Published in the September 2006 issue of Today’s Hospitalist
Ask physicians what worries them about managing patients’ pain, and you’ll likely hear a long list of fears about choosing the right drug and dose, anxieties over potential legal hassles, and concerns about dependence and addiction.
But according to Steven Pantilat, MD, physicians face a more insidious barrier to good pain control: a reluctance to trust patients’ perceptions about pain. Dr. Pantilat, a hospitalist who is widely recognized as a guru of pain management, recalled one liver transplant patient who, post-transplant, complained of pain “only to have a nurse roll her eyes in disbelief.
That kind of response not only presents a barrier to adequate pain treatment, but it’s more common than most physicians would care to admit. “The major issue is to believe that patients have pain,” said Dr. Pantilat, who is director of the palliative care service at the University of California, San Francisco. “The good news is that the patient will tell you.”
During a presentation last spring at the annual meeting of the Society of Hospital Medicine (SHM), and in a follow-up interview with Today’s Hospitalist, Dr. Pantilat acknowledged that physicians have legitimate concerns about pain management, particularly when prescribing narcotics. But he also said that pain management, if done correctly, puts most of those concerns to rest.
One of the major problems with pain treatment today, Dr. Pantilat said, is that physicians create their own barriers to adequate pain control. They may be too cautious, for example, and spend time trying to identify the source of patients’ pain, when they should be focused on getting the pain under control.
At the SHM meeting, Dr. Pantilat said that insights into physicians’ attitudes toward pain management can be found in a survey of medical oncologists published in the July 15, 1993, issue of Annals of Internal Medicine. While oncologists should be highly skilled in pain management, many said that they were concerned about their ability to make sure that patients were really in pain. They also said they worried about the potential for legal action from over-treating patients for their pain.
While physicians may be concerned about over-treating pain, Dr. Pantilat told the audience that under-treatment may be just as big a problem. He noted that states like California have addressed the issue by legislating pain-management training for providers.
It’s only natural that physicians are more comfortable treating pain that has an obvious source “think end-stage cancer “and can be stymied by chronic pain and “less directed” pain such as abdominal distress. That’s why they need to take a few simple steps to assess patients’ reports of pain severity.
For starters, Dr. Pantilat urged physicians to consider using the traditional zero-to-10 pain scale. It’s neither perfect nor highly scientific, he admitted, “but it works.”
If possible, you should also classify your patient’s pain so you know what you’re dealing with. Dr. Pantilat said that treating neuropathic pain “associated with such conditions as diabetes, HIV, alcoholism and stroke “may require a different approach and algorithm than treating muscle, bone or visceral pain. And treating pain in patients who are experiencing spiritual or somatic pain or depression will also be challenging.
To successfully manage severe pain and keep on top of possible side effects, hospitalists need to work closely with nurses and assess patients’ response frequently. Dr. Pantilat said that ideally means every 15 minutes for the first two hours and every four hours if the management strategy appears to be working. Even patients in moderate pain should be checked every few hours, he added, to avoid breakthrough situations.
He also urged physicians to talk to patients directly about their pain treatment plan. That not only sends the message that you believe they have pain, but it gives patients in severe pain some hope that relief is on the way.
Dr. Pantilat tells patients what medicine he is prescribing and the dose they will be given. He then stresses that they must tell him how much pain they’re having- “and let him know if the dosage isn’t high enough, so he can prescribe more. He also assures them that both he and the nursing staff will respond if the plan doesn’t work.
And hospitalists who find themselves beyond their comfort zone in treating severe pain should enlist a pain management team, if one is available, or contact a pharmacist and nurses experienced in palliative care.
Therapeutic approaches: the pre-opioid approach
Another frequently cited concern is the potential for side effects from drugs like morphine. But those concerns, Dr. Pantilat said, are “typically overblown” and can lead to inadequate control.
The safe use of opioids “isn’t all that difficult,” he added, if hospitalists follow these basic principles: Start with a low dose, increase dose in response to pain, assess pain using a scale, and then increase dose by percentages if patients are having moderate to severe pain.
“You do have to start slow, and go slow [with titration],” he said, “but serious side effects and true anaphylaxis to opioids is rare.”
But before you even think about opioids, Dr. Pantilat said, here are other effective therapies you should consider. He suggested starting patients with mild to moderate pain on nonopioid medications, such as acetaminophen or nonsteroidal anti-inflammatory drugs.
For moderate to severe neuropathic pain, first-line medications include opioids, along with tricyclic antidepressants, gabapentin, tramadol hydrochloride and, as indicated, a 5 percent lidocaine patch.
“These first-line medications have shown at least a 30 percent reduction in pain intensity scores in 30 percent of patients studied,” Dr. Pantilat said. He cautioned, however, that managing neuropathic pain can be extremely challenging. “It is difficult to get them to zero [percent pain] “and often you have to combine multiple drugs.”
Opioids: How much should you prescribe?
When treating severe pain, the key with opioids is to start with a dose that’s likely to bring near-term relief of severe pain. In an opioid naive patient, start with 2-4 mg IV.
For oxycodone, the starting dose is 5-10 mg. For patients with renal disease or failure, Dr. Pantilat prefers using Dilaudid at starting doses of 0.4-1 mg IV.
Patients at the end of life may require and can tolerate 40 mg to 50 mg an hour of morphine, and a bolus dose of up to 100 mg is not out of the question for patients who have already been on high-dose morphine.
“If the patient is in severe pain, I might repeat the morphine 4 mg IV every 15 minutes,” he said. “By 15 minutes, you’ll have a good sense of how people are reacting to the dose. By 30 minutes, you’ll have seen the maximum effect.” If the patient is still in severe pain at 45 minutes, he added, “double the dose again.”
As a rule of thumb, opioids can be titrated up by 25 percent to 50 percent for moderate pain, and 50 percent to 100 percent for severe pain, Dr. Pantilat said.
“It gets more difficult for hospitalists with the higher doses,” he said. But even so, the dose-doubling principles apply. “A 100 mg morphine bolus seems huge,” Dr. Pantilat explained. “It is big, but not for the patient who’s been working up to it.”
Physicians treating post-operative patients likewise worry about high doses, but they tend to forget that pain severity will typically decrease substantially over a few days. At that point, the dose can be reduced in tandem, and hospitalists should avoid basal rate continuous infusion in these patients.
When prescribing tricyclic antidepressants, Dr. Pantilat recommended starting with a very lose dose “about 10 mg “at night, and then increasing the dose very slowly, especially with elderly patients.
“The challenge here is that in any one hospitalization you are unlikely to realize the benefits of starting that drug,” he said. “But you will at least have a few days to see what the side effects are going to be.” He noted that he prefers nortriptyline to amitriptyline because nortriptyline has fewer side effects.
Lidocaine patches are the most straightforward pain management approach, but even with patches, physicians may “under-dose.” Up to three 5 percent patches can be used simultaneously for a 12-hour period, ideally on a 12-hours-on, 12-off schedule.
Then there is meperidine, which Dr. Pantilat advised against using altogether. The drug has a short half-life, is neurotoxic and can cause seizure at doses as low as 600 mg in a 24-hour period.
“Why give someone who is in pain and is already irritable something that’s neurotoxic,” he asked, “especially when there’s a risk of seizure after repeated doses?”
Dr. Pantilat also offered the following strategies for better pain control:
- Adjust dose and frequency. “We adjust dose to provide adequate pain control, so giving the same dose more frequently won’t help if someone only goes from 10 to a 7,” he said. “You have to up the dose.”
Likewise, if the patient reports that her pain has gone from a 7 to a 4 but the relief lasted less than six hours, more frequent dosing is in order.
- Use lower doses of multiple medications. Combining lower doses of several drugs may provide better control and minimize the side effects of any single drug.
- Anticipate and treat drug side effects. Common side effects include dry mouth, constipation, nausea and vomiting, and sedation or somnolence. Sedation and somnolence may improve as patients adjust to dosing “or you may need to prescribe a stimulant medication. Anticipate constipation and prescribe stool softeners and laxatives along with opioids.
- Avoid “PRN” prescribing. Don’t treat chronic, severe or anticipated pain “PRN.” That was a major factor in a celebrated 2000 verdict in which an internist was found guilty of elder abuse for under-treating a hospitalized patient’s pain with PRN meperidine. Instead, for opioid naive patients, write a regular schedule of pain medications and work with the nurse to ensure frequent assessment for dose titration.
- Document both response and function. According to Dr. Pantilat, physicians need to do a better job documenting patients’ response to pain treatment.
And even when physicians document pain scores in the chart, they’re less likely to document functional results. Be sure to note when a patient who couldn’t get out of bed is now going to physical therapy and walking because his pain is under control.
- Steroids, non-drug therapies. Other helpful strategies include using steroids intermittently as an add-on for metastatic bone disease, and combining one or more non-pharmacologic approaches with drugs. Heat, ice, massage, physical therapy and acupuncture, among other treatments, can bring relief or help patients cope better with persistent pain.
Heading off fears of addiction
Physicians also need to break down another major barrier to better pain control: their own or their patients’ fears about becoming dependent or addicted to opioids.
Dr. Pantilat cited the case of a 67-year-old woman with metastatic breast cancer admitted to the emergency department for increasing hip pain. She had been taking two tablets of acetaminophen and oxycodone (Percocet-5/325) every four hours. But as the pain increased, she upped the dose herself to two tablets every two to three hours, explaining that she didn’t want to take morphine because “it made her feel like a drug addict.”
Had the patient been adequately educated on the differences among dependence, tolerance and addiction, she might have been more open to a different therapeutic approach, Dr. Pantilat said, especially because the high doses and self-medication with acetaminophen “could have killed her liver.”
When the woman was admitted to the ward and converted to 15 mg IV of morphine every three hours, her pain was much better controlled. She was eventually discharged on 120 mg of oral long-acting morphone three times a day.
Finally, Dr. Pantilat urged hospitalists to always keep this delicate balancing act in mind: the need to weigh pain control and function. Use targeted questions on function, desired function level and pain scores, and then structure dosing to optimally manage patients who choose tolerating some pain over being “knocked out.”
“Some patients will accept a 3 pain level over a 1 level,” he said, as long as they can get some relief, think more clearly and perform daily activities. “What you are trying to do is maximize their function.”
Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.