Improving pain management: Call to action

Pain management has come a long way since Florence Nightingale witnessed the horrors of battlefield surgery. Yet many nurses believe it hasn’t advanced far enough. Nursing pain management experts and nurse leaders who gathered at the American Nurses Association’s (ANA’s) national House of Delegates (HOD) meeting this summer are promoting an agenda that aims to improve management of both chronic and acute pain.

The state of pain

At the HOD, nurse leaders resoundingly passed the “Improving Pain Management” resolution written by Dorothy Stratman-Lucey, MSN, RN, BC, PNP, president of Illinois Nurses Association’s (INA) District 10. In the report accompanying the resolution, Lucey pointed out that at least 70 million Americans live with persistent pain and 50% to 75% of patients die in moderate to severe pain.

“Pain is epidemic across our country,” says Lucey, pain management coordinator and anesthesia nurse practitioner at Shriners Hospital for Children in St. Louis, Mo. “Relieving patients’ pain is something all nurses need to be passionate about. Yet, while evidence-based research on pain management has increased over the years, the knowledge base of most physicians, nurses, and even consumers has not.”

As a result, changes in health practices haven’t kept pace—and this leads many patients to believe no effective pain strategies exist. Lucey relates a recent encounter with an acquaintance who told her she’d been suffering with cervical pain for 20 years. “No one was empowering her to even ask for better pain management, let alone provide her with effective relief,” Lucey says. “This scenario is being repeated across the United States. Because of untreated, undertreated, or inappropriately treated pain, the elderly have no quality of life and people are dying in excruciating pain.”

When the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) added pain assessment and management standards in 2001, Lucey thought pain management would take a big step forward nationwide. “But assessment hasn’t often led to action,” she says.
INA member Joan Wentz, MSN, RN, believes the JCAHO standards have helped somewhat. “Change has been slow, but we have to start somewhere,” she says. She believes the hospice and palliative care programs that surged in the mid-1990s have helped push the pain management agenda.

“Every person—from birth to death—will experience pain,” says Wentz, a former assistant professor at Barnes-Jewish Hospital College of Nursing and Allied Health in St. Louis. “And I believe most nurses and physicians don’t want patients to be in pain unnecessarily. But they need to be aware of what they can do for their patients. Pain management is every nurse’s responsibility. It’s incumbent upon nurses to get more information about pain management and not rely on on-the-job training from colleagues that may be outdated.”

“Nurses have long been taught that pain is a symptom, not a disease in and of itself,” states Wentz. For example, when clinicians see a diabetic patient with a foot ulcer, they often assume the pain is a byproduct of the ulcer. However, the pain may be neuropathic and needs to be treated in a specific way.

One obstacle to effective pain management centers on a misconception about pain medication addiction that some physicians, nurses, and patients hold to this day. “Many still define dependency and addiction the same way, though they are vastly different,” Lucey says.

Placebos and pain interventions

Wentz believes healthcare facilities should adopt policies that prevent placebo use. “That says we don’t believe a patient is actually experiencing pain,” she asserts. She also contends that p.r.n. analgesic orders are ineffective for maintaining therapeutic drug levels.

Lucey points out that a range of pain interventions exists today. Treatments include physical and occupational therapy (such as myofascial releases and craniosacral work), medications, external and internal stimulators, and interthecal pumps and other high-tech approaches. “Nurses and physicians aren’t always taught how to differentiate among types of pain, as well as the newer treatment therapies, to even order the correct pain management regimen,” Lucey says.

State regulations and “DEA paranoia”

Another barrier to effective pain management centers on state regulations that prevent advanced practice registered nurses (APRNs) from prescribing controlled substances. (Some states allow APRNs to prescribe Schedule II and III controlled substances, while others don’t.) In some communities, APRNs serve as primary care providers; if state regulations restrict them from prescribing scheduled drugs, adequate pain management may be sorely lacking.
Another obstacle is paranoia about the Drug Enforcement Administration (DEA), which has investigated clinicians who prescribe and administer opioids. Though only a tiny fraction of nurses have been disciplined for improperly prescribing or administering controlled substances for pain control, many worry about excessive regulatory or legal scrutiny, according to Cynthia Haney, JD, a senior policy fellow in ANA’s Department of Practice and Policy. The result is “a chilling effect on appropriate prescribing that has led to patient suffering—especially in chronic care and hospice settings.”

Progress in pain management and education took a step backward in 2004 when the DEA abruptly withdrew from its website an interdisciplinary educational document to guide healthcare professionals and law enforcement personnel on appropriate management and regulation of prescription pain medications. The document resulted from years of collaboration and negotiation among the DEA and pain management, hospice, and palliative care groups seeking to balance effective pain management with law enforcement’s concerns about addiction and drug diversion.

“It had the potential to be a powerful educational tool for healthcare professionals and law enforcement alike,” Haney says. “But it was removed reportedly because it was at odds with the more traditional hard-line law enforcement approach favored by then-Attorney General John Ashcroft.”

Some observers believe the DEA may be reviewing some of its restrictions. One proposed rule change would allow practitioners to write sequential prescriptions for Schedule II drugs.

Strategies and support

In passing the HOD resolution, nurse leaders asked ANA to promote several strategies, including support for:

• consumer and professional education on pain management
• legislative and regulatory authority for APRNs to prescribe controlled substances
• measures to ensure that nurses who appropriately prescribe or administer controlled substances to relieve pain aren’t subject to criminal prosecution or excessive regulatory scrutiny
• primacy of pain management over the fear of addiction when prescribing or administering controlled substances.

ANA also collaborated with the American Society for Pain Management Nursing (ASPMN) to release “Pain Management Nursing: Scope and Standards of Practice.” This publication, along with the “ANA Pain Management Certification Resource Package,” is available from ANA’s publishing arm at www.nursesbooks.org.

The American Nurses Credentialing Center (ANCC), ANA’s credentialing arm, also developed a certification exam on pain management in conjunction with ASPMN. The exam is intended to allow nurses at the generalist level to demonstrate competence in managing patients with pain. It has been administered three times since October 2005. So far, more than 575 nurses are certified in pain management, with 250 more potentially eligible pending recent exam results.

ANA also is advocating for pain care policy in the larger context of healthcare system reform. After months of gathering expert and public opinion, the congressionally authorized Citizens’ Health Care Working Group included a recommendation that focuses on end-of-life pain and palliative care. ANA strongly supports this initiative and will continue to promote expanded research and education on pain and palliative care—as well as access to these services—as the U.S. Congress evaluates the Working Group’s recommendations.

If you wish to get involved in state pain initiatives, visit the website of the American Alliance of Cancer Pain Initiatives (www.aacpi.wisc.edu). For additional information and to join the pain management movement through the “Power Over Pain” campaign, visit http://www.poweroverpaincampaign.org/. For ASPMN resources, go to www.aspmn.org.

Susan Trossman, RN, is the senior reporter in ANA’s Communications Department.

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