TH's Pain Primer

The Hospitalist. 2007 April;2007(04):

April 1, 2007 | The Hospitalist

For more information about pain management, attend the following sessions at the SHM Annual Meeting in Dallas:

Pain Management” on Thurs., May 24, from 10:35-11:50; and
“Non-Pain Symptom Management” on Thurs., May 24 from 1:10-2:25.

Pain: The Hospitalist’s Responsibility

According to Health, United States, 2006, the federal government’s annual, comprehensive report on America’s health, issued last November by the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics, one-quarter of U.S. adults say they suffered a bout of pain lasting 24 hours or more in the past month. One in 10 says the pain lasted a year or more.

The CDC chose to focus on pain in the latest annual report “because it is rarely discussed as a condition in and of itself; it is mostly viewed as a byproduct of another condition,” says lead study author Amy Bernstein, who also cites the medical costs of pain and pain disparities among different population groups. Other studies have identified physicians’ self-reported discomfort with their training in pain management and with their ability to manage their patients’ pain.

Pain is also the reason many patients end up in the hospital, and treating pain should be the expectation of every hospitalist, says Robert V. Brody, MD, chief of the pain service at San Francisco General Hospital and a frequent presenter on pain management topics at clinical workshops for hospitalists. Effective pain management begins with the pain assessment, but equally important is the follow-up to reassess how the pain responds to initial measures, Dr. Brody says. If initial approaches fail to manage the pain, try again with a new dose, drug, or combination. Then reassess and repeat as often as necessary—viewing the pain challenge as a puzzle to be solved.

Resources and Tools in Pain Management

Chapter 18 of the standard hospitalist textbook Hospital Medicine, by Wachter, Goldman, and Hollander (Lippincott Williams & Wilkins, Second Edition, 2005), “Pain Management in the Hospitalized Patient,” by Robert V. Brody, MD, an expert source for this article, addresses general principles of pain management, assessment, equi-analgesic dosing for opioids, and the management of pain under special circumstances.
The Oxford Textbook of Palliative Medicine by Doyle, Hanks, Cherny, and Calman (Oxford University Press, Third Edition, 2005) includes in its 1,270 pages considerable detail on all aspects of pain management, including specific syndromes and diseases, as well as on the management of side effects
The End of Life/Palliative Education Resource Center at the Medical College of Wisconsin (www.eperc.mcw.edu) offers a variety of online resources on pain management and other topics in palliative care. These include its comprehensive list of “Fast Facts”—brief, one- to two-page, peer-reviewed outlines of key information and citations on a variety of pain-related topics, including Oral Opioid Dosing Intervals (#18), Opioid Dose Escalation (#20), and Calculating Opioid Dose Conversions (#36).
In February, the American Academy of Hospice and Palliative Medicine released the fourth edition of its Primer of Palliative Care, covering in its 133 pages the essential topics of pain management (www.association-office.com/AAHPM/etools/products/products.cfm).
The American Pain Society publishes a pocket-size guide called Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain (fifth edition, 2003, www.ampainsoc.org).

Pain is defined by the International Association for the Study of Pain as “an unpleasant experience associated with actual or potential tissue damage to a person’s body.” Key to that definition, notes Dr. Brody, is the recognition that pain is ultimately a subjective phenomenon, reflecting the patient’s perception of and emotional reaction to the unpleasant sensation. Patients are thus the best source of information on how much pain they are experiencing.