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Pain management

Copyright © 2006 Society of Hospital Medicine

Pain, defined by International Association for the Study of Pain (IASP), as an unpleasant experience associated with actual or potential tissue damage to a person's body, is a very common presenting or accompanying symptom of hospitalized patients. Pain management involves utilizing various modalities to alleviate suffering and restore patient function. Proper assessment and treatment of pain can improve clinical outcomes, discharge planning and patient and family satisfaction. Pain management of inpatients necessitates understanding the various mechanisms that cause pain, properties of analgesic pharmacological and non‐pharmacological modalities, as well as the accurate assessment of severity and treatment response. Hospitalists assess and manage patients experiencing pain. This role encompasses empathy, clinical excellence, and understanding of the myriad obstacles, cautions and specific knowledge, skills and attitudes necessary for appropriate pain management. Hospitalists serve as leaders of multidisciplinary teams to develop policies and protocols to improve pain management in their health care system.

KNOWLEDGE

Hospitalists should be able to:

  • Describe the mechanisms that cause pain.

  • Describe the symptoms and signs of pain.

  • Differentiate acute, chronic, somatic, neuropathic, referred and visceral pain syndromes.

  • Differentiate tolerance, dependence, addiction and pseudo‐addiction.

  • Describe the value and limitations of the physical examination and various validated pain intensity assessment scales.

  • Explain the relationship between physical, cultural and psychological factors and pain and pain thresholds.

  • Discuss the genetic, social, and psychological factors that may contribute to opioid addiction.

  • Explain the indications and limitations of non‐pharmacological methods of pain control available in the inpatient setting.

  • Explain the indications and limitations of non‐opioids including acetaminophen, nonsteroidal anti‐inflammatory drugs (NSAIDs), and topical agents.

  • Explain the indications and limitations of opioid pharmacotherapy.

  • Explain the indications and limitations of other analgesics including, tramadol, tricyclic agents and anti‐epileptic medications in the treatment of various pain syndromes.

  • Describe specific factors that affect dosing regimes, such as drug half‐life, renal and hepatic function.

  • Establish functional criteria for discharge.

SKILLS

Hospitalists should be able to:

  • Elicit a detailed history and description of pain and review the medical record to determine likely source and acuity of pain.

  • Review patient pharmacologic and psychosocial history and identify factors contributing to pain or factors that might impact its management.

  • Conduct a physical examination to determine the likely source of pain.

  • Order and interpret diagnostic studies to determine the source of pain when underlying acute illness is suspected.

  • Assess pain severity using validated measurement tools.

  • Formulate an initial pain management plan.

  • Determine appropriate route, dosing and frequency for pharmacologic agents based on patient‐specific factors.

  • Reassess pain severity and determine the need for escalating therapy and/or adjuvant therapies.

  • Determine equianalgesic dosing for pharmacologic therapy when needed.

  • Titrate short and long acting narcotics to desired effect.

  • Predict and counteract as needed expected analgesic side effects, including use of reversal and specific agents, especially in elderly.

  • Initiate appropriate therapies to prevent and treat constipation when using opioid analgesics.

  • Anticipate and manage side effects of pain medications including respiratory depression and sedation, nausea, vomiting and pruritis.

  • Assess and communicate need for pain management during medical consultation.

ATTITUDES

Hospitalists should be able to:

  • Promote the ethical imperative of frequent pain assessment and adequate control.

  • Appreciate that all pain is subjective and acknowledge patients' self‐reports of pain.

  • Appreciate the value of patient controlled analgesia.

  • Discuss with patients and families the goals for pain management strategies and functional status, and set targets for pain control.

  • Recognize indications for specialty consultation, which may include pain service, anesthesiology, and physical and rehabilitation medicine.

  • Employ a multidisciplinary approach to the assessment and management of patients with pain that begins on admission and continues through all care transitions.

  • Educate patients and physicians on the importance of appropriate use of opioids in pain management and explain the rarity of opioid addiction in the setting of appropriate pain management.

  • Establish and maintain an open dialogue with patients and families regarding care goals and limitations, which may include palliative care and end‐of‐life wishes.

  • Address resuscitation status early during hospital stay; implement end‐of‐life decisions by patient and/or family when indicated or desired.

  • Document treatment plan and discharge instructions, and communicate with the outpatient clinician responsible for follow‐up.

  • Provide and coordinate resources to patients to ensure safe transition from the hospital to arranged follow‐up care.

  • Utilize evidence based recommendations, including the World Health Organization (WHO) step approach to pain management.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, Hospitalists should:

  • Lead, coordinate, or participate in efforts to develop educational modules, order sets, and/or pathways that facilitate effective pain management in the hospital setting, with goals of improving outcomes and patient satisfaction, decreasing length of stay, and reducing re‐hospitalization rates.

  • Lead, coordinate or participate in efforts to measure quality of inpatient pain control and operationalize system improvements and reduction of barriers to adequate pain control

  • Lead, coordinate or participate in efforts to establish or support existing multidisciplinary pain control teams.

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