Why It Matters
Discussion of the opioid epidemic often overshadows at least one preventable cause: the suboptimal management of acute pain.
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Look Upstream to Address Pain and the Opioid Crisis

By Patricia McGaffigan | Tuesday, March 19, 2019

Photo by Marc-Olivier Jodoin | Unsplash

The opioid epidemic is undoubtedly one of the most pervasive and multifaceted challenges facing our health care systems and communities today. Each day is headlined by news of more initiatives, programs, and investments to deal with patients, families, and communities whose lives have been devastated by these powerful medications.

These downstream efforts to tackle the opioid crisis are critical. We define, legislate, and implement limits and protections on opioid prescribing practices, and provide for rehabilitation services and support. We expend immeasurable resources of people, money, and time in reacting to the opioid epidemic. Yet, all this focus on the consequences of the problem often overshadows at least one preventable cause: the suboptimal management of acute pain.  

Over many years, much of our clinical practice became wired to tactics meant to eliminate patient reports of pain. Clinicians became conditioned to reach for opioids as a first-line solution, often prescribing opioids without conducting a comprehensive patient assessment or identifying non-opioid alternatives.  

As with many public health crises, however, the downstream practices, energy, and money spent on mitigation of the problem must be matched by looking upstream to the roots and foundation of our clinical practice. It is possible to dramatically improve the assessment and management of patients with acute pain. Moreover, it is our duty to develop comprehensive, holistic plans of care for patients that reduce or eliminate the use of opioids to the extent possible and prevent their misuse.       

With these goals in mind, IHI convened an interprofessional expert panel to develop a resource that safety, clinical, and executive leaders could use to create safe acute pain management programs in their organizations.

The panel outlined a two-part paradigm shift to 1) provide comfortable, safe care for patients with acute pain, and 2) debunk the myth that total prevention of pain is a realistic goal.

The panel identified four foundational elements to achieving this paradigm shift:

  • A common vision of acute pain management as a patient safety priority — This means organizations agree — from their executive level to the front lines — that acute pain management is a safety issue that requires a coordinated and consistent approach. It also means engaging with stakeholders in the community, such as first responders and public health departments, to ensure alignment with community needs and goals.
  • Patient- and family-centered acute pain assessment, management, and monitoring —This means, for example, patients and families should be included in care plan development through the use of shared decision-making tools. This should include communicating to patients and families early on about their functional goals and their expectations around pain and pain medicine.
  • Comprehensive education, training, and evaluation of effectiveness of training — Both patients and clinicians hold misperceptions about pain, pain treatment, and opioids. Education and training can help focus goals on emotional and physical functioning and comfort instead of the elimination of pain. We must also train staff to accurately assess pain, avoid cultural biases, and promote equitable treatment of patients.
  • Effective systems of care — Any robust program requires the infrastructure and allocation of resources to support it. In safe acute pain management, this involves standardizing practices, efficient and adequate workflows, and monitoring and measuring practices and outcomes.

We can look at these four elements as the poles holding up the tent of safe acute pain management. They are interrelated, and weakness in one pole will compromise the overall structure.

The expert panel’s work informed a guide and toolkit (called Advancing the Safety of Acute Pain Management) that provides practical action steps for safety leaders and others to take in their organizations to achieve this paradigm shift. It establishes the upstream vision and provides guidance, exemplars, and recommendations for effective mobilization of leaders and care teams to more optimally address acute pain and reduce contributors to the opioid crisis.

Health care is full of constant stimuli and crises that tempt us to focus only downstream, addressing symptoms and consequences of our care. The opioid epidemic demands that we pay more attention upstream, anticipating and addressing problems before they arise and, ultimately, providing better care overall.

Patricia McGaffigan, RN, MS, CPPS is IHI's Vice President, Patient Safety Programs.

This project was made possible by financial support from Pacira Pharmaceuticals to further the patient safety mission and the delivery of safe care. IHI exercised sole and independent control of all content and editorial decisions related to the project. IHI does not in any way endorse or recommend any products or services provided by Pacira or any other commercial entity, nor is any commercial influence or bias allowed or reflected in the content of this resource.  

Editor’s note: The Advancing the Safety of Acute Pain Management report (including its recommendations and assessment templates) will be featured at an all-day workshop at the IHI Patient Safety Congress, May 15–17, in Houston.

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