The skillful management of pain is one of the most valuable services a physician can provide.This service calls into play many components of the art and science of medicine and the technological skills that physicians possess. The result of pain management, skillfully done, is most rewarding to the patient and physician alike.

In many respects, the mechanism of pain is a mystery, but it is a mystery that is being progressively untangled. There have been many advances in our knowledge, allowing a better understanding of pain mechanisms and the therapeutic approaches to pain. We now know that:

1. Pain may be perceived peripherally, at several levels in the spinal cord and mid brain, and in the central nervous system. This knowledge allows pain to be classified and to be treated in different ways, depending on the level where it is perceived.

2. There are natural-endogenous agonist and antagonist influences and some knowledge of how these can be brought into play.

3. There are many factors which influence pain, i.e.:

1. The patient's general situation with his family, employment, finances, spirituality, marital status, et al.;

2. The patient's previous responses to pain and to pain medications;

3. The patient's disease, whether it is due to an acute problem where healing and return to normal is expected, a terminal problem where progression of the disease to death within an estimated six (6) months or less, or a chronic non-terminal source of the pain where neither of the outcomes stated above is expected; and

4. The patient's attitude toward the pain.

4. Pain therapy is multimodal and with the above knowledge, a plan of therapy can be selectively evolved that is effective in most cases. A general recitation of these modes is as follows:

1. Behavior modification-psychological evaluation and intervention;

2. Physical therapy ranging from therapeutic exercises and joint manipulation to a variety of modalities including hydrotherapy, thermotherapy, manipulation to change threshold of sensory nerve ends (TENS), and others;

3. Analgesics to include NSAIDS, antidepressants and anticonvulsants;

4. Where indicated, a variety of maneuvers ranging from nerve blocks to ablative surgery; and

5. Controlled substances, including drugs for anxiety and depression, as well as opioids of appropriate strength.

With a working knowledge of all these things, the physician, using good clinical judgement, can create and carry out a plan that will satisfactorily resolve most pain problems and minimize the side effects and potential side effects of all these modes of therapy.

Many physicians are astute in the management of acute pain associated with surgery, trauma, and procedures. A growing number of physicians are becoming adept in the management of the pain of terminal disease. These terminal diseases include a number of cancers, AIDS, a number of progressive neurological diseases, end-stage heart and lung disease, and a variety of other disorders.

Adequate relief of acute pain requires regular doses of an ample amount of medication, as well as supportive measures with physical therapy therapeutic exercises, i.e., walking and breathing exercises, et al. Here the physiologic injury is soon repaired, and the patient returns to normal.

Palliative terminal care requires much supportive treatment involving psychosocial, pastoral care,

physical therapy, family therapy, and a degree of occupational therapy. Compassionate care on the part of all care givers to the patients and their families is a must. Medication must be managed skillfully to assure that increasing amounts are appropriate. Therapy and medication are required for the wide variety of problems that inevitably arise with these situations. The ability to help patients to die graciously and in comfort has traditionally been an outstanding asset of physicians who care for these patients.

The Mississippi State Board of Medical Licensure supports the adequate treatment of all pain. In the acute and terminal categories of pain, the Board's concern is that they not be under treated.

Chronic pain of the non-terminal disorders is where problems arise. It is here that skills in pain management are stretched to the limit. All of the skills embodied in the art and science of medicine and the technologies involved in pain management are called into play.

Successful management in the case of chronic non-terminal pain requires:

1. Patient evaluation skills to provide a diagnosis and mechanism for the pain.

2. Management skills in evolving a plan of therapy that brings all the multimodal elements of the therapeutic armamentarium under consideration and selects out those that are most appropriate in each particular case.

3. Self-evaluation skills to know what you know, and to know what you do not know, and to know when consultation may be sought with pain specialists, addictionologists, orthopedic surgeons, neurologists, neurosurgeons and others who can provide help in establishing a diagnosis and a mechanism for the pain, and can help evolve an appropriate plan of therapy.

4. Appropriate and timely monitoring of all modes of therapy including medications.

5. Awareness of and a watchful eye for the possibility of drug dependency and/or addiction where controlled substances are used.

6. Documentation of all evaluations, the plan of therapy, observations made on follow-up visits (especially the response to therapy and the continuing need for therapy, including everything but especially with regard to controlled drug use). Remember, if it is not documented, who is to say that it happened.

1. The Mississippi State Board of Medical Licensure publishes a book entitled LAWS, RULES AND REGULATIONS GOVERNING THE PRACTICE OF PHYSICIANS (M.D./D.O.) AND PODIATRIST (D.P.M.). Section 2 of this publication is entitled "RULES PERTAINING TO PRESCRIBING, ADMINISTRATION AND DISPENSING OF MEDICATION." We strongly suggest you familiarize yourself with these rules and regulations based on the law.

2. Follow all of the steps described in the section on the successful management of non-terminal chronic pain.

3. Know that a medical record documenting all things is not only part of good patient management, but allows any outside agency (such as the Mississippi State Board of Medical Licensure) that may examine these records to have good insight into what was done, medications prescribed, dosage of medications, how often medication is given, and time period medication is prescribed.

4. Know that the Board will have no quarrel with you if:

(a) an appropriate good faith history and physical, along with other appropriate studies to make a diagnosis and to understand so far as is possible the mechanism of the pain;

(b) a plan of therapy is evolved and utilized using all the available modes of therapy available and appropriate for each particular patient;

(c) appropriate consultation is obtained;

(d) controlled substances are used only after all other measures and non-controlled analgesics are found to be ineffective; and

(e) all of this is timely and appropriately documented.

Bibliography

1. LAWS, RULES AND REGULATIONS GOVERNING THE PRACTICE OF PHYSICIANS (M.D./D.O.) AND PODIATRISTS (D.P.M.).

2. ACUTE PAIN MANAGEMENT - Clinical Practice Guideline. U.S. Department of Health and Human Services.

3. MANAGEMENT OF CANCER PAIN - A Clinical Practice Guideline. U.S. Department of Health and Human Services.

4. Several personal communications from physicians who are pain specialists.

5. Pain policies of a number (30 +) of the state medical boards.

6. Proceedings of a symposium entitled EVOLVING TRENDS IN THE MANAGEMENT OF CHRONIC PAIN, Editor Thomas G. Kantor, M.D., THE AMERICAN JOURNAL OF MEDICINE, Jul. 31,1996 Vol. 101(1A).

7. M.D. News, December, 1996 and March, 1997.

8. Continuing Controversies - Opioids and controlled substances in chronic benign pain - A survey of State Medical Boards, C. Norman Shealy, M.D., Ph.D., American Journal of Pain Management, Vol. 7, No. 1, January,1997, pp. 10-14.

 

NOTE: This broad overview is intended as a beginning effort to deal with a complicated subject. Response from anyone who has ideas will be welcomed. The Board will ask for a formal response by several of the pain specialists and addictionologists around the state to appear in succeeding newsletters.