Take two aspirin and call me in the morning

Editorial Take Two Aspirin and Call Me in the Morning The title of this editorial speaks to the “simplicity” of effective pain management. In a nutshell, one can approach the effective management of pain by having the patient take an analgesic medication—and the result is instantaneous pain relief. Right??? The thesis of my editorial is that effective pain management is NOT a simple matter. If it were as simple as the provision of an analgesic prescription or the implementation of the World Health Organization’s analgesic ladder, then we would not have a major public health problem, namely, the undertreatment of acute and chronic pain. Now, I am well aware of all of the patient, provider, and system barriers to effective pain management. The focus of this editorial is not on these barriers but on the complexity of effective pain management from the perspective of patients, their family caregivers, and providers. The major tenants of any effective pain management plan are assessment, intervention, and evaluation. The initial assessment of pain is performed to ascertain the cause of the pain. Most of us engaged in pain management have adopted a systematic approach to pain assessment and try to capture the multiple dimensions of the pain experience. Yet, how many of us have tried to ascertain the following information from a patient as part of our routine assessment of pain: How do you make a decision about when to tell your health care provider about a pain problem? How do you decide when to take your pain medication? I suggest that we know virtually nothing about how patients make decisions about when to tell clinicians about pain and when to take pain medications. Answers to these questions would provide valuable information on how to improve patients’ level of adherence with their pain medication regimen. Equally important from the patients’ perspective is an assessment of the patients’ level of knowledge about their pain problem and about effective pain management. This information is critical to the development of an effective teaching plan for each patient. Obtaining this type of information and developing a pain management plan for the individual patient is an extremely complex task. Family caregivers need to be included in every pain assessment. We need to have information about

their knowledge of the patient’s pain problem, as well as about their knowledge and attitudes about pain management. Adding this level of detail to the development and implementation of the pain management plan adds an additional layer of complexity. The interventions for pain management are extremely complex. Pain experts have tried to simplify the prescription of analgesics using such strategies as the stepped approach of the World Health Organization’s analgesic ladder. Although I applaud these efforts as a good beginning, I believe that in some ways this approach has done a disservice to pain management. The development of an effective pain management plan, particularly the titration of analgesics and the use of effective combinations of pharmacologic and nonpharmacologic approaches, are as complex as the titration of vasopressor drugs in the intensive care unit. In fact, the titration of vasopressor drugs is easier because clinicians have direct measures of heart rate and blood pressure to use to achieve therapeutic outcomes. Virtually nothing is known about the most effective approaches for titrating analgesic medications. Systematic investigations have not been performed to allow us to predict with any certainty if we increase a patient’s dose of morphine by “x” amount what the expected decrease in pain should be. Titration of analgesics and the use of combinations of different analgesics require expert knowledge and a great deal of time and skill. More systematic approaches to titration need to be tested to allow us to adjust doses with more certainty regarding outcomes and to provide patients with more rapid pain relief. An evaluation of the effectiveness of the pain management plan is another example of the complexity of this aspect of patient care. Using the example of evaluating the effectiveness of vasopressor therapy, the outcomes measures are relatively simple and objective, namely, heart rate and blood pressure. Think about the myriad of outcome measures that can be evaluated as part of a pain management plan: pain intensity, pain relief, functional status, adherence to the pain medication regimen, and side effects of the regimen. Each of these outcomes has a number of additional questions that can be evaluated and may require an intervention. The pain management plan

Pain Management Nursing, Vol 1, No 3 (September), 2000: pp 67-68

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Christine Miaskowski

becomes more complex as we add additional pharmacologic and nonpharmacologic strategies. I have not provided an exhaustive list of the complexities involved in pain management. The point of this editorial is to begin to raise awareness regarding the complexity of effective pain management. Although some pain problems can be managed with a simplistic and straightforward approach, I believe that these cases are extremely limited. I think that we need to start discussing the complex nature of pain management with our colleagues in other specialties. This dialogue will strengthen our position as experts in a specialized field. In addition, if we think about the complexities of pain management from the patients’, family caregivers’, and clinicians’ perspectives, we will ask more meaningful and clinically relevant research questions. Studies designed to answer these research

questions should help to improve the management of acute and chronic pain. I am grateful that the prescription “take 2 aspirin and call me in the morning” allows the patient the option of calling the clinician. I believe that we need to spend more time interacting with patients and their family caregivers to develop individualized treatment plans that are effective in reducing pain and improving patient outcomes.

Christine Miaskowski, PhD, RN, FAAN Editor

© 2000 by the American Society of Pain Management Nurses doi: 10.1053/jpmn.2000.9858