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Changing
Pain-Management Methods Bring Greater Relief
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Thursday,
June 13, 2002 |
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BY
TROY GOODMAN
THE SALT LAKE TRIBUNE
It's barely 8 a.m. at
University Hospital, and pain-management doctor
Jeffrey Swensen has been in high gear for hours.
He started his shift overnight with a call to
help with a gunshot trauma. At 2 a.m. he
answered another digital pager call to reinject
a bone-surgery patient whose pain drug was
starting to wear off.
As his shift ends in the
morning, Swensen visits with several post-op
patients in their rooms. He also stops by to
check on the pain levels of a double-lung
transplant recipient who, with nursing help, can
slowly sit upright and tell visitors he is
feeling "OK."
Swensen says with this type
of urgent surgical procedure, the
lung-transplant patient is lucky to be moving
and staying awake without mind-numbing
narcotics. A few months ago, before his team of
post-op pain-care experts started making the
rounds, the anesthesiology service was less
patient-sensitive and ran a greater risk of
leaving someone prostrate during recovery with
severe soreness and aches.
"This is a major change
from the way things have been done in the
past," Swensen says, amazed at the
transplantee's cheery demeanor. "The fact
that he looks and feels this good is
amazing."
Patients with such acute
pain, routinely undertreated in the past, have
begun to get adequate relief thanks to major
changes in the way medical experts focus on
post-op and long-term recovery. Better drugs,
more training and new practices are only part of
the solution.
There also is a change in the
mindset among doctors and the nonmedical
community about tackling pain, says Bruce
Ferrell, of the University of California at Los
Angeles School of Medicine. He sees a vanishing
-- and wrong-headed -- stereotyping of whiny,
malingering patients replaced by doctors paying
close attention to every ache and groan.
"I get a lot of calls
from nursing homes where people want to know,
'Is this person in pain? I can't tell,' "
Ferrell says, applauding such pain awareness.
Untreated suffering is still
a major health-care crisis in this country. More
than 50 million Americans suffer from chronic
pain caused by various diseases and disorders,
and each year an additional 25 million
experience acute pain as a result of injury or
surgery, according to the nonprofit American
Pain Foundation.
Expanding on the new
awareness, Swensen, who also serves as the U.'s
director of cardiothoracic anesthesia, began in
February with a five-person team of doctors,
medical residents and nurse practitioners. The
team members perform and monitor most of the
hospital's targeted anesthetic shots, dubbed
"blocks," along with epidurals and
general anesthesia cases.
They also stay on top of the
latest in pain drugs and medicine-delivery
systems, reading and writing clinical studies on
needles or new below-the-skin injections of
anesthesia that could triple duration times.
For aging patients,
especially those considered "chronic
pain" sufferers, the American Geriatrics
Society recently released new pain-management
guidelines. The recommendations are geared
toward the aged, including those with
Alzheimer's and other cognitive diseases.
"Most importantly for
all older patients," the New York-based
geriatrics group said, "is the panel's
admonition to clinicians that pain not be
associated with aging, and that no patient be
given a placebo for pain." Society members
also repeated an earlier statement in favor of
opioid treatments for severe pain, including the
controversial morphine-like drug OxyContin.
Abuse of the OxyContin drug
has slowed pain-management advancements over the
past year, several doctors say, because
addiction cases appeared in concert with a broad
crackdown on painkillers. In
Utah, the case of Robert Weitzel has
sensationalized the use of morphine to aid the
terminally ill.
Weitzel is a psychiatrist
charged in the 1995 deaths of five geriatric
patients via morphine overdoses; the homicide
case against him is scheduled to begin later
this year.
Weitzel defends his
actions, saying he prescribed morphine as
"comfort care" to patients who were at
death's door when they were admitted to his
geriatric/psychiatric unit at the Davis Hospital
and Medical Center in Layton.
Morphine and Demerol are
still regularly used, but local and national
medical coalitions have used the Utah case, and
others like it, to ask the question: Why is it
so tough to get routine pain assessments and
tailored anesthesias or other treatments through
pills rather than shots?
"Doctors are very
stressed for time," Swensen offers as
explanation. Also, few physicians receive any
formal training in pain management and
managed-care groups are loath to hire pain
specialists for their patients.
To help with the renewed
awareness, the American Pain Foundation and the
geriatric group have issued a set of questions
that doctors can use to interview patients,
including such basics as, "How often [over
the past week] has pain interfered with your
ability to take care of yourself?"
There also are intensity
scales and behavior descriptions to help assess
patients who can't describe their suffering, for
whatever reason, to their doctor in their own
words.
18 Experts recommend writing
down information about your pain, what helps to
ease it, and bring this written information to
your doctor or clinic appointment. Suggested
self-questions:
Where and how does your pain
hurt? Does it move from one place to another?
Tell exactly how the pain feels. Does it feel
like it's on the inside of your body, or does it
seem like it is on the outside? Point to the
places that hurt and draw an outline of a body
to show others.
When does the pain happen?
How long does it last? Does the pain come and
go, or is it there all the time? Have you ever
had this pain before? Describe when it begins
and usually ends and talk about activities,
daily goals it keeps you from accomplishing.
What do you think causes the
pain? It's not always true that pain means a
cancer is spreading or has recurred. Pain may be
caused by constipation, not moving around as
much as usual, or other reasons not related to
your disease or surgery. Your doctor and
caregivers need to know what you think is
happening, then let them worry about looking for
the pain's root cause.
How are you currently taking
medications to relieve pain? Sometimes
ineffective medications might work better if
they are taken in a different way. Describe
exactly how and when you take drugs now. Your
doctor or nurse needs to know if the way you are
taking medicine is different from the
instructions on the bottle.
How long does pain relief
last? Does all of the pain go away after you
take the medicine or does it return before the
next dose?
Do you have any side effects
from medicines you are taking? Medicines for
severe pain cause constipation, so expect to be
asked about bowel movements at each visit.
Discuss your allergies to medicines and other
things. Describe how the allergy showed itself
and when you first noticed it.
Do you have any concerns
about taking medicines for pain? Many people
worry unnecessarily about taking medicines,
especially narcotics or opiates, for pain
relief. Remember, addiction rarely occurs in
people taking medicines specifically for pain,
yet many people take less than the needed dose
because of drug fears.
What is your goal for pain
relief? You may be asked to set a goal (for
example, two on a scale of zero-to-10) of daily
comfort. Also, consider goals focused on
activities you would like to carry out --
walking without pain, being able to work again,
etc.
o
Words to Describe Pain:
Aching
Sharp
Dull
Burning
Crushing
Pins and needles
Sore
Stabbing
Prickling
Pounding
Throbbing
Shooting
Crampy
Knotlike
Deep
On the surface
Pressing
Stretching
Tight
Pinching
Tender
Electric
Pulsing
Gnawing
-- Source: American Pain
Foundation
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