Pain Management in Hospitalized Neurological Patients

Study results show that a structured educational intervention for staff aimed at improving knowledge of pain assessment and treatment has little effect on outcomes as measured by pain scores.

New Orleans, LA — October 13, 2013 — At a poster session at the 2013 Annual Meeting of the American Neurological Association, Maisha Robinson, MD, presented preliminary data on interventions to improve pain management in hospitalized neurological patients. Robinson, the first author on the paper, is double board certified in neurology and palliative care and practices at the Mayo Clinic in Jacksonville, FL.

Several studies suggest that many hospitalized patients experience significant pain, and often, that pain is undertreated. In academic centers, staff may have a limited knowledge of treatment strategies for pain. Robinson explained that pain control represents a particular challenge in neurological patients for a variety of reasons, including the need for reliable neurological exams.

In this ongoing study, Robinson and colleagues are seeking to obtain a baseline assessment of pain management in hospitalized neurology patients. The study authors also seek to compare the effectiveness of pain management before and after a structured educational intervention for staff (focused most heavily on neurology residents). This included education about pain management principles, methods of pain assessment, therapeutic strategies, the WHO analgesic stepladder of pain medications, and strategies for reassessment and follow-up.

Thirty patients made up the pre-intervention group. At this time, 16 patients have been assessed in the post-intervention group, but the researchers plan to enroll a total of 30 people in the trial. All participants completed a brief pain questionnaire when they were admitted. Their pain was then reassessed after discharge and at 30 days later.

Admission diagnoses included a wide range of neurological conditions, including peripheral neuropathy, headache, subarachnoid hemorrhage, radiculopathy, intraparenchymal hemorrhage, ischemic stroke, metastatic cancer, myelopathy, and seizure.

In these interim results, both groups showed increases in the number of patients on opioids, antidepressants, and antiepileptics between admission and discharge. The use of antiepileptic drugs increased the most dramatically in both groups, nearly doubling in both. “I think that shows neurologists are comfortable with what they are comfortable with. We know seizure medications can help with neuropathic pain, so we’re very comfortable prescribing anti-epileptic medications, but you don’t see that similar trend with prescribing antidepressants or opioids,” said Robinson.

Both groups reported initial severe levels of pain (8.2 out of 10 in the pre-intervention group versus 8.8 in the post-intervention group). At discharge, the perceived level of pain had decreased to 6.7 in the pre-intervention group and 5.7 in the post-intervention group. Thirty days after discharge these numbers dropped to 3.4 and 3.7 respectively. At least thus far, the data does not represent a significant difference in pain levels between the two groups at either time.

If these results hold, the present intervention was not as successful in improving pain management in hospitalized neurological patients as the researchers had hoped. Robinson concluded, “If the results are similar, I think there might be a number of reasons for that. Looking at a more interdisciplinary approach to pain could really be helpful. And perhaps pain gets better on its own—perhaps we don’t need an intervention.”