No Sadder State: Living With Chronic Nonmalignant Pain
By Diane Goodman, APRN, BC, MSN-C, CCRN, CNRN
Recent statistics demonstrate that approximately 15% of adults in the U.S. live with various types of chronic nonmalignant pain (median percentage point prevalence, Pain Physician, 2009). Whether this pain stems from diabetic neuropathy, fibromyalgia, disk disease, osteoarthritis, rheumatoid arthritis or a multitude of additional ailments, the patients would tell you that effective management of their discomfort is far from being reality.
Unfortunately, when a patient with chronic nonmalignant pain is seen in the emergency room, or admitted as an inpatient, an acute process that produces pain may be ignored completely or grossly undertreated. Providers erroneously assume the patient is already taking a prescribed analgesic, and that should "cover their needs." What a disappointing, unfortunate state of affairs this attitude perpetuates, for the patient with chronic pain may need more medication as opposed to less when an acute process occurs.
Dealing with pain on a daily basis is a delicate balancing act for the patient who wants to be both functional and comfortable. Not every patient in pain seeks drugs via every opportunity or every specialist. The multitude of patients with chronic nonmalignant pain manages their day-to-day needs by taking enough medication to be able to complete ADLs as well as live an independent life. The majorities of patients with chronic pain do not escalate drug dosages, or shop physicians seeking an arsenal of opioids to ingest at random. Physicians and caregivers apparently still need evidence that this is true.
Recently, I was seen in an emergency department for assessment of chest pain that felt ominously similar to what I had experienced in the past when diagnosed with bilateral pulmonary emboli. As soon as the chest CT was read as negative for thrombi, I was admitted to a telemetry bed for overnight observation. My analgesic orders did not "carry over," so I was neither offered pain medication, nor asked about discomfort for the remainder of my stay, even though I cried out at least once when trying to reposition myself in bed. As this cavalier approach to my physical discomfort grew tiresome, I asked for an analgesic. At that time, I was informed that "nothing had been ordered" and I would have to wait for the hospitalist to call in orders.
How did healthcare arrive at such a sad state of affairs? It would seem appropriate for a patient with a chief complaint of "chest pain" to be assessed and treated for pain once admitted to an acute care facility. Should the patient be allowed to be more uncomfortable than they would be at home? Even at discharge, when asking for a possible muscle relaxant, or alternate agent to ease distress, we were told to check with the primary care physician, who, by the way, was not available at that time.
For once, I felt thoroughly saddened by my peers in the healthcare profession. If I, as a midlevel provider, received such an appalling lack of care related to an acutely painful process, how would an elderly patient fare? What about an ischemic stroke patient, who might not be able to articulate pain? Or a patient who places all trust in their providers, assuming they will be given what is "best" for them, whether they verbalize the need for medication or not?
I cannot stress vehemently enough that not all patients experiencing pain are drug-seeking. Patients on chronic pain medication need to be asked about a pain history, which would include an overview of when and where they usually experience pain. They should be asked to "rate" their pain, as well as to describe how the acute pain differs from what they normally experience. They should be queried about a "pain goal," and what medications have proved to be effective for them in the past. They should not be ignored or assumed to be comfortable by providers who have become apathetic to the needs of patients.
I hope this narrative provides a wake-up call to at least one individual working in healthcare. To paraphrase a quote utilized by pain specialists: pain may be unavoidable, suffering is optional. We can and should do better. I'm angry, disappointed and shaken by my experience, for there is no sadder state than to be provided care by those who have forgotten what "care" should mean. As for my chest pain, the culprit turned out to be a re-injury of previously fractured ribs!