October 6, 2001
Try HAMSTER for pain management
BY COREY NASON REESE
Nine out of 10 Americans over the age of 18 report suffering from some kind of pain at least once a month, and 42 percent of them report experiencing pain every day, family physician Penny Tenzer, M.D., said Thursday.
"A substantial number of these patients either do not report their pain or never receive the proper treatment," said Tenzer.
She is an assistant professor in the family medicine and community health department of the University of Miami in Florida and directs the family practice residency affiliated with the university. She and psychologist Heidi Stanley, Ph.D., director of behavioral science in the department, presented HAMSTER, a systematic approach they created for helping a patient with chronic nonmalignant pain.
The steps in this approach: History, Assessment of pain, determination of the Mechanism of pain, evaluation of Social and psychological factors, Treatment, Education and Reassessment.
For the history and pain assessment, Tenzer recommended using severity scales in which one represents very minor pain and 10 identifies extremely severe pain. Research shows the single most reliable indicator of the existence and intensity of acute pain is the patient's self-report.
Patients' descriptions of pain are determined by their beliefs about their pain, Stanley said. She discussed the social and psychological factors of pain -- the anger, depression and anxiety associated with pain.
"Pain beliefs are associated with greater physical disability and depression in chronic pain patients. In the cognitive behavioral model, thoughts create feelings, and that can indirectly affect our pain protection," Stanley said.
Discussing treatment, Tenzer focused on medication, using the World Health Organization's stepladder of pain management. The first tier involves nonopioid analgesics; the next tier consists of weak opioids; and the third tier has strong opioids, such as morphine, methadone or fentanyl.
Pharmacological adjuvants can include antidepressants, anticonvulsants, anxiolytics and topical agents. Nonpharmacological adjuvants such as physical therapy, massage and acupuncture can also be helpful, said the presenters.
Tenzer addressed the recent OxyContin abuse controversy and said the highest dosage had been removed from the formulary. "The real problem is addiction," she said. "In and of itself, OxyContin is not a bad drug. We need to look closer at addiction rather than the specific medication. If it's not OxyContin, it may be another medication."
Often patients with chronic pain feel a loss of control over every area of their lives, including their thinking, feeling, spiritual life, occupation and relationships, Stanley said.
"The loss of control may actually make the pain worse. Our goal is to restore a sense of control and calm to the patient. One way is with cognitive behavioral therapy," Stanley explained. "This encourages patients to change the thought processes from anxiety-producing thoughts to more balanced thoughts in order to help lower their levels of anxiety or anger."
She also discussed relaxation, deep diaphragmatic breathing, hypnosis, biofeedback, acupuncture, physical therapy, spirituality and family therapy.
"One of the greatest fears for these patients with chronic pain is that you they'll be in pain and won't be able to get to you," Tenzer said. "I'd encourage you to commit to them to be there."
FP Report is published by the AAFP News Department.
Copyright © 2001 by American Academy of Family Physicians.
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