Does screening for pain correspond to high quality care for veterans?

Prevalence of Pain and Associated Clinical Characteristics in 10-Year Survivors of Head and Neck Cancer

OBJECTIVE

Pain prevalence in long-term head and neck cancer (HNC) survivors is important but understudied to date. The present investigation examined pain prevalence, associated clinical characteristics, and disease-specific health-related quality of life (HRQOL) in a cohort of survivors 10 years postdiagnosis (N = 187).

STUDY DESIGN

Retrospective cohort study.

SETTING

Single-institution tertiary care center.

METHODS

Pain was assessed using a single-item numeric rating scale. Clinical characteristics were abstracted from the patient medical record and HNC-specific HRQOL scores were measured using the Head and Neck Cancer Inventory (HNCI) and are presented by the pain subgroup.

RESULTS

At 10 years postdiagnosis, 56.7% reported no pain, 20.3% reported mild pain, 16.0% reported moderate pain, and 7.0% reported severe pain. Most patients with moderate or severe pain at the 10-year follow-up assessment also had advanced-stage disease at diagnosis. Multiple linear regression analyses indicated that advanced-stage disease at diagnosis was a significant predictor of pain at 10 years postdiagnosis controlling for age, sex, and comorbidity status (β = .184, t = 2.193, P = .030, sr2 = 0.025). Across all HNC-specific HRQOL domains, those reporting moderate/severe pain at 10 years postdiagnosis failed to reach a score of 70 which is indicative of high functioning on the HNCI in the areas of aesthetics, eating, speech, and social disruption.

CONCLUSION

Pain is a significant issue in long-term HNC survivors up to 10 years postdiagnosis. More research is needed to understand the correlates and types of long-term pain exhibited after treatment, including the implementation of screening and intervention into clinical workflow to improve outcomes and optimize HNC survivorship care.

Patient and Caregiver Prioritization of Palliative and End-of-Life Cancer Care Quality Measures

BACKGROUND

Development and prioritization of quality measures typically relies on experts in clinical medicine, but patients and their caregivers may have different perspectives on quality measurement priorities.

OBJECTIVE

To inform priorities for health system implementation of palliative cancer and end-of-life care quality measures by eliciting perspectives of patients and caregivers.

DESIGN

Using modified RAND-UCLA Appropriateness Panel methods and materials tailored for knowledgeable lay participants, we convened a panel to rate cancer palliative care process quality measure concepts before and after a 1-day, in-person meeting.

PARTICIPANTS

Nine patients and caregivers with experience living with or caring for patients with cancer.

MAIN MEASURES

Panelists rated each concept on importance for providing patient- and family-centered care on a nine-point scale and each panelist nominated five highest priority measure concepts ("top 5").

KEY RESULTS

Cancer patient and caregiver panelists rated all measure concepts presented as highly important to patient- and family- centered care (median rating ≥ 7) in pre-panel (mean rating range, 6.9-8.8) and post-panel ratings (mean rating range, 7.2-8.9). Forced choice nominations of the "top 5" helped distinguish similarly rated measure concepts. Measure concepts nominated into the "top 5" by three or more panelists included two measure concepts of communication (goals of care discussions and discussion of prognosis), one measure concept on providing comprehensive assessments of patients, and three on symptoms including pain management plans, improvement in pain, and depression management plans. Patients and caregivers nominated one additional measure concept (pain screening) back into consideration, bringing the total number of measure concepts under consideration to 21.

CONCLUSIONS

Input from cancer patients and caregivers helped identify quality measurement priorities for health system implementation. Forced choice nominations were useful to discriminate concepts with the highest perceived importance. Our approach serves as a model for incorporating patient and caregiver priorities in quality measure development and implementation.

Cross Disciplinary Role Agreement is Needed When Coordinating Long-Term Opioid Prescribing for Cancer: a Qualitative Study

BACKGROUND

Cancer pain is highly prevalent and often managed in primary care or by oncology providers in combination with primary care providers.

OBJECTIVES

To understand interdisciplinary provider experiences coordinating opioid pain management for patients with chronic cancer-related pain in a large integrated healthcare system.

DESIGN

Qualitative research.

PARTICIPANTS

We conducted 20 semi-structured interviews with interdisciplinary providers in two large academically affiliated VA Medical Centers and their associated community-based outpatient clinics. Participants included primary care providers (PCPs) and oncology-based personnel (OBPs).

APPROACH

We deductively identified 94 examples of care coordination for cancer pain in the 20 interviews. We secondarily used an inductive open coding approach and identified themes through constant comparison coming to research team consensus.

RESULTS

Theme 1: PCPs and OBPs generally believed one provider should handle all opioid prescribing for a specific patient, but did not always agree on who that prescriber should be in the context of cancer pain. Theme 2: There are special circumstances where having multiple prescribers is appropriate (e.g., a pain crisis). Theme 3: A collaborative process to opioid cancer pain management would include real-time communication and negotiation between PCPs and oncology around who will handle opioid prescribing. Theme 4: Providers identified multiple barriers in coordinating cancer pain management across disciplines.

CONCLUSIONS

Our findings highlight how real-time negotiation about roles in opioid pain management is needed between interdisciplinary clinicians. Lack of cross-disciplinary role agreement may result in delays in clinically appropriate cancer pain management.

"Sometimes you wonder, is this really true?": Clinician assessment of patients' subjective experience of pain

BACKGROUND

Pain is a subjective experience that must be translated by clinicians into an objective assessment to guide intervention.

OBJECTIVE

To understand how patients' subjective experience of pain is translated by primary care clinicians into an objective clinical assessment of pain to effectively guide intervention.

METHODS

We conducted nine multidisciplinary focus groups with a combined total of 60 Veteran affair (VA) primary care providers and staff from two large VA medical centers in California and Oregon. We used content analysis methods to identify key themes pertaining to clinical assessment of a subjective experience.

RESULTS

We present four emergent themes. Theme 1: Pain is a highly individualized and subjective experience not adequately captured by a simple numeric scale; Theme 2: Conflict commonly exists between the patient's reported experience of pain and the clinician's observations and expectations of pain; Theme 3: Providers attempt to recalibrate the patient's reported experience to reflect their own understanding of pain; and Theme 4: Providers perceive that some patients may overreport their pain because they do not know how to standardize their subjective experience.

CONCLUSIONS

A persistent challenge to pain assessment and management is how clinicians reconcile a patient's subjective self-reported experience with their own clinical assessment and personal biases. Future work should explore these themes from the patient perspective.

Pain Screening in the Older Adult With Delirium

BACKGROUND

In patients with cognitive impairments who are unable to self-report pain, nurses must rely on behavioral observation tools to assess and manage pain. Although frequently employed in medical-surgical units, evidence supporting the psychometric efficacy of the Pain in Advanced Dementia (PAINAD) for pain screening in older adults with delirium is lacking.

AIM

To examine the psychometrics of the PAINAD for older adults with delirium in medical-surgical settings.

DESIGN

A descriptive repeated measures design.

SETTING

Medical-surgical units in an urban tertiary care hospital.

PARTICIPANTS

Sixty-eight older adults with delirium.

METHODS

Patients with delirium unable to self-report pain were screened by two data collectors with the PAINAD and the Critical Care Pain Observation Tool (CPOT). Patients with a PAINAD score ≥3 or a CPOT score ≥2 received a pain intervention. Pain assessments were repeated 30 minutes post baseline or pain intervention.

RESULTS

Patients were predominately female (58.8%) with dementia (71%). Thirty-nine patients screened positive for pain and received a pain intervention. PAINAD reliability was strong (Cronbach's α = 0.81-0.87; interrater intraclass coefficients [ICC] = 0.91-0.94; test-retest ICC = 0.76-0.77). Construct validity was supported by a statistically significant interaction effect between time (baseline versus follow-up) and condition (pain intervention versus no pain group; Rater 1: F(1,66) = 8.31, p = 0.005, η_p² = 0.11; Rater 2: F(1,66) = 8.22, p = 0.006, η_p² = 0.11.

CONCLUSIONS

The PAINAD is a reliable and valid tool for pain screening for older adults with delirium in medical-surgical settings.

CLINICAL IMPLICATIONS

Pain and delirium frequently co-occur in the older adult population. Best practices require a holistic assessment for contributing pain and non-pain factors in patients exhibiting distress.

"It Encourages Them to Complain": A Qualitative Study of the Unintended Consequences of Assessing Patient-Reported Pain

The "Pain as the 5th Vital Sign" initiative intended to address undertreatment of pain by encouraging routine pain assessment and management. In the Veterans Health Administration, routine pain screening has been practiced in primary care for more than a decade, but has not improved the quality of pain management measured using several process indicators, and some have expressed concerns of potentially fostering undesirable use of prescription opioids. We sought to evaluate the consequences of routine pain screening on clinical practice. We conducted 9 interdisciplinary focus groups with 60 primary care providers and staff from 5 outpatient Veterans Health Administration clinics. We identified 5 themes reflecting 1 intended and 4 unintended consequences of routine pain screening: it 1) facilitates identification of patients with pain who might otherwise be overlooked, 2) may need to be targeted toward specific patients and contexts rather than universally applied, 3) often shifts visit focus away from more emergent concerns, 4) may encourage "false positives" and prompt providers to intervene when treatment is not a priority, and 5) engenders a "pain problem" and hinders patients from considering alternative strategies. These findings suggest changes to support patient-centered pain assessment and improve targeted screening and interventions for population pain management.

PERSPECTIVE

This article describes some of the potential unintended consequences of implementing routine pain screening in primary care. This information may help clinicians be more strategic in their consideration and use of pain screening among their patients.

Screening using the fifth vital sign in the electronic medical recording system

Purpose

To investigate the usefulness of screening for patient symptoms as the fifth vital sign using an electronic medical recording system.

Patients and methods

In the electronic medical recording system, all admitted patients received routine nurse-based assessment of discomfort (defined as any physical symptom) at every vital sign check regarding item 2 of the Support Team Assessment Schedule Japanese version (STAS-J). All cancer patients admitted to oncology units were screened at 1-week intervals. Screening-positive was defined when patients had a STAS-J score of 2 or more at least two times in a week. For all screening-positive patients, the palliative care team reviewed each patient's medical records, and provided written recommendations as needed. The primary outcomes were the proportion of screening-positive patient, and the proportion of patients deemed to need additional palliative treatment in the screening-positive patients.

Results

Of 2427 patients screened, 223 (9.1%; 95% confidence interval, 8-10%) met the screening-positive criterion. A total of 12 (5.4%; 95% confidence interval, 3-9%) of them were deemed to need additional palliative care, including six patients referred to the PCT within 1 week. In the remaining 211 screening-positive patients, 100 had received adequate palliative care, 68 had already been referred to the palliative care team and 43 had self-limiting transient discomfort.

Conclusion

This screening system was feasible but the majority of screening-positive patients did not require additional palliative care interventions.

Improving pain care through implementation of the Stepped Care Model at a multisite community health center

PURPOSE

Treating pain in primary care is challenging. Primary care providers (PCPs) receive limited training in pain care and express low confidence in their knowledge and ability to manage pain effectively. Models to improve pain outcomes have been developed, but not formally implemented in safety net practices where pain is particularly common. This study evaluated the impact of implementing the Stepped Care Model for Pain Management (SCM-PM) at a large, multisite Federally Qualified Health Center.

METHODS

The Promoting Action on Research Implementation in Health Services framework guided the implementation of the SCM-PM. The multicomponent intervention included: education on pain care, new protocols for pain assessment and management, implementation of an opioid management dashboard, telehealth consultations, and enhanced onsite specialty resources. Participants included 25 PCPs and their patients with chronic pain (3,357 preintervention and 4,385 postintervention) cared for at Community Health Center, Inc. Data were collected from the electronic health record and supplemented by chart reviews. Surveys were administered to PCPs to assess knowledge, attitudes, and confidence.

RESULTS

Providers' pain knowledge scores increased to an average of 11% from baseline; self-rated confidence in ability to manage pain also increased. Use of opioid treatment agreements and urine drug screens increased significantly by 27.3% and 22.6%, respectively. Significant improvements were also noted in documentation of pain, pain treatment, and pain follow-up. Referrals to behavioral health providers for patients with pain increased by 5.96% (P=0.009). There was no significant change in opioid prescribing.

CONCLUSION

Implementation of the SCM-PM resulted in clinically significant improvements in several quality of pain care outcomes. These findings, if sustained, may translate into improved patient outcomes.

Stepped care model of pain management and quality of pain care in long-term opioid therapy

Successful organizational improvement processes depend on application of reliable metrics to establish targets and to monitor progress. This study examined the utility of the Pain Care Quality (PCQ) extraction tool in evaluating implementation of the Stepped Care Model for Pain Management at one Veterans Health Administration (VHA) healthcare system over 4 yr and in a non-VHA Federally qualified health center (FQHC) over 2 yr. Two hundred progress notes per year from VHA and 150 notes per year from FQHC primary care prescribers of long-term opioid therapy (>90 consecutive days) were randomly sampled. Each note was coded for the presence or absence of key dimensions of PCQ (i.e., pain assessment, treatment plans, pain reassessment/outcomes, patient education). General estimating equations controlling for provider and facility were used to examine changes in PCQ items over time. Improvements in the VHA were noted in pain reassessment and patient education, with trends in positive directions for all dimensions. Results suggest that the PCQ extraction tool is feasible and may be responsive to efforts to promote organizational improvements in pain care. Future research is indicated to improve the reliability of the PCQ extraction tool and enhance its usability.

Using health information technology to improve adherence to opioid prescribing guidelines in primary care

Objective:

To evaluate the impact of a clinical dashboard for opioid analgesic management on opioid prescribing and adherence to opioid practice guidelines in primary care.

Methods:

A pre/postimplementation evaluation using electronic health record (EHR) data from patients receiving chronic opioid therapy (COT) between April 1, 2011 and March 31, 2013. Measures include annual proportions of COT patients who received urine drug testing, signed an opioid treatment agreement, had a documented assessment of pain-related functional status, and had at least 1 visit with a behavioral health provider.

Results:

Adherence to several opioid prescribing guidelines improved in the postimplementation year compared with the preimplementation year: (1) the proportions of COT patients with a signed opioid treatment agreement and urine drug testing increased from 49% to 63% and 66% to 86%, respectively. The proportion of COT patients with a documented assessment of functional status increased from 33% to 46% and those with a behavioral health visit increased from 24% to 28%. However, there was a small decline in the proportion of patients prescribed COT from 3.4% to 3.1%.

Discussion:

Implementation of an opioid dashboard led to increased adherence to certain opioid practice guidelines and a decline in COT. This may be attributable to more efficient team-based pain management facilitated by the dashboard and increased transparency of opioid prescription practices. Health Information Technology solutions such as clinical dashboards can increase adherence to practice guidelines.

Routine screening for pain combined with a pain treatment protocol in head and neck cancer: a randomised controlled trial

BACKGROUND

We compared the effectiveness and cost of a pain screening and treatment program, with usual care in head and neck cancer patients with significant pain.

METHODS

Patients were screened for the presence of pain and then randomly assigned to either an intervention group, consisting of a pain treatment protocol and an education program, or to usual care. Primary outcome was change in the Pain Severity Index (PSI) over three months.

RESULTS

We screened 1074 patients of whom 156 were randomized to either intervention or usual care. Mean PSI was reduced over three months in both groups, with no significant difference between the two groups. The Pain Management Index (PMI) at three months, was significantly improved in the intervention group compared with usual care (P<0.001), as was Patient Satisfaction (mean difference in scores was statistically significant: -0.30 [-0.60 to -0.15]). All subjects reported clinically significant levels of anxiety and depression throughout the study. Treatment costs were significantly higher for intervention (mean=£400) compared with usual care (£200), with a low likelihood of being cost-effective.

CONCLUSIONS

There was no difference in the Pain Severity Index between the two groups. However there were significant improvements in the intervention group in patient satisfaction and PMI. The pain screening process itself was effective. Sufficient benefit was demonstrated as a result of the intervention to allow continued development of pain treatment pathways, rather than allowing pain treatment to be left to nonformalised ad hoc arrangements.

Towards a pain free hospital: an in-depth qualitative analysis of the pain experiences of head and neck cancer patients undergoing radiotherapy

BACKGROUND

Treatment for head and neck cancer can frequently be a painful experience with implications for patients in terms of quality of life, nutrition and ultimately treatment outcomes. Pain may arise for a number of reasons in this patient group including the influence of localised tissue damage from radiotherapy, the effects of chemotherapeutic agents as well as the disease process itself. Early identification of cancer pain, through screening and early analgesic and pain management are thought to be the most appropriate approaches to the problem.

AIM

To explore in-depth, patients' views of the experience of pain related to radiotherapy for head and neck cancer, within the context of a randomised controlled trial (RCT) of pain screening and intervention.

SAMPLE

A purposive sample of head and neck cancer patients undergoing radiotherapy who were participating in a separate RCT of a proactive pain screening intervention.

METHODS

A qualitative design using one-off, face-to-face, in-depth interviews. Data were inductively analysed for themes using thematic analysis. Data were collected from September 2012 to January 2013.

FINDINGS

Eight participants were interviewed. Several issues around pain management arose and the influence of various factors became apparent. Four dominant themes emerged: facets of radiotherapy pain in head and neck cancer, facilitators and barriers to pain management, pain services and finally interdisciplinary working.

CONCLUSION

The specific issues faced by head and neck cancer patients undergoing radiotherapy highlight the need for pain relieving interventions delivered by pain specialists, in tandem with the development of robust self-management strategies. An integrated approach to care is optimal, comprising pain screening at each outpatient encounter, and review by specialists as necessary.

The Quality of Pain Treatment in Community-Dwelling Persons with Dementia

BACKGROUND/AIMS

Despite pervasive and debilitating pain among elders, it is underassessed and undertreated; and cognitive impairment can add challenges. We assessed the quality of pain care for community-dwelling elderly patients with dementia.

METHODS

We phone interviewed 203 Veterans Affairs primary care outpatients with dementia and pain and reviewed medical records to score 15 quality indicators of pain assessment and management.

RESULTS

Pain assessment was documented for 98%, and a standard pain scale was used for 94%. Modified pain scales were rarely used. Though 70% self-reported pain of 'quite bad' or worse, charts documented no pain in 64%. When pain was identified, treatment was offered to 80%; but only 59% had a follow-up assessment within 6 months. Nonpharmacological interventions were underused.

CONCLUSION

Community-dwelling elders with dementia are underdiagnosed and undertreated for pain.

Survey of Primary-Care Providers on Perceived Benefits of and Barriers to PainTracker

Management of chronic pain is a common and complex challenge in primary care. Patient-reported outcomes surveys can help assist the patient with chronic pain to communicate the symptoms to their provider and engage the patient in treatment planning and evaluation to improve both quality of care and patient outcomes. A web survey was used to assess clinic providers' perceived ease of use, barriers to use, and clinical benefits of a patient-reported outcomes survey, termed PainTracker. More than half the respondents were satisfied with PainTracker and 76% of respondents agreed that PainTracker helps patients participate in their pain management. Although only a first step, this study helps evaluate the benefits of involving patients in their pain management care.

A postal screener for pain and need for treatment in older persons in primary care

OBJECTIVES

To test the Pain intensity, Enjoyment in life, General activity questionnaire (PEG) as a postal screener for pain in older persons.

DESIGN

Population-based survey. Postal screening questionnaires followed by an interview of a sample of participants.

SETTING

Family practices.

PARTICIPANTS

Persons aged 75 and older (N = 243; 95 interviewed).

MEASUREMENTS

Screening included the PEG, a three-item abbreviated version of the Brief Pain Inventory (BPI), plus an additional question on treatment need. Pain severity and related interference was assessed (BPI) during the interview, as was the current (need for) pain treatment.

RESULTS

The median PEG score of the 243 persons participating in the screening (response 76%) was 2.0 (interquartile range 0-4.7). Seventy-nine (35%) had moderate to severe pain (PEG score ≥ 4), of whom 56% reported current pain treatment and 15% stated that they might ask for help. For a PEG score cutoff of 4 or greater, sensitivity was 0.81 and specificity was 0.78 to find scores of 4 or greater on one or both BPI subscales during the interview. For the question on need for treatment, replies on the screener and the interview were not always consistent. Of the 43 interviewed participants with a PEG score of 4 or greater, 60% received treatment. Of the 17 without current pain treatment, 10 still reported pain, three of whom said that they might ask for help.

CONCLUSION

The PEG can be used as a postal screener to detect the presence of pain in older persons, but treatment needs cannot be established using the PEG alone or in combination with a simple additional question.

Preliminary validation of the Defense and Veterans Pain Rating Scale (DVPRS) in a military population

BACKGROUND

The Army Surgeon General released the Pain Management Task Force final report in May 2010. Among military providers, concerns were raised that the standard numeric rating scale (NRS) for pain was inconsistently administered and of questionable clinical value. In response, the Defense and Veterans Pain Rating Scale (DVPRS) was developed.

METHODS

The instrument design integrates pain rating scale features to improve interpretability of incremental pain intensity levels, and to improve communication and documentation across all transitions of care. A convenience sample of 350 inpatient and outpatient active duty or retired military service members participated in the study at Walter Reed Army Medical Center. Participants completed the five-item DVPRS-one pain intensity NRS with and without word descriptors presented in random order and four supplemental items measuring general activity, sleep, mood, and level of stress and the Brief Pain Inventory seven interference items. Using systematic sampling, a random sample was selected for a word descriptor validation procedure matching word phases to corresponding pain intensity on the NRS.

RESULTS

Parallel forms reliability and concurrent validity testing demonstrated a robust correlation. When the DVPRS was presented with the word descriptors first, the correlation between the two ratings was slightly higher, r = 0.929 (N = 171; P < 0.001), than ordering first without the descriptors, r = 0.882 (N = 177; P < 0.001). Intraclass correlation coefficient was 0.943 showing excellent alignment of word descriptors by respondents (N = 42), matching them correctly with pain level.

CONCLUSIONS

The DVPRS tool demonstrated acceptable psychometric properties in a military population.

The practitioner proposes a treatment change and the patient declines: what to do next?

OBJECTIVE

This study describes how pain practitioners can elicit the beliefs that are responsible for patients' judgments against considering a treatment change and activate collaborative decision making.

METHODS

Beliefs of 139 chronic pain patients who are in treatment but continue to experience significant pain were reduced to 7 items about the significance of pain on the patient's life. The items were aggregated into 4 decision models that predict which patients are actually considering a change in their current treatment.

RESULTS

While only 34% of study participants were considering a treatment change overall, the percentage ranged from 20 to 70, depending on their ratings about current consequences of pain, emotional influence, and long-term impact. Generalized linear model analysis confirmed that a simple additive model of these 3 beliefs is the best predictor.

CONCLUSION

Initial opposition to a treatment change is a conditional judgment and subject to change as specific beliefs become incompatible with patients' current conditions. These beliefs can be elicited through dialog by asking 3 questions.

How much time do low-income patients and primary care physicians actually spend discussing pain? A direct observation study

BACKGROUND

We know little about how much time low-income patients and physicians spend discussing pain during primary care visits.

OBJECTIVE

To measure the frequency and duration of pain-related discussions at a primary care clinic serving mostly low-income black patients; to investigate variables associated with these discussions.

DESIGN

We measured the frequency and duration of pain-related discussions using video-recorded primary care visits; we used multiple regression to evaluate associations between discussions and patient self-report variables.

PARTICIPANTS

A total of 133 patients presenting to a primary care clinic for any reason; 17 family medicine residents.

MAIN MEASURES

Independent variables were pain severity, health status, physical function, chief complaint, and whether the patient and physician had met previously. Dependent variables were presence of pain-related discussions and percent of total visit time spent discussing pain.

KEY RESULTS

Sixty-nine percent of visits included pain-related discussions with a mean duration of 5.9 min (34% of total visit time). Increasing pain severity [OR 1.69, 95% CI (1.18, 2.41)] and pain-related chief complaints [OR 4.10, 95% CI (1.39, 12.12)] were positively associated with the probability of discussing pain. When patients discussed pain, they spent 4.5% more [95% CI (0.60, 8.37)] total visit time discussing pain for every one-point increase in pain severity. Better physical function was negatively associated with the probability of discussing pain [OR 0.65, 95% CI (0.48, 0.86)], but positively associated with the percent of total visit time spent discussing pain [3% increase; 95% CI (0.32, 5.75)] for every one-point increase in physical function). Patients and physicians who had met previously spent 11% less [95% CI (-21.65, -0.55)] total visit time discussing pain. Pain severity was positively associated with time spent discussing pain only when patients and physicians had not met previously.

CONCLUSIONS

Pain-related discussions comprise a substantial proportion of time during primary care visits. Future research should evaluate the relationship between time spent discussing pain and the quality of primary care pain management.

Measuring pain impact versus pain severity using a numeric rating scale

BACKGROUND

Routine assessments of pain using an intensity numeric rating scale (NRS) have improved documentation, but have not improved clinical outcomes. This may be, in part, due to the failure of the NRS to adequately predict patients' preferences for additional treatment.

OBJECTIVE

To examine whether patients' illness perceptions have a stronger association with patient treatment preferences than the pain intensity NRS.

DESIGN

Single face-to-face interview.

PARTICIPANTS

Outpatients with chronic, noncancer, musculoskeletal pain.

MAIN MEASURES

Experience of pain was measured using 18 illness perception items. Factor analysis of these items found that five factors accounted for 67.1% of the variance; 38% of the variance was accounted for by a single factor labeled "pain impact." Generalized linear models were used to examine how NRS scores and physical function compare with pain impact in predicting preferences for highly effective/high-risk treatment.

KEY RESULTS

Two hundred forty-nine subjects agreed to participate. Neither NRS nor functioning predicted patient preference (NRS: χ2 = 1.92, df = 1, p = 0.16, physical functioning: χ2 = 2.48, df = 1, p = 0.11). In contrast, pain impact was significantly associated with the preference for a riskier/more effective treatment after adjusting for age, comorbidity, efficacy of current medications and numeracy (χ2 = 4.40, df = 1, p = 0.04).

CONCLUSIONS

Tools that measure the impact of pain may be a more valuable screening instrument than the NRS. Further research is now needed to determine if measuring the impact of pain in clinical practice is more effective at triggering appropriate management than more restricted measures of pain such as the NRS.

From documentation to the problem: controlling postoperative pain

PROBLEM

Adequate pain control continues to be an enigma in the face of the Joint Commission (TJC) well-intended pain management standards. Notable in the pain standards is the mandate to make pain the fifth vital sign to increase pain visibility and awareness.

METHOD

The following databases were searched: EBSCOHost, CINHAL, PubMed Central, Medline, and government/societies sites for guidelines on pain control. Various search terms used included pain, post operative pain, pain control, pain as the 5th vital sign, pain documentation, pain assessment, Joint Commission Pain Standard, PRN effectiveness, and pay-for-performance.

FINDINGS

Accredited facilities are mandated to have plans to assess for pain and evaluate pain management effectiveness. These mandates have necessitated a flurry of initiatives and programs by hospitals and healthcare facilities focusing on documentation processes to meet TJC compliance. Notable programs include Pain as the 5th Vital Sign and PRN (as needed) effectiveness documentation. Many facilities have programs to assess and document pain but lack programs that effectively control patient's pain.

CONCLUSION

This article is a call for facilities to refocus on pain control. A need to evaluate current programs by facilities is evident. Studies show that Pain as the 5(th) Vital Sign and PRN effectiveness documentation are not effective and invariably have not met the goals of TJC pain standard--adequate and effective pain control.

Implementation of the veterans health administration national pain management strategy

Since its introduction in 1998, the VHA National Pain Management Strategy has introduced and implemented a series of plans for promoting systems improvements in pain care. We present the milestones of VHA efforts in pain management as reflected by the work of the Strategy. This includes the development of the Strategy and its current structure as well as a review of important initiatives such as "pain as the fifth vital sign" and the stepped care model of pain management.

Prescription sharing, alcohol use, and street drug use to manage pain among veterans

CONTEXT

Efforts to promote awareness and management of chronic pain have been accompanied by a troubling increase in prescription medication abuse. At the same time, some patients may misuse substances in an effort to manage chronic pain.

OBJECTIVES

This study examines self-reported substance misuse for pain management among veterans and identifies the contributing factors.

METHODS

We analyzed cross-sectional data from the Help Veterans Experience Less Pain study.

RESULTS

Of 343 veterans, 35.3% reported an aberrant pain management behavior (24% reported using alcohol, 11.7% reported using street drugs, and 16.3% reported sharing prescriptions to manage pain). Poorer mental health, younger age, substance use disorders (SUDs), number of nonpain symptoms, and greater pain severity and interference were associated with aberrant pain management behaviors. In multivariate analysis, SUDs (odds ratio [OR]: 3.9, 95% confidence interval [CI]: 2.3-6.7, P<0.000) and poorer mental health (OR: 2.3, 95% CI: 1.3-4.3, P=0.006) were associated with using alcohol or street drugs to manage pain; SUDs (OR: 2.4, 95% CI: 1.3-4.4, P=0.006) and pain interference (OR: 1.1, 95% CI: 1.0-1.2, P=0.047) were associated with prescription sharing; and SUDs (OR: 3.6, 95% CI: 2.2-6.1, P<0.000) and number of nonpain symptoms (OR: 6.5, 95% CI: 1.2-35.4, P=0.031) were associated with any aberrant pain management behavior.

CONCLUSION

Veterans with a history of SUDs, greater pain interference, more nonpain symptoms, and mental health concerns should be carefully managed to deter substance misuse for pain management.