The article is from the June 2008 issue of Practical Pain Management.
"As the public becomes increasingly aware of the availability of potent drugs for pain relief, the number of patients seeking pain management is rising. Unfortunately, because of addiction issues, fear of regulatory scrutiny, and lack of knowledge, many primary care physicians are reluctant to maintain patients who have chronic non-cancer pain on opioids. Ever-increasing numbers of such patients are getting referred by primary care providers to pain specialists for initial evaluation and treatment but, when the treatment includes chronic opioids, many internists and family physicians are reluctant to take back the patients and continue prescribing scheduled drugs for them. As a result, pain specialists are left with an ever-growing number of patients in their clinics who require ongoing follow-up for medication management.
Medication management of chronic pain can be time-consuming and complex. Chronic pain patients are often depressed because of the adverse consequences that their pain syndromes have had on their lives. Typically, they are initially defensive because previous health care providers, family, and/or friends may not have taken the patient's pain problem seriously enough or expressed that "it's all in your head." Such patients need an empathetic ear and respectful treatment. Additionally, if opioids are prescribed, their use requires not only familiarity with the drugs, but also attention to potential problems of abuse and addiction. Patients who are on chronic opioids need to be seen on a regular basis (every 1-3 months) to be monitored and reassessed. All these factors make medication management of chronic pain a time consuming process-something that many physicians are reluctant to undertake.
Fortunately, a new paradigm is emerging that can alleviate the shortage of health practitioners who will provide medication management of chronic pain patients. Nurse Practitioners (NPs) and Physician Assistants (PAs) are taking an increasingly active role. Currently, pain clinics are often headed up by one or more interventionalists (often, anesthesiologists) whose focus is on invasive procedures. Some of them also provide pharmacologic treatment.
Recognizing the need for medication management, pain clinics are increasingly hiring physician assistants, nurse practitioners, and nurses to assess the patients, prescribe pain medications, and monitor the patients' progress with follow-up visits and clinical urine drug testing. In some practices, the clinician providers function fairly independently in their role of medication management while in others there is an ongoing collaboration with the physicians.
In yet other pain clinics, the physicians initiate invasive and/or medication treatment, and then collaborate with NPs and PAs to extend their reach and to reduce the overall cost of long-term medical management of their patients. Additionally, those NPs and PAs ''lith additional training in pain medicine have, at times, found homes in primary care practices, where they can provide pain management services that might othenvise not be available.
Articles about nurses' role in pain management are increasingly appearing in the nursing literature. For example, the role of nurses in a pain and palliative care program established at the Veterans Administration Medical Center in Salt Lake City in 1999 was provided by Jennings.' More recently, Kaasalainen et al surveyed 16 nurse practitioners in long-term care facilities in Ontario, Canada, and found that a gap in physician availability exists in such facilities but that the available NPs are not being used to their full potential in managing pain among elderly residents. The barriers to NP pain management included time constraints; prescribing restrictions; lack of knowledge; difficulties in assessing pain; physician, staff, resident, and family reservations about use of opioids; and poor collaboration with physicians.
Next week: The Role of Physician vs. Non-Physician Provider...
