TH's Pain Primer

The Hospitalist. 2007 April;2007(04):

April 1, 2007 | The Hospitalist

Start with the Assessment

Pain assessment identifies the location, cause, intensity, duration, and nature of the pain, recognizing that many chronically ill patients may have more than one source of pain. It is important to establish why the patient is in pain because different pain responds to different treatments. It may also be helpful to know how long the patient has experienced the pain, how it was treated prior to the hospitalization, how it responded to treatment in the past, what makes the pain better or worse, and how it affects sleep, appetite, or physical activity.

Have the patient describe what the pain is like—the quality of the pain—using his or her own words, suggests Carol Jessop, MD, a hospitalist and palliative care physician at Alta Bates Summit Medical Center in Berkeley, Calif. There may also be psychological or spiritual elements of the pain—other sources that are not physical but contribute to a pain experience that is very real to the patient. A thorough pain assessment also evaluates the patient’s psychological state, including depression and anxiety, as well as past history of alcohol or drug use. It covers the patient’s and the patient’s family’s attitudes toward the use of opioid analgesics, their cultural context, and the meaning that the patient ascribes to his or her pain.

It can take a long time to gather all of that information as part of a comprehensive pain history, however—time that busy hospitalists may not be able to spare, says Dr. Bekanich. Fortunately, not every hospitalized patient requires this level of detail. But if there is reason to expect complications or difficulties in bringing the pain under control, if the pain doesn’t respond to standard analgesic treatments, or if there are reasons for avoiding opioid analgesics, then it may be worth making the time—or recruiting someone who can take a detailed pain history that would provide a baseline for future assessments.

“The most important thing to remember is that pain is what the patient says it is,” says Dr. Pantilat. “We are challenged by wondering whether the patient is really in pain. The answer has to be yes. You have to trust the patient unless you have specific reasons not to.

“It seems to me the first assessment of the patient’s pain may need to be more complex: Is there something new going on with this patient?” he continues. “If someone comes into the hospital with a new fracture or a kidney stone, you don’t need to spend as much time figuring out the pain’s source. But if it is chronic pain that has been unmanaged for a significant amount of time, that’s when you sit down and say, ‘OK, tell me about your pain.’ There’s no one size fits all in pain assessment.”

SHM and Joint Commission Standards Regarding Pain

Pain management is one of SHM’s core competencies for hospitalists (available at: www.hospitalmedicine.org/Content/NavigationMenu/Education/CoreCurriculum/Core_Curriculum.htm). According to this core competency, “pain management involves utilizing various modalities to alleviate suffering and restore patient function.” This competency calls for knowledge of the mechanisms of pain, the symptoms and signs of pain, the relationship among physical, cultural, and psychological factors, and the indications and limitations of opioid pharmacotherapy and other analgesics.

SHM’s core competency of pain management also describes the skills needed to assess and treat pain, the attitudes related to the subjective nature of pain and the multidisciplinary approach to pain, the hospitalist’s role in system organization and improvement, and the ethical imperative of frequent pain assessment and adequate control.

JCAHO emphasizes pain management as an important aspect of clinical care in the hospitals it surveys, as specified in the following standard:

Standard RI.2.160

Patients have the right to pain management.

Rationale for RI.2.160

Patients may experience pain. Unrelieved pain has adverse physical and psychological effects. The hospital respects and supports the right of patients to pain management. In accordance with the hospital’s mission, this may occur through referral.

Element of Performance for RI.2.160

1. The hospital plans, supports, and coordinates activities and resources to ensure that pain is recognized and addressed appropriately and in accordance with the care, treatment, and services provided including the following:

Assessing for pain;
Educating all relevant providers about assessing and managing pain; and
Educating patients and families, when appropriate, about their roles in managing pain and the potential limitations and side effects of pain treatments.