Pain Management: Nurses Providing Comfort, Relief

The millions of Americans suffering from pain offer nurse pain management specialists a rewarding opportunity to relieve distress and improve patients’ quality of life. But all nurses share a responsibility for asking about and taking action to mitigate pain.

"Pain management is not just for nurses specializing in it," said Cassie Snyder, MS, RN, immediate past president of the American Society of Pain Management Nurses (ASPMN) and the director of pain management services at Lehigh Valley Hospital in Pennsylvania. "The only way we will be able, as a country, to tackle the problem of chronic pain in the decades ahead is to get everyone involved."

According to monographs released in 2003 by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 90 percent of Americans regularly suffer from pain. Injuries and surgery trigger about 25 million acute episodes and twice that many people experience chronic pain. With an aging population, it expects a tremendous increase in the number of patients needing relief.

"There has not been solid research into the prevalence of pain and its impact throughout the years. My best guess would be there is most probably an increase in pain as we survive many illnesses that at one time would have taken our lives prematurely," said ASPMN President Micke A. Brown, BSN, RN, manager of public outreach for the American Pain Foundation. "We also have an increase in awareness of pain, as patients are starting to admit they are suffering."

Many patients do not acknowledge experiencing pain or the problems it causes in their lives. Brown said, as a society, we reward stoicism. But not dealing effectively with pain is expensive. A recent study published by the Journal of the American Medical Association estimated workers’ lost productivity due to pain costs U.S. businesses at $61.2 billion annually.

"We’re not getting people to understand when they are having pain that is not relieved over time, that it is important to seek out care," Brown said. "Unresolved pain can be detrimental."

Yet too many patients still hear from doctors that "you just have to learn to live with it," so many patients stop introducing the topic.

"As nurses, it’s our responsibility to use our ability to sit down and talk, garner trust and allow people to tell their stories," said Brown, who explained that simply listening validates patients’ pain problems. "Then you can start to talk about options and work with that person and family to help them get the right type of care."

Paul Arnstein, Ph.D., APRN-BC, FNP-C, and assistant professor at Boston College in New Hampshire, said the JCAHO’s standards and emphasis on pain assessments and management have raised nurses’ awareness of the issue. As incoming president of ASPMN, he plans to reach out to all nurses and nurse practitioners and encourage them to increase their knowledge about pain management and refine their palliative skills.

Medical and nursing schools often do not teach new practitioners about pain and pain-management techniques. Brown said, currently, no nursing graduate education track exists for nurses wanting to pursue pain management in clinical practice. She would like to see more pain-related coursework included in undergraduate and graduate education.

The association and the American Nurses Credentialing Center are working on a certification exam, which should be ready in 2005.

Pain management nurses work in a variety of settings, notably in hospitals and cancer centers, with palliative care providers and in ambulatory settings. Pharmaceutical companies employ these nurses in educational roles. Other specialists offer consulting services.

Acute pain differs from chronic pain, so clinicians must tailor therapies accordingly. Management of acute pain requires blocking the sensation until healing can take place. The initial aggressive treatment is tapered off as the patient improves and is ready for rehabilitation.

The nature of chronic pain is more variable. It may wax and wane in intensity. It often affects sleep and mood. Patients frequently experience changes in their quality of life and ability to perform activities of daily living due to chronic pain.

Clinicians may use medications, interventional procedures, implantable pumps and other techniques to control chronic pain. Nurses will often instruct patients in nondrug techniques and coping strategies.

"Patients with chronic pain are more of a challenge to manage," said Snyder, explaining that patients often arrive with high expectations. But it may take months to titrate doses and find the right solution for that person.

The Lehigh Valley Hospital center refers patients back to their primary physician when he or she is comfortable prescribing the opiate and adjuvant medications, but many doctors are not. Therefore some patients have received treatment at the center for years. Snyder and the other nurses have come to know the patients quite well. She considers working in pain management a wonderful nursing job, a sentiment echoed by other nurses specializing in the field.

"Nothing is more satisfying, as a health care professional, than to work with somebody who is uncomfortable and lower that level of discomfort and do it relatively quickly," Brown said. "That has always given me a sense of making a difference."

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