Heal the Whole Hurt

The Hospitalist. 2007 July;2007(07):

July 1, 2007 | The Hospitalist

What can be achieved in the hospital often is more of a Band-Aid, sometimes even a step backward in terms of the lifestyle changes necessary to get patients out of their passive response to their chronic pain, Dr. Massey says.

The hospitalist’s job is to see what can be done to make patients more comfortable and then send them home with a referral to the pain service, if that is indicated. “I’m happy to help with an intervention in the hospital but, ultimately, we’d like the patient to be less dependent on opioids to treat their pain,” says Dr. Massey. “I know that nothing I can do will really change the situation until I get them out of the hospital and can initiate physical therapy and behavioral interventions.”

There are no shortcuts to permanent pain relief, which can be long, slow, hard work using evidence-based medicine, Dr. Massey says. But it also involves a frank discussion with the patient, which may be hard in the hospital.

“One of the questions we ask patients is: How many times have you visited the emergency room for pain?” says Dr. Massey. “If the answer is more than four in a year, there are likely to be psychological co-morbidities. The challenge for the hospitalist is, ‘How can I arrest this acute pain episode, and then what can I contribute to helping the patient find the help he or she needs to prevent the next episode?’ That means trying to establish rapport and pointing the person to appropriate follow-up pain resources. If you go too hard too fast, the patient may reject what you’re offering. But if you do nothing, you’re facilitating a continued passive approach that doesn’t lead to meaningful solutions.”

Dr. Massey recently saw a woman who had been in the ED 48 times in the previous year for pain that had a major behavioral component. The hospital hired him after the 48th visit to find a different approach to controlling the patient’s pain.

Make Pain a Priority

“My hospitalist group meets regularly to discuss difficult topics, and pain often comes up,” says Stephen Bekanich, MD, hospitalist and palliative care physician at the University of Utah Medical Center in Salt Lake City. “The more you can focus on pain, the more time you spend making it a priority, you are sending a message: This is important to me. You communicate to nurses and other staff that you take pain seriously.”

Dr. Fishman concurs. “Ultimately, it is an issue of priorities and how to prioritize what gets done in the hospital,” he says. “Why would a health professional ever categorize pain relief as a lower priority? We have wandered far from our compassionate mission as doctors when that happens.

“In the real world, when there is no one else to do it, and no pain clinics available, the responsibility for pain management falls on the provider at the front lines, often the emergency physician and the hospitalist. Hospitalists are becoming de facto pain specialists for patients with chronic and terminal conditions. These patients are looking for support, comfort, and redirection. This can also be one of the most rewarding aspects of hospital practice. It really brings you back to the roots of medicine.” TH

Larry Beresford is a regular contributor to The Hospitalist.

Pain Treatment Modalities

This chart categorizes and summarizes the variety of pain treatment modalities that might be available to the hospitalist. Because there are so many, we have not included specific doses or instructions for use.

Non-opioid analgesics for mild to moderate pain: Analgesics such as acetaminophen, aspirin, and non-steroidal anti-inflammatory drugs (NSAIDs) are fundamental in managing acute and chronic pain from a variety of causes. They may be combined in commercial formulations with codeine or other opioids. They often are recommended—even when stronger opioids are being used. Take care not to exceed recommended daily maximums. No NSAID is a priori more effective than another in the general population, although there is great inter-patient variability in their response.
Opioid analgesics: These drugs are the mainstay of managing moderate to severe pain and the types of pain challenges hospitalists face every day. Experts say opioids typically offer the best approach to short-term pain management in the inpatient setting and, when used correctly and closely monitored, provide effective pain relief with limited risk. Oral administration is preferred. There are situations where other routes are indicated, including intravenous, which is the quickest and most precise route for titration, intramuscular and transdermal, as well as sustained-release pills. Opioids can be long-acting or short-acting. Hospitalists should be familiar with equi-analgesic dosing conversion and able to substitute equivalent doses between methods of administration. Pain experts also recommend becoming familiar with a few short- and long-acting opioids and their use for the majority of pain cases.
Patient-controlled analgesia (PCA): The PCA pump is a boon for treating acute pain in the hospital setting, offering patients the opportunity to control how much analgesia they get, and when, by pressing and releasing a control button connected to the computerized infusion pump. PCAs can be prescribed with a basal rate of analgesia administration plus an incremental dose, typically equal to 50% to 100% of the basal rate over a 24-hour period, with safety features to prevent receiving more than the recommended dose and lock-out intervals between doses, defined in minutes. A digital history can be generated, and the PCA can free nurses from frequent requests for analgesics from the patient. It is recommended that hospitals establish criteria for which patients are appropriate for PCAs because they can be overused, especially for chronic pain exacerbations that could be managed orally.
Adjuvant analgesics: A diverse list of adjuvant analgesics is also used to treat pain. In some cases they may allow a reduction in the total dose of opioids required to achieve pain relief. They may also be used to address types of pain not well managed by opioids, such as neuropathic pain. Patients with severe chronic pain often experience anxiety or depression, which can be treated by the appropriate adjuvant drug in order to achieve optimal pain management. Classes of analgesic adjuvants include:
- Anticonvulsants, including gaba-pentin, pregabalin, lamotrigine, and carbamazepine;
- Select antidepressants (e.g., tricyclic antidepressants, duloxetine, citalopram venlafaxine, bupropion, and paroxetine;
- Local anesthetics;
- Alpha-2 adrenergic agonists;
- NMDA receptor antagonists;
- Corticosteroids;
- Muscle relaxants; and
- Hypnotics and anxiolytics
Interventional pain treatments: Interventional pain techniques in a variety of mechanisms can be used to address pain problems resistant to the usual oral analgesics. Most often these interventions are provided by a pain specialist in the anesthesia department or acute pain service, although hospitalists are encouraged to start learning which techniques are appropriate for which kinds of hospitalized patients. Interventional pain techniques refer to surgical interventions to block, stimulate, modulate, ablate, or otherwise deaden the nerves transmitting pain messages to the brain. Other interventional techniques include fluoroscopy technology, radio-frequency ablation, and cryoanalgesia.
Non-pharmacological pain treatments: Non-pharmacological pain techniques are even more varied, although they may not be readily accessible in the hospital. Non-pharmacological techniques can be used as adjuvants to morphine, helping to reduce the total analgesic dose required. Or, when pain is not responsive to the usual techniques, these alternatives may be utilized to help the patient gain control over their pain. They include:
- Cognitive/behavioral therapies;
- Psychological counseling;
- Support groups;
- Meditation/relaxation/guided imagery;
- Distraction;
- Music therapy;
- Heat and cold;
- Exercise;
- Biofeedback;
- Hypnosis;
- TENS (trans-electrical nerve stimulation); and
- Complementary/alternative therapies such as acupuncture, acupressure, aroma therapy, and therapeutic touch
Other: Other pain techniques include radiation or chemotherapy to alleviate pain from intruding cancer tumors, along with physical therapy and other applications of rehabilitation medicine for different kinds of pain.

—LB