Each month, Dr. Lynette Menefee tackles pressing issues in pain management with one of the nation's leading practitioners. This month, Dr. Menefee speaks with Maripat Welz-Bosna, RN, MSN, who has worked as the Clinical Nurse Coordinator for the Comprehensive Pain/Rehabilitation Program at Drexel University College of Medicine.

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Questions

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Dr. Lynette Menefee: Maripat Welz-Bosna, as a nurse practitioner specializing in pain medicine, we are very happy to talk with you today about pain medicine in nursing and about the use of opioids for treatment of nonmalignant pain.

There aren’t many nurses like you - with a particular interest in pain medicine - are there?

Maripat Welz-Bosna: I am not sure of the exact numbers, but those who work in pain are growing. There are a few very important nursing organizations such as the American Society of Pain Management Nurses [ASPMN], and the American Pain Society [APS], that have a large membership. Those who work in pain cover a broad spectrum of nursing disciplines from research to post-op.

LM: How did you become interested in pain medicine?

MWB: It was one of those things "Be careful what you ask for, you just might get it!" My background prior to pain medicine was Oncology and then Hospice nursing for many years. During my hospice career, I was called to go into hospitals or nursing homes when a referral had been made. I remember going into one hospital where the pain management nurse had made the referral. She explained that she worked in the hospital and helped with pain consults, and that began my curiosity with the specialty.

After I left my job as a hospice care nurse, I was offered a position as a pain management nurse at one of the University hospitals in the area. Little did I know that I would be working with one of the leading physicians in the area of pain medicine. At the time I began working with this physician, I was very familiar with the use of opioids for pain, specifically cancer pain. However, I had no idea of the prevalence of non-malignant chronic pain. I also was unfamiliar with all the various adjuvant medications, which can be used for chronic pain.

LM: What do nurses learn about pain management in their training? Do you think that training is changing with the Joint Commission’s new standards?

MWB: I do believe that JCAHO has made an impact on people’s awareness of the prevalence of pain, and that physicians and nurses need to take a patient’s statement of pain seriously. On the other hand, I believe there is still a long way to go in changing people’s stereotypes and really changing the culture within hospitals. In my nursing training, it wasn’t until my masters/advanced training that pain became a focus; and to a point, it was because I chose to make it my focus. Prior to this, it was not elaborated on during nursing school. We were all taught, "pain is whatever the patient says it is", but then we were never really taught the practice of titrating medications for the use of pain. We were never taught that pain itself could be a medical diagnosis, or the existence of a multitude of chronic pain diagnoses.

LM: Can you give a personal example of how expert training in pain makes a difference in nursing care?

MWB: I think if nurses and physicians were given training in pain medicine starting early and continuing throughout school, including clinical rotations and residency, there would be a lot less personal bias. Additionally patients could potentially be diagnosed and treated earlier.

I remember doing my first H&P on a woman with Complex Regional Pain Syndrome. Here was a woman sitting across from me, stating that she felt as if "her entire left foot was on fire." She was unable to wear shoes on that foot and she said that her bed sheets made her have shooting pains up her leg. At that time I was unfamiliar with this pain syndrome. And unfortunately there is very little testing that can be done to help with a diagnosis, so that makes all pain syndromes difficult for those in the medical profession. Additionally, pain is subjective, which makes it difficult for some to understand or believe. It’s really important for clinicians to be aware of all the factors that can contribute to a patient’s pain, and not to just be focused on what is causing the pain.

I remember speaking with one of our new patients after his evaluation and him telling me that no other program had been so thorough in evaluating him [our average is 1-2 hours] and that no other program had asked how "he was feeling". No one had evaluated him for depression; no one had ever asked how well he was sleeping, or how his chronic pain was affecting his family relationships. No one had asked how his pain was affecting him at work and did he feel stress from his employer. It was at this time I began to understand how pain affects the whole person, and how caring for a patient with chronic pain can be a balancing act. All areas of a patient’s life must be addressed if one is to truly treat them well.

LM: Do you have any thoughts on critical things to consider when working with a chronic pain patient?

MWB: I work and have been trained that a chronic pain patient needs comprehensive treatment. If you have a patient who suffers with chronic pain and you focus only on the pain, while never addressing other psychosocial issues that may be present, a patient will not have a good outcome. The same is true for the physician who never deals with a patient not sleeping at night, or waking frequently due to pain. The lack of sleep will then carry over to the day and in most cases, increase a patient’s pain, and at times increase a patient’s depression. One must take a holistic approach in the care of pain patients to achieve the best outcome.

LM: There’s a perception – perhaps it’s wrong – that oncology nurses are better with pain management than nurses in a post-operative setting. Is this true? Is there still the perception among nursing staff that patients who want or request opioids are drug seeking or addicts?

MWB: I believe that both nursing disciplines are good in pain management, but again, in different ways. Post-operative nursing is dealing with acute pain from surgery. They may be more familiar with epidural analgesia than the oncology nurse. On the other hand, those in oncology may be more familiar with titration of an opioid from one route to another, or the use of adjuvant medications for the treatment of pain.

I do believe there is still a lot of misconception that a patient requesting medication for pain is drug seeking. There is also the misconception that if a chronic pain patient comes in for surgery, they do not require additional amounts of an opioid for pain control. Often if a pain patient undergoes selective surgery, they are instructed that the medication they are already taking for their chronic pain "should be enough to take away their post-op pain". When they request additional medication, they are often denied medication or classified as drug seeking. I have found with many of our patients, when they have been required to be hospitalized for something not related to their pain syndrome, they are often denied their regular dosage of medication, or if converted from an oral dosage to PCA they are converted to a much lower amount.

For many of our patients who require surgery, we often send a letter to the treating physician with the patient’s oral opioid dosage and the conversion dosage for PCA. We ask that if there are any concerns or questions, to please contact us directly. This has worked well for many of our patients. But there have been cases when a patient has been denied their medication, and the physician in charge of the patient’s hospitalization refused to call or page us.

LM: From a nursing perspective, what are the biggest barriers you see to adequate pain treatment for patients with pain?

MWB: Access to comprehensive care. I help to answer questions and monitor a website for chronic pain patients run by the National Pain Foundation (sponsored by the American Academy of Pain Medicine Physicians). The most frequently asked question on the site is "I live in such-and-such area, do you know of any physicians who work with chronic pain patients?" The second most frequently asked question is help in finding a physician willing to continue medication management for their chronic pain. It is extremely difficult for pain patients today to find a physician willing to see them on a long-term basis and continue to prescribe their medications.

I have found that patients in rural areas rarely find a physician willing or able to treat chronic pain. Those who live in metropolitan areas are able to find a pain physician, however these physicians are spread so thin that in some cases there is a 3-6 month wait time for an initial evaluation.

There is a great lack of pain medicine physicians who just provide medication management. A patient can find numerous physicians willing to perform procedures for their pain syndrome, but when a patient just requires good medication management, these physicians are few and far between!

LM: Thank you for talking with us today, Ms. Welz-Bosna. You are doing very important work and we wish you well.