Practice Rounds: The power of suffering: Methods to gauge pain don't always add up

The problem with pain is that you can't measure it like a mountain or sugar. Trying to pin it down is like asking: How long is a shadow? How much air is in a balloon?

"Pain is so personal. It's almost like talking to a patient about his or her mother," said Dr. C. Christian Paine, UMMC assistant professor of pediatrics.

In order to treat it, though, health-care givers must appraise it and make a judgment, in part by asking patients to rate theirs on a scale of 1 to 10.

"And my 10 may not be your 10," said UMMC pharmacist Dr. Andrew Ostrenga.

Still, based on patient satisfaction scores, caregivers at UMMC had been doing a great job at this - until a couple of years ago; that's when the scores - especially those linked to pain relief - plummeted. The Medical Center has been trying to find out why.

"We don't do conversations about pain well - as nurses or physicians," said Dr. Janet Harris, former chief nursing executive officer.

"Some patients come here believing they will not have to deal with pain after surgery.

"We have pain experts here, but they aren't called as often as perhaps they should be.

"Everyone believes they're managing pain but, clearly, we're not," she said, indicating the patient surveys. "And, to me, that's all that matters."

Failure has moral consequences, but it also has monetary ones: Hospitals are reimbursed by the Centers for Medicare and Medicaid Services (CMS) based in part on patient satisfaction. Frustrating a patient can be costly.

But the Medical Center, like other medical institutions, walks a tightrope - the one between the fear of failing its patients and the fear of addicting them.

Helping caregivers maintain their balance is one task of UMMC's Pain Management Committee, which includes Ostrenga and Paine.

After completing a fellowship in pediatric hospice and palliative medicine, Paine now listens to patients more carefully.

"When patients are asked if the hospital staff cared for them, they don't talk about their pneumonia," he said.

"They weren't just thinking, 'Have they treated my illness?' They talk about: 'Did they bring me a drink when I was thirsty? Did they adjust my position or give me a pillow?'

"What they remember is how much people cared."

Marcie Brown of Jasper has no complaints about that. In June, her son Jonathan Brown, in his early 20s, underwent surgery at UMMC after suffering a damaged hip and ankle in a traffic accident.

Marcie Brown did say her son's scheduled medication didn't always arrive on time. On the other hand, everyone was keeping tabs on his pain, trying to make him more comfortable.

"They were nice and helpful," she said.

How important is comfort to a patient?

"Surgery patients are more concerned with pain than with death," said Dr. Ike Eriator, professor in the Department of Anesthesiology and director of the Pain Fellowship.

But providers are often concerned about doing too much about pain.

When it comes to prescribing opioid pain relievers (morphine, codeine, etc.), Mississippi ranked sixth (per 100 persons) in 2012, the U.S. Centers for Disease Control and Prevention reported on July 1 - although it ranked 43rd for high-dose opioids.

Then, there are the providers' personal biases.

"At UMMC we see the sickest of the sick, a large chronic pain population; that may make some caregivers jaded," Ostrenga said.

There are patients who claim their pain is a 7 when it's a 2. But that's often because "they don't trust us," Ostrenga said. "They want to make sure they get some pain relief.

"There are patients who come in who are addicts, but we can't assume they all are."

Bias afflicts the culture as well: No pain, no gain. Bite the bullet.

"It is the belief that to be a man is to not complain," Eriator said. "This needs to change.

"Providers must pay more attention to pain management." That's what the pain scale is for - not so much as a measure for preciseness, but to sound an alarm.

"We also have to believe it and do something about it," Eriator said.

For her part, Jennifer Stephen decided to believe.

"Before that, I was the judge and jury," said Stephen, clinical director of pediatric emergency and lab services. "I finally decided to be an advocate for the patient. It was very freeing for me.

"If you are aware of your own thoughts and doubts, you can better treat the patient. How you manage pain depends on the patient."

Managing it does not necessarily mean medicating it. There are other treatments - distractions, music therapy, play (for children), massage, meditation.

"But we have to do something," Stephen said.

Whatever is done, the patient should be involved. In her role, Harris made sure that every nursing unit designated a "pain champion" - someone trained to help patients deal with particularly harsh pain.

That means communication, which is also a key to managing a patient's expectations, Ostrenga said.

"If you're having major bone surgery, you're going to have major pain. We must explain that to the patient and come up with a goal.

"If the patient agrees that 7 is the goal, then the answer will be: 'Yes, my pain was controlled.'"

Managing pain well can speed recovery, Paine said. "If you feel better physically, then you feel better emotionally, spiritually.

"If you don't treat the suffering in all its forms, then you're not really making the patient well."

PAIN MANAGEMENT RECOMMENDATIONS

• Let your first allegiance be to your patient.

• Train “pain champions” – nurses, managers, educators, etc. – to be resources for patients and caregivers.

• Educate surgery patients beforehand about pain
expectations.

• Establish hospital protocols for dealing with pain; this may include a “pain threshold” as a guide for when to give medication or other treatments.

• Set daily pain goals with patients.

• Communicate better with patients and their family members.

• When called for, use methods of pain relief or management in addition to medication.

Sources: Dr. Ike Eriator, Janet Harris, Dr. Andrew Ostrenga, Dr. C. Christian Paine, Jennifer Stephen 

FACTORS AFFECTING PERCEPTIONS OF PAIN

• Depression (from loss of job, disfigurement, etc.)

• Anxiety (such as fear of hospital, fear of death, worry about family)

• Anger (from delays in diagnosis, unavailable physicians, failure of therapy and more)

Source: Dr. Ike Eriator