Note: This is Part 3 of The Hospitalist’s series on pain and hospital medicine. Part 1 appeared on p. 45 of the April issue, and Part 2 appeared on p. 33 of the June issue.
Hospitalists face demands for pain care every day. Usually, the general pain principles described in the first two articles in this series and the use of a few opioid analgesics with which the hospitalist has become familiar can supply relief.
But what about the more difficult cases in which psychosocial influences or a history of substance abuse complicates the patient’s pain? Perhaps it is a chronic pain case that has never been adequately addressed, or the patient keeps turning up in the emergency department (ED) complaining of out-of-control pain. Other examples of difficult-to-manage pain include complex regional pain syndrome, post-herpetic neuralgia, other neuropathic pains, sickle cell anemia, and patients at high risk of opioid toxicity.
These cases are like a leaky bucket for the hospital—costly, frustrating, unsatisfying to the patient, and prone to bad outcomes, says Jerry Wesch, PhD, director of the pain service for the Alexian Brothers Health System in greater Chicago. “These are the patients who tend to bedevil everybody in the hospital,” he says.
Dealing with such patients is a demanding task.
“You don’t have chronic pain without a psycho-social-spiritual overlay,” adds Scott Fishman, MD, chief of the Division of Pain Medicine at University of California-Davis in Sacramento. “Their emotional lives are deteriorating. They can’t sleep, they’re depressed, and their physical functioning is also deteriorating. There are all kinds of situations that demand use of a full spectrum of bio-psycho-social interventions in addition to opioid analgesics.”
These complex, unresolved cases are likely to have emotional, social, or spiritual manifestations. But what does that mean to a busy hospitalist with a short window of opportunity to address patients’ pain before pointing them toward discharge? A psychologist, social worker, or chaplain may have something to contribute to pain management. Meanwhile, the rest of the caseload is clamoring for the hospitalist’s attention.
Make Pain Management Multidisciplinary
A dizzying array of pain modalities can be brought to bear on complex pain cases. These range from opioid analgesics to a variety of adjuvant non-opioid medications to interventional techniques involving surgery, spinal injections, nerve blocks, nerve stimulation, and nerve destruction techniques.
There are also complementary methodologies (e.g., acupuncture) that have been shown to reduce the volume of narcotics needed for pain control, even though how they work is not well understood.
But how many hospitalists call on acupuncturists, hypnotists, or teachers of guided-imagery meditation for their patients? Many of these techniques are more appropriately initiated in the outpatient setting, but the hospitalist still has a responsibility to make sure “frequent fliers” with complex pain complaints get connected post-discharge to a pain service that can offer long-term relief. The challenge is applying the acute treatment models of the hospital to chronic pain syndromes that are not optimally addressed in crisis mode.
Jonathan Weston, MD, a hospitalist at Penrose Hospital in Colorado Springs, Colo., says these difficult, chronic pain cases are the bane of the hospitalist’s working life. These patients show up at night in the ED saying, “ ‘I’m in so much pain, please don’t send me home,’ ” he says. “The emergency physician puts them on an IV drip and their pain is relieved for the moment, but only one facet of that pain has been addressed.”