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[Editorial]
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Be the CEO of Your Own Pain By Maryan Pelland Pain is much more than just an unpleasant sensation. Doctors know that pain prevents effective recovery from illness or surgery and can have a major negative effect on the quality of life. Managing or alleviating pain, acute or chronic, has been hit and miss at best. In the past, someone else made decisions about your pain, and didn't necessarily base those decisions on your specific needs or level of pain. New federal standards implemented by the Joint Commission on Accreditation on January 1 are officially changing that. Hospitals, clinics and nursing homes now risk losing their accreditation if they fail to assess patient pain from the moment of admission through discharge - and treat it on an individual basis. Dr. June H. Dahl, professor of medicine, University of Wisconsin at Madison was one of the key players in setting the new standard into practice. Dr. Dahl, who calls herself a soldier in the fight against ineffective pain management, has worked on this project since 1997. "Education by itself doesn't change a practice," she said. "You have to get inside the institutions. Linking the new standards to accreditation, to how a facility is judged, does that." Now, along with blood pressure, heart rate and other vital signs, medical staff asks each patient to evaluate her level of pain. It goes like this - on a scale of zero to ten, with zero being no pain, and ten being pain that would take you to the emergency room right now, describe the pain you are feeling at this moment. People's tolerance for pain differs widely, so the patient is usually asked to help set goals: on the 0 to 10 scale, where does significant discomfort begin? At what point do you feel you need relief? "Together," says R.N. Rosemary Davis of Woodstock, "patient and provider work out the exact point at which medication needs to be given in order for it to work before the target level of pain is reached. That gives the patient ownership of his own wellbeing." In many cases, the patient is empowered to provide her own relief through new technologies like a PCA, or patient-controlled-analgesia, a little switch that puts measured amounts of pain reliever into a running IV line. And pharmaceutical manufacturers, recognizing the emphasis on pain management and intervention over the past few years, have made research in these areas a priority. They've come up with a myriad of medicinal patches, better and safer drugs and more precise delivery systems. So, doctors, nurses and hospitals include patient input in the treatment plan, and they have an arsenal of 21st Century weapons against pain. How is that idea panning out in real clinical settings? Davis says patients recover more quickly, "If you're in pain and can't get up, that creates more problems. Feeling better, moving around, having a good appetite all contribute to a quicker recovery." Then what is the patient's role and is he fulfilling his responsibility in managing his own pain? Experts agree that the system is headed in exactly the right direction. Dr. John Prunskis, MD, of the Illinois Pain Treatment Institute, East Dundee, says though there is no substitute for accurate diagnosis and treatment of the underlying cause of a problem, managing pain goes a long way toward recovery. "Over the last three years there has been an explosion of new information and diagnostic tools, so it's easier to get to the root. But involving a patient and encouraging them to work for their own goals puts us on the right track." Prunskis believes there are some challenges along the way - some patients may ask for more medication than is optimum; some may seek too little; some might be reluctant to take medication at all. But the keys to overcoming such challenges all stem from properly educating the patient and effectively supervising the entire treatment plan. Do patients become addicted to pain medication when they are able to get it whenever they want it? Not one expert saw this as a major problem. Prunskis said it can't be ruled out. "There are some people who use pain medication for something other than pain. But that is a small risk from our point of view." Davis agreed, "It is far more likely that patients will ask for less than they need - from a fear of becoming addicted, or from a sense of stoic strength." That stoicism is far from uncommon in mature Americans brought up to endure adversity, especially those of hearty middle-American stock. Nobody wants to be labeled a whiner. "The pivot point of this is that the pain is what the patient says it is," Prunskis explained. "If a patient is by nature stoic, they may downplay their level of pain and there is no way to gauge that. We try to insure comfort. We encourage them to realize it's ok to use medication when it's needed and it's very ok to express your own needs when you're hurting." It's important to realize that from the medical point of view, pain assessment isn't just a scale with numbers. It's about providers observing, listening, talking, assessing function, according to Dahl. "Providers must look at quality of life, functional status, what the pain is keeping the patient from doing. It's not simple, but medicine isn't simple - you have to ask the right questions and look at the patient closely. That's what tells you the treatment plan is appropriate," she said. Patients who use pain medication in a supervised treatment plan do not become addicted, according to Debbie Camacho, an Elgin RN with a background in oncology. She said, "Lots of people fear addiction, but that is highly unlikely. It's ok to ask for help - once pain gets out of control,it's hard to get it back under control. We educate people, show them the evaluation scale from our first contact with them. Sherman Hospital developed a patient education booklet, age-specific, to make our role and theirs very clear." Most nurses are in agreement, if a patient expresses concern about addiction, a serious conversation is in order. According to Davis, "Once surgical recovery patient understands that the dosage may increase at first to find the proper level of relief,but then will decrease as the body heals, the fear is alleviated." Giving the patient control and input helps here, too, Camacho pointed out. "If you can express your own needs and help decide the level of discomfort that's tolerable to you, the fear of taking too much, too long, seems to lessen." Overall, the consensus is that people don't want to hurt; pain is not fun. Effective use of pain evaluation and pain management depends upon diligent work from both sides, the patient and the care givers. Davis said,"It hinges on your approach. Our job is to be sensitive, educate, and treat." Professor Dahl pointed out, "Though many of us think it isn't acceptable to talk about our pain, it's important that we do just that. Let me tell you, the idea that maybe suffering makes us better people is grossly, completely overrated. We have the right to treatment." But with rights come responsibilities, she concludes. As a patient, whether your pain is acute - the result of an injury or surgery, or chronic from an illness or long term condition like arthritis, pain management professionals advise you to be part of process; be actively involved. Don't look to be nurtured; look to be treated, and be willing to help yourself. Dr. Prunskis advises patients to ask a lot of questions, make notes about how you feel, what triggers the pain, how things are working for you. Ask your pharmacist about drug interactions when you get a new prescription. She can tell you about allergies and other precautions, too. Be sure you understand the instructions included with your medication, and read the literature. Doctors advise that every medication, whether you take it in a hospital or clinical setting or get it from the pharmacy, has side effects; it's important to be very mindful and watch for them. But pain has its own set of side effects. Professor Dahl says that among other things, pain elevates blood pressure, restricts elimination, affects your ability to absorb nutrition and constricts your breathing. No one can heal properly under those conditions. "We're focused on this pain issue now, and it's about time. People are seeking and getting treatment in this century for conditions that would have killed them in the fairly recent past. Our complaints are more complicated and potentially much more painful than ever before. We need to share the responsibility for understanding and managing the pain so we can affect the cure."
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