CorrectCare

Pain Treatment in Corrections: Striving for a Community Standard of Care

by Jane Grametbaur, RN, CCHP-RN, CCHP-A

Pain comes in many shapes and forms, from the agony of cancer pain to the trauma of severe emotional pain. Medical professionals in the community have long accepted the importance of adequately treating and controlling pain in their patients. But how does the need for adequate pain identification and control integrate into the management of the correctional population?

The terms manipulative and drug seeking often come to mind when considering the type of inmates housed in our correctional facilities, and, in all fairness, a large number of those arrested and serving time have substance abuse problems on admission, as numerous studies have shown.

Nevertheless, a significant number of the correctional population at some time or another will have a true need for pain control. The inmate diagnosed with terminal cancer, the inmate who suffers from chronic, intractable pain or the inmate who recently had major surgery, like the population in the community, will have a valid need for adequate pain control. Multiple studies have shown that patients who receive adequate pain relief require less medication than those who have inadequate pain relief.

The ‘Fifth Vital Sign’
Pain assessment and management have always been a key part of a nursing or medical assessment. In 1998, the Veterans Health Administration initiated a National Pain Management Strategy that addresses the subject of pain and its treatment in a systematic, comprehensive manner. In 1999, the state of California designated pain as the “fifth vital sign” and enacted Assembly Bill 791, which states, “It is the intent of the Legislature that pain be assessed and treated promptly, effectively, and for as long as pain persists.” The California Board of Registered Nursing’s policies on pain control state that pain must be assessed each time the nurse takes vital signs, and that the assessment is based on the patient’s self report.

With both the California Board of Registered Nursing and VHA setting standards for pain assessment, adequate pain assessment and treatment will become the standard of care nationwide. Currently, numerous hospitals, including the City of Hope and Johns Hopkins, have policies and procedures for the assessment and treatment of pain. In addition, pain management clinics have become widespread in the past 10 years.

Policies and Procedures
In formulating policy and procedures, you first must define pain as well as determine when and how to assess pain.

Correctional health administrators should expect resistance from staff, especially those who have become accustomed to dismissing inmate complaints of pain as manipulation. The key to staff compliance is education. Assessing pain along with vital signs helps ensure that staff will remember to perform an assessment. Initial assessment should include the location, onset, duration, quality and radiation of pain, as well as alleviating and provoking factors.

Although the level of pain, by definition, is based on the patient’s subjective report, pain can be quantified. A numerical scale and the Wong-Baker facial grimace scale provide a simple method to assess the severity of pain. Numerous other pain assessment scales are in use nationwide, including scales to assess pain in patients with cognitive impairment and dementia.

Depending on the patient’s report of pain, staff may use nonpharmacological approaches to treatment such as relaxation, hot pack, cold packs, deep breathing, meditation or exercise.

When nonpharmacological methods show no effect, nursing protocols can provide staff with the option to give the patient over-the-counter medication such as Tylenol or Motrin, in keeping with the facility’s policies.

Staff will require education not only on nonpharmacological treatment of pain but also on when to refer pain to an advanced practice provider or the physician. Inmates who have chronic, long-term, nonresolving pain not controlled with nonpharmacological measures should be evaluated by a higher level practitioner.

In addition, inmates suffering from acute onset of pain will require careful assessment for emergent or life-threatening conditions and possible referral to a higher level practitioner or to the emergency room, if necessary.

Treatment of the inmate with severe, progressive, intractable pain may become highly problematic, especially in facilities that have policies that do not allow narcotic pain medication. For example, treatment of an inmate with terminal cancer may require the facility to send the inmate to a hospital for inpatient admission for narcotic pain control.

An inmate with a history of drug addiction presents a unique challenge in treatment. However, the goal here is the same as for a nonaddicted patient: to relieve pain and to restore function. Treatment of the addicted inmate may require additional education and perhaps even a written contract concerning the goals of treatment, frequency of prescriptions and refills, and frequency of visits to the advanced-level practitioner.

Once pain is assessed and treated, staff should follow up with the inmate to reassess the effect of the intervention. Follow-up might consist of instruction to the inmate to submit a medical message slip stating that the pain has not resolved or scheduling inmate for reassessment with the RN or the physician.

Thorough documentation of the inmate complaint of pain, assessment, intervention and reassessment of the treatment gives providers an accurate history and assists in the provision of continuity of care.

Quality Care
The standard of care for correctional institutions is the same as that in the community. Many studies have shown that patients who receive adequate pain relief use less pain medication and have a better quality of life. With careful planning and proper education, policies dealing with the adequate control of pain can be effective in the correctional environment.

— About the author: Jane Grametbaur, RN, CCHP-RN, CCHP-A, is the principal for Grametbaur & Associates Legal Nurse Consultants, Riverside, CA, and specializes in correctional cases. To contact her, email jgrametbaurrn@aol.com.

[This article first appeared in the Summer 2011 issue of CorrectCare.]