Break the reaction to high pain scores

By | January 19, 2019

Pain usually cannot be “treated” like a standard ear infection. Treating patients in pain requires setting realistic expectations, using a variety of approaches, and patience. One patient I treated months ago highlights these points.

At 6 a.m., I was ready for the change of shift at the hospital. The night doctor who took care of my patients was frustrated. He snapped, “You really should have had a better plan for her. I kept getting calls all night.” We were talking about a 16-year-old female who had been hospitalized for weeks due to a nasty infection. Now, her pain was the main thing keeping her in the hospital.

Disheartened, I shuffled over to the nurse’s station, to check in with the night nurse for my patient in pain. The nurse was also exasperated. “Are we medically neglecting her pain?” she asked.

I felt as if I was wearing a scarlet letter, a punishment for not fixing my patient’s pain. Training in the era of the opioid epidemic, I am particularly cautious when prescribing pain medications. I know that most addictions to pain medications start in the doctor’s office. I also know that more than 63,000 people that died in 2016 from drug overdoses. However, it was news to me that more than 17,000 of those people died from overdosing on prescription opioids. That is more than 25 percent. Dying from the drugs that we gave them.

As a physician, it is hard for me to accept that I cannot immediately fix pain. The cornerstone of pain management is to help the patient do meaningful activities, and not to eliminate pain entirely. These activities could include going for a walk or playing with a grandchild. Changing the goal from “pain-free” to “functional” allows both patients and health care providers to focus on specific, measurable goals.

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It is important for the health care provider to be clear with the patient and with all members of the health care team that the patient may not be completely pain-free at the end of treatment.

As part of their protocol, nurses at most hospitals ask patients every couple of hours how bad their pain is, on a score of 0 to10. This was challenging for the nurses caring for my patient in pain. No one likes to look back on days worth of data, and see patients consistently reporting 9/10 pain.

It is hard to break this reaction to high pain scores, but it is necessary. What happens when doctors allow themselves to react to pain scores without context? They do what I did – use several medications with short, ineffective trials. By the end of two weeks of caring for this patient, I had used three doses of six different pain medications, all without good result. As soon as a medicine did not work, I discontinued it. After all, I know how addictive these medicines are.

This frantic approach left the patient without many options. None of the medicines “worked,” and the pain scores were still high. Perhaps if I had not reacted so strongly to each individual pain score, I could have found a more sustainable medication regimen that worked for this patient.

Treating pain also requires a variety of approaches. Nurses and supervisors asked me – have you thought of complementary therapies for pain? It was a great point. In large German clinical trials, acupuncture has been shown to decrease pain. In fact, the VA system, recently approved reimbursement for acupuncturists as they grapple with perhaps the most pain-ridden subpopulation in the U.S.

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I signed my patient up for every single complimentary therapy that the hospital offered. However, there is little data available for many of these complementary therapies. This makes it difficult to anticipate the peak effect of these therapies and use them meaningfully for different types of pain. Not only do medical trainees need more education on how to use complementary and alternative therapies more effectively, but more research on the true efficacy of these methods is also needed.

Finally, it is important for health care providers to reflect on their experiences treating patients suffering from pain. It was only during a long lunch meeting that I realized I was feeling hopeless about treating this patient and reached out to other colleges for help. Psychologists who were not personally involved in the case were able to provide insight into the patient’s coping strategies and help me refine my pain management plan.

Through a combination of medication, motivation, and reflection, my patient’s pain was eventually treated. Prior to discharge, she was doing laps around the hospital wing. Her sassy attitude returned, an excellent prognostic sign. Weeks later, nurses asked me about her. I beamed when I said she was discharged home without pain medication.

Sejal Parekh is a pediatric resident.

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