- The Washington Times - Tuesday, December 26, 2000

When you enter a hospital, you have a right to have your pain properly treated.

That sounds like common sense, yet millions of Americans suffer every day because pain is routinely ignored or undertreated.

But starting next week, the nation's hospitals must make a major change: New standards require that every patient's pain be measured regularly from the time they check in just like other vital signs are measured and proper pain relief be provided.

The rules also put hospitals at risk of losing their accreditation over the issue.

Patients should expect at least to be asked to rate how they're feeling, from zero (no pain) to 10 (the worst pain imaginable). Small children will use pictures to rate pain. The score determines what steps the hospital must take to help.

To stress how important the changes are, the new standards actually put in writing that "patients have the right" to proper pain assessment and treatment.

Some hospitals already are handing out leaflets and posting signs in the halls telling patients about that right, so they know it's OK in fact, crucial to complain if a doctor or nurse doesn't help.

Better, it's not just hospitals that must take the new steps, but nursing homes and outpatient clinics accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The commission adopted the standards more than a year ago but gave facilities until January to comply.

It's "a watershed event," said Dr. Russell Portenoy, pain medicine chairman of New York's Beth Israel Medical Center. "No one has ever promised patients no pain. But what JCAHO wants to do is promise people their pain will be assessed and managed in a state-of-the-art way."

Many centers still are scrambling to comply. Teaching health workers who aren't pain specialists how to treat pain can take some time and many doctors inappropriately shun narcotics, a treatment mainstay for numerous types of pain, because they think patients will get hooked on them.

"This is not going to happen overnight," cautioned American Pain Society president-elect Christine Miaskowski, nursing chair at the University of California at San Francisco.

"Patients are going to have to demand better care," she said. "Unrelieved pain has negative effects. Just like they need an antibiotic to treat infection, they need analgesics to treat their pain."

But many patients don't know they don't have to suffer or that pain is more than bothersome, it actually hinders healing.

So being a stoic isn't good. Revealing how much pain you're in doesn't "bother the doctors" or distract them from treating your underlying disease, common excuses.

"People think it's like an 11th commandment: 'Thou had surgery, thou should have pain.' … Or that if you have cancer, you must have pain," said June Dahl, a University of Wisconsin pain specialist who helped write the standards. "Pain can be relieved."

How big is the problem? Cancer provides the best estimates: About 40 percent of cancer patients have undertreated pain. One in four elderly cancer patients in nursing homes receives no treatment at all for daily pain. Last year, Oregon's medical board disciplined a doctor for treating a dying cancer patient's pain with Tylenol.

Look beyond hospitals and some 9 percent of Americans suffer chronic pain, ranging from back injuries to rheumatoid arthritis. Specialists say four of every 10 patients with moderate to severe pain don't get adequate relief.

One of the biggest challenges is teaching nonspecialists that narcotic painkillers such as the opiates morphine and codeine and synthetic opioids such as fentanyl are the mainstay for many types of pain, Dr. Portenoy says.

Many doctors hesitate to prescribe opiates or opioids because they are heavily regulated and can be abused by addicts. Morphine and codeine, for example, are derived from the same poppy plant as heroin.

But for people who have never abused drugs and have no history of psychological problems, hardly any become dependent on pain medicine, Miss Miaskowski said.

Another complaint, heavy sedation, usually wanes in three to four days, she said.

So what's "state-of-the-art" treatment? For moderate to severe pain from acute illness or surgery, expect a short-acting opioid like Percocet, or morphine in a patient-controlled quick-dose pump. For cancer, expect a long-acting version of morphine or oxycodone, or a fentanyl skin patch.

For chronic pain not due to cancer, new guidelines recommend similar narcotics.

Methadone is an alternative when those drugs fail, and doctors also are trying antidepressants and antiseizure drugs like gabapentin for patients with nerve-related pain.

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