Pain and the Burn Patient
By: Michael N. Skaredoff, M.D.
The skin is our interface with the outside world. Because the skin is so richly supplied with nerve endings, any serious burn is will
have different pain. Therefore different pain assessment techniques and management strategies will be appropriate depending on the population. Five general populations will be discussed: elderly (burn survivors), infants and children (burn survivors), cancer and AIDS patients, patients at the end of life, and patients who have difficulty communicating (burn survivors).
result in severe, prolonged pain. In addition to the pain of the process itself, Most burn patients must undergo frequent dressing changes, wound cleansings and rehabilitation
hydrotherapy. In addition, one must also consider myofascial pain due to immobilization, denervation pain secondary to burn injury, and sympathetically maintained pain.
Many patients at the outset are intubated, and therefore unable to make their needs known; it is therefore critical that the
staff be unusually attentive to these issues. Usually the first step in pain control in the burn unit involves intravenous opioids (morphine, fentanyl) supplemented by benzodiazopenes (diazepam, chlordiazopoxide, lorazepam). Intramuscular administration is usually unpredictable. With less severe burns, oral intake of long acting opioids may be used, but in the INPATIENT setting, the preferred route is intravenous, controlled by the patient. Patient Controlled Analgesic (PCA) units are quite reasonable in the inpatient setting, but when the patient makes the transition to outpatient treatment, other methods need to be employed. The simplest regimen is that of a long acting opioid supplemented by smaller doses of fast acting opioid to act as a "rescue" or "breakthrough" dose. The problem with many of the short acting opioids on the market is 1) they contain a significant amount of acetominophen, which over time may be detrimental to the liver and kidneys; and 2) most of these medications take about 20-30 minutes to work. Clearly another approach is needed. Fortunately, there is a short acting medication in an oral lozenge format (Actiq™, Cephalon) which can be efficaciously used in anticipation of a painful procedure. Severely painful procedures will still have to be done under either deep sedation or general anesthesia.
There are several special problems that impact burn patients in particular: Both adults and children may have cardiac and respiratory instability. Pain therapy must be so tailored so as to avoid these problems; in practice this may be very challenging. A second problem is hypotension that occurs as a result of vasodilation. Similar considerations apply. Nonsteroidal antiinflammatory drugs (NSAIDS) should be avoided to reduce the risk of gastrointestinal bleeding.
Burns in Children represent another very special case. There is a tendency to deny analgesics to children. Opioids are a fine
choice, but it must be borne in mind that the analgesic half-life is shorter and clearance is increased in acutely burned children. PCA therapy has been used successfully with
older children; enrolling the parents in the therapeutic regimen increases the odds for success.
CHOOSING A PAIN MANAGMENT CLINIC
Without a doubt, there is a serious pain crisis in this country. Access to adequate (not even "good") pain management is a
difficult process, fraught with a number of pitfalls and false pathways, regardless of where the patient lives. Even those individuals who have gone and researched their
problem and have all the right information and are willing to stand up for themselves find it hard to find help. This is a simple step-by-step guide to finding that care.
The obvious place to start is at the door of the primary care provider PCP. Depending on the condition, pain may be treated
right then and there. Alternatively, the PCP can recommend or refer a given patient to a pain care specialist.
Alternatively, the local hospital can be called to see if any pain services are available. In an ideal world, this would happen almost all the time; however, for a variety of
reasons, many PCPs are reluctant to get involved with pain management. Pain management can be very time consuming and labor intensive, and often uses scheduled drugs which
might trigger state or federal regulatory scrutiny. [That indeed is a reality that all pain clinics must deal with: extensive use of Schedule III (drugs such as hydrocodone/APAP) and Schedule II (drugs such as morphine) trigger audits--the only way to survive one intact is to have absolutely meticulous record keeping]. The upshot of all this is that a person suffering from pain has to do his/her own homework. With computer access available at many public libraries, there are several websites that can be very helpful in finding a pain clinic in your area:
1)www.pain.com is the Dannemiller foundation--an excellent database sorted by state and Canadian province, as well as a number of pain clinics in Europe and Australia/New Zealand
2)American Academy of Pain Management www.aapainmanage.org [209-533-9744]
3)American Academy of Pain Medicine www.painmed.org [847-375-4731]. The membership directory can be down loaded
4)American Board of Pain Medicine www.abpm.org [847-375-4726]
5)American Society for Action on Pain www.asappain.com. Skip Baker is an activist for this group and has a database available with comments recommended
James Goedhart is another pain activist out west who runs a pain bulletin board and message center. This is highly recommended.
What to look for:
There are, in my mind, four different types of pain management centers
1) The "block shop" this is the most prevalent -- usually this consists of a member of two of the anesthesia department of a given hospital who has an interest in pain management, and gets referrals from various surgeons(usually orthopedists) to do (primarily) epidural steroid injections or sympathetic blocks. While some patients might benefit from these procedures, many patients require more than these procedures and will need care indefinitely. The nature of any given procedure is that it is episodic.
2) Practitioners employed by or under contract with insurance companies. These practitioners are often encountered in workmen's compensation cases. Their job is to evaluate the patient and to recommend a plan of action. Because of their employment, the possibility that the desires of the insurer may color the decision making process must be taken into account.
3) The "gimmick shop". There are a number of small store-front or even much larger outfits that tout one or at most two therapies to the exclusion of almost everything else. Little used therapies (such as prolotherapy--which indeed has its place in the grand scheme of things) may be extensively used. Often, these treatments are expensive, not covered by insurance, and have to be paid for out of pocket.
4)The multidisciplinary pain clinic. This can be a single practitioner who "farms out" ancillary servicess or a clinic with several services literally under one roof. This type of pain clinic uses a variety of services, including: medical therapy, interventions (blocks)when indicated, physical therapy, counseling, and other types of alternative therapies (such as acupuncture or chiropractic) when indicated. I feel that this is the clinic that to which one should go.
You want a specialist or clinic that will do a comprehensive review of your pain problem. It really is imperative that you get all your medical records you can get. Most pain patients have long histories, and it helps a great deal to have things organized, especially:
1) Medications taken (dose, frequency, whether it worked or not)
2) Surgical procedures
3) Allergies and adverse reactions to medications
What you need to do before your first meeting:
1) Whether the practitioner is board ceritifed in his/her speciality?
2) What hospital affiliations?
3) What experience in treating the particular type of pain problem you have?
Jim Goedhart also advocates that "THE QUESTION" be asked: "Do you use medical therapy in your pain and if so, are opioids (when indicated), part of the plan of treatment?" This last question has to be asked with some care as it is also well known that pain clinics are also vulnerable to people having not pain but drug seeking behavior.
When you get there:
Most comprehensive first visits take anywhere from an hour to 2 hours. The visit should include:
-A comprehensive patient interview
-An appropriately thorough physical examination (depending on the problem)
-A discussion of findings
-A discussion of the proposed plan of treatment.
Sometimes, there is so much that a given patient is overwhelmed and not much in the way of questions is asked. The solution for this is to have a companion who does not have a pain problem to be the observer and 'advocate'.
Finally, chronic pain is just that: chronic. The pain will not go away. The goal of treatment often is to increase FUNCTION by reducing pain. Research has indicated that a 50-60% reduction in pain may be a realistic goal.
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