COMMENTARY

November 2002: The Problem of (Managed) Pain

Priscilla Scherer

Disclosures

November 13, 2002

Introduction

Recently, a close friend underwent a complicated bowel resection at a center well known and respected for its GI surgery service. The IV Demerol wasn't touching his pain postop, so the staff, in consultation with the pain service, changed the order to Dilaudid, and then to morphine. But within about 3 days, they decided it was time to taper him off the IV medications and start oral Vicodin. Part of a well-researched, evidence-based pain protocol, I'm sure, and I'm sure it may have almost always worked. But this fellow's pain was unrelieved and his surgeon restored the IV medications for a couple more days. This back-and-forth went on for about a week. The impression my friend got from them was that his pain should not have been that bad, so he was either a wimp or liking the drugs a little too much. And he was left wondering whether he was becoming addicted or, alternatively, that if the pain should not have been that bad, then something must be going terribly wrong with him, which it was -- but not as wrong as dying, which is what he thought and which, of course, made the pain even worse.

The surgical team did not look for an underlying cause for the pain that didn't go away, not until several days later...and then, there it was, an abscess the size of a baseball. Great relief all around, some chagrin, "No wonder you were in pain!"

What is our problem with pain? Based on my friend's experience and that of others, it seems that the very purpose of pain -- to warn you (and your doctor) that something's wrong -- may be overlooked by a system of fragmented management and care. And this makes me think that it's time to turn pain management back to the provider who knows the patient best: the primary surgeon or internist, the family doc, the general neurologist, in consultation with the pain specialists when necessary, but only then.

In her aptly titled book Pain: The Fifth Vital Sign , journalist Marni Jackson notes that in 1995, James Campbell, president of the American Pain Society, was the first to suggest that pain should be assessed along with temperature, pulse, blood pressure, and respiratory rate as the fifth vital sign, and that changes in pain should be charted along with these other signs of well-being or ill health, in the hospital and at the doctor's office. Given the fact that at least 20% of all adults experience some kind of ongoing or recurrent pain, compared with 30% of adults over age 45 who have high blood pressure, the routine assessment of a person's pain makes a lot of sense.

In his book Pain and Suffering, William K. Livingston, a pioneer in pain research and theory, described a ride he once took in a neighbor's open Ford Model T.

The car was in an advanced stage of dissolution and as it rattled and swayed along I expected that at any moment it might lie down in the middle of the road. The old man did little talking and I could see that he was obviously worried about something.... I asked him the cause for his concern and he replied, "She ain't running right, Doc. That loud sound you hear just come this morning but I just can't seem to place it! ...It's right down thar somewheres going 'chuck-a-lug-chuck-a-lug' all the time and getting louder and louder. Can't you hear it, Doc? It's just as plain." Only then did I realize that he had long since identified the source of all the customary creaks and rattles in the old car, so that he was no longer hearing them and could give his entire attention to the new sound.

Livingston used this example to illustrate habituation, but I think it could just as well support my contention that the primary care providers -- the ones who know the patient best and see him or her first -- may be the ones who are also best equipped to assess and manage a patient's pain because they know that patient so well. They know how he responds to discomfort in general, how she tolerates medications, whether he's a complainer or a silent sufferer.

Now, maybe I'm hopelessly naive or extremely lucky to have a smart, experienced, savvy primary care physician (PCP) who does know me well enough to know that if I need more than aspirin, something is very wrong. And maybe I'm minimizing the amount of information and education needed to provide good primary care pain management and what it would take to bring everyone up to speed. But maybe not.

I asked several pain specialists about the idea of putting pain management into the hands of the primary care provider, and although their thoughts on how this could be implemented differed, not one of them disagreed with the concept.

"There's not a cut-and-dried answer to this question," said Patricia Bruckenthal, Clinical Assistant Professor of Nursing and Adult Health at the State University of New York, Stony Brook, and co-director of the Pain Management Medical Associates at St. John's Hospital in Smithtown, New York. "Many pain conditions can be managed at the primary care level. For example, the need for ongoing opioid analgesics should not require consultation by a pain specialist any more than managing hypertension always indicates the need for a cardiologist." But she also cautions that more complicated management problems -- interventional procedures, complex psychosocial needs, or polypharmacy with various analgesics and adjuvant medications -- do require a specialist.

Keith Edwards, Director of the Western New England Pain and Headache Center in Bennington, Vermont, agrees but advises prudence. "The first line of pain management should rest with the PCP, who would refer difficult cases to the specialist." But, Edwards adds, such referrals should be made "within the first 3 months," before chronic pain signals remodel the nervous system. "Too often, we don't see the patient for 6-12 months into their pain situation, and by then the pain has become chronic and is more refractory. In the case of a neuropathic pain syndrome, intervention with specific agents that prevent or reverse central sensitization should begin as early as is practical."

Bruckenthal believes, however, that "if a PCP has a strong and appropriate referral network -- an anesthesiologist specializing in pain procedures and a psychologist dedicated to the needs of pain patients, and so on -- almost any pain condition could be managed in primary care." But, she adds, "the internist or primary care provider would have to take a special interest in pain and receive certification, just as they do with diabetes or cardiology, for example, and know when they should refer."

So...what would it take to bring the primary care community up to speed?

In The Fifth Vital Sign, Jackson states that most medical students receive no more than 1 hour of instruction about pain management. That is probably a simplification, but it may reflect the amount of instruction students believe they receive on this topic. This perception may be because instruction on pain in medical training is as fragmented as the healthcare system. According to Rollin Gallagher, Professor of Psychiatry, Anesthesiology, and Public Health and Director of Pain Medicine, MCP Hahnemann School of Medicine, Philadelphia, Pennsylvania, doctors in training may get a bit of information about headaches and neuropathic pain when they rotate through neurology, or when they learn about complications of diabetes in the endocrinology rotation; postop pain is covered in surgery or anesthesiology, and cancer pain with oncology, etc. But there are few dedicated overviews of pain management for medical students and residents, and probably little testing about it since it is only a small part of each specialty's bigger picture. And, of course, this picture is complicated by a number of other issues, political and otherwise, not the least of which is the apparent need to focus on reimbursable activities to ensure an economically viable medical practice.

In 1999, Gallagher, author of the CME program The Conundrum of Pain and Depression and a leading proponent of pain management in the primary care setting, proposed a model for primary care of patients with chronic pain, the Pain Medicine and Primary Care Rehabilitation Model. In it, he recommends "that physicians with a special expertise in pain medicine staff a pain center that provides support and consultation to a network of offices with informed primary care providers and physical therapy programs" that are dispersed in the community, close to homes and jobs, "to facilitate an occupational focus to rehabilitation." His model starts with prevention, urging prompt assessment and treatment of acute pain, which, if managed successfully, will not have a chance to kindle into chronicity, and relies on evaluations by community-based adjuncts: psychiatrists or behavioral medicine specialists, work and family assessments, and so on. If symptoms persist or worsen despite following these step-wise algorithms, the patient is then referred to the pain center for evaluation and treatment.

Decades after the first calls for improved pain management for patients and its subsequent iterations, we are still where we've always been with pain management -- suspicious, impatient, and ineffective. Dr. Gallagher believes strongly that his community model of cooperative pain medicine/primary care in pain management and rehabilitation is the way "to improve the dismal statistics of this problem."

What do you think about this problem? Please share your opinions about the state of pain management and possible solutions with me at neuroeditor@webmd.net.

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