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16 Articles in Volume 19, Issue #2
Analgesics of the Future: Inside the Potential of Glial Cell Modulators
APPs as Leaders in Pain Management
Cases in Urine Drug Monitoring Interpretation: How to Stay in Control
Complex Chronic Pain Disorders
Efficacy of Chiropractic Care for Back Pain: A Clinical Summary
Hydrodissection for the Treatment of Abdominal Pain Caused by Post-Operative Adhesions
Letters: The Word "Catastrophizing;" AIPM Ceases Operations; Patient Questions
Management of Severe Radiculopathy in a Pregnant Patient
Managing Pain in Adults with Intellectual Disabilities
Pain in the Courtroom: An Excerpt
Q&A with Howard L. Fields: How Patients’ Expectations May Control Pain
Special Report: CGRP Monoclonal Antibodies for Chronic Migraine
The Management of Chronic Overlapping Pain Conditions
Vibration for Chronic Pain
What are the dangers of loperamide abuse?
When Patient Education Fails to Improve Outcomes: A Low Back Pain Case

APPs as Leaders in Pain Management

Is there value in having an Acute Pain Service, and can APPs take the lead? Our resident APP responds.
Pages 22; 24-25
Page 2 of 2

The hospital supported my practice, but financially, I was not a member of any medical service; I was an independent practitioner. Some doctors had trouble conceptualizing that my prescribing decisions were mine alone. They did not understand that my practice was my responsibility and had nothing to do with them. I prescribed heavy opioids regularly and never had any problems.”

APPs Can Lead APS & They Can Lead Now

Over the past 10 years, the representation of APPs as leaders within their respective organizations and as resources for pain management has significantly increased. At Stanford Health Care, for instance, where I practice, the Acute Pain Service manages, on average, a consult service of 30 to 40 patients a day. The Acute Pain Service at Stanford employed its first APP solely dedicated to APS in 2012, and now boasts seven full-time APPs. Memorial Sloan Kettering was the first cancer center in the country to have a service dedicated to treating pain in people with cancer.8

The value of an in-hospital APS, for all the reasons mentioned above, is disputed by few. But what if there were no acute pain services in a facility? What would be the best strategies for acute pain management? The answer lies in community engagement of all clinicians involved in that patient’s care, and was introduced by American Society of Anesthesiologists in a concept named The Perioperative Surgical Home.9 This concept was first introduced in 2013, and has been shown to increase patient satisfaction, reduce hospital costs, and decrease complications.10 The perioperative surgical home is defined by the American Society of Anesthesiologists as “a patient-centered and physician-led multidisciplinary and team-based system of coordinated care that guides the patient throughout the entire surgical experience.”11 APPs in all specialties that care for patients where there is an anticipation of hospitalization or surgery are involved in this burden of care, which includes implementing a treatment plan for anticipatory pain management, as well as active and post-discharge pain management. The following is a hypothetical case scenario in which APPs are integral to such a process.

A Hypothetical Example

A 65-year-old male on morphine 20 mg/day for chronic osteoarthritis is at his pre-op H&P consultation visit with the surgical PA for surgery in 2 weeks. The surgical PA activates the services “perioperative surgical home, total joint replacement program,” which calls for the patient to be evaluated by the APRN at the hospital anesthesia pre-op clinic. The plan for analgesia will include a multimodal approach with non-opioid analgesics, mindful opioid management, and regional nerve block catheter.

On the day of surgery, the surgical PA communicates with the orthopedic surgical resident about the plan for pain management and discharge, while the patient is in the pre-op holding area having his peripheral nerve block catheter inserted by the CRNA. During his post-surgical hospital stay, he has a consult with the in-patient APS PA. On the day of discharge, the patient schedules a post-surgical follow up and a two-week follow-up visit with his primary care NP. He is given a two-week supply of post-surgical pain medications, including opioids with instructions for weaning safely off these medications.

This is an overly simplistic scenario. While the perioperative surgical home model further considers greater patient complexities and needs, this hypothetical case demonstrates the importance of care coordination and communication. APPs, in various instances, serve as the continuity clinicians in many aspects of patient care.

Next Steps

Pain is complex and the acuity of hospitalized patients’ pain management needs has increased, with high opioid tolerance, addiction, depression, and anxiety now on the list. Standard-of-care expectations1 have left many organizations in great need. Advance Practice Providers can fill these needs by establishing acute pain consult services within institutions (ie, acute care hospitals, sub-acute institutions, health maintenance organizations). APPs may also seek employment as pain resource clinicians within an institution, or through programmatic development with systems/policies/protocols for pain management within their current institutions. Going forward, APPs also have an active role to play in the perioperative surgical home,10 as primary care clinicians, surgical specialty clinicians, members of the anesthesia team, hospitalists, nocturnists, and pain management specialists.

 

Read previous For the APP columns:

Last updated on: March 4, 2019
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