WHAT A PAIN IN THE NECK!

WHAT A PAIN IN THE NECK!
Understanding the Role of the APRN in Pain Clinics

BY LINDA SULLIVAN, DSN, FNP-BC, PNP-BC, Director of Advanced Practice, Mississippi Board of Nursing

Chronic or acute pain are problems that have plagued man from the start of time.  Our forefathers had some interesting remedies for pain which included leeches, potions and even drilling into people’s skulls.   As recently as the 1950s, there were many interesting and sometimes smelly concoctions that momma always said worked. I wonder how many of you are old enough to remember the old Mustard Plaster?  Now there was a pain treatment!  In fact, we have always sought to treat pain in ways that were both efficient and effective and caused no problems either for the prescriber or the patient.

Being first thought of as a punishment from God, pain is now recognized as the most common problem reported by patients and often requires both pharmacological and non-pharmacological intervention. Ancient healers recognized the dangers associated with pain medications and sought other means of treating pain that did not involve drugs or herbs as used in those times. However, in the 1600s, the drugs of choice were opium and a mixture of opium and sherry called Laudanum for pain relief.  While effective in dealing with pain, these were highly addictive treatments and thus quickly fell into disfavor among health care providers and patients. The question, however, still exists today: how does one treat the pain and spare the patient from addiction or other harmful effects of pharmacological interventions?

Management of pain has long been a concern among health care providers and patients alike, and more than likely will continue to be a challenging aspect of care for all health care providers. In humans, pain is often considered the “fifth vital sign” that all health care providers must assess, but an accurate and correct assessment is a complicated and often elusive task. 

Despite the fact that pain is the oldest medical problem documented, we continue to have misunderstandings related to the physiology of pain.  In the mid 17th century, Rene Descartes was the first to propose a link between the mind-body connection associated with pain.  Melzac and Wall (1965) challenged the notion of a hard wire connection between mind and body and suggested that pain resulted from the integration of information from a variety of sources which can be modified by both emotional and behavioral information.  This information may then be interpreted within the spinal cord and taken to the brain for further interpretation.

Pain is a complex clinical problem. Assessment is dependent in part on verbal reports of the patient, and often these physical perceptions may be modified by cognitive and affective factors. The prevalence of pain as a problem in its own right has grown since 1945, and new therapeutic alternatives have developed from research and from new theoretical perspectives.   The birth of pain centers throughout the country is a relatively new phenomenon not being noted until around 1984-86.  This explosion requires the attention of health care providers and their licensing boards so as to ensure the safety of the patients and provide assurance that care is being delivered in these facilities at the highest level, resulting in the best possible outcomes.  Currently there are approximately 2,000 pain management programs, clinics and centers in the country.  Only about one-half of these are nationally accredited.  Accrediting bodies include the American Academy of Pain Management and the Commission on Accreditation of Rehabilitation Facilities (CARF).

The current concerns regarding pain management centers are multifaceted.  The first is, “Are the health care providers prepared appropriately?” The second is, “What standards of care are the treatment regimes based on, and how does one determine pharmacological versus non-pharmacological treatment plans?”  The next concern would be, “When is the appropriate time for a referral to be made to a pain center?”  Other concerns include; “How are drug seekers identified in these clinics?” “How long is too long to stay on a pharmacological controlled substance?”  “How often and by whom should the patient be re-evaluated?” And lastly, “What is the role of the advanced practice registered nurse in these clinics?”

To answer these questions, one has to consider many aspects of the pain care spectrum. Assessments and treatment plans can best be done when the health care provider has the appropriate education and training. Currently, anesthesiologists are trained in many aspects of pain management, and the advanced practice registered nurse (APRN) in many cases is working collaboratively with these physicians.  What the APRNs employed in these settings need to acknowledge is that they too need expanded training and education. Therefore, it is appropriate, and perhaps it should be mandatory, that all APRNs in pain clinics not only have a certain percentage of their continuing educational courses related to pain management but can demonstrate additional technical or “hands on” training in these areas.  In many states, APRNs that work in these settings have a mandatory participation in the National Association for Pain Management or the American Academy of Pain Management.

The importance of both continuing education and establishing appropriate collaborative agreements with those who are also experts in the area are critical to the success of the utilization of the APRN in pain management and can, in fact, add to the success of any pain management facility.  Knowledge of the latest and most appropriate tools in this arena is paramount to efficacious treatment of all patients. To this end, the development of policies that guide the practice of pain management are critical, and experts agree that these need to be clearly delineated and followed. National certification should be considered an indicator that there is a greater likelihood of having qualified providers, but again the lack of oversight in these areas makes gauging this marker difficult.
When a patient first arrives at a health care facility, whether it is a family practice or a pain clinic, it is important for the health care provider to gather information related to the past history of this problem.  Asking questions about what has been done to date regarding these problems is essential, and obtaining test results done prior to the visit to your clinic assists the health care provider in creating the most appropriate plan of care. Health providers should conduct a thorough assessment of pain experienced by a patient on a regular basis, according to a written protocol established by the health care facility or health care provider.  Pain shall be assessed in all patients using a combination of patient’s self report, an assessment, and/or a pain intensity tool. This self report includes answers to the questions related to when the pain started, location, duration, intensity and what makes it better and what makes it worse.  A pain intensity tool addresses the location, duration, onset, and characteristics of pain, the patient’s goals, and alleviation of causative factors. These may be used but again are subjective in nature and not necessarily accurate.  The first visit should also include an inventory of what medications are currently being used and a determination of the effectiveness of these drugs.  Appropriate studies that can support both the diagnosis and treatment plan should be ordered to validate the findings of these tools.  Physical examinations shall be conducted as indicated.  All these finding should be recorded in the patient’s record and be documented in a complete and thorough fashion.

All patients should be re-assessed on a regular basis for pain level and changes in pain, recorded according to a written protocol established by the health care facility or health care provider.  All pain assessments and re-assessments shall be documented in the patient’s clinical record.  More than one pain intensity tool may be used by the health care facility or health care provider.  At least annually, health care facilities shall ensure competency in pain assessment among appropriate clinicians as designated by the health care facility.  This can be accomplished by continuing education and peer evaluation.

Given the complexity of the problems associated with the management of pain, it is imperative that the advanced practice registered nurse is knowledgeable in the area of pain management so as to be considered a credible practitioner with expertise in this area if they choose to practice in the pain arena.  The importance of both continuing education and establishing appropriate collaborative agreements with those who are also experts in the area are critical to the success of the APRN in pain management and can add to the success of any pain management facility. •