OR: Pain, Healthcare's Persistent Challenge, 6 unitsPage 9 of 22

7. Pain Management Approaches

Pain has traditionally been managed in two ways: self-management or using the pain medicine model. The self-management model—especially for chronic pain—is supported by strong evidence and has the benefit of involving patients in their own care (NIH, 2013).

The pain medicine model (which includes primary and specialty care) is supported by relatively weak evidence, particularly in chronic pain care, and often fails to involve the recipient as an active participant. Although the pain medicine model has weaker demonstrated efficacy, it is widely used because of a strong business model, industry support, and focus of training in healthcare professionals (NIH, 2013).

Increasingly, these two models are being combined with complementary approaches into what is referred to as integrative medicine (discussed in a later part of this class). In this model, the strengths of the two models are combined: pain is viewed holistically and assessed and treated in conjunction with psychological, medical, social, spiritual, and environmental influences. Currently, an integrative approach to pain care is encouraged for all patients (PPSG, 2014b).

Self-Management of Pain

Self-management is defined as a strategy used by the patient to manage or minimize the impact of a chronic condition on everyday life. The basic tenets of self-management include:

  • Active participation by the patient
  • Treatment of the whole person, not just the disease
  • Empowerment of the patient (NIH, 2013)

Although some people seek professional help immediately, most try to self-manage their pain. This can include talking to friends, searching the internet, or attending group classes or programs intended to educate a person about pain management. Self-management also includes exercise, ice, heat, positioning, limiting activity, over-the-counter (OTC) medications, and education. In many cases, self-management is highly successful.

Pain Medicine Model

The pain medicine model is widely accepted and widely used. It is based upon the idea that pain is an acute, treatable disease. This approach usually begins with the primary care physician followed by a referral to a pain specialist or pain clinic.

Primary care practitioners are an early step in the pain care journey, treating 52% of chronic pain patients in the United States (IOM, 2011). Primary care clinicians provide the initial assessment or diagnosis and serve as a starting point for specialty services, including prescription medications and referrals to imaging, physical and occupational therapy, or other integrative practitioners (IOM, 2011).

Primary care clinicians assist patients in making decisions about specialty services and elective procedures. They are also responsible for the majority of pain medicine prescriptions. In 2008 analgesics constituted 10.1% of all drugs prescribed for adults (IOM, 2011).

The development of a comprehensive treatment plan is important, utilizing appropriate pharmacologic and nonpharmacologic interventions. Treatments should be regularly re-evaluated for effectiveness, adjusted as needed, with side effects quickly addressed. The treatment plan should include a complete assessment and a clearly written plan of care (PPSG, 2014b).

Many hospitals have acute pain services (APS) that provide consistent pain management throughout the course of a patient’s stay hospital stay. Hospitals with formally organized acute pain services are more likely to follow a formal written post operative pain protocol than hospitals without acute pain services (Nasir et al., 2011).

The personnel comprising the typical acute pain service included:

  • Anesthesiologists (95%)
  • Advanced practice nurses (45%), registered nurses (32.5%), pharmacists (11.3%)
  • Physician assistants (8.8%)
  • Physical medicine and rehabilitation physicians (6.3%)
  • Surgeons (5%)
  • Neurologists (3.8%)
  • Others (oncologists, social workers, and psychologists) (Nasir et al., 2011)
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