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FP Report
March 2001 • Volume 7 • Number 3

Pain, pain, go away

How new pain standards impact FPs

BY SHERI PORTER

"Pain can be beneficial; it can warn us something is wrong with our bodies. But when it persists, it has no redeeming virtues. None!" So said June Dahl, Ph.D., a professor of pharmacology at the University of Wisconsin-Madison. She spent two years working with the Joint Commission on Accreditation of Healthcare Organizations to develop the new Pain Standards for 2001 (see box). It was Dahl who initially brought the issue to the JCAHO table.

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The new standards, which took effect Jan. 1, apply to JCAHO-accredited hospitals and health care facilities. The standards call on these facilities to ensure that pain is assessed and managed appropriately. The JCAHO accredits 80 percent of the nation's hospitals, which account for 96 percent of inpatient admissions.

"Pain now has become a major issue," Dahl said. "Look at the media attention. It's put pain on every hospital's radar screen. "

As it should be, she said. "Undertreated pain is a major public health problem. It's more than an unpleasant sensation -- it adversely affects our bodies and our minds."

And pain is costing the United States plenty -- more than $100 billion annually in health care costs and lost productivity.

Richard Brown, M.D., associate professor in the family medicine department at the University of Wisconsin-Madison, said he hopes the new focus on pain management will evoke a positive change in practice patterns for FPs. Brown has traveled the country conducting seminars on pain-related topics for health care professionals.

"I think FPs vastly underrecognize and undertreat chronic pain. I hope these standards sensitize more FPs to ask patients more frequently about their pain and lead them to prescribe appropriately," he said.

Pain management practices of the past need updating, said Brown. And one area ripe for reform is education.

"We're not well-trained in pain assessment. We're not well-trained in pain management," said Brown. "Many issues in pain management overlap with addiction medicine, and we're not well-trained in that, either."

Excerpts from JCAHO standards*

  • Patients have the right to appropriate assessment and management of pain.
  • Pain is assessed in all patients.
  • Policies and procedures support safe medication prescription or ordering.
  • The patient is monitored during the post-procedure period.
  • Patients are educated about pain and managing pain as part of treatment, as appropriate.
  • The discharge process provides for continuing care based upon the patient's assessed needs at the time of discharge.
  • The health care organization addresses care at the end of life.
  • The organization collects data to monitor its performance.

Go to http://www.jcaho.org/standard/pm.html for these standards, explanations of their intent and examples of implementation.

Some initial basic education in a standard CME format is imperative, said Brown. But he doesn't think pain training should stop there.

In the seminars he's led, audience responses have been revealing.

"I'm aware sometimes at the end of my talks that physicians feel motivated to try the kind of opioid prescribing that I'm recommending, but they feel they won't have anyone to turn to, to ask the questions that inevitably will come up," said Brown.

He envisions a national resource network of knowledgeable pain experts available for phone consultations. He would also like to see the Academy develop a pain management kit with flowsheets, patient contracts and clinical algorithms.

Paul Van Gorp, M.D., of Long Prairie, Minn., chair of the AAFP Commission on Quality and Scope of Practice, serves on a JCAHO professional and technical advisory committee. Van Gorp said the new standards will help practitioners think of pain assessment "almost like another vital sign measurement."

Van Gorp reports a positive trend already occurring in his state: a new awareness of the appropriateness of opioid analgesic prescription. "This will be an important factor in improving pain control, because many practitioners have been downright afraid to use controlled substances in adequate doses for fear of reprisal or investigation by their board of medical examiners," Van Gorp said.

But Van Gorp voiced a concern as well. "Some patients just don't need a pain assessment; to assess every patient's pain would sometimes be a waste of time."

Another issue was raised by John Beasley, M.D., professor of family medicine at the University of Wisconsin-Madison.

"All patient health issues are worthwhile -- but as soon as you get into mandating one specific thing, you're saying this is more important than everything else," Beasley said. "This is just one more issue to add to the complexity of the agenda for primary care physicians."

Michael Ashburn, M.D., president of the American Pain Society, based in Glenview, Ill., said growing scientific evidence shows that treatment of a patient's pain, as well as the underlying disease, is important to the patient's survival.

"Our patients tell us this is important," said Ashburn, a professor of anesthesiology and medical director of the pain management programs at the University of Utah Health Sciences Center and the Primary Children's Medical Center in Salt Lake City.

"These standards are more than just writing a new policy," said Ashburn. "They're about implementing a system-wide change to address the needs of people with pain. That's a huge task."

Read more about pain at these Web sites

FP Report is published by the AAFP News Department.
Copyright © 2001 by American Academy of Family Physicians.

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