Pain is a very common presenting or accompanying symptom in hospitalized patients. Pain management relies on the use of 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. Managing pain in inpatients necessitates understanding the various mechanisms that cause pain, properties of analgesic pharmacologic and nonpharmacologic modalities, and accurate assessment of severity and treatment response. Hospitalists assess and manage patients experiencing pain. This role requires that hospitalists be aware of current issues and controversies in pain management. Opioid therapy, for example, is a well-established approach for treating severe acute pain and cancer-related pain, and opioids are the most commonly prescribed drug class in the United States.1 However, the continued increase in opioid prescription coincides with an increased number of poisoning deaths. Poisoning deaths involving opioid analgesics have more than tripled since 1999.2,3 To best manage patients’ pain, hospitalists must demonstrate empathy, clinical excellence, and an understanding of the myriad obstacles, cautions, 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 healthcare system.
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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 pseudoaddiction.
Describe the value and limitations of the physical examination and various validated pain intensity assessment scales.
Recognize indications for specialty consultation, which may include pain service, anesthesiology, and physical and rehabilitation medicine.
Explain the relationship among physical, cultural, and psychological factors and pain and pain thresholds.
Describe the indications and limitations of opioid pharmacotherapy.
Discuss the genetic, social, and psychological factors that may contribute to opioid addiction.
Describe the indications and limitations of other analgesics including tramadol, tricyclic agents, and anticonvulsant medications in the treatment of various pain syndromes.
Describe the indications and limitations of nonopioids including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and topical agents.
Describe specific factors that affect dosing regimens such as drug half-life, renal function, and hepatic function.
Describe the indications and limitations of nonpharmacologic methods of pain control available in the inpatient setting.
Establish functional criteria for discharge.
Hospitalists should be able to:
Elicit a thorough and relevant history and description of pain and review the medical record to determine the likely source and acuity of pain.
Review patient pharmacologic and psychosocial history and identify factors contributing to pain or factors that might affect its management.
Perform 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 the appropriate route, dosage, and frequency of dosing for pharmacologic agents on the basis of 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 opioids to desired effect.
Predict and counteract as needed expected analgesic adverse effects, including use of reversal and specific agents, especially in older patients.
Anticipate and manage adverse effects of pain medications including respiratory depression and sedation, nausea, vomiting, and pruritis.
Initiate appropriate therapies to prevent and treat constipation when a patient is taking opioid analgesics.
Assess and communicate the need for pain management during medical consultation.
Recognize the signs and symptoms of addiction and assess patients for prescription drug abuse when appropriate.
Educate patients on the adverse effects of prescription drug abuse.
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.
Document treatment plans, provide clear discharge instructions, and communicate with the outpatient clinician responsible for follow-up to ensure a safe transition.
Hospitalists should be able to:
Employ a multidisciplinary approach to the assessment and management of patients with pain that begins at admission and continues through all care transitions.
Follow evidence-based recommendations, including the World Health Organization (WHO) step approach to pain management.
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.
Appreciate the importance of a patient/family-centered approach for establishing the goals for pain management strategies and setting targets for pain control.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Lead, coordinate, and/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 rehospitalization rates.
Lead, coordinate, and/or participate in efforts to measure quality of inpatient pain control, operationalize system improvements, and reduce barriers to adequate pain control.
Lead, coordinate, and/or participate in efforts to establish or support existing multidisciplinary pain control teams.