The push to provide analgesic medication to patients in discomfort has been — in some ways — a big pain.
From concerns about unknowingly abetting the manipulative, drug-seeking patient to the perception that the stage could be set for narcotic addiction in someone with a legitimate need, pain treatment for emergency patients has been marked by controversy.
But like the numbing effect of intravenous Demerol, relief has arrived.
An official policy by the Joint Commission on Accreditation of Healthcare Organizations now makes pain assessment part of the scoring process and review mechanism for hospital and medical center accreditation. In fact, according to the JCAHO, pain management isn't just part of the new procedural critique, it is now a full-fledged patient right. Under the new regulations, pain is considered akin to a vital sign. So right along with taking a pulse or checking respiration, patients will be assessed for pain. The joint commission worked with a panel of pain experts to develop new and revised standards, and they were to begin being implemented in January.
The change is getting the warmest of welcomes from several emergency physicians who have studied pain management. One of them, Carolyn Sachs MD, who presented a paper on abdominal diagnoses at ACEP's annual meeting, said she sees the trend in pain management as a much-needed correction. “I would agree that many physicians undertreat pain,” said Dr. Sachs, an assistant professor of emergency medicine at the University of California, Los Angeles.
“A lot of physicians do a poor job assessing pain.” - Dr. Carolyn Sachs
“Unrelieved pain has enormous physiological and psychological effects on patients.” - Dr. Dennis O'Leary
“A narcotic doesn't reduce the diagnostic ability. In some cases, you can't even do an exam without that.” - Dr. Robert Vissers
“Don't be afraid to treat pain.” - Dr. James Ducharme
She also said she hopes the movement will bury a common myth. The old saw is that analgesia can cloud a diagnosis. “Like a lot of things in medicine, it was one of those dictums that was never proven,” she said. In fact, the medical literature now shows that a relaxed state aids a diagnosis, although the studies so far have been fairly small, she said.
“A lot of physicians do a poor job assessing pain,” Dr. Sachs added.
The introduction of the joint commission standards on pain management culminates a two-year collaborative effort between the commission and the University of Wisconsin Madison Medical School. It was originally funded by the Robert Wood Johnson Foundation, and the project included a variety of professional groups and associations, including the American Pain Society.
The standards state that patients and their families need to be educated about effective pain management, and calls upon institutions to adequately address patient needs for symptom management.
The JCAHO anticipates that all accredited health care organizations, with the exception of laboratories, will be required to comply with the standards in 2001.
“Unrelieved pain has enormous physiological and psychological effects on patients,” said Dennis S. O'Leary, MD, the president of the JCAHO, in a statement on the issue. “Research clearly shows that unrelieved pain can slow recovery, create burdens for patients and their families, and increase costs to the health care system.”
In New Jersey, physicians are getting an early start. Under a new law, hospitals in the state are required to evaluate how much pain patients are experiencing and to treat their discomfort. “Any law that legislates physician [behavior] is controversial,” commented Dr. Sachs. However, having pain assessment become a matter of legal mandate “in general, may be a good idea,” she said, referring to the actions taken by New Jersey legislators.
Will diagnostic skill suffer because of pain treatment? Not likely, said Robert Vissers, MD, the residency program director at the University of North Carolina. For one thing, many emergency physicians never bought the idea that pain interfered with clinical signs, anyway. For another, many know how to use ultrasound and other imaging studies very effectively, despite a few turf battles with radiology departments.
Moreover, it isn't emergency physicians who have been reluctant to prescribe pain killers. In general, “we have no problem giving analgesia for abdominal pain,” Dr. Vissers said. Some surgeons, on the other hand, have had a chilling effect on pain relief, at least in some of the circumstances he's seen. When certain surgeons in certain specialties learn analgesia has been used, they say, “I'm not going to operate,” he said.
To some extent, Dr. Vissers said he sympathizes with them. There is some evidence that anti-inflammatory medication is effective at doing its designated function: quelling swelling. In such cases, when inflammation is reduced, even imaging expertise can be misleading, such as when an organ looks healthy because tissues have responded to pain-reducing anti-inflammatory therapy. Still, the verdict isn't in yet on this observation, either. More studies are needed, he stressed.
The standards state that patients and their families need to be educated about effective pain management, and call upon institutions to adequately address patient needs
And when it comes to abdominal pain, determining etiology can be a tough clinical call, he said. “It doesn't follow the rules. It doesn't read the textbooks,” Dr. Vissers said. But that's precisely the reason treating pain can pay off, said James Ducharme, MD, the director of emergency medicine at St. John Hospital in New Brunswick, Canada. He recalled a recent patient who pointed to her abdomen and reported that “everything hurt.”
Demerol not only brought relief, it led to a more distinct diagnosis, he said. “It [the pain] was very clearly localized after 15 minutes,” he said. The pain had gone from severe and diffuse to quadrant-specific, he said.
She was sent to the surgical suite where her appendix was removed.
Dr. Vissers and Dr. Ducharme have two pieces of advice for any physician still clinging to the notion that pain treatment masks symptoms: titrate carefully and banish worry. “Don't be afraid to treat pain,” said Dr. Ducharme. “A narcotic doesn't reduce the diagnostic ability,” said Dr. Vissers. “In some cases, you can't even do a exam without that.”
The new pain management standards, along with examples of compliance, are included in the 2000–2001 standards manual. The standards and intents appear in different areas in each of the joint commission's accreditation texts. Updates on the JCAHO's pain assessment position and implementation can be seen at the web site www.JCAHO.org. Scroll down the menu to “Top Spots,” find “Standards, Revisions for 2001,” and click on the first item in the table of contents.