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Advancing the Practice of Pain Management
Knowledge and Technology vs Clinical Practice: The Gap

NICU Procedures

Survey of 14 of 38 Canadian NICUs (11-93 to 2-94)
Daily logs of procedures/analgesia for 1 week

N = 239 infants (23 - 42 weeks)
Total of 2134 invasive procedures/0 pain intervention

Heelstick	1298/0
IV start	451/0
Venipuncture	179/0
Umbilical vessel cath	31/0

Analgesia given 17 times for 7 procedures:

Arterial puncture	88\2
Et intubation	35\2
LP	28\1
Peripheral arterial line	6\4
Bladder cath	6\1
Chest tube insertion	5\3
Misc others	7\4

Analgesia given for other reason (eg, surgery) during 129 procedures Total analgesia/anesthesia for 6.8% invasive procedures

Use of analgesia not related to NICU pain protocol

Reference: Johnston C and others: Clin J Pain 13(4):308-312, 1997.

End Of Life: Pediatric Cancer

Survey of 103 parents whose child died of cancer (1990 -1997)
Interviews conducted average 3.1 years after death
Focused on quality of life during last month of life

Deaths:

• 79% progressive disease
• 21% treatment-related complication
• 49% in hospital; 45% in ICU
• almost 50% of those in hospital had ventilator support during last 24 hr

Parental reports: 89% of children experienced substantial suffering from one of 4 problems: fatigue, pain, dyspnea, poor appetite

• More than 50% suffered from 3 or more of these problems
• Pain treated in 76%, successful in 27%
• Dyspnea treated in 65%, successful in 16%
• Documentation by MDs of symptoms significantly different from parental report
• Involvement of hospice: child more calm, peaceful before death; effect on pain control not mentioned

Reference: Wolfe J and others: NEJM 342 (5):326-333, 2000.

Chronic Pain In America

• 56% of 805 individuals with chronic, moderate to severe pain have been suffering for more than 5 years.
• 41% report that their pain is out of control; that number rises to 58% among those with the most severe pain (8, 9 or 10 on a scale of 1 to 10 — with 10 representing "the worst pain imaginable").
• Among those in severe pain, 46% took over a year to obtain pain relief.
• 47% have changed doctors at least once since their pain began.
• Almost a quarter—22%—have switched 3 or more times.
• The primary reasons for changing doctors include patients' continued suffering (42%), doctors' lack of knowledge about pain (31%), doctors not taking their pain seriously enough (29%), and doctors' unwillingness to treat it aggressively (27%).

Reference: American Pain Society, American Academy of Pain Medicine, and Janssen Pharm, 1999.

Cancer Pain In America

Survey from computerized database of 1,492 nursing home residents in 5 states

N=13,625	65 yr or older
4,003	reported daily pain
24%	85 yr or older
29%	75-84 yr
38%	65-74 yr
26%	received no analgesia
Ages 85 and older received least analgesia

Reference: Bernabei and others, JAMA, June 17, 1998.

Postoperative Pain In America

Survey of over 7000 published studies

• Half of patients given conventional pain therapy—most of 23 million surgical cases/yr have moderate to severe pain.
• "PRN" pain control results in prolonged delays because patients may delay asking for help.
• Aggressive prevention of pain is better than PRN treatment because, once established, pain is more difficult to suppress.
• Patients have right to prevention of or adequate relief from pain.
• Physicians need to develop pain control plans before surgery and inform patient about pain during and after surgery.
• Fears of postsurgical addiction to opioids are generally groundless.
• Patient-controlled medication via infusion pumps is safe.

Reference: Agency for Health Care Ruling and Research, 1994.

Barriers to Effective Practice Pain Management

• Inadequate knowledge
• Individual and Social Attitudes: Pain
• Individual and Social Attitudes: Drugs
• Lack of Accountability

Inadequate knowledge

Outdated and inadequate

Education deficits

Learned ignorance (apprenticeship)

Incorrect information (texts)

Personal-opinion based beliefs

Uninformed consumer

*A Survey of NLN accredited baccalaureate nursing programs revealed that 48% spent four hours or less on pain (Graffam, 1990).

*One survey of graduating baccalaureate nursing students showed that only 13% thought cancer pain management should be taught as part of the nursing curriculum (Sheehan, et al, 1992).

*Nursing textbooks contain inaccurate, confusing, and often irrelevant information about pain (Ferrell, et al, 1999).

*Nursing faculty knowledge about pain, especially analgesics, tends to be very inadequate (Ferrell, et al, 1993).

*Non-nursing college students are misinformed about pain (McCaffery and Ferrell, 1996).

Individual and Social Attitudes: Pain

Pain is good and necessary

Diagnostic aid (trauma, LOC)

Monitors disease progression (cancer, head injury)

Builds character

Part of life

Medical professionals in charge of pain; handmaiden attitude

Individual and Social Attitudes: Drugs

Narcotics are bad and unnecessary — Just say NO to drugs

   Addiction

   Respiratory depression

   Hemodynamic instability

   Depressed LOC

   Decreased peristalsis

   Too much trouble, risk, and cost

Schedule II Drugs (i.e., morphine, fentanyl, meperidine, oxycodone, hydromorphone)

Each filing requires written prescription
patient name, address, and phone; practitioner's name, address, and drug enforcement agency (DEA) #, and date

In case of emergency, verbal prescriptions for schedule II substances may be filled; however, the practitioner must provide a signed prescription within 72 hours.
Schedule II prescriptions cannot be refilled.

Assessment/documentation/ administration

Titration and side effects

Too expensive (i.e., EMLA, fentanyl, Toradol; Zofran for N/V)

Lack of Accountability

Inadequate quality assurance and evaluation (staff and family)

Minimal administrative support

No published and visible standards or patient's rights

No professional sanctions (ethical conduct, incident reports)

No One In Charge of Pain

Strategies to Improve Practice

• Education
• Practice Guidelines
• Pain Standards
• Attitude "transplant"
• Administrative support
• Personal/professional investment
• The Ten Commandments of Pain Management

Education

Baseline data (chart audit, pretest)

Pain team; Pain resource nurse (Ferrell, et al, 1993)

Pain rounds

Staff and student education

International Association for the Study of Pain (IASP) Curriculums

Facts, Assessment, Management (pharmacologic and nonpharmacologic)

Publications

Agency newsletter (Pain team, Pharmacy, Nursing, Medicine, Ethics)

Poster ("Penelope Pain")

Current articles and Reference texts

Videos (Whaley & Wong's Pain Assessment & Management, Mosby, 800-426-4545; Greenberg and others, 1999)

Site visits; Consultants/speakers/grand rounds

Experiential learning

Buffered lidocaine

EMLA

Laser therapy (snap of elastic band)

Dorsal penile nerve block (DPNB) (nursing assistance) (Fontaine, 1990)

Pain PCA Race for Relief (pocket calculator)games (Bilderback, 1991)

Comfort converting (giant Tylenol-Gelcap shapes cookie)

Diagnosing for donuts (donuts for authors)

Section Showdown/Family Feud (APS Guidelines)

For other teaching techniques, see www2.nmind.net/nthomas

Consumer education and rights

Publications (AHCPR; Cowles, 1993)

Joint Commission of Accreditation of Health Organizations (JCAHO) complaint hotline - 800-994-6610

Practice Guidelines

Agency for Health Care Policy and Research (AHCPR) (800-358-9295)

American Pain Society (APS)

World Health Organization (WHO) Analgesic Ladder

American Academy of Pediatrics (AAP) Statement On Neonatal Anesthesia

AAP Report On Children with Cancer

American Association of Pain Management (AAPM) and APS use of opioids for the treatment of chronic pain

Pain Standards

Joint Commission of Accreditation of Health Organizations (JCAHO) accreditation and pain standards

• recognize the right of patients to appropriate assessment and management of pain
• assess the existence and, if so, the nature and intensity of pain in all patients
• record the results of the assessment in a way that facilitates regular reassessment and follow-up
• determine and assure staff competency in pain assessment and management, and address pain assessment and management in the orientation of all new staff
• establish policies and procedures which support the appropriate prescription or ordering of effective pain medications
• educate patients and their families about effective pain management
• address patient needs for symptom management in the discharge planning process
• maintain a pain control performance improvement plan

Attitude transplant

Consciousness awareness

Survey, questionnaire, interactive video, family interviews

Collaborative practice

Rationalize the irrational

Opioid respiratory depression vs antibiotic anaphylaxis

Opioid withdrawal vs steroid withdrawal

Diagnosis fracture by pain rating vs x-ray

LOC, sedation, coma, and Narcan

Convenience

Preprinted PCA or IV orders

Available guidelines and equipment (Buffered Lidocaine, EMLA)

Well-trained staff (PCA, DPNB)

Simple assessment tools (scales, behaviors, documentation)

Legal liability (Jury, 1991; Lipman, 1997; Rich, 1997)

Administrative support

Make pain visible and staff accountable for its relief

Patient evaluation:

• How satisfied were you with the amount of pain you had?
• How would you rate the way your pain was controlled?

Continuous Quality Improvement (American Pain Society, 1995)

1. Assuring that a report of unrelieved pain raises a "red flag" that attracts clinician's attention
2. Making information about analgesics convenient where orders are written
3. Promising patients responsive analgesic care and urging them to communicate pain
4. Implementing policies and safeguards for the use of modern analgesic technologies
5. Coordinating and assessing impementation of these measures

Adherence to guidelines (ex. documented assessment, use of DPT, IM route, adjusted dose, appropriate drug — morphine vs meperidine)

Staff evaluations

Reinforcement

Pain award

Sanctions

Incident reports

Ethical review

Personal/professional investment

Commitment

Mentor & Mentee

Advocacy

Successful negotiator (Walker & Wong, 1991)

Action-oriented, risk-taker

The Ten Commandments of Pain Management

1. Thou shalt believe the patient's report of pain.
2. Thou shalt assess and reassess the patient's response to pain interventions.
3. Thou shalt not be afraid of prescribing/administering opioid analgesics.
4. Thou shalt not prescribe inadequate amounts of any analgesic.
5. Thou shalt not use the abbreviation p.r.n. for continuous pain.
6. Thou shalt reassure the patient and family that risk of opioid addiction is rare.
7. Thou shalt provide support for the whole family.
8. Thou shalt not limit thy approach simply to the use of analgesics, but also adjuvant drugs and "mind-body" techniques.
9. Thou shalt not be afraid to ask colleagues' advice.
10. Thou shalt have an air of quiet confidence and cautious optimism.

Modified from Robert W. Twycross, Practical Palliative Care Today. Spring 2000, Vol. 2. Center for Palliative Studies at San Diego Hospice, San Diego, CA 92103.

TAKE A PROJECT AND MAKE A DIFFERENCE

GOLDEN RULES FOR PAIN RELIEF

Whatever is painful to adults, is painful to children until proven otherwise. Pain control must be based on scientific facts, not on personal beliefs or opinions.

Additional Information

• Bibliography: Advancing The Practice Of Pain Management

March 15, 2002

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