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Pain unnecessary with today's advances by Heather Woolwine Public Relations One of the most subjective experiences a person can face is pain. It’s different for everyone, whether mental, physical or emotional, and managed in different ways.   MUSC efforts during National Pain Awareness Month in September, as well as year-round, boast the underlying goal of managing and relieving as much pain from the mind, body or soul as possible.   “Pain is not necessary with today’s advanced techniques and medications,” said Sherri Stewart, R.N. and new coordinator of the Children’s Hospital pain management program. “We have put together a multidisciplinary team of physicians, child life specialists, pharmacists, psychologists, nurses, and social workers to address all aspects of pain in children with the goal of increasing communication and understanding of pediatric pain.”   Although the Children’s Hospital-specific pain management program is relatively new, two other MUSC staff members have been on the front lines for years. Winnie Hennessy, R.N., Palliative Care Program, and Rick Smith, M.D., director of MUSC’s pain clinic.   Hennessy chairs the MUSC Pain Committee, which is responsible for policies that reach across the institution. “There is so much more to pain than people, including health care professionals, realize,” she said. “It can be a disease. One of the hardest things for people who suffer from chronic pain is the social stereotype that they are complainers or drug addicts because they need help in managing their pain. There are differences among dependence, tolerance, and addiction that often are not recognized, even by health care workers.”   The difference Hennessy referred to is taught during the fundamental years of most types of health care study. Dependence means that a person’s physiology becomes so accustomed to a substance that he or she would experience withdrawal symptoms if the medication were stopped. Withdrawal (or abstinence syndrome) is not necessarily an indicator of addiction. Addiction occurs when a psychological dependence upon a substance facilitates the use of that substance for unintended purposes, and causes continued use despite the harm it causes. Tolerance describes another physiological phenomenon characterized by a decrease in the therapeutic effect of a substance given stable dosage levels, but doesn’t always indicate an addiction. Characteristics of addiction are not just characteristics of abuse of opiates but can also be manifested through other agents of abuse like food, exercise, sex, and alcohol.   “A person can become physically dependent on a substance they take for pain and still not become an addict,” Hennessey said. “They are two completely different things. If all health care professionals would remember this basic teaching and believe in it, pain management everywhere would be a much better system.”   Hennessy admits that it will take years to change an existing bias against some patients who experience chronic pain, and knows that multidisciplinary buy-in is the key.   “You have to believe what patients say, and if you don’t, then you need to self-reflect on why you don’t believe them,” she said. “If the answer is rooted in your personal views of medication or lack of experience with people who have chronic pain, then refer them to a pain specialist. Sometimes we blame the patient instead of looking at how the system works. Lots of patients have pain with no apparent cause and some physicians and nurses believe that because they can’t find it, it must not exist. That might be true 5 percent of the time. Pain is subjective and health care is a visual, objective culture. Everything health care workers do is based on objective data. If all the diagnostic testing comes back negative and we can’t objectively see what’s wrong then it must not be there. That’s not always the case. Objective data doesn’t always match the pain experience. Health care workers are faced with not believing the clinical picture or the patient, and this challenges the culture of heath care. That’s hard to deal with because we’ve all been taught to have faith in diagnostic tools no matter what.”   “If a patient says they have pain, then they have it in some form or another,” Smith said. “Pain always has a right to be addressed, but not all pain can be eliminated. Even our many state-of-the-art techniques still don’t allow elimination of all pain. Of course total elimination is a goal of ours and the field is definitely growing in terms of what we have to offer patients.”   According to Stewart, pain is whatever her patients say it is, given the proper tools to explain in the best way possible what they are feeling. Nursing staff, physicians and a variety of other disciplines work together to explain pain scales and discover behavioral indicators that determine a patient’s pain level. Behavioral indicators are especially important for young children with no verbal skills either due to age or disease progression.   “The gold standard in pediatric pain management is not relying so heavily on the physical indicators, instead using self-report, parent report, and behavioral cues to gauge pain. Adults are the same except they get numeric pain rating scales or in case of illiteracy, facial expression scales,” Stewart said.   “Even though pain measurement is subjective, it’s still valuable to the patient and a physician to say ok, I was a ten yesterday and I’m a seven today,” Smith said.     Even after clinicians agree that a patient is in pain, treatment of the pain is highly varied based on a person’s disease, symptoms, and life stage.     “In the pediatrics population there are lots of non-pharmacological measures like swaddling for infants, pacifiers, music, massage, distraction, and play therapy, and all areas depend on the type of pain and its cause,” Stewart said. “In terms of medication, there is no greater risk of an allergic reaction to medication for a child than an adult. A lot of parents fear that if a child takes a medication, specifically opiods, that their child will become addicted and that’s not really possible. They may experience withdrawal symptoms, but the chance for addiction is very slim.”   “What’s the difference between putting a patient on Zoloft, insulin, or blood pressure medication for the rest of their life versus pain medication to manage chronic pain? There’s a huge social stigma attached to opiods because of the confusion associated with dependence and addiction,” Hennessy said. “Of course that means there are many  legal and societal roadblocks to managing pain through medication in the form of opiods.”     “Overall, I think there needs to be a better understanding of medications and the best way to use them so that patients can be helped by them and physicians can prescribe them effectively,” Smith said. “Chronic pain responds best to multi-disciplinary approach including intervention procedures, medication, psychological or psychiatric treatment, physical therapy and other modalities within alternative medicine like acupuncture. In addition, it would be in the best interest of the patients if pain management were expanded within the primary care setting. “Currently, there are not enough pain specialists to handle all of the community’s need for chronic pain management, so ideally we’d like to work together with primary care physicians to help as many patients as possible.”     “I think it’s a safe assumption to say that just about all pain can be managed,” Hennessy said. “But patients must understand that what’s offered only works if they are compliant and also that some conditions are lifelong and that there will be good and bad days.”     “There are lots of options out there, but the most important thing that any patient or family member of a patient can do is to make a plan to manage the pain,” Stewart said. “Some people feel that you have to suffer or they fear discussing their pain because they don’t want to be labeled complainers or whiners. Some parents will tell their kids to just tough it out. Why? We’re here to promote a pain free environment, and that means minimizing pain in any way possible and putting people at ease about pain.” An IOP Perspective on Pain Management How is pain management different for IOP patients? Patients do not seek psychiatric care because of complaints of physical pain. Likewise, psychiatric clinicians may be less attuned to identifying pain and looking for an underlying physiological cause or referring the patient for diagnosis and treatment. Some problems such as sleep disturbance, anxiety, agitation, or fatigue may look like psychiatric symptoms but result from physical pain and vice versa. It can be a challenge to sort that out!  A patient’s psychiatric condition may serve as a barrier to effective pain management. Some patients may not be able to participate in pain screening and assessment due to the acuity of their psychiatric disorder. Their frightening delusions, hallucinations, or overwhelming depression may actually contribute to their tolerance of more pain or unwillingness to discuss the issue.  Is it difficult to manage pain with IOP patients? Psychiatric conditions may serve as barriers to effective pain management if the patient is unable or unwilling to participate in pain screening and assessment. Education of clinicians about the prevalence of pain in this population has been a significant accomplishment.  The notion of addiction is another issue.  Patients may seek professional help to decrease or stop the use of analgesics, and clinicians may have concerns about risking addiction by prescribing and administering certain pain relievers. What has the IOP done to become more pain aware? IOP staff became involved with the MUSC Pain Committee to give the IOP an identified place in the Pain Management organizational structure. IOP leadership drafted the IOP section of the MUHA pain policy which specifies how and when behavioral health patients are screened and assessed for pain. Pain screening was introduced as the 5th vital sign so that patients are asked if they are experiencing any discomfort when their other vital signs are taken.  IOP staff have been trained during orientation when first hired, as well as annually through competency verification. We created a flow sheet on which nursing staff document pain screening and assessment, a novel addition to the behavioral health patient chart. Submitted by Gene Boyd, Institute of Psychiatry   Friday, Sept. 2, 2005 Catalyst Online is published weekly, updated as needed and improved from time to time by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. Catalyst Online editor, Kim Draughn, can be reached at 792-4107 or by email, catalyst@musc.edu. Editorial copy can be submitted to Catalyst Online and to The Catalyst in print by fax, 792-6723, or by email to petersnd@musc.edu or catalyst@musc.edu. To place an ad in The Catalyst hardcopy, call Community Press at 849-1778.