us to meet our patients’ needs and reduce their suffering. To reduce the possibility that providers might overprescribe narcotics in an effort to improve HCAHPS scores, CMS has dropped the pain domain from value-based purchasing calculations. Other ongoing strategies include local, state and national efforts to

  1. Increase the scrutiny around narcotics prescribing practices.

  2. Provide training and educational resources, including updated prescriber guidelines, to assist health professionals in making informed prescribing decisions and address the over-prescribing of opioids.

  3. Expand access to naloxone (Narcan) to reverse the effects of opioid overdoses and help reduce the number of deaths associated with them.

  4. Advance the use of comprehensive medication-assisted treatment (MAT) programs that combine the use of medication with counseling and behavioral therapies to treat substance use disorders.

As health care providers, we are trying to attack this epidemic from every angle. Providing effective pain management and curtailing the opioid epidemic represent two very important public health priorities. Both must be addressed in a thoughtful, comprehensive manner, and neither should happen at the expense of the other.