National summit tackles institutional’ obstacles to pain management

Ethics committees must meet requirements

No one — no matter how ill — should suffer needlessly from pain, and treating pain is as much a health care provider’s responsibility as treating the patient’s underlying medical condition. That’s the ethic driving the Joint Commission on Accreditation of Healthcare Organiza- tions’ new pain management standards.

Released to the public in August 1999, the standards set specific benchmarks for evaluating and treating pain. According to the standards, health care facilities must:

• recognize the right of patients to appropriate assessment and management of pain;

• identify pain in patients during their initial assessment and, where required, during ongoing periodic reassessments;

• educate patients and their families about pain management.

The standards are not a separate document, but new requirements incorporated into each of the Joint Commission’s accreditation manuals. Health care organizations accredited by the Joint Commission will be scored on the new standards beginning in 2001. (See Medical Ethics Advisor, September 1999, p. 101.)

Hospital administrators, physicians, nurses, and ethics committees, however, are just beginning to realize that putting those standards into practice is not as easy as simply following the rules. Implementing the standards will mean a sea change in clinical attitudes, education, and practice.

"I view the institution of these standards as a seminal event in the history of health care. They establish, for the first time, that evaluating and treating pain is no longer an option, but this is really the first step. Now comes the real work," says Perry G. Fine, MD, professor of anesthesiology and associate medical director at the University of Utah Pain Management Center in Salt Lake City.

Fine and other pain management experts recently spoke at a national summit, co-sponsored by the Joint Commission and the American Pain Society, designed to educate providers about the new standards. The summit’s goal was to prepare providers for the difficult task of implementing the requirements at their institutions. More than 400 providers from across the country attended the Leadership Summit on Pain Management: New Expectations for Pain Assessment and Treatment, held May 22 in Chicago. A second summit will be held July 31 in Los Angeles.

Complex biases in the form of caregiver attitudes, patient attitudes, and misalignments in the structure of reimbursement and payment systems present significant obstacles to adequate pain management, and they will have to be addressed, says Fine. "We have to have the attitude that pain management is essential, just like taking vital signs and treating infection and trauma. And, there are now very good means of evaluating and treating pain, that patients and even many providers are not fully aware of.

"If only we had the same approach to other areas of patient care that we traditionally have to the management of pain. The analogy would be a patient coming in with bacterial pneumonia, and the physician — instead of doing culture sensitivities and treating with the appropriate antibiotics — goes back to, Well, we’ll do some cupping and postural drainage and give you some anti-fever medication and just hope for the best.’ It’s archaic," Fine explains.

Patient education is essential

Although much of the blame for undertreatment of pain is laid at the feet of physicians and nurses, patient attitudes about pain present one of the biggest barriers to appropriate pain management, says June L. Dahl, PhD, professor of pharmacology at the University of Wisconsin Medical School, which helped develop the Joint Commission standards, and a speaker at the summits.

"One of the critical standards is in the education chapter," says Dahl. "It states, The patient will be taught that pain management is an essential part of their care.’ Facilities will have to address the issue of patient education because consumers are one part of the equation."

Many patients do not report pain or underreport their pain for a variety of reasons, she adds. "Within our culture there are a variety of factors. We have the macho culture, where there is a feeling among some people that they should just put up with pain," she says. "We also have stoicism, which is different than the macho behavior, but with a similar effect. We also have some people who believe that suffering is necessary for redemption, that pain can be purifying’ in a way."

Other patients are simply afraid of the medications involved in treating pain, Dahl continues. "They are afraid of side effects and do not know that side effects can be controlled, or they are worried about dependence or addiction."

It doesn’t help that terms like addiction, dependence, and narcotics are frequently misused in public discourse and in the media, she says. "I don’t even like to use the word narcotic anymore because it has been misused so often to mean drugs that are illegal," Dahl says. "I have even seen newspaper articles that referred to cocaine as a narcotic. I use the term opioids instead."

She has encountered patients who considered themselves addicts because they need to keep taking the medication in order to prevent or treat the pain.

"One patient said to me, I am addicted,’ and when I asked her why she thought she was addicted, she said, If I don’t take the medicine, the pain comes back,’" Dahl relates. "That was the most interesting definition of addiction that I had ever heard of. But, if you look in the literature, even recent textbooks, you will see a confusion about withdrawal symptoms and addiction, when almost everyone would go through a withdrawal in that situation. We can’t withdraw suddenly from tons of drugs, but that is not addiction, it is a physical dependence."

Many physicians may not have the appropriate education to adequately assess and treat severe acute or chronic pain, which may explain why they are unable to dispel some of the myths surrounding pain medication, say Dahl and Fine. Many clinicians may have their own incorrect beliefs.

"Sadly, these issues are not taught well in medical school and postgraduate training," Fine says. "There are no requirements along the line for physicians to have to demonstrate competency in the basic elements of pain assessment and pain management. You cannot get hospital privileges if you cannot demonstrate competency in CPR, but there is no equivalent standard for being able to assess and treat the far more universal and debilitating complication of pain that is out of control."

A basic competency, suggests Fine, would be to include an understanding of basic approaches to pain control, know processes to evaluate pain in ways that are pertinent to the clinical situation, use standardized approaches to treatment, and document the approaches.

"So, basically, the physician would have a standard evaluation for anyone who is at-risk or of an identified risk population for having pain. It would be a default to evaluate the intensity and etiology of the pain, then that would trigger a care plan to treat the pain. There is no departure in this from what is considered a good standard of care in any other domain of medicine."

However, evaluating pain is different and understandably difficult for many physicians who have not had training and education in this area, argues Dahl.

"Pain is a subjective concept," she explains. "There are not many objective measures of pain. The only way you can know if patients are experiencing pain is to ask them. You don’t ask someone if they have hypertension, you take their blood pressure and you know. You don’t ask someone if he or she has diabetes, you take the blood sugar."

Physicians must learn how and when to appropriately do a pain assessment. "Determine what is the intensity of the pain. What is the quality? What makes it better? What make it worse? What medicines have you taken and how do they work?" she says. "Then you should screen for anxiety and depression because these things can exacerbate pain."

Many physicians end up undertreating simply because they don’t know what to do to treat chronic pain.

Nurses are part of the equation

It’s also a common misconception that the way to improve pain management is getting physicians to do a better job of prescribing pain medication, says Dahl. "This is an important issue because there are physicians who underprescribe pain medication. But lots of times nurses will say to me, If only the physician would prescribe appropriately, pain management would not be a problem.’ But, I have found that, even when the doctors do prescribe appropriately, the nurses will not administer as much as the doctor has ordered."

Surveys in the nursing literature indicate that many nurses simply do not believe patients who say they are experiencing unexplained severe pain, she says. "There is this disconnect. I also hear from nurses who are doing a pretty good job of pain management that many of their colleagues have the attitude that, I just don’t believe that person is in that much pain.’"

There also are forces outside the hospital and provider environment that present obstacles to pain management, such as scrutiny of the drugs used to alleviate pain and low reimbursement of pain treatment.

"There is this whole regulatory environment surrounding the appropriate use of opioids," says Fine. "There is a huge mythology around this, where people are very misinformed and physicians are anxious and running scared. Medical boards are not adequately informed, and there needs to be a lot of social adjustment to ensure that there is adequate prescribing."

Lack of adequate reimbursement is another obstacle, says Fine. Most third-party payers do not properly reimburse visits for the evaluation of uncontrolled pain, and many will only cover the cost of a limited number of pain medications.

"For chronic pain patients, especially, there is nothing efficient and easy about treating the problem," he says. "These are complex, time-consuming problems. In the same manner that you cannot do good coronary artery disease care and you cannot do a revascularization procedure in a 7.5-minute visit, you cannot value and manage over time chronic pain patients in seven to 15 minutes a visit and get paid $18 to do it, when it costs that much just to have a medial assistant escort the patient to the room."

Though they can do little about the regulatory or reimbursement environment, hospital ethics committees will be challenged to ensure their facilities meet the new requirements despite myriad obstacles.

Families of patients frequently come to her expressing frustration at the lack of attention and effective intervention given to a loved one’s pain, says Dahl. "That is why it is so critical that we have the standard in the organization and ethics chapter that patients have a right to adequate pain management," she reiterates. "So, when people call me, totally frustrated with the care a loved one has received — often that loved one may have died — I can say, Please go see the ethics committee. That is what they are for.’"

And, she notes, it would be wise for facilities to consider such complaints within the context of an ethics committee meeting because the alternative is often a courtroom. "These people are usually not trying to create a lot of problems for the hospital or for the doctor. They are trying to reach someone within the organization who can address this issue and make sure that other people do not suffer the way their loved one did."

When these families are rebuffed, they may seek a remedy through the court system, she adds. "People need to be aware of how important ethics committees are, and ethics committees need to take these issues very seriously."

June Dahl, University of Wisconsin Medical School, 1300 University Ave., Madison, WI 53706. Telephone: (608) 263-4900.

Perry Fine, University of Utah Pain Management Center, Salt Lake City. Telephone: (801) 585-7690.

The Wisconsin Cancer Pain Initiative has published a resource manual, Building an Institutional Commitment to Pain Management, the Wisconsin Resource for Improvement. The manual outlines the key elements of institutionalizing pain management and contains sample documents shared by pain management groups around the country. For more information, visit the American Alliance of Cancer Pain Initiatives Web site: http://www.aacpi.org.

• The new Joint Commission standards are available on-line at the organization’s Web site: http://www. jcaho.org/standard/pm_mpfrm.html.