Home Education of nurses and medical doctors is a sine qua non for improving pain management of hospitalized patients, but not enough
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Education of nurses and medical doctors is a sine qua non for improving pain management of hospitalized patients, but not enough

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Published/Copyright: April 1, 2017
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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 15 Issue 1

In this issue of the Scandinavian Journal of Pain, Kristian Dahl Friesgaard, Charlotte Paltved, and Lone Nikolajsen from Aarhus, Denmark, report on their study evaluating effects of an educational intervention on acute pain in the emergency department [1]. Lars Sturesson and co-workers studied the effect of making mandatory nurses’ documentation of how they evaluate pain and how they manage pain in the emergency department of a Stockholm Hospital [2,3]. Viveke Andersson and her co-workers established an Acute Pain Service that take care of patients also in the medical wards, not only surgical wards, in the major hospitals in Gothenburg, Sweden [4,5]. Kristiina Heikkilä and co-workers in Finland focused on the often insufficient documentation of pain and pain management in hospitals [6].

1 Improving in-hospital pain management is not difficult, but requires motivated, well-trained nurses and physicians with some extra resources

More than 20 years ago, during my sabbatical at Inselspital University Hospital in Berne, Switzerland, in Professor Dick Thomson’s Department of Anaesthesiology and Critical Care, I helped introduce and implement a hospital wide improvement of acute pain management with focus on patient-controlled IV analgesia (PCA) and epidural analgesia on the surgical wards [7]. I realized that for that to be possible with minimal risk of dangerous errors, a comprehensive educational programme was necessary before we could hope to implement such a big change in attitudes and praxis [7,8,9]. All aspects of that experience are well documented in one of the Baillière’s Clinical Anaesthesiology International Practice and Research books from 1995 [10]. Rereading the chapters in that book, I find that most of what a group of motivated and enthusiastic doctors and nurses need today, 25 years later, in order to plan and implement an in-hospital pain management programme, is well covered [10]. The continued experience in Berne and Oslo during two decades is explained [9,10].

When reviewing the literature at that time, in 1992–3, it was clear that management of acute pain in hospitals was inadequate in 1992, as it was 20 years before [11], and also 40 years prior to 1992 [12], and unfortunately this sad state of affairs for managing acute pain still exists in many hospitals today [13]. In published observational studies during the last three decades, when trying to document improved pain management by using patients’ satisfaction as main outcome, the results have often been meagre [1,2,3,4,5].

2 Why is it difficult to make in-hospital patients satisfied with management of their pain?

It is a major undertaking to improve knowledge and change attitudes, especially among physicians [11], and the efforts by enthusiastic nurses, physiotherapists, and pain-specialists do not easily change attitudes among physicians. I am tempted to cite the following strong statement from Clark in the Lancet in 1993; it is still a reality in many places today, 25 years later [11]:

“Doctors think they deal with pain well. That this is a delusionary idea is well documented but still not accepted by most physicians. Since beliefs are not subject to normal rules of scientific persuasion, simple explanation of the self-evident does not alter medical practice; only social pressure or consumer demand seem effective. The first has driven the development of terminal care and the second has altered obstetric analgesia. Attention has now turned to postoperative pain.”

Attention to postoperative pain has improved in many places, leading to monitoring pain as the “fifth vital sign” in “pain-free hospitals”. Patients have been equipped with opioid tablets and prescriptions for opioid analgesics when leaving the hospital, without clear instructions to the patient’s primary care physician on how to taper and discontinue opioids. This has been fuelling the opioid epidemic in the USA [14]. This has been part of the increasing “liberal” praxis of prescribing potent opioids for acute as well as chronic pain, leading to worrisome increase in over-dose fatalities from opioids, especially when combined with hypnotics and anxiolytics, including alcohol. The pendulum is now rapidly swinging back towards more strict guidelines for prescribing opioids in the USA [14]. This is influencing similar guidelines in Scandinavia.

3 Using potent opioids ad libitum for acute postoperative pain is not a good solution

There is no way around a comprehensive educational programme before any improvement in safe and effective pain management can occur for hospitalized patients. This is especially true for patients who have surgery. Without appropriate knowledge and attitudes among all health care providers with responsibilities for in-hospital patients, including doctors, nurses, and administrators of economic resources – this “everlasting challenge” is going to be with us and our patients for a long time still [9,10,13]. More opioids mean more complications.

4 A hospital-wide educational programme is a sine qua non, but not enough to increase patients’ satisfaction with management of their acute pain

A systematic effort and commitment from the top of the administration of the hospital to the nurses at the bed-side, with education in lectures, videos, and hands-on training is even more necessary now that patients are allowed to stay in the hospitals for only the least possible days – even after major surgery, and more complex surgical operations are done in the out-patient departments. Information and education of patients are equally important [9,10].

5 Patients are satisfied with pain management when meeting caring health care providers in a positive, healing context

The patients do not need to be in a “pain-free hospital”. They are satisfied in a positive environment, being treated by well trained nurses and physicians with appropriate empathy, showing that they care and do their best, and also being concerned with possible adverse effects of opioids and other analgesics, respiratory depression in particular [10]. It is not well known, yet, that the increasing practice of combining pregabalin (for acute neuropathic pain) and opioids after surgery can increase respiratory depression and cognitive decline [15].

6 For patients with “difficult to relieve pain” after surgery, the Acute Pain Service (APS) should be extended to the time after leaving the hospital by an APS-outpatient clinic

One important development, shown to be highly effective, by Elina Tiippana and co-workers in Helsinki, Finland, is that their APS continue their responsibilities for the (about) 10% of all surgical patients who have difficult-to-relieve pain during the first weeks after surgery [16,17,18,19]. These patients are at high risk of developing chronic pain conditions with neuropathic components [17,19]. This risk can be reduced by taking better care of them during the weeks following discharge from the surgical wards or day-case surgical facilities [16,17,18,19]. They need specific treatment for neuropathic pain, and if their postoperative pain continues for more than a few weeks, they are referred for a “fast-track” comprehensive evaluation by the chronic pain-clinic specialists [16], bypassing often long waiting lists at their chronic pain clinic.

An important observation by the Helsinki APS-Outpatient Clinic in Eija Kalso’s department is that they have been able to taper and discontinue strong opioid drugs that the patients do not need [16]. This reduces the risk of postoperative pain patients becoming long-term opioid users who may develop an opioid abuse disorder [14,17,19,20].

7 Enhanced Recovery after Surgery (ERAS) programmes are important initiatives

Surgeons now take more focused responsibility in improving postoperative management by emphasising all aspects of optimizing recovery after major surgery: pain relief is one important part of the ERAS-programmes as documented by Feldheimer and co-workers in Acta Anaesthesiologica Scandinavica in 2016 [21]. This development is necessary for progress: the operating surgeons must be involved in helping their patients through the most painful and most “challenging” period after major surgery, collaborating with the APS and the chronic pain clinic; otherwise the efforts by enthusiastic nurses and pain specialists are doomed to failure [22,23,24,25].

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2016.11.004.

Oslo University Hospital, Department of Pain Management and Research, Pbox 4956 Nydalen, 0424 Oslo, Norway. Fax: +47 23073690.

  1. Conflict of interest: None declared.

References

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Published Online: 2017-04-01
Published in Print: 2017-04-01

© 2017 Scandinavian Association for the Study of Pain

Articles in the same Issue

  2. Scandinavian Journal of Pain
  3. Editorial comment
  4. Cardiovascular risk reduction as a population strategy for preventing pain?
  5. Observational study
  6. Diabetes mellitus and hyperlipidaemia as risk factors for frequent pain in the back, neck and/or shoulders/arms among adults in Stockholm 2006 to 2010 – Results from the Stockholm Public Health Cohort
  7. Editorial comment
  8. Exercising non-painful muscles can induce hypoalgesia in individuals with chronic pain
  9. Clinical pain research
  10. Exercise induced hypoalgesia is elicited by isometric, but not aerobic exercise in individuals with chronic whiplash associated disorders
  11. Editorial comment
  12. Education of nurses and medical doctors is a sine qua non for improving pain management of hospitalized patients, but not enough
  13. Observational study
  14. Acute pain in the emergency department: Effect of an educational intervention
  15. Editorial comment
  16. Home training in sensorimotor discrimination reduces pain in complex regional pain syndrome (CRPS)
  17. Original experimental
  18. Pain reduction due to novel sensory-motor training in Complex Regional Pain Syndrome I – A pilot study
  19. Editorial comment
  20. How can pain management be improved in hospitalized patients?
  21. Original experimental
  22. Pain and pain management in hospitalized patients before and after an intervention
  23. Editorial comment
  24. Is musculoskeletal pain associated with work engagement?
  25. Clinical pain research
  26. Relationship of musculoskeletal pain and well-being at work – Does pain matter?
  27. Editorial comment
  28. Preoperative quantitative sensory testing (QST) predicting postoperative pain: Image or mirage?
  29. Systematic review
  30. Are preoperative experimental pain assessments correlated with clinical pain outcomes after surgery? A systematic review
  31. Editorial comment
  32. A possible biomarker of low back pain: 18F-FDeoxyGlucose uptake in PETscan and CT of the spinal cord
  33. Observational study
  34. Detection of nociceptive-related metabolic activity in the spinal cord of low back pain patients using 18F-FDG PET/CT
  35. Editorial comment
  36. Patients’ subjective acute pain rating scales (VAS, NRS) are fine; more elaborate evaluations needed for chronic pain, especially in the elderly and demented patients
  37. Clinical pain research
  38. How do medical students use and understand pain rating scales?
  39. Editorial comment
  40. Opioids and the gut; not only constipation and laxatives
  41. Observational study
  42. Healthcare resource use and costs of opioid-induced constipation among non-cancer and cancer patients on opioid therapy: A nationwide register-based cohort study in Denmark
  43. Editorial comment
  44. Relief of phantom limb pain using mirror therapy: A bit more optimism from retrospective analysis of two studies
  45. Clinical pain research
  46. Trajectory of phantom limb pain relief using mirror therapy: Retrospective analysis of two studies
  47. Editorial comment
  48. Qualitative pain research emphasizes that patients need true information and physicians and nurses need more knowledge of complex regional pain syndrome (CRPS)
  49. Clinical pain research
  50. Adolescents’ experience of complex persistent pain
  51. Editorial comment
  52. New knowledge reduces risk of damage to spinal cord from spinal haematoma after epidural- or spinal-analgesia and from spinal cord stimulator leads
  53. Review
  54. Neuraxial blocks and spinal haematoma: Review of 166 case reports published 1994–2015. Part 1: Demographics and risk-factors
  55. Review
  56. Neuraxial blocks and spinal haematoma: Review of 166 cases published 1994 – 2015. Part 2: diagnosis, treatment, and outcome
  57. Editorial comment
  58. CNS–mechanisms contribute to chronification of pain
  59. Topical review
  60. A neurobiologist’s attempt to understand persistent pain
  61. Editorial Comment
  62. The triumvirate of co-morbid chronic pain, depression, and cognitive impairment: Attacking this “chicken-and-egg” in novel ways
  63. Observational study
  64. Pain and major depressive disorder: Associations with cognitive impairment as measured by the THINC-integrated tool (THINC-it)
https://doi.org/10.1016/j.sjpain.2017.02.001

Articles in the same Issue

  2. Scandinavian Journal of Pain
  3. Editorial comment
  4. Cardiovascular risk reduction as a population strategy for preventing pain?
  5. Observational study
  6. Diabetes mellitus and hyperlipidaemia as risk factors for frequent pain in the back, neck and/or shoulders/arms among adults in Stockholm 2006 to 2010 – Results from the Stockholm Public Health Cohort
  7. Editorial comment
  8. Exercising non-painful muscles can induce hypoalgesia in individuals with chronic pain
  9. Clinical pain research
  10. Exercise induced hypoalgesia is elicited by isometric, but not aerobic exercise in individuals with chronic whiplash associated disorders
  11. Editorial comment
  12. Education of nurses and medical doctors is a sine qua non for improving pain management of hospitalized patients, but not enough
  13. Observational study
  14. Acute pain in the emergency department: Effect of an educational intervention
  15. Editorial comment
  16. Home training in sensorimotor discrimination reduces pain in complex regional pain syndrome (CRPS)
  17. Original experimental
  18. Pain reduction due to novel sensory-motor training in Complex Regional Pain Syndrome I – A pilot study
  19. Editorial comment
  20. How can pain management be improved in hospitalized patients?
  21. Original experimental
  22. Pain and pain management in hospitalized patients before and after an intervention
  23. Editorial comment
  24. Is musculoskeletal pain associated with work engagement?
  25. Clinical pain research
  26. Relationship of musculoskeletal pain and well-being at work – Does pain matter?
  27. Editorial comment
  28. Preoperative quantitative sensory testing (QST) predicting postoperative pain: Image or mirage?
  29. Systematic review
  30. Are preoperative experimental pain assessments correlated with clinical pain outcomes after surgery? A systematic review
  31. Editorial comment
  32. A possible biomarker of low back pain: 18F-FDeoxyGlucose uptake in PETscan and CT of the spinal cord
  33. Observational study
  34. Detection of nociceptive-related metabolic activity in the spinal cord of low back pain patients using 18F-FDG PET/CT
  35. Editorial comment
  36. Patients’ subjective acute pain rating scales (VAS, NRS) are fine; more elaborate evaluations needed for chronic pain, especially in the elderly and demented patients
  37. Clinical pain research
  38. How do medical students use and understand pain rating scales?
  39. Editorial comment
  40. Opioids and the gut; not only constipation and laxatives
  41. Observational study
  42. Healthcare resource use and costs of opioid-induced constipation among non-cancer and cancer patients on opioid therapy: A nationwide register-based cohort study in Denmark
  43. Editorial comment
  44. Relief of phantom limb pain using mirror therapy: A bit more optimism from retrospective analysis of two studies
  45. Clinical pain research
  46. Trajectory of phantom limb pain relief using mirror therapy: Retrospective analysis of two studies
  47. Editorial comment
  48. Qualitative pain research emphasizes that patients need true information and physicians and nurses need more knowledge of complex regional pain syndrome (CRPS)
  49. Clinical pain research
  50. Adolescents’ experience of complex persistent pain
  51. Editorial comment
  52. New knowledge reduces risk of damage to spinal cord from spinal haematoma after epidural- or spinal-analgesia and from spinal cord stimulator leads
  53. Review
  54. Neuraxial blocks and spinal haematoma: Review of 166 case reports published 1994–2015. Part 1: Demographics and risk-factors
  55. Review
  56. Neuraxial blocks and spinal haematoma: Review of 166 cases published 1994 – 2015. Part 2: diagnosis, treatment, and outcome
  57. Editorial comment
  58. CNS–mechanisms contribute to chronification of pain
  59. Topical review
  60. A neurobiologist’s attempt to understand persistent pain
  61. Editorial Comment
  62. The triumvirate of co-morbid chronic pain, depression, and cognitive impairment: Attacking this “chicken-and-egg” in novel ways
  63. Observational study
  64. Pain and major depressive disorder: Associations with cognitive impairment as measured by the THINC-integrated tool (THINC-it)
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