Pain Management Standards: Their Role in Improving the Quality of Care

JCAHO Standards on Pain Management: Toward Improved Management of Pain in Older Adults

"You will encounter health care professionals who are resistant to the fact that there are now standards for pain management that accredited health care facilities have to meet,” began June L. Dahl, PhD, Professor, Department of Pharmacology, University of Wisconsin Medical School, Madison. “We have to help them understand why it’s so important to have standards.” Not only is pain common in older adults, but pain in older persons is often undertreated, Dr. Dahl explained.

In 1994, Cleeland and colleagues¹ looked at outpatients being treated at Eastern Cooperative Oncology Group facilities; they discovered a high percentage of persons with inadequate pain management for cancer and found that the elderly were at special risk. In 1998, in another study involving 14,000 residents of long-term care facilities in the Northeast² with cancer, the authors found treatment in these facilities to be extremely poor. Dr. Dahl was also struck by the results of a recent survey published in the September/October 2000 issue of Modern Maturity magazine:³ respondents said that they feared being in pain more than they feared dying.

In 1985, Levin and associates⁴ found the same feelings among residents of the state of Wisconsin. “It’s sad that 15 or 16 years later, these fears still exist,” lamented Dr. Dahl. There are many myths about pain in the elderly and about pain medicine. One myth is that pain is a natural part of aging that one simply must deal with, and reporting it is therefore not necessary. There are also myths about the long-term use of analgesics and fears about the use of opioids. “Clearly one has to be extremely thoughtful about particular prescribing practices in older persons, but that doesn’t prohibit the use of any drug,” said the speaker. Staff members are often not trained in pain management, and in some settings there is a very rapid turnover. Efforts have been made to improve the knowledge base of persons who take care of  patients in pain, but nevertheless the problem persists.

Last but not least is the fact that there are a high number of cognitively impaired people suffering pain. “The question is, why do we still have this problem if we have identified it so well for such a long time and we know the reasons for the problem?” Dr. Dahl asked—“It is because there are significant barriers in the facilities themselves.” Processes that are critical to the delivery of pain management within clinical settings, as well as traditional views of care, have not supported effective pain management. Environments may be hostile or at least not conducive to effective pain management. Recognition of this fact provided the motivation for approaching the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to request that pain assessment and management be incorporated into the standards that are used to accredit the nation’s health care facilities. The new standards gained JCAHO approval in July 1999. Since these are standards, not guidelines, the language is critical, said Dr. Dahl. The new language in all the Joint Commission manuals for various types of health care organizations reveals the following:

• Facilities must recognize the right of patients to appropriate assessment and management of pain

• Facilities must screen patients for pain on admission

• If pain is present, they must perform a comprehensive assessment

• They must record the assessment in a way that facilitates regular reassessment and follow-up

• They must set standards for monitoring and intervention

• They must educate providers and assure staff competency

• They must establish policies that support appropriate prescription or ordering of pain medicines

• They must provide patient and family education on effective pain management

• They must include patient needs for symptom control in discharge planning

• They must collect data to monitor the effectiveness and appropriateness of pain management

“In short, the goal of all of this is to do what one might call ‘institutionalizing pain management,’” said Dr. Dahl. “What one wants to accomplish—and the purpose behind these standards is to weave pain management into the fabric of the organization—is to make pain management an integral part of patient care, done on a daily basis for everyone.” “Instead of looking upon these standards as threats, as elements that will just make life miserable and create the need for filling out more and more forms and adding more and more stress, what one really, I hope, will think is that these standards are tools that can be used to advance pain management in one’s setting; tools that will allow caregivers to accomplish things they have perhaps always wanted to accomplish but were prevented by an environment, which may not have been friendly or conducive to making change,” she emphasized.

In conclusion, Dr. Dahl said, “When we think about standards, we’re always thinking about the burden on the health care provider. What we’ve got to think about is what this means for patients, because that’s where the focus ultimately needs to be.” She spoke of a woman who came into a health care facility feeling that life was not worth much anymore because of the severity of her chronic pain. The standards that were implemented in that facility should be credited for the report this patient later gave, “Now I can enjoy my meals, I can sleep through the night, I’m a real person now, I’m not just pain walking around.”

References

1. Cleeland CS, Gonin R, Hatfield AK, et al. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med 1994;330(9):592-596.

2. Bernabei R, Gambassi G, Lapane K, et al. Management of pain in elderly patients with cancer: SAGE (Systematic Assessment of Geriatric drug use via Epidemiology) Study Group. JAMA 1998;279(23):1877-1882.

3. Redford GD. Their final answers: An exclusive Modern Maturity survey. Modern Maturity. September/October 2000: 66, 68.

4. Levin DN, Cleeland CS, Dar R. Public attitudes toward cancer pain. Cancer 1985;56(9):2337-2339.

Unprecedented Changes in State Law, Regulations, and Guidelines Related to the Use of Opioids for Analgesia

One of the goals of my work is to ensure that regulatory policy involving drugs and professional practice follows medicine instead of the other way around,” said David E. Joranson, MSSW, Senior Scientist and Director of the Pain and Policy Studies Group, World Health Organization Collaborating Center for Policy and Communications in Cancer Care, the University of Wisconsin Medical School Comprehensive Cancer Center, Madison, WI. “It is important for medicine and science to be allowed to expand and contract and move forward without being hampered by regulatory policy,” he added.

Prior to 1989, there were only a few state pain policies, laws, or statutes, and by the end of 2000, there were approximately 70. Some states have more than one policy—for example, a statute and a guideline. The state laws or statutes that have been adopted, typically called intractable pain treatment acts, aim to encourage physicians to take measures to treat pain, including the use of controlled substances. Regulations and policy statements or guidelines may not have the force of law, but they nevertheless typically express the attitude and policy of state medical boards and some state pharmacy boards, Mr. Joranson pointed out. His team of four people has evaluated more than 350 relevant state policies, grouping them into two categories: those that enhance pain management and those that impede it.

In the first category, he said, a state policy should recognize that controlled substances are necessary for public health, and that there is a hazard when they are misused. A policy should also recognize that pain management is a part of general medical practice, not a specialty. Additionally, a policy should recognize that the medical use of opioids is legitimate professional practice and that pain management is encouraged.

In the second category involving policies that impede pain management, some policies suggest that opioids should only be used as a last resort, and that they are ordinarily outside of legitimate professional practice unless a specific law grants the authority to prescribe them. According to Mr. Joranson, this is one of the shortcomings of intractable pain treatment acts. Another shortcoming is laws suggesting that opioids hasten death, when in fact, clinically, this has been resolved to a myth. An additional impediment is the confusion between the concepts of physical dependence or analgesic tolerance and the concept of addiction. The figure shows the results of Mr. Joranson’s group’s study. Some states had as many as 20 provisions that were impediments, and at the same time a few more that were enhancers. California had the most of both types of provisions, and New York had the second most provisions. Kansas had a high number of positive provisions and almost no impediments. Kansas has adopted a special model guideline from the state medical board, which the speaker called “an extremely positive statement about improving pain management in medical practice.”

This model was developed by the Federation of State Medical Boards of the United States, with the help of Mr. Joranson’s group. It contains a preamble that suggests several guidelines; if a physician is prescribing within these guidelines, he or she should have nothing to fear from the state board, the speaker said. These guidelines pertain to the typical aspects of good medical practice: evaluation of the patient, treatment plan, informed consent and agreements, periodic review, consultation, medical records (documentation), and compliance with the existing state law. The preamble goes on to define a number of important terms in the area of pain medicine and addiction medicine, so that past confusion is clarified. The language of the model policy, which was adopted by the Federation in May 1998, makes the following statements:

• The people of the state should have access to appropriate and effective pain relief.

• Physicians should view effective pain management as a part of quality medical practice for all patients with pain, including the pediatric as well as geriatric patients.

• All physicians should become knowledgeable about not only opioids, but all effective methods for pain treatment, as well as the statutory requirements for prescribing controlled substances. The model policy can be found on Mr. Joranson’s group’s website at www.medsch.wisc.edu/painpolicy. On the website, one can also find the status of a pain policy in one’s state, and can read the state’s policy in its entirety, whether it be a law, a regulation, or a guideline. Finally, one can read an article written by Mr. Joranson and his colleagues¹ about the trends in the medical use and abuse of opioids.

Reference 1. Joranson DE, Ryan KM, Gilson AM, Dahl JL. Trends in medical use and abuse of opioid analgesics. JAMA 2000;283(13):1710-1714.

Effectively Managing Pain in Older Adults: What Is the Standard of Care?

“Most of us are treating a broad range of patients who certainly do not represent a homogeneous population,” said Wendy Stein, MD, CMD, Assistant Professor of Geriatrics at University of California Extension, Santa Cruz, CA, and Medical Director of Long-Term Care Services at San Diego Hospice, San Diego, CA. “Our patients are quite frail and in my case range from 65 years of age (in my primary care practice) to 111 years. Obviously, their assessment and management needs are going to be extremely different, especially toward the end of life.” Multiple studies have shown that older adults have an increased prevalence of different types of pain syndromes that are rather unique to this population. Osteoarthritis is extremely prevalent, although not all cases are symptomatic or impede function on a daily basis. Most of the cancer pain studies have demonstrated an increased prevalence as individuals age. “So we need to think about the fact that most of these cancer pain patients in these studies are actually older patients with pain,” Dr. Stein pointed out. “If we can do a better job and perhaps buy those patients another year of independent living, that’s an important quality-of-life concern,” she added. She explained that many patients do not consider anything that they can procure without a prescription to be a medication.

However, both acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with end-organ toxicity and increased danger, particularly in the frail elderly population. Physicians readily prescribe those drugs, but are very concerned about prescribing a category of medications that, literally, patients can take for 20 years without a threat of end-organ toxicity (if properly dosed and administered). There is a need to balance what the speaker called “social opioid therapy” with the medical realities of appropriate prescribing. Balance is also needed between the risks and benefits of treatments, including nondrug interventions for older patients. An evaluation of mental status at baseline is essential. “If we do a good job at the initial assessment,” Dr. Stein stated, “we actually make our lives as clinicians much easier because we figure out very quickly for our individual patients what items of either ADLs (activities of daily living) or IADLs (instrumental activities of daily living) are impacted by increases in pain. We also need to know a history of previous side effects with medications, such as constipation and impaction. I’ve had more good pain regimens fail because of hospitalization for impaction. So I work with nurses constantly to make sure that this is under control before even thinking about adding a medication that could make it worse,” she said. Dr. Stein referred to two studies in regard to the validity of pain complaints by cognitively impaired patients.

Patricia Parmelee and colleagues,¹ at the Philadelphia Geriatric Institute, followed a group of mildly to moderately impaired patients as their dementia increased over time. The researchers found that when patients complained of pain, their complaints were indeed real, but as their dementia progressed, they became poorer reporters of pain. The second study was conducted by Ferrell and associates² on patients with moderate to severe cognitive impairment in 10 various Los Angeles nursing homes. The investigators found that often, patients could make their needs known in qualitative if not quantitative ways; 83% of them could complete at least one of five standardized assessment tools that were presented, and 35% of them could complete all five. The clinician needs to determine what tool works best with which patient, Dr. Stein said, and have each member of the team apply the same tool, documenting it in the patient record and passing along the information.

Following those studies, some work was done by Kovach and colleagues³ in Wisconsin involving several nursing homes. Dr. Stein expressed that this was a step forward into empiric trials of pain medication. The nursing staffs were educated to perform physical assessment and to look through patient charts when there were changes from underlying baseline behavior, as nurses are well aware of what is normal for a particular patient in a dementia unit. “Seeing changes from baseline mental status is perhaps our greatest clue for a potential pain problem,” Dr. Stein reiterated. Regarding prescribing medication, a number of tools to aid physicians are already in existence.

The three-step World Health Organization analgesic ladder⁴ starts with nonopioid analgesics, with or without appropriate adjuvant drugs, all of which have dose ceilings when pain persists or worsens; next, opioids should be used for moderate pain, all but one of which also have dose ceilings; finally, there are Step-3 opioids for severe pain. “For those of us who do a lot of end-of-life work, it really makes little sense to start at Step 2 (for the most part, combination opioids) when we know that the patient is going to have increasing pain needs over time. It may make more sense to go directly to low-dose Step 3 opioids,” Dr. Stein recommended. “I think it is always important that, as geriatricians, we give just what is required and no more,” she advised. “If we can give one drug for two or three purposes, that’s even better.”

It is also important that adequate trials be given to medications before switching. There is a tendency to make changes quickly, and, particularly in a population with decreased hepatic metabolism and renal clearance, abrupt changes can create an even worse mix and a potential for delirium. One good aspect of getting older is that you get “a bigger bang for the buck” when a drug lasts longer, said Dr. Stein. Many of the studies do not address the effect of drugs on the central nervous system (CNS), or the fact that some NSAIDs can actually lead to delirium-type symptoms in older persons. Most of the literature promotes the use of NSAIDs on a short-term basis for acute inflammatory processes, and the use of more “gero-friendly” drugs, such as the salicylates teamed with misoprostol or a cyclooxygenase-2 inhibitor. “We need to remember not just the GI (gastrointestinal) effects and renal effects, but the potential for CNS side effects,” the speaker reminded. Dr. Stein concluded with this thought: “Many of us truly practice from primary care geriatrics to the last breath of life, and that’s the unusual and wonderful part of the work that we do everyday. We can do 10 years of wonderful geriatric care with patients, transitioning them from one setting to another. If in the last days and hours of life we fail to do effective symptom management, that’s what the family takes away with them, and it affects not only their memories of their family members, but how they themselves view aging, end of life, and perhaps long-term care.”

References

1. Parmelee PA, Smith B, Katz IR. Pain complaints and cognitive status among elderly institution residents. J Am Geriatr Soc 1993;41(5):517-522.

2. Ferrell BA, Ferrell BR, Rivera L. Pain in cognitively impaired nursing home patients. J Pain Symptom Manage 1995;10(8): 591-598.

3. Kovach CR, Griffie J, Muchka S, et al. Nurses’ perceptions of pain assessment and treatment in the cognitively impaired elderly: It’s not a guessing game. Clin Nurse Spec 2000;14(5): 215-220.

4. Ventafridda V, Saita L, Ripamonti C, De Conno F. WHO guidelines for the use of analgesics in cancer pain. Int J Tissue React 1985;7(1):93-96.