Bringing Pain to the Forefront of Treatment
Throughout history, pain has tormented both patients and their families and plagued clinicians with a lack of definitive treatment and management. New standards on assessing and managing pain introduced by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) seek to lighten this burden and provide some clarity. Beginning this month, the Commission will begin enforcing compliance in accredited organizations for these standards, which were established after a two-year collaborative effort between the Commission and the University of Wisconsin-Madison Medical School and funded in part by the Robert Wood Johnson Foundation. The standards affect a variety of health care groups and will be included in manuals for:
- Ambulatory Care
- Behavioral Health Care
- Home Care
- Health Care Networks
- Long Term Care
- Long Term Care Pharmacy
Instrumental in the establishment of these guidelines were the Commission's Professional and Technical Advisory Committees, Standards and Survey Procedures Committee and Board of Commissioners, along with numerous health care professionals, professional groups and associations, consumer groups and purchasers.
In operation since 1951, the Commission–an independent, not-for-profit organization–sets standards and accredits various health care organizations and industries. In order to receive accreditation through this Commission, recognized nationwide as a benchmark of quality, an on-site survey is mandatory every three years for an organization or every two years for a laboratory. The Commission's standards delineate a group's level of performance based on both what it has and what it does, with patient outcomes playing an integral part. The 28-member panel governing the Commission represents a variety of professions from health care to industry and is comprised of nurses, physicians, consumers, employers, labor representatives, health insurance administrators and educators, among others.
"Pain management became an emerging discipline in the mid-1970s," says Richard Weiner, PhD, executive director of the American Academy of Pain Management (AAPM). "At that point, we had no standards, no consensus and no curriculum for dealing with pain. It didn't matter which profession you were in, there was simply no training in dealing with pain management."
Even today, he points out, most medical school curriculum devotes a mere two to four hours to the topic of pain management. "So if you miss that lecture, you have missed the topic," he notes. He goes on to explain that the treatment of pain generally comes at one of two levels. Treatment for acute pain arising, for example, from a sprained ankle or traumatic injury, generally results in a conclusive resolution. On the other hand, the treatment of chronic pain is often elusive and enigmatic.
"When you're treating a chronic condition where the patient has been in pain for, say, up to six months or more, that can be a real problem," states Dr. Weiner. "Up to now, there have been no standards, no training facilities and few people involved in doing this type of care." Compounding these obstacles is the fact that patients suffering from chronic pain–especially of unknown origin–are often viewed by the medical community as suspect and may be labeled a malingerer or someone who is just seeking attention.
Pain is an epidemic, with chronic pain resulting in heavy costs, not only in relation to its management, but also in terms of lost productivity. In addition, pain has myriad social implications, with the patient, family, practitioners and payors all having different concerns. Dr. Weiner continues, "Throughout the eons, people in pain have sought relief, whether it's from a physician, an herbalist, a shaman or the church. And our understanding of chronic pain has been sorely lacking, especially the interplay between physical, psychological, social and family factors, as well as how pain is modulated."
It was in the mid-1970s when Dr. Weiner, along with a small cohort of colleagues who included both clinicians and researchers, began sharing their findings on how to diagnose, treat and manage pain. Soon newsletters and white papers began to circulate among this growing group. New journals were started, protocols sprang up, conferences were held in various cities and nascent organizations began to form, among them the AAPM, a diverse, multidisciplinary group.
In March of 1999, the Joint Commission's Board of Commissioner's Standards and Survey Procedures Committee approved the new standards on pain, and additions were made in August of 1999. Throughout 2000, the standards were assessed through various means, including interviews, policy reviews and other evidence. The standards were adopted at the Leadership Summit on Pain Management in July of 2000 and set for implementation beginning this year.
"While the Commission's guidelines have always been there," adds B. Eliot Cole, MD, MPA, "pain was never mentioned. These new guidelines have pain-specific tenets added to each section, and the Commission is trying to get the broadest implementation to the existing guidelines." Dr. Cole, also an AAPM member, will, along with Dr. Weiner, be meeting with the Commission soon to discuss the establishment of a national database compiling 10 years worth of data.
The first standard in each manual states that every patient has a right to have pain assessed and managed appropriately, including having their complaints of pain respected and the assurance of competent pain management services. "There are all kinds of nuances in these guidelines for pain evaluation," says Dr. Cole. "They include how to provide treatment, therapeutics rules and continuity of care. Pain management is addressed from the time the patient is admitted to a facility up until discharge, and even into the follow-up care received after discharge."
According to Dr. Cole, another large component of the new guidelines is education. "Issues of informed consent are driving some of this," he observes. "Patients cannot tell what they want and need unless they are properly educated. And it's important that both the family and the patient are informed, so that everyone is getting the information he or she needs.
"We're also trying to make patients fully aware that this is a two-way street," Dr. Cole continues. "They have an obligation to be responsible for reporting their doubts or concerns to their doctor. For example, if patients are afraid of becoming addicted to pain medication, but don't want to admit that to the doctor, they may minimize the amount of pain they are feeling so that medication won't be prescribed."
In line with this thinking, the new guidelines not only cover patients' rights, they cover patients' responsibilities as well. To reinforce the educational aspect, the guidelines indicate that information should be presented to patients and their families more than once and in more than one form. The guidelines covering education extend to the providers as well, indicating they should be trained on the particular methods that a facility uses for assessment and management when they begin employment, and then receive continuing education at regular intervals.