Nov/Dec 2007

Pain Management — Speaking to Social Work
By Terry Altilio, LCSW
Social Work Today
Vol. 7 No. 6 P. 44

A social worker and pain management specialist explains why understanding the needs of persons living with pain is so important to social work.

Stephen Colbert, the anchor of a satirical news show airing on the TV network Comedy Central, had the misfortune of breaking his wrist. In his own inimitable style, he used his injury during the month of August to provoke humor and, in a clever and thoughtful act, auctioned his autographed cast to raise money for the Yellow Ribbon Fund, a charity assisting injured American service members and their families.

Colbert’s antics included pretending to swallow a handful of pain medication, feigning uncontrolled use as if he were feeding an addiction or altering his mood. Colbert’s comedy indulged existing fears and judgments about the behaviors of people with pain and the addictive potential of pain medications. These fears epitomize worries of prescribers, patients, and family and make it increasingly difficult for persons with pain to get adequate care.

Shortly before Colbert broke his wrist, Associated Press (AP) author Frank Bass wrote an article detailing a 90% increase in the amount of five major painkillers sold at retail establishments between 1997 and 2005. The figures were based on an AP analysis of statistics from the Drug Enforcement Administration, and while the increase in volume continues, the percentage is decreasing, perhaps fueled by high-profile arrests, prosecution of prescribers, and increased caution about the prescribing of opioid medications. While there was a reported 150% increase in 2001, the increase was roughly 2% in 2005.

In June, prior to Bass’ article, Tina Rosenberg authored a New York Times Magazine piece, “When Is a Pain Doctor a Drug Pusher?” In addition to discussing issues related to pain and its treatment, this article describes the current climate in which physicians may be charged as criminals for behaviors that in the past may have been described as malpractice or tended to by organizations such as state medical boards.

The Bass and Rosenberg articles are emblematic of public attention to the complex environment in which clinicians practice and persons with pain attempt to secure care. In response to the concern related to the rise of prescription drug abuse, legislation is proposed and crafted in efforts to contain abuse. Joining prescription monitoring programs is a recent federal mandate requiring that prescriptions for Medicaid beneficiaries be written on tamper-resistant prescription forms. Signed into law by the president on May 25 as part of the U.S. Troop Readiness, Veterans’ Care, Katrina Recovery, and Iraq Accountability Appropriations Act of 2007, it was to be effective as of October 1. In addition to the short period between the enactment and effective dates and the consequent potential for disruption of care, the law applies only to Medicaid recipients, who are among the neediest and most vulnerable Americans, and raises the question of discrimination.

Why Should This Matter to Social Workers?
You’ve just read a sampling of the media, public health, and legislative activities that inform the milieu within which the clinical care of persons with pain occurs. Social work, with its tradition and commitment to social justice, respect for persons, advocacy, and empowerment, has an opportunity to embrace issues reflected in the complex questions that relate to pain management, and these values also make acceptance of the following realities untenable.

The Scope of the Problem
The undertreatment of pain is a public health problem that has emotional and physical consequences and is estimated to cost the American public nearly $120 billion per year, which includes not only medical treatment but also the impact on society resulting from sick days and decreased productivity at work. The consequent suffering—physical, spiritual, and emotional—is beyond calculation.

Each year, approximately 50 million people experience serious chronic pain lasting six months or more, and another 25 million experience acute pain from injuries and surgeries. As the population ages and people live with chronic illnesses, competent pain management is essential to our commitment to ease suffering and maximize quality of life. As veterans return with service-related injuries, the shared mandate of healthcare professionals is to ensure they receive holistic and competent pain care. While prescription drug abuse is an increasing problem, denying medications to those who suffer with pain and use medications appropriately because of our national inability to curb illicit drug abuse violates the principles of justice and beneficence.

Disparities in Pain Management
Vast disparities are evident in the care of persons with pain. Studies indicate that older adults, women, those with limited fluency in English, those who lack private insurance, and those who are ethnically diverse are the most likely to be undertreated for their pain (Bonham, 2001; Breitbart et al., 1996; Cleeland et al., 1994; Dannemiller Memorial Educational Foundation, 2004; Hoffmann & Tarzian, 2001; Unruh, 1996). Pain is prevalent and often untreated among frail older adults living in the community and nursing facilities, particularly among elders and patients with dementia (Bernabei et al., 1998; Fox, Raina, & Jadad, 1999; Landi et al., 2001). Dying patients can be expected to suffer persistent pain at rates exceeding 40% (Teno, Weitzen, Wetle, & Mor, 2001).

Many factors contribute to pain undertreatment, including, but not limited to, myths and misconceptions about opioid use and addiction, unequal access and inadequate healthcare for the poor, regulatory barriers, and ineffective education of healthcare practitioners about their professional and ethical responsibility to effectively treat pain.

What Is Pain?
The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. While it is unquestionably a sensation in part or parts of the body, it is always unpleasant and, therefore, an emotional experience” (Merskey & Bogduk, 1994). It is clear from this definition that pain involves the physical and emotional self. Pain is usually, but not always, associated with tissue injury. When an objective basis cannot be found, inexperienced clinicians are often confounded and consequently may challenge the credibility of a patient’s report of pain, creating an environment of mistrust. This absence of a discernable cause can increase distress and demoralize those who seek a cause and expect that either pain will end or the medical experts will find a cause that subsequently can be remedied.

Pain is a subjective and emotional experience, and the perception and expression of pain can be influenced by cultural, ethnic, or religious values and beliefs. These variables can impact the patient/family/clinician interface, presenting challenges to the clinician’s ability to recognize, accurately assess, and treat pain, thereby contributing to undertreatment in the most vulnerable populations.

Pain and the related psychological, family, quality of life, and socioeconomic issues present an ideal opportunity for social work interventions. Pain is best treated in the setting of a multidimensional assessment where the complex interplay between biological, medical, social, religious/spiritual, psychological, and cognitive/behavioral dimensions is understood and incorporated into the treatment approach.

Treatment planning encompasses these aspects of a person’s experience and includes acknowledging the suffering and potential negative effects of chronic pain. Goals often focus on enhancing functioning, recovering meaning, and improving quality of life. The adjustment involved when a life is temporarily or permanently changed by pain involves a process of loss and adaptation, which is a significant focus of clinical intervention.

Depression, anxiety, addiction, and other psychiatric issues can exacerbate a patient’s pain experience and require thorough expert assessment for the treatment plan to respond to all aspects of the problem. Pain may coexist with suffering, distress, or psychiatric symptoms or may be discrete but related problems. Depression and anxiety may be preexisting concerns or a direct consequence of living with pain. The clinical task is to partialize the issues and, when necessary, create a treatment plan that responds to the whole person.

The Synergy of Pain and Social Work Practice
In addition to the undertreatment of pain as an ethical and public policy concern, a small number of social work experts since the late ‘70s have articulated a role for the profession in the complex and rich specialty of pain management. Whether practicing in a private office, healthcare system, addiction program, or mental health setting, the ramifications of pain often surface and, when recognized, present an opportunity to provide and advocate for competent, compassionate pain management. In addition to anxiety and depression, consequences of unrelieved pain can include impaired function, sleep and appetite disturbances, demoralization, and hopelessness. These sequelae also can extend beyond the person with pain to family and caregivers.

The social work model of care—based on an assessment of the person in environment and including social, economic, cultural, and spiritual aspects of experience—is congruent with the efforts to move beyond the medical model to a multidimensional focus and, most currently, beyond the clinical relationship to the political, regulatory, and legislative arenas. Psychosocial factors impact pain and, reciprocally, pain impacts the psychosocial spiritual life of patients, their families, and caregivers. Whether pain from migraine headaches or arthritis or pain associated with a life-limiting illness, the approach to care extends beyond the physical.

Social workers bring a worldview based on an appreciation of a “person in environment” perspective, and the engagement process “starts where the client is.” These key social work values are embedded in a treatment approach that views pain as a multidimensional experience and defines competent and compassionate care as beginning with the patient’s report of pain. Clinicians’ ongoing assessment and expertise expands and informs the multidimensional work that is often key to assisting people who have been overwhelmed by pain to recover their voice and create avenues of hopefulness and meaning in their lives. The unique heritage of social work creates an expectation of holistic assessment and interventions, ranging from the practical to the clinical to policy aspects of the pain experience. Interventions can range from the following:

• psychodynamic therapy, cognitive behavioral techniques, or problem solving;

• individual, family, or group modalities;

• education, advocacy, and negotiation of systems;

• resource finding or development, networking;

• practical needs;

• discharge planning and referral; or

• public policy.

In Conclusion
“Human dignity requires and demands that unnecessary, treatable pain be relieved. Severe or chronic pain blocks or seriously impedes the realizations of all other human values. Relief of unrelenting pain is required to allow the human being to reflect, enjoy human relationships, and even to think and function on a most basic level” (Johnson, 2001).

As pain has moved beyond the physical to a biopsychosocial, spiritual model, it has also become the focus of the media, legislators, and litigators. The landscape of opportunity for social work involvement has broadened and, if we hear it, there is a loud invitation for social work to respond. At the same time, the vulnerability of persons living with pain increases and social work participation in this rich and complex issue has the potential to make a critical impact.

— Terry Altilio, LCSW, is social work coordinator in the department of pain medicine and palliative care at Beth Israel Medical Center in New York City. In addition to clinical work, she lectures and writes about the role of social work in the specialties of pain and palliative care.

Resources
Loscalzo, M. & Jacobsen, P.B. (1990). Practical behavioral approaches to the effective management of pain and distress. Journal of Psychosocial Oncology, 8, 139-169.

MacDonald, J.E. (2000). A deconstructive turn in chronic pain treatment: A redefined role for social work. Health and Social Work, 25(1), 51-58.

Mendenhall, M. (2003). Psychosocial aspects of pain management: A conceptual framework for social workers on pain management teams. Social Work in Health Care, 36(4), 35-51.

References
Bernabei, R., Gambassi, G., Lapane, K., Landi, F., Gatsonis, C., Dunlop, R., et al. (1998). Management of pain in elderly patients with cancer. SAGE study group. Systematic Assessment of Geriatric drug use via Epidemiology. The Journal of the American Medical Association, 279(23), 1877–1882.

Bonham, V.L. (2001). Race, ethnicity and pain treatment: Striving to understand the causes and solutions to the disparities in pain treatment. Journal of Law, Medicine and Ethics, 29(1), 52-68.

Breitbart, W., Rosenfeld, B.D., Passik, S.D., McDonald, M.V., Thaler, H., & Portenoy, R.K. (1996). The undertreatment of pain in ambulatory AIDS patients. Pain, 65 (2-3), 243-249.

Cleeland, C.S., Gonin, R., Hatfield, A.K., Edmonson, J.H., Blum, R.H., Stewart, J.A., et al. (1994). Pain and its treatment in outpatients with metastatic cancer. The New England Journal of Medicine, 330(9), 592-596.

Dannemiller Memorial Educational Foundation. (2004). The role of race, ethnicity and gender in the treatment of pain. Pain Report, 7, 9-11.

Fox, P.L., Raina, P., & Jadad, A.R. (1999). Prevalence and treatment of pain in older adults in nursing homes and other long-term care institutions: A systematic review. Canadian Medical Association Journal, 160(3), 329-333.

Hoffmann, D.E., & Tarzian, A.J. (2001). The girl who cried pain: A bias against women in the treatment of pain. Journal of Law, Medicine & Ethics, 29(1), 13–27.

Johnson, S.H. (2001). Relieving unnecessary, treatable pain for the sake of human dignity. Journal of Law, Medicine & Ethics, 29(1), 11-12.

Landi, F., Onder, G., Cesari, M., Gambassi, G., Steel, K., Russo, A., et al. (2001). Pain management in frail, community-living elderly patients. Archives of Internal Medicine, 161(22), 2721-2724.

Merskey, H. & Bogduk, N. (1994). Classification of chronic pain: Descriptions of chronic pain syndromes and definitions of pain terms, 2nd ed. Seattle, WA: IASP Press.

Teno, J.M., Weitzen, S., Wetle, T. & Mor, V. (2001). Persistent pain in nursing home residents. The Journal of the American Medical Association, 285(16): 2081.

Unruh, A.M. (1996). Gender variations in clinical pain experience. Pain, 65(2-3), 123-167.