Fear of addiction and a lack of understanding of the scope of pain management are the biggest obstacles to optimal pain relief, says Denice Economou, RN, MN, CNS, AOCN, senior research specialist and project director for survivorship education for quality cancer care at the City of Hope in Duarte, California.
Ms Economou is a founding board member of the Southern California Cancer Pain Initiative. She lectures frequently on pain management, palliative care, and end-of-life pain management issues, and did so at the Oncology Nursing Society 35th Annual Congress held May 13 to 16 in San Diego, California.
Ms. Economou spoke with Medscape Nurses about current challenges in the field of pain management, with an emphasis on the psychological aspects.
Medscape: Pain specialists have been trying for years to educate clinicians on how best to manage pain, yet many patients still seem to suffer needlessly. Why?
Ms. Economou: The two biggest barriers to good pain management by healthcare providers are fear of addiction and not understanding what pain management consists of.
Healthcare professionals are still afraid to manage pain. At the City of Hope, we have trained thousands of nurses in pain management over the years, but the problem is that nurses can't manage pain alone. They have to have a physician write the orders.
For years, physicians never had a course in how to manage pain. That has changed in many places. A lot of medical schools now have pain management courses, and younger physicians have become more interested in managing it, but the pendulum has swung back now to fear of addiction. Also, many physicians still don't realize that there is more to pain management than giving a shot of Demerol. Pain management is multimodal and multidisciplinary. It includes physical, psychological, social, and even spiritual management. That is the model we use at City of Hope. When you realize that pain interacts or interferes with function in every one of those areas, you see that effective pain management requires more than just a physician or nurse.
Medscape: Can you describe the multimodal approach?
Ms. Economou: We use adjuvant medications, such as nonsteroidal anti-inflammatory drugs and muscle relaxants; we use nonpharmacological therapies such as heat and cold; and we address psychosocial issues. I often ask my patients, "What am I treating: is it pain, is it anxiety, is it depression?" Because if I'm treating anxiety or depression, opiates aren't the right drug. I need to understand what their pain is.
That's why it's so important to get patients to use the 0 to 10 scale so they can communicate their pain to us. If someone says, "my pain's at 11", then I know he's in horrific pain. If he just says, "my pain is really bad," I don't know what that means.
Doctors, for their part, have to understand that it's no longer enough simply to order 10 mg of morphine subcutaneously every 3 to 4 hours. That's not pain management.
Communication is key for nurses also. They need to be able to say to the doctor: "The patient's rating their pain an 8 out of 10. They say the pain is in the right lower quadrant. It feels achy. It's continuous. If I give them a shot, it goes down to a 6." In other words, give the doctor information so he or she can determine the cause or the source of the pain, because it's better to treat the source of the pain than to throw medication at something without trying to figure our why it's so uncomfortable.
A few years ago, we had a patient who had a cast on his leg and kept complaining of pain. We kept giving him medication, which made him drowsy, but he still complained of the pain, and so finally we cut the cast off and sure enough, there was a piece of the cast material that had somehow broken off and was sticking into his leg, so of course he was in pain; he didn't need opiates. It's important for us as healthcare professionals to think about what we're doing, know what it is that we're treating, and be sure we are using the right intervention.
We also have to think about our choice of words. Words can mean different things to people of different ages or from different cultures. For example, you can ask someone if they're in pain and they'll say no, but if you ask if they're uncomfortable, they'll say yes. Or they may deny feeling pain, but if you ask whether they're walking, sleeping, or eating as usual, they'll say no, which is an indication that they are in fact in pain.
Medscape: The concept of suffering implies that there is a psychological and a physical component to pain.
Ms. Economou: We often ask patients, "What does this pain mean to you?" Some people suffer with cancer pain because they believe it is penance for something they did when they were younger. One man didn't want pain management because he felt he needed to suffer for having cheated on his wife. I explained that that wasn't really what God wanted for him, and eventually he allowed us to treat his pain and dealt with his guilt separately, which relieved a lot of his suffering. But this story illustrates the psychological implications of physical pain.
Medscape: Some clinicians are reluctant to treat pain too aggressively for fear that the patient will become or remain addicted. How do you feel about that?
Ms. Economou: There are definitely patients who are addicts — and there are addicts who are in pain. We can't not medicate someone just because they have a history of drug addiction but now have lung or breast cancer with bone metastases, which we know cause pain. One of my patients who was on methadone maintenance had undergone radiation treatment for breast cancer and had been burned, so she had excruciating topical pain. Fortunately for her, we could see the source of her pain, and we could see the burns healing, so we could back down on the medications when it became appropriate. We were able to manage her cancer pain while keeping her on her methadone maintenance program.
Medscape: How do you deal with the problem of secondary pain?
Ms. Economou: There are people who use their pain to manipulate others, whether it's to get workers' compensation or for some other reason. That's when you've got to pull in your resources and call in the psychiatrist or the social worker to help understand the mechanisms underlying these cases beyond the physical sources of pain. Again, you treat the source of the discomfort. If the source is an emotional issue, then we get the specialists in who can help us understand it and treat it.
I once had a patient who lay in bed and moaned while her 4 children stood around her and asked what they could do for her. When her children were out of the room, I said that she didn't really seem to be in that much pain and hadn't used a lot of pain medication, and she replied, "Yes, but it's just so great to have my kids around." I have 3 sons, so I thought, I have to remember that.
Ms. Economou has disclosed no relevant financial relationships.
Norra MacReady • Medscape Medical News © 2010 Medscape, LLC