Pain Medicine Service Research Articles

Regional anesthesia

Regional Anesthesia and Acute Pain Medicine Service, Yale University School of Medicine, New Haven, Connecticut, USA Correspondence to Thomas M. Halaszynski, DMD, MD, MBA, Associate Professor of Anesthesiology, Director, Orthopedics and Regional Anesthesiology, Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06525, USATel: +1 203 785 2804; fax: +203 785-6664; e-mail: [email protected]

The Role of the Oncologist in Palliative Care

From the Cancer Pain and Palliative Medicine Service, Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel. Reprints: Nathan Cherny, MBBS, FRACP, FRCP, Cancer Pain and Palliative Medicine Service, Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel 91031. E-mail: [email protected].

Creation of a Novel Recuperative Pain Medicine Service to Optimize Postoperative Analgesia and Enhance Patient Satisfaction

Many patients have difficulty with pain control after transition from patient-controlled analgesia modalities to oral analgesics. The creation of a Recuperative Pain Medicine (RPM) service was intended to bridge this gap in pain management at the Hospital for Special Surgery. Specific goals were to improve patient and staff satisfaction with management of postoperative oral analgesics by improving clinical care, administrative policies, and patient and staff education. Primary outcome measures for improved satisfaction were Press Ganey surveys and staff surveys. From inception in Aug 2007 to Dec 2008, RPM has seen 6,305 patients for discharge planning and education and 997 patients for pain management consultation. Administrative and educational accomplishments have included creation of a patient "Helpline" for emergent phone questions regarding postdischarge home pain medications, a policy for prescribing pain medications for home discharge, patient education booklets, a pain management webpage on the Hospital for Special Surgery website, and direct education of staff. Press Ganey measurements of patient satisfaction increased from 87th percentile up to the 99th percentile among peer institutions since the implementation of RPM. Staff satisfaction was 92% positive regarding the RPM service's function and patient management. An RPM appears to be an effective means to optimize postoperative pain management after transition off patient-controlled analgesia devices. Further research is needed to ascertain the exact cost-benefit and potential impact on postoperative quality-of-life measurements.

Bodily symptoms: a new approach

As medicine deals increasingly with chronic disease and acknowledges the importance of patients’ quality of life, there is an increasing need to address patients’ symptoms. The traditional way of considering symptoms is only as indicators of disease pathology. In medicine, the focus is on bodily pathology and in psychiatry on psychopathology. The assumption is that the patients can then be categorized as medical or psychiatric and that treatment of bodily pathology and psychopathology respectively will effectively relieve their symptoms. This simple model is, however, increasingly proving to be inadequate. There is a new more integrated way of thinking about bodily symptoms. Rather than start with the pathology and then consider the symptoms, it suggests that we actively address both pathology and the symptoms themselves. The available evidence tells us that chronic symptoms usually have multiple causes and that to effectively treat them we often need combined physical and psychological management strategies. Consequently, symptom focussed care requires that we develop new systems for assessing and managing symptoms that run parallel with existing systems for managing bodily pathology. It is also driving a new area of research, symptom research. Finally, the symptom perspective should make us think about how we organise our currently fragmented approaches to symptom management and combine the pain medicine, palliative medicine and liaison psychiatry services into a more coherent approach to symptom management.

Long-term outcomes during treatment of chronic pain with intrathecal clonidine or clonidine/opioid combinations

To evaluate the effectiveness of intrathecal clonidine or clonidine/opioid admixture for the treatment of chronic pain states, a retrospective chart audit of 15 patients seen by the Pain Medicine and Neurosurgical Services was performed. Subjects included 9 men and 6 women aged 26–86 years. Diagnoses included complex regional pain syndrome, neuropathic pain, and cancer pain. All patients received a trial of single-shot and/or short-term infusion of clonidine. Those reporting a significant reduction in pain, or at least 50% reduction in their visual analog scale (VAS), received long-term therapy. Intrathecal clonidine as a single-shot dose, infusion, or as intrathecal polytherapy did not improve VAS scales from pre-treatment values in 5 patients. Ten patients reported significant pain relief or >50% decrease in VAS scores with the initial trial and received long-term therapy. Two received clonidine alone for 7–11 months before the therapy failed; others failed after just a few days. Seven of eight initially responded to clonidine alone (75–950 μg/day) before failing and requiring a second drug. Three received hydromorphone (200–8000 μg/day) and four morphine (0.15–15 mg/day) with clonidine. Four patients then failed 2-drug therapy (duration 6–21 months). Two continue with intrathecal clonidine/hydromorphone (duration 19–29 months) and 1 with clonidine/morphine (duration 21 months). After initiation of intrathecal clonidine, one patient reported good relief with clonidine/morphine until his death 5 months later. In this population, intrathecal clonidine was of limited utility for most patients. It may be of benefit for subset(s) of patients, but in our experience, duration of relief is typically <18 months.

Early experience of liaison psychiatry input into a newly-established pain medicine service

Early experience of liaison psychiatry input into a newly-established pain medicine service

Acute pain medicine: Organizing an acute pain medicine service

N UMEROUS STUDIES illustrate that the majority of postsurgical patients recall moderate to severe pain during their hospital stay.l-4 In 1973, Marks and Sachar 2 reported a landmark investigation showing that 73% of patients receiving opioid analgesia suffered from moderate to severe distress for a multitude of reasons, including lack of sophistication regarding analgesic usage and exaggerated apprehension of the dangers of addiction. In response, the Agency for Health Care Policy and Research developed and published the Acute Pain Management: Operative or Medical Procedures and Trauma guidelines in 1992. 5 These guidelines were developed (1) to reduce the incidence and severity of acute postoperative and posttraumatic pain, (2) to educate patients about the need to communicate unrelieved pain so they can receive prompt evaluation and effective treatments, (3) to enhance patient comfort and satisfaction, and (4) to contribute to fewer postoperative complications and, in some cases, shorter hospital stays after surgical procedures. Despite these and other guidelines, acute pain continues to be a significant clinical problem. Anesthesia-based acute pain services (APSs) have evolved in response to this prevalent problem. First described by Ready et al 6 in 1988, an APS can improve postoperative analgesia in a safe and effective manner. This report will focus on the organization and benefits of a modem APS.