NEW EFFORTS AGAINST AN OLD FOE: PAIN

When Frances first entered the Brandywine Nursing Home in Briarcliff Manor,
N.Y., with chronic obstructive pulmonary disease, diabetes and severe
osteoporosis, she was suffering from intense pain in her back and hips.
Doctors there prescribed mild pain medicines including Tylenol, but nothing
brought relief.

"I felt that they didn't really understand the extent of my pain," said
Frances, 57, who spoke on the condition that she not be further identified.
"I think they felt it was just arthritis and it wasn't serious, but it was
very debilitating. Some nurses would dismiss the pain as just anxiety."

At the time, Frances said she could sit in a chair for only a half-hour
before excruciating pain sent her back to bed.

But a year after she arrived, in 1997, Brandywine began an innovative
program aimed at treating pain better. Jill L. Loeb, a nurse who
specializes in pain management, required pain assessments for each patient
and treatment with medications or nondrug approaches like relaxation
techniques, massage and even comfort food.

In adopting these steps, Brandywine is part of a movement that is sweeping
the medical care system, changing how pain is being treated in hospitals,
nursing homes, home health care agencies, outpatient medical centers,
mental health facilities and elsewhere.

Last January, the Joint Commission on Accreditation of Healthcare
Organizations, which accredits the majority of the country's medical
facilities, developed new mandatory standards for the assessment and
treatment of pain. It was the first time that the Joint Commission or any
other accrediting body had issued standards focusing on pain, or any
specific symptom.

By next month, surveyors will begin scoring pain management programs and
applying the results in accreditation.

"Institutions are scrambling now to figure out how they are going to meet
the standards and what they need to do to properly deal with patients in
pain," said Jim Guest, executive director of the American Pain Foundation,
a consumer advocacy group based in Baltimore. "Over time the standards will
get patients better care and less pain."

The standards require medical institutions to recognize and inform patients
about their right to appropriate pain assessment and treatment. The
assessment includes the level and characteristics of pain in every patient,
using pain scales like a 0-to-10 rating scale or pictures of expressive
faces for children.

For instance, in a home-care settings, visiting nurses would now be
required to ask clients' level of pain and to refer them for treatment if
necessary. The standards also require institutions to develop protocols for
treatment. If a patient's pain score rises above four, a pain specialist
may be automatically called in for a consultation, for example.

The standards require physicians to treat pain until it is relieved, when
possible, and they mandate education on pain management for doctors, nurses
and other health care workers.

Since the early 1970's a growing body of evidence has shown that pain is
grossly undertreated in this country. More recent research that revealed
inept treatment of pain made it a priority for the Joint Commission, which
began working on the guidelines in 1997.

One study, published in The New England Journal of Medicine in 1994, found
that of 1,308 outpatients with metastic cancer, 42 percent of those with
pain were not given adequate pain medicine. In 1992, the Agency for
Healthcare Research and Quality, a research branch of the United States
Department of Health and Human Services, concluded that half of the people
who have surgery have inadequate pain relief.

"Every year since then, we continue to get reports that pain is
undertreated," said Dr. June Dahl, professor of pharmacology at the
University of Wisconsin Medical School, who played a leading role in
initiating the pain standards set by the Joint Commission.

Last February, The New England Journal of Medicine published a study of 103
children who died of cancer. Based on interviews with parents and a review
of the children's medical records, 89 percent of the children suffered from
pain or other symptoms in their last month of life, and of those treated
for pain, only 27 percent got adequate relief.

In 1998, The Journal of the American Medical Association reported a study
from Brown University of 13,625 cancer patients age 65 or older who were
living in nursing homes. Of those suffering from pain, 42 percent were not
given any medication at all or were given only aspirin or acetaminophen
(Tylenol).

"We also know that undertreated pain has incredible adverse effects not
only on individuals but on institutions and on society as a whole," Dr.
Dahl said.

For instance, research shows that when patients' postsurgical pain is not
treated, they tend to have less rapid return of respiratory and bowel
function; they don't get out of bed as quickly; and they have longer
hospital stays, Dr. Dahl said.

Research also shows that when acute pain is not treated, it can turn into
chronic pain. Pain is estimated to cost $100 billion a year in the United
States in medical bills and lost work days, the American Pain Society said.

Surveys by Ms. Loeb at Brandywine show that after patients participate in
the program, pain that was rated as 5 or above on a 0 to 10 scale is
consistently reduced to 3 or 2.

Frances's pain intensity, which initially scored an 8 to 10, decreased to 0
to 2. Her life no longer revolves around her pain. Instead, she can focus
on members of her family when they visit and participate in activities.

The new approach to pain faces formidable barriers. Many health care
workers still erroneously believe that adequate pain relief can leave
patients addicted to the drugs. And many avoid morphine, a powerful
painkiller, for fear it will cause respiratory failure and death.

"This is certainly a risk, although when it's used appropriately, it's easy
to avoid complications through monitoring and by gradually increasing the
dose as patients develop a tolerance to its respiratory effects," Dr. Dahl
said.

Also, many fear regulatory sanctions for overprescribing opioids, or narcotics.

Many nurses and doctors receive little training in pain management.

"You pick your pet pain medicines that work for you," said Dr. Dennis S.
O'Leary, president of the Joint Commission. "You don't bother to learn
about the interplay of these medications with others, nor about other
modalities."

Patients, too, have their own barriers to relief. Many do not want to admit
they have pain or believe that pain is a normal symptom of aging, and
patients themselves worry about addiction to opioids and the side effects
of medications.

"The Joint Commission is forcing medical professionals and consumers to
confront our biases and our misconceptions about pain," Ms. Loeb said.

Dr. Dahl said: "We've had enormous efforts made to educate physicians,
we've had symposiums, wonderful articles, a lot of continuing education,
and these things have not changed the practice of how pain is managed. We
had to put some teeth into this so that there are requirements. Because of
these standards, pain is now on every hospital's radar screen."

At Brandywine, the staff did an initial audit of who was in pain, what
medications they were receiving and whether they were effective. Every
resident is now assessed for pain upon admission, and nurses assess
patients in the pain management program at every shift.

Brandywine also offers nondrug pain treatments like meditation, massage,
physical therapy and guided imagery. The nursing home has also educated the
entire staff, from the housekeeping department to doctors, in the
importance of pain management.

"When we first started the program, I got some of my best referrals from
housekeeping and maintenance staff, because some residents are more
comfortable complaining to these people than to nurses," Ms. Loeb said.

Similar efforts are under way elsewhere. Englewood Hospital in New Jersey,
a midsize hospital with 520 beds, has developed a pain management team made
up of physicians and nurses from various specialties. There is also a
24-hour pain service, which patients can call if their pain is not
controlled by their primary physician. The hospital offers seminars for its
medical staff, said Dr. Jeffrey Gudin, clinical director of the Center for
Pain Management at the hospital.

At the University of Utah Health Sciences Center, Dr. Michael Alan Ashburn,
the medical director for pain programs at the Health Sciences Center, said,
"We've made pain a fifth vital sign, along with temperature, pulse,
respiration and blood pressure."

The university also added basic courses on pain assessment and treatment
into the core curriculum at its medical school.

Other hospitals have changed the medications they use, adding newer pain
medications and interventions like injections that block nerves or epidural
treatments for abdominal surgery and lower body pain; combining pain
medications; and decreasing the use of drugs like Demerol, which has
adverse effects on the central nervous system but is widely prescribed.

"Everywhere I go where they've implemented the standards, I've seen real
outcome changes," said Chris Pasero, a pain management consultant in
Rocklin, Calif. "For example, patients are able to walk easily after
surgery, to deep breathe and to do rehabilitation faster because they don't
have pain. In chronic pain settings, we're seeing improvements in quality
of life and people being able to go back to work."

Carole Patterson, director of the standards interpretation group at the
Joint Commission, said that a midyear survey she conducted indicated that,
although some organizations were further behind than others, on the whole
it was clear that they would be able to meet the standards by January.

Meanwhile, the number of workshops on pain has drastically increased, as
has the number of pain management consultants.

"If we have done nothing else but increase awareness, we have done a great
deal," Dr. O'Leary said.