| HOME | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|---|
| ||||||||||||||||||||||||||||||
Guest Editorial |
a Division of Geriatrics, Saint Louis University, and Geriatric Research Education and Clinical Center, St. Louis Veteran's Administration, Missouri
Joseph H. Flaherty, Division of Geriatric Medicine, St. Louis University School of Medicine, 1402 South Grand Boulevard, M238, St. Louis, Missouri 63104 E-mail: flaherty{at}slu.edu.
Decision Editor: John E. Morley, MB, BCh
WHENEVER a person has contact with the health care industry, they need to be asked if they have pain. In 1999, the Veteran's Administration declared "war" on pain by making it their 5th vital sign (1), and at the beginning of 2001, the Joint Commission on Accreditation of Health Care Organizations has warned that it will be looking at organizations' pain assessments in their accreditation judgments (2). So how can the two studies about pain in this month's Journals (3)(4) help us in this fight against pain?
First, both studies provide evidence that pain assessment does not have to involve highly technical instruments such as a multicolored doppler or some fancy nuclear medicine imaging procedure. Engel and colleagues (3) show directly that nursing assistants' (NA) assessment of pain is unbiased and more accurate in some respects (concerning pain intensity) than higher-trained licensed practical nurses (LPN). Snih and colleagues (4) show that asking one simple question may help predict future disability: "In the past month, did you notice any pain or discomfort when you stood or walked?" This question was asked by research assistants, who may or may not have had a medical background. Thus, someone, anyone, and in the best situation, everyone, involved in the care of the patients should be asking about pain.
Second, the study by Snih and colleagues (4) gives us hope that fighting the war against pain can help our health care system, not just the patient. In fact, not treating pain may be costly. Snih and colleagues (4) show that pain may predict future disability. This loss of function can be very costly in terms of caregiver burden and long-term institutionalization (5)(6). The question is not whether or not we should treat pain more aggressively, but, rather, if we aggressively treat chronic pain, can we prevent disability-associated negative outcomes? The answer must be yes. Although it is comforting to know that we are starting to put pain control a little higher on the health care priority list, we have to admit that this may be a bit of an uphill battle. What are the researchers of chronic pain up against? Two examples are the lipid-lowering statins used to prevent myocardial infarction and the newer antiplatelet drugs used to prevent strokes. These are expensive treatments, but the medical and lay communities have accepted these because they know how disabling stroke and myocardial infarction can be. So whether it is medication or nonpharmacological modalities to control pain, the onus is on researchers to prove that not only do these treatments work (i.e., control pain) but that these treatments prevent disability associated with pain.
Snih and colleagues (4) are very aware of how important this relationship is between pain and disability. They do a good job of challenging the accepted belief that disability is primarily related to the common chronic diseases. In their fourth logistic regression model predicting the odds of lower body activities of daily living disability, they controlled for depression, diabetes, stroke, heart attack, and cancer, all potentially debilitating diseases. Pain and depression remained independent predictors of lower-body disability. In another logistic regression model predicting the inability to perform tandem balance, 8-foot walk, and chair stands, only pain remained an independent predictor, whereas the other chronic diseases fell out of the model. Is this true? Is pain a better predictor of disability than these common chronic illnesses? The data are not that strong, and the study looks only at the incidence of disability over a 2-year period. However, the data do suggest that any future interventional studies on chronic illnesses, such as diabetes or cardiovascular disease, need to evaluate pain as a baseline-confounding characteristic in study patients, or else the negative outcomes of disability will be skewed toward those with pain.
Another hypothesis generated from these data is whether or not pain in patients with chronic illnesses is a predictor of other outcomes besides disability, such as hospitalization. An analogy to this is the fact that patients with chronic illnesses who are depressed, compared with those who are not depressed, not only have more disability (7)(8), but intervening may decrease the rate of hospitalization (9). Thus, future studies on pain would be much more powerful if they could show positive outcomes, such as prevention of hospitalization.
The third helpful piece of information these studies offer is that this war against pain will not cost an arm and a leg. Consider the cost of evaluation of pain versus that of stroke or myocardial infarction. The study by Engel and colleagues (4) shows that some of the lowest-paid persons can evaluate pain (which tells us maybe we need to pay them more!), whereas it takes highly paid neurologists (who come with their mandatory MRI and myriad other highly technical procedures) and cardiologists (who come with a number of fancy tools that only they have been trained to interpret) to evaluate cerebrovascular and cardiovascular disease. The cost of treatment of pain versus cerebrovascular and cardiovascular is definitely comparable when we consider the number of patients needing medications to show a beneficial outcome. For example, the use of higher-priced antiplatelet agents (clopidrogel and ticlopidine) versus aspirin would prevent approximately 1 (CI 0.2–1.9) cerebrovascular event per 100 patients treated over a period of 2 years (10). In another meta-analysis of five large cardiovascular disease-related randomized controlled trials of a mean duration of 5.4 years (combining primary and secondary prevention trials), the number needed to treat with lipid-lowering statins to prevent one major coronary event was 28 (CI 23–34) (11). Even if one assumes that all patients with a cerebrovascular or cardiovascular event go on to become disabled, the amount of medication costs to prevent cerebrovascular disability (treat 100 patients at approximately $75/mo x 24 months = $180,000 to prevent 1 patient from becoming disabled) or cardiovascular disability (treat 28 patients at approximately $75/mo x 60 months = $126,000 to prevent 1 patient from becoming disabled) is quite high. In comparison, if a high-potency narcotic (even if it costs $200/month) can prevent disability in as few as 1 in 25 patients over a period of 24 months, the sum cost would still be less than that of the statins and the antiplatelet agents ($200/mo x 24 months x 25 patients = $120,000).
In all fairness, though, myocardial infarction and stroke are serious causes of mortality, and science has come a long way to curb these number one and three killers in the United States. So would it be unfair not to consider in this financial equation the mortality risk associated with pain? Clearly not as strong an argument as that for stroke and myocardial infarction, but there is something here to think about. A longitudinal study of 1930 Swedes born between 1892 and 1915, who were interviewed in 1968, 1974, and 1981, found associations between mortality risk and pain in the following five areas: chest pain, abdominal pain, headache, rectal pain, and pain in the extremities (10). Whereas we might be able to explain the first four associations as "pain was a marker or symptom of a serious underlying disease" (e.g., cardiovascular), pain in the extremities (hands, elbows, legs, and knees, according to the interview) likely refers to arthritic-type pain. In the end, however, using decreased mortality as a reason to treat pain will likely not be the best strategy. In this study and in other studies, no associations were found between mortality risk and pain in the back and hips (12)(13)(14).
The fourth piece of strategic information we get from these studies is that both studies involve minority populations. Almost 80% of patients in the study by Engel and colleagues (3) were African American, and all of the patients in the study by Snih and colleagues were Mexican American. Thus, unlike the high-cost cardiology studies (15), we do not have to extrapolate data based on white middle-aged men and apply them to our often underserved minority patient population.
The last thing these studies do is to tell us that even though we are fighting a very important war, we have a long fight ahead of us. Neither study indicated that pain evaluation and treatment are adequate. The NAs and the LPNs in the study by Engel and colleagues (3) do only a fair to good job of judging patients' pain frequency and intensity compared with residents' subjective assessments. The study by Snih and colleagues finds a prevalence of pain (on the basis of the answer to their one simple question) of 30.3%, which they say may be an underestimation. But do not give up hope. Pain assessment and treatment are and will continue to become more feasible. Even in a study of patients with a mean Folstein Mini-Mental State exam of 12 ± 7.9, it was found that 83% of patients who had pain could complete at least one of the pain scales (16). Furthermore, even older frail patients can, and should when necessary, be treated with narcotics.
In conclusion, these two studies are a piece of ammunition in the armamentarium in the war on pain. They should give future researchers encouragement that pain evaluation does not take superhuman technology, but superhumane assessments, and that interventions that fix pain need to look at major outcomes, such as disability and utilization of health care resources. For clinicians, these studies are a call to arms, so that if an "abnormal" pain vital sign shows up in a patient's charts, whether it is written by the medical students or nurses assistants, they will know that it may be as serious as a heart attack and that treating it will greatly benefit the patient.
Received February 20, 2001
Accepted February 21, 2001
References
This article has been cited by other articles:
 |
|
 |
|
  A. L Harrison The Influence of Pathology, Pain, Balance, and Self-efficacy on Function in Women With Osteoarthritis of the Knee Physical Therapy, September 1, 2004; 84(9): 822 - 831. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. E. Morley Editorial: Hot Topics in Geriatrics J. Gerontol. A Biol. Sci. Med. Sci., January 1, 2003; 58(1): M30 - 36. [Full Text] [PDF]
|
|
|
|
|
|
J. E. Morley, H. M. Perry III, and D. K. Miller Editorial: Something About Frailty J. Gerontol. A Biol. Sci. Med. Sci., November 1, 2002; 57(11): M698 - 704. [Full Text] [PDF]
|
|
|
|
|
|
J.-P. Michel, S. Pautex, D. Zekry, G. Zulian, and G. Gold End-of-Life Care of Persons With Dementia J. Gerontol. A Biol. Sci. Med. Sci., October 1, 2002; 57(10): M640 - 644. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. E. Morley and J. H. Flaherty Editorial: Putting the "Home" Back in Nursing Home J. Gerontol. A Biol. Sci. Med. Sci., July 1, 2002; 57(7): M419 - 421. [Full Text]
|
|
|
|
|
|
J. E. Morley and J. H. Flaherty Editorial It's Never Too Late: Health Promotion and Illness Prevention in Older Persons J. Gerontol. A Biol. Sci. Med. Sci., June 1, 2002; 57(6): M338 - 342. [Full Text]
|
|
|
|
|
|
J. E. Morley Editorial: Drugs, Aging, and the Future J. Gerontol. A Biol. Sci. Med. Sci., January 1, 2002; 57(1): M2 - 6. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||
| HOME | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|---|
