EXECUTIVE SUMMARY

As of Jan. 1, 2018, The Joint Commission will judge accredited hospitals according to newly revised standards for pain assessment and management. The standards are intended to address some of the unintended consequences of a nationwide focus on the under-treatment of pain, reflected in earlier versions. The revised standards push practitioners to offer alternatives to opioids when appropriate, and to engage patients in treatment planning for their pain so that realistic expectations are established.

  • The opioid epidemic causes 91 opioid deaths every day, according to the CDC.
  • The new standards advise hospitals to make pain management an organizational priority with a leader or leadership team in place to set policy and monitor key metrics.
  • Hospitals are advised to identify programs for complex management and opioid treatment, and to facilitate access to prescription drug monitoring programs.

After a lengthy review, The Joint Commission’s (TJC) newly revised pain assessment and management standards take effect this month for all accredited hospitals (http://bit.ly/2igjxLK). First implemented in 2001 in response to what many experts saw at the time as a large-scale problem in the under-assessment and treatment of pain, the new standards seek to address what is a growing national crisis — an opioid epidemic that causes an astounding 91 opioid overdose deaths every day, according to the CDC.

While TJC clearly recognizes that there were unintended consequences from the earlier focus on untreated pain, with the new guidelines, the organization is nonetheless striving to ensure that providers maintain their focus on effective pain control, but in a way that is consistent with safe opioid prescribing practices and mindful of the dangers posed by addiction to powerful pain medications.

Take a Leading Role

Based on an extensive literature review, field research, public comment period, and consultation with a technical advisory panel and a standards review panel, TJC’s revised guidelines call on hospitals to make safe opioid prescribing an organizational priority by establishing a leader or leadership team that will develop metrics and regularly monitor performance improvement in opioid prescribing.

While many EDs have already developed their own improvement programs in this area, Stephen Cantrill, MD, an emergency medicine physician at Denver Health and chair of the opioid guideline writing panel for a clinical policy review on the prescribing of opioids for adults published by the American College of Emergency Physicians (ACEP) in 2012,1 stresses that emergency physicians must be involved in any new leadership efforts undertaken by hospitals.

“Pain is a major component of what we do in emergency medicine,” Cantrill says. “Emergency medicine needs to be involved certainly in the hospital aspects of this. They need to have an active voice and make sure that what the hospital proposes is consistent with what is achievable.”

Consider Alternatives

The revised guidelines direct hospitals to provide non-pharmacologic pain modalities, where appropriate. These may include physical modalities such as acupuncture or chiropractic services, relaxation therapy, and cognitive behavioral therapy. While it is not clear how TJC will evaluate hospitals on this requirement, many experts agree it is an area where emergency providers can make strides, although there is no question that pressure to expedite patients through the ED presents added challenges.

Speaking on behalf of the American Academy of Pain Medicine, Michael Hooten, MD, a psychiatrist and anesthesiologist who specializes in pain medicine at the Mayo Clinic, suggests that it is generally not feasible to deliver non-pharmaceutical, behavioral interventions for pain in a busy ED, although he notes that this type of care frequently is part of the infrastructure in pediatric EDs.

“I think in general what [TJC] wants is for a hospital system to have these [non-pharmaceutical] services available, and then for [providers] to apply them where they are clinically appropriate,” he says.

TJC’s guidelines state that when a patient’s desire for a safe, non-pharmaceutical therapy cannot be met, hospitals should inform the patient about where such services can be provided.

Some pioneering EDs have developed comprehensive programs and goals aimed at providing patients with alternatives for pain. For instance, the ED at St. Joseph’s Regional Medical Center in Paterson, NJ, developed the Alternatives to Opiates (ALTO) program two years ago with the primary aim of using alternative therapies for pain such as trigger point injections, nitrous oxide, and ultrasound-guided nerve blocks whenever possible. While the ALTO program first targeted five common pain conditions, including renal colic, sciatica, headaches, musculoskeletal pain, and extremity fractures, the focus has expanded.

“We are now looking always for alternative options rather than just giving opioids,” explains Mark Rosenberg, DO, MBA, FACEP, the chairman of emergency medicine and medical director for population health in the St. Joseph’s Health System. “It is now the culture and strategy of the department.” Rosenberg adds that the program’s reach has expanded beyond the ED to community partners and practitioners as well as the other departments in the hospital. “We are now setting up a multidisciplinary task force of all the major specialties,” he says. “We are driving the fact that we want to use alternative treatments for pain prior to using opioids, and everybody is on board.”

Identify Resources, Programs

TJC’s guidelines ask hospitals to provide staff and licensed independent practitioners with a range of resources and programs so that they can improve their pain assessment and pain management practices. Such resources should cover how to use opioid medications safely based on the needs of the patient population served.

Related to this requirement, the guidelines direct hospitals to provide practitioners with the services available for the referral of patients with complicated pain management needs, and to identify treatment programs for patients with opioid use problems. While such recommendations make sense, they don’t address the fact that many communities do not have nearly enough resources for complex pain management or opioid treatment, Hooten observes.

“Another problem is just because I have a fantastic treatment center in Minneapolis doesn’t mean that my patient has the correct insurance or the ability to access [this center’s] care,” he says. “So, just because you refer somebody doesn’t mean they can gain access. Insurance status doesn’t gain you access to healthcare, especially substance use treatment and mental healthcare. Many of those services are carve-out types of businesses. It can be difficult.”

Cantrill agrees with these sentiments, noting that losing the Affordable Care Act, which is under threat in Congress, would be a “terrible blow” in this area, further restricting access to treatment programs. “This is a woefully under-served area of medicine,” he says. “It is under-supported and under-recognized.”

Facilitate Access to PDMPs

TJC’s guidelines direct hospitals in states that offer prescription drug monitoring programs (PDMP) to facilitate both provider and pharmacist access to these databases. However, both Cantrill and Hooten agree that there needs to be considerable improvement in the functionality and usability of most PDMPs.

“I am in a chronic pain clinic, so I have staff who help [providers] access these very clumsy programs online. These websites are not slick. They are like using something from 2005. They are ... not very efficient,” Hooten relates. “I can imagine in an ED [using the PDMP] would be a real time-killer. You would almost have to have someone whose job was to monitor the database on every patient if you are going to prescribe opioids.”

Cantrill states that PDMPs are part of a very fractured system in which every state offers its own program. This makes it particularly difficult to access data on patients across state lines. “Every program is different in terms of who gets entered, in terms of the delay time that is allowed, and in terms of who gets access to the data,” he says. “It is a real mishmash.”

However, Cantrill notes that some states have started to implement functionality where pertinent data from the PDMP will be pushed to the patient’s electronic medical record (EMR) so that the provider will see the information automatically when he or she pulls up the record. This eliminates the burden of logging into a separate program and hunting for the information. Cantrill would like to see more states add such functionality and work together to make the PDMP data consistent across different states.

Hospital leaders must work with their clinicians to identify and obtain the equipment required to monitor patients who are at high risk for adverse outcomes from opioids, according to the revised standards. Respiratory depression is the most dangerous adverse event from opioid analgesics; however, the standards note that the literature does not point to a clear, optimal monitoring strategy. Therefore, the guidance suggests that such decisions should be left to the clinical team and their consultations with leadership on obtaining appropriate monitoring equipment.

The standards state that medical staff members must be involved in pain assessment, pain management, and the safe prescription of opioids by taking part in the establishment of protocols and quality measures, and the ongoing review of this data. Along similar lines, the standards note that hospitals must define the criteria for the screening and assessment of pain that is consistent with a patient’s age, condition, and ability to understand. However, the standards allow that different care settings may require different assessment tools or methods.

In particular, the standards state that patients will be screened for pain during ED visits and at the time of admission. The reason for this requirement is to prevent the misidentification and under-treatment of pain, according to the standards.

When pain is identified, the standards state that patients should be treated with either non-pharmacologic or pharmacologic strategies or a combination of the two, and patients with complex pain conditions or addictions should be referred to appropriate providers.

Engage With Patients

Treatment plans for pain should be based on evidence-based practices as well as a patient’s condition, medical history, and pain management goals, according to the standards. Further, the standards state that patients should be engaged in the treatment planning process. The reason for this requirement, in part, is so that realistic expectations can be set and education can be conveyed.

While emergency providers generally are pressed for time, such conversations are important, Rosenberg emphasizes. “We are responsible for managing pain in our patients, and the success of that has to be determined by the patient,” he says. “If I sit and talk about the goals for pain care, and then talk about why I am giving the patient these treatment options, the patient will be much more satisfied, and I will be much more successful in managing the patient’s pain.”

Rosenberg, who also served as a member of the technical advisory panel for TJC’s revised standards, notes that engaging in such a conversation is a big change from a few years ago when his goal in therapy was to get the patient to near zero pain.

“I could give the patient large doses of opioids for relatively minor conditions because I wanted to get him to zero pain, and I wouldn’t think much of it,” he says.

However, Rosenberg notes that now the conversation focuses on getting the patient to the point where he or she can perform the activities of daily living rather than getting to zero pain, and the patient needs to understand that.

“We can come to a better understanding. I may even send the patient home with some opioids and tell him that I don’t want him to use them unless he has severe pain and can’t sleep at night,” he explains.

If the patient feels the need to take the opioids, Rosenberg will advise him or her to use the medication very cautiously. Rosenberg provides only a small number of pills, and then if the pills are not used within three days, he instructs the patient to dispose of them.

“I need to set the patient’s pain goals to different expectations than we had years ago,” Rosenberg notes. “This is probably more important than the pain medication that I prescribe.” Talking to patients about their pain becomes a major part of their treatment, Rosenberg adds. “It is important to the patient, and it is important to me.”

When treating a patient for pain, the standards direct hospitals to reassess the patient’s pain, checking to see how the patient is responding to the treatment and progressing toward treatment goals. The standards note that the use of numerical pain scales is not sufficient to assess pain, and that a more important barometer is how the pain is affecting the patient’s ability to perform basic functions, such as the ability to take a deep breath, turn over in bed, go to the bathroom, or walk, similar to the goals Rosenberg describes.

The standards also direct hospitals to assess for any signs of side effects or risk factors associated with the treatment.

Upon discharge, patients and families should receive education relating to pain management, according to the revised standards. This should include direction on the pain management plan of care, side effects related to the treatment, and any actions or activities that could make the pain condition worse. The education also should address how to use and store any pain medication safely, and how to dispose of any opioid medications, if they are prescribed.

The standards also call on hospitals to collect and analyze data on pain assessment and management. This should cover information about the types of interventions used and their effectiveness as well as the timing of reassessments. The standards state that a focus of analysis should be on identifying needed changes and steps to improve safety and quality.

Cantrill notes that while he is always concerned about placing new burdens on practitioners, he believes TJC’s revised standards are moving in the right direction in terms of concerns about opioid prescribing.

“Part of it is an opportunity to broach the topic [with patients] that we may not be able to always make them pain free,” he says. “Can we alleviate the pain? Yes. Can we get to zero? We may or may not be able to, and that may be an unrealistic expectation.”

REFERENCE

  1. Cantrill SV, Brown MD, Carlisle RJ, et al. Clinical policy: Critical issues in the prescribing of opioids for adult patients in the emergency department. Ann Emerg Med 2012;60:499-525.

SOURCES

  • Stephen Cantrill, MD, Emergency Physician, Denver Health, Denver. Email: scantrill@q.com.
  • Michael Hooten, MD, Psychiatrist and Anesthesiologist, Pain Medicine, Mayo Clinic, Rochester, MN. Email: hooten.william@mayo.edu.
  • Mark Rosenberg, DO, MBA, FACEP, Chairman, Emergency Medicine; Medical Director, Population Health, St. Joseph’s Health System, Paterson, NJ. Email: rosenbm@sjhmc.org.