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Module 4:=
Pain
Management
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E
P
E
C
P
E
C
Pain
= Management
= Management
<=
b>FAST
FACTS
<=
b>Module
1
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Pain Assessment in the Cognitively Impaired
Author(s): L. Scott Wilner, MD; Robert Arnold, MD
The inability of cognitively impaired patie=
nts
to communicate information
about pain places them at high risk for inadequate pain control. Two common risk groups in palliative care=
include:
•Pati=
ents
with underlying brain pathology—e.g. dementia, =
Parkinson’s disease, stroke, developmental
abnormalities; and
•Pati=
ents
receiving sedating medication—e.g. ICU patients receiving sedative/hypnotics to control anxiety/agitati=
on from mechanical ventilation.
ACGME Competencies: Medical Knowledge, Patient Care,
System-based Practice
Keyword(s): Pain assessment
Pain Assessment in the
Cognitively Impaired
Recommended strategies to assess pain in
these patients include t=
he
following:
•Ask the=
=
patient—many patients who appear cognitively impaired may still be able to provide useful informa=
tion
concerning pain;
<=
/b>
•Interview the
caregivers and family—patterns of particular behaviors may have developed that indicate pain (e.g=
. placing a hand on the forehead for headache);
<=
/b>
•Review the medical
record for known pain-inducing pathology (e.g. diabetic with painful neuropathy that
was manifest when the patie=
nt
was cognitively intact);
•Complete a physical
examination and directed laborator=
y studies to assess for common pain-inducing problems
(e.g. fracture, UTI)
In addition to these measures, clinicians
should use a validated pain rat=
ing
system for the cognitively impaired. Such rating systems focus the =
following observational items:
•fac=
ial
expression
•body
posture
•voc=
alizations
•app=
etite
•int=
eractivity
•
Pain Assessment in the Cognitively Impaired can be foun=
d at:
Pain Assessment in the
Cognitively Impaired
•Dol=
oplus-2
scale =
http://www.doloplus.com/versiongb/index.htm
(1997)
•Ass=
essment
of Discomfort in Dementia Protocol (1999)
•Pain
assessment in advanced dementia (2003).
•Che=
cklist
of nonverbal pain indicators (2000)
•Pain
assessment for the dementing elderly (2003)
•Pain assessment for seniors with limited ability to
communicate (2004) &#=
13;
•Abb=
ey
pain scale (2004)
To date, there are no trials comparing t=
hese
different instruments. Thus,
clinicians should choose one tool and use it consistently to =
ensure uniformity among health care providers and ac=
ross
shifts.
&=
#13;
Pain Assessment in the
Cognitively Impaired
References=
3;
Closs SJ, Barr B, Briggs M, et al. A
Comparison of Five Pain Ass=
essment
Scales for Nursing Home Residents with Varying Degrees <=
span
style=3D'position:absolute;top:36.25%;left:10.11%;width:97.56%;height:4.0%=
'>of Cognitive Impairment. J Pain and Symptom Manage.
March, 2004; 27(3);
196-205.
Pain Assessment in the
Cognitively Impaired
Oral Opioid Dosing Intervals &=
#13;
Author(s): Weissman, D.
A new patient
was referred to see me about cancer pain management. She was taking an oxycodone/acetaminophen combination product f=
or
breakthrough pain. I asked her how
long it provided pain relief; she said, "only about 3 hours". I
asked how often she takes it, she sa=
id,
"every 6 hours, that's what it says on the bottle".
The most commonly prescrib= ed oral opioids include the short-acting products, administered as either single agents (oral morphine, hydromorphone, oxycodone and codeine) or = as combination products containing acetaminophen or aspirin (e.g. Percocet, Roxicet, Tylox, Vicodin, Lortab, Codeine w/ Tylenol). In published sources the recommended dosing intervals for these products varies from every 4 hours,= to 4-6 hours to 6 hours. Howeve= r, the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline recommends dosing intervals for all these produc= ts at q 3-4 hours, an interval more consistent with patient reports of pain relief.
<= /span>
The most commonly prescrib= ed oral opioids include the short-acting products, administered as either single agents (oral morphine, hydromorphone, oxycodone and codeine) or = as combination products containing acetaminophen or aspirin (e.g. Percocet, Roxicet, Tylox, Vicodin, Lortab, Codeine w/ Tylenol). In published sources the recommended dosing intervals for these products varies from every 4 hours,= to 4-6 hours to 6 hours. Howeve= r, the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline recommends dosing intervals for all these produc= ts at q 3-4 hours, an interval more consistent with patient reports of pain relief.
<= /span>
ACGME Competencies: Medical Knowledge, Patient Care
Keyword(s): Addiction, Adult, Chronic non-malignant
pain, Controlled substance regulations, =
Pain, Pain assessment, Pain treatment
Is there a problem with
prescribing oral opioids q4-6 or q 6 hours. In th=
e inpatient setting, nursing research from the 1980's
indicated that nurses are more likely=
to
administer the minimum drug dose at the longest allowable interval-an orde=
r written 1-2 tabs q 4-6, will often result in 1 tab q6h,
with inadequate analgesia. In the home
setting, patients and families are often excessively concerned about opioi=
d addiction and opioid side effects, so that if the
prescription on the bottle says "take every 6 hours", patients are apt to follow this
recommendation, even if the pain returns in 2=
-4
hours.
Is there a danger to more frequent drug administration? There is no danger of dosing intervals as often as every 2 hours for single a= gent products (e.g., morphine), in patients with normal renal function, as the peak effect will be reached in 60-90 minutes and there is rapid renal excretion. For combination products, the dosing interval should not be less than every 4 hours to avoid excessive acetaminophen (e.g., 2 Percocet tabs every 4 hours =3D 4 grams acetaminophen/24 hours, the maximum daily recommended dose).
Is there a danger to more frequent drug administration? There is no danger of dosing intervals as often as every 2 hours for single a= gent products (e.g., morphine), in patients with normal renal function, as the peak effect will be reached in 60-90 minutes and there is rapid renal excretion. For combination products, the dosing interval should not be less than every 4 hours to avoid excessive acetaminophen (e.g., 2 Percocet tabs every 4 hours =3D 4 grams acetaminophen/24 hours, the maximum daily recommended dose).
References:
· Acute Pain Manage= ment Guideline Panel. Acute Pain Management: Operative or Medical Procedures and Trauma Clinical Practice Guideline. AHCPR Publication No. 92-0032. Rockville, MD. Agency for Health Care Policy and Research, US Department of Health and Human Services, Public Health. Service, 19= 92. (see also Management of Cancer Pain, 1994).
<= /span>= · Fox LS. Pain management in the terminally ill cancer patient: an investigatio= n of nurses attitudes, knowledge and clinical practice. Military = Medicine 1982; 147: 455-460.
<= /span>· Cohen FL. Postoperative pain relief: patients status and nurses medication choices. Pain 1980;9:265-274.
<= /span>
· Acute Pain Manage= ment Guideline Panel. Acute Pain Management: Operative or Medical Procedures and Trauma Clinical Practice Guideline. AHCPR Publication No. 92-0032. Rockville, MD. Agency for Health Care Policy and Research, US Department of Health and Human Services, Public Health. Service, 19= 92. (see also Management of Cancer Pain, 1994).
<= /span>= · Fox LS. Pain management in the terminally ill cancer patient: an investigatio= n of nurses attitudes, knowledge and clinical practice. Military = Medicine 1982; 147: 455-460.
<= /span>· Cohen FL. Postoperative pain relief: patients status and nurses medication choices. Pain 1980;9:265-274.
<= /span>
Citati=
on
for referencing: Weissman, D. Fast Fact and Concepts #18: Oral Opioid Dosing Intervals, July, 2000. End-of-Life Physic=
ian
Education Resource Center
Subcutaneous
Infusions
Au=
thor(s):
Weissman, David E
SUBCUTANEOUS
OPIOID INFUSIONS
An intravenous opioid infu= sion is the standard of care for managing moderate-severe pain or dyspnea when the oral/rectal route is unavailable or frequent dose adjust= ments are needed. However, IV infusions have the burden of needing intravenous access. As death nears, the burden of maintaining IV access, especially in the home setting, can be enormous. An alternative well known among hospice professionals, but little appreciated in other care settings, is the subcutaneous (SQ) route for continuous, PCA or intermittent opioid injections (1,2).
Drugs
Morphine, hydromorphone (Dilaudid), fentanyl and sufentanil can all be safely administered as a continuous SQ infusion.
<= /span>
An intravenous opioid infu= sion is the standard of care for managing moderate-severe pain or dyspnea when the oral/rectal route is unavailable or frequent dose adjust= ments are needed. However, IV infusions have the burden of needing intravenous access. As death nears, the burden of maintaining IV access, especially in the home setting, can be enormous. An alternative well known among hospice professionals, but little appreciated in other care settings, is the subcutaneous (SQ) route for continuous, PCA or intermittent opioid injections (1,2).
Drugs
Morphine, hydromorphone (Dilaudid), fentanyl and sufentanil can all be safely administered as a continuous SQ infusion.
<= /span>
ACGME Competencies: Medical Knowledge, Patient Care =
3;
Keyword(s): Addiction, Chronic non-malignant pain,
Controlled substance regulations, Pain, Pain
assessment, Pain treatment
Dosing equivalents
SQ dosing is equivalent to= IV; a 3 mg/hr IV morphine infusion is equal to an 3 mg SQ infusion.
Pharmacokinetics
SQ infusions can produce t= he same blood levels as chronic IV infusions. There is no data to suggest that cachectic, febrile or hypotensive patients have problems with drug absorpt= ion (3).
Volume and Drug Choice
The limiting feature of a = SQ infusion is the infusion rate; in general, SQ tissue canabsorb up to 3 cc/hr; for higher volumes hyaluronidase
(Wydase) can be administered=
. At
low opioid requirements morphine is the drug of choice; a switch to hydromorphone is indicated for a high opioid requirement
due it's higher intrinsic potency (6:1=
),
thus the need for a smaller infusion volume.
<= /span>
SQ dosing is equivalent to= IV; a 3 mg/hr IV morphine infusion is equal to an 3 mg SQ infusion.
Pharmacokinetics
SQ infusions can produce t= he same blood levels as chronic IV infusions. There is no data to suggest that cachectic, febrile or hypotensive patients have problems with drug absorpt= ion (3).
Volume and Drug Choice
The limiting feature of a = SQ infusion is the infusion rate; in general, SQ tissue can
<= /span>
Administration
Use a 25 or 27 gauge butte= rfly needle-place on the upper arm, shoulder, abdomen or thigh. Avoid the chest wall to prevent iatrogenic pneumothorax during needle insert= ion. The needle can be left indefinitely without site change unless a local reaction develops-typically, patients can keep the same needle in place for up to one week a= t a time.
Toxicity
Local skin irritation, itching, site bleeding or infection can occur; of these, skin irritation <= /span>is the most common, easily treated by a needle site cha= nge.
Patient acceptance
Patients readily appreciate the ease of SQ administration as an alternative to IV access.
<= /span>
Use a 25 or 27 gauge butte= rfly needle-place on the upper arm, shoulder, abdomen or thigh. Avoid the chest wall to prevent iatrogenic pneumothorax during needle insert= ion. The needle can be left indefinitely without site change unless a local reaction develops-typically, patients can keep the same needle in place for up to one week a= t a time.
Toxicity
Local skin irritation, itching, site bleeding or infection can occur; of these, skin irritation <= /span>is the most common, easily treated by a needle site cha= nge.
Patient acceptance
Patients readily appreciate the ease of SQ administration as an alternative to IV access.
<= /span>
References
Bruera E, Brenneis C, Michaud M, et al. Use=
of
the subcutaneous route for the administrati=
on
of narcotics in patients with cancer pain. Cancer 1988;62:407-411.
Storey P. Subcutaneous infusion for control of cancer symptoms. J Pain Symptom Manage 1990;5:33-41.
Waldman CS, Eason JR, Ramb= ohul E, et a;. Serum morphine levels-a comparison <= span style=3D'font-family:Arial;font-size:67%;text-shadow:auto;color:white; mso-color-index:0'>between continuous SQ and IV infusion in post-operative analgesia. Anaesthesia 1984;39:768-= 771.
<= /span>
Storey P. Subcutaneous infusion for control of cancer symptoms. J Pain Symptom Manage 1990;5:33-41.
Waldman CS, Eason JR, Ramb= ohul E, et a;. Serum morphine levels-a comparison <= span style=3D'font-family:Arial;font-size:67%;text-shadow:auto;color:white; mso-color-index:0'>between continuous SQ and IV infusion in post-operative analgesia. Anaesthesia 1984;39:768-= 771.
<= /span>
Citation for
referencing: Hallenbeck J. Fast Fact and Concepts #28: Subcutaneous Opioid Infusions, November, 2000. End-of-L=
ife
Physician Education Resource Center&=
#13;
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Au=
thor(s):
Warm, Eric; Weissman, David E
ACGME Competencies: Medical Knowledge
Keyword(s): Addiction, Chronic non-malignant pain,
Controlled substance
regulations, Pain, Pain assessment, Pain treatment
It is well
recognized that physician's fear of fear of regulatory scrutiny (DEA, stat=
e =
medical boards), is a major contributor to the problem =
of
under treatment of pain. A recent landm=
ark
lawsuit should be a wake-up call for all physicians that this type of practice poses its own legal liability. An 85-year-old
California man with metastatic lung carcinoma sp=
ent
the final week of his life in severe pain. Three years after his death his children sued his doctor alleging that the physician
had failed to prescribe drugs powerf=
ul
enough to relieve their father's suffering. This was one of the first U.S.
cases in which a doctor has gone=
on
trial for allegedly under-treating a patient's pain. By a 9 =
to 3 vote the jury decided that the physician's lack of
attention to pain constituted elder abuse, award=
ing
the family $1.5 million (the amount was reduced to $250,000). To win, =
lawyers convinced the jury that under-treatment of pain=
was
"reckless negligence". Until recent=
ly,
lawyers would have considered such a suit un-winnable. Given politically <=
/span>savvy aging baby boomers, as well as the preponderance =
of
sound scientific evidence for the prop=
er
assessment and treatment of pain, we can probably expect more such =
verdicts. How can
physicians better protect themselves from charges of under-<=
/span>treatment of pain?
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Review yo=
ur
own practice--are you currently meeting JCAHO standards? Find out at: http://www.jcaho.org =
and AHQR (a.k.a. AHCPR) http://www.ahrq.gov/clinic/c=
pgarchv.htm pain guidelines?
Crosswalk of JCAHO Standards and Palliat=
ive
Care - with PC Policies, Procedures and Assessment Tools
CAPC has developed the 2004 Crosswalk of JC= AHO Standards and Palliative Care to provide hospitals with the policy = and administrative foundation for delivering palliative care services that are consistent with JCAHO standards. To download in Windows right-click link and choose "Save target as..." or for MacOS hold the control key and click = to download.
http://www.capc.org/jcaho-cr=
osswalk
· Improve your knowledge and skills in pain assessment=
and
treatment. (Some states, s=
uch
as California, now require mandatory pain CME).
CAPC has developed the 2004 Crosswalk of JC= AHO Standards and Palliative Care to provide hospitals with the policy = and administrative foundation for delivering palliative care services that are consistent with JCAHO standards. To download in Windows right-click link and choose "Save target as..." or for MacOS hold the control key and click = to download.
· Learn about and utilize your local
consultation resources for pain management.
<=
/b>
· Improve your knowledge and skills in
assessing substance abuse disorders; learn
about
and utilize your local resources for substance abuse referrals and treatme=
nt.
· Improve your understanding of the dr=
ug
regulatory system and how it functions-
learn about the common triggers for regulatory review .<=
span
style=3D'font-size:67%'>
![](3D"slide0183_image004.gif")
Intractable Pain Treatment
Act
Medical
Board Regulation
Texas Medical Association
Pharmacy Board Policy Statement
Texas Medical Association
Pharmacy Board Policy Statement
State Laws, Regulations, and
Other Official Policies
Other Official Policies
Cr=
ane M,
Treating pain: damned if you don't? Med Economics, Nov 19,
2001, pp 67-69.
Weissman DE , Doctors, Opioids and the law: The Effect=
of
Drug Regulations on Cancer Pain Management. Se=
min
Oncol 20(Suppl A): 53-58, 1993.
Gilson AM, Joranson DE.=
Citati=
on
for referencing. Fast Facts and Concepts #63 The legal liability of undertreatment of pain. Warm E and Weissman DE. March,
2002. End-of-Life Physician
Education Resource Center
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Why
patients do not take their opioids.
Au=
thor(s):
Robert Arnold, MD
ACGME Competencies: In=
terpersonal
and Communication Skills, Medical Knowledge, Patient Care
=
<=
span
style=3D'font-family:Arial;font-size:67%;color:white;mso-color-index:0'>Keyword(s):
Addiction, Chronic non-malignant pain, Controlled subst=
ance
regulations, Pain, Pain assessment, Pain treatment
=
;
Patien=
ts
have many of the same misconceptions regarding opioids that health =
care providers have. This Fast Fact discusses common
reasons that patients do not ta=
ke
prescribed opioids, thus resulting in unnecessary pain and suffering.
=
;Fear
of Addiction Patients are very afraid =
of
“becoming hooked”; they confuse physical dependence with psychological dependence
(addiction). As a result, patients try=
to
limit their intake and often wait until the pain is severe before <=
/span>using opioids.
Fear of Tolerance Patients of=
ten
worry about taking pain medicine “too early” in =
their disease course. They believe that if the pain gets
worse they will have already taken
the “best” medicine and thus have severe pain during the dying=
process. A related belief is that if they take the medi=
cine
on a regular basis, their body w=
ill
“get used to it” and thus the pain medicine will no longer be =
effective.
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The Good Patient Patients frequently don’t “ want to
bother” the doctor with complaints. Particularly with pain, they may feel
their report of pain is a criticism.
Patients may believe that “good patients” do not complain abou=
t pain or ask for more medicine. Our society has a very
ambivalent view towards pain=
and
pain treatment, believing that it is better if patients are =
“strong”, minimizing their symptoms.
<=
/span>The
Meaning of Pain Patients may view their p=
ain
as a punishment for past bad dee=
ds,
or view the pain experience as an opportunity for growth or =
personal redemption. When present, such beliefs lead
patients not to discuss their
pain with their health care team and to defer using analgesics.
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Opioid Toxicity=
Patients are concerned about opioid side effects, =
especially mental impairment, nausea and constipation.
Pain as a symptom Patients may believe that treating the symptom rather =
than the cause of the pain (e.g. cancer) is a bad idea.
They worry that this may ?mask? t=
he
disease?s progression so that future medical decisions =
are not made in a timely manner.
Patient Assessment Tips
Patients want to please their doctor, thus
asking, “Are you taking your medici=
ne”
is likely to result in the patient saying “yes”. To better understand the patient ‘s beliefs regarding pain
medicine and how they are taking t=
heir
medicine one should:
1.use non-judgmental phrasin=
g. Tell me exactly how you take your =
pain medicine. Often it is
easier for patients to tell you that they are not taking the medicine the way they were prescribed if=
you
acknowledge how hard it is=
to
take the medicine; It must be really <=
/span>hard to take all these pills. How often, in the last
week, have you found that
you forget one or two?
2.normalize the patient conc=
erns. Some patients worry that if they <=
span
style=3D'position:absolute;top:51.5%;left:20.97%;width:78.83%;height:3.5%'=
>take the pain medications, they will become addicted=
. Do
you have this worr=
y?
3.explicitly ask about their
health beliefs regarding opioids. Ask what they know about morphine or whether they have any family
members who have taken morphine and
what the experience was like.
4.Ask about side effects=
at every visit in the same way that you ask about pain. Moreover, ask about whether the patient not=
ices
any other changes that s/he
believes might be caused by the opioids.
=
;
References
Cleeland, C. S. (1988). &qu=
ot;Clinical
cancer: 31. Barriers to the managemen=
t of
cancer pain: the roles of patient and family." Wis Med J 87(11): 13=
-5.
Ersek, M. (1999). <=
span
style=3D'font-family:Arial;font-size:75%;text-shadow:auto;color:white;
mso-color-index:0'>"Enhancing effective pain management by addressing patient barriers to analgesic use."<=
/i> JHPN 1(3): 8796.
Ward, S. E., N. Goldberg, et al. (1993). "Patient-related barriers to =
management of cancer pain." Pain 52(3): 319-24.
Gunnarsdottir, S. et al (2002). Patient-related barriers to pain <=
span
style=3D'position:absolute;top:53.5%;left:14.41%;width:87.07%;height:4.0%'=
>management: The barriers questionnaire II=
(BQ-II). Pain, 99, 385-396.
Citation for
referencing. Fast Facts and Concepts # 83 . Why patients do not take their opioids. Arnold R. February 2003.
End-of-Life Physician
Education Resource Center
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BL=
OCKS
OF THE SYMPATHETIC AXIS FOR VISCERAL PAIN
&=
#13;
Au=
thor(s):
Gary M. Reisfield, M.D. and George R. Wilson, M.D.
The sympathe=
tic
nervous system is present along the length of the axial skeleton; <=
/span>most of the various plexi and ganglia are readily
accessible to percutaneous interr=
uption.
In the palliative care setting, the most common indicat=
ion
for interrupting the sympathetic =
axis
is to control pain arising from malignancies of the abdomino-pelvic viscera. Visceral pain is often described as constant, =
deep
and is difficult to localize and
characterize. When such a pain syndrome is recalcitrant to meticulous =
application of drug and behavioral therapy, or if the
patient is intolerant to drug therap=
y,
consultation should be sought for consideration of anesthetic and <=
/span>neurolytic procedures. In particular, the following
procedures have an established record =
of
success in well-selected patients.
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=
1.Celiac
plexus block . Us=
ed
for upper abdominal pain, most comm=
only
for pancreatic cancer pain; it is also appropriate for pain involving the GI tract from the
distal third of the esophagus =
to
the transverse colon, the liver and bilia=
ry
tract, the adrenals and mesentery.
2. Superior hypogastric plexus block. Applicable to malignant pain of the gastrointestinal tract from th=
e descending colon to the rectum, as well as the <=
/span>urogenital system.
3. Ganglion impar block. Pain involving the rectum and perineum.
&=
#13;
These
procedures are performed under radiographic guidance (fluoroscopy <=
/span>or CT) to prevent damage to nearby organs, vessels and
spinal cord.
Initially, a diagnostic/prognostic block is performed u=
sing
local anesthetic; the analgesic
response is assessed by patient and physician.
Note: an analgesic response to a diagnostic block is the onl=
y pa=
thognomonic
test for success.
If the respo=
nse
is satisfactory, a therapeutic neurolytic block is performed with ethyl alcohol or phenol. Neurolytic blocks may pro=
vide
several months of analgesia and
may be repeated.
The diagnostic and therapeutic blocks are usually separ=
ated
by at least a day in order=
to
fully assess the response; however, logistical difficulties or extremely debilitated patients occasionally warrant
performance of both blocks on a
single occasion.
Module 4
Module 4
Cancer Pain . Philadelph=
ia: JB Lippincott Company,
1993:377-425.
= Citation for referencing: Reisfield GM and Wilson GR. F= ast Facts and Concepts #97. Blocks of the sympathetic axis for visceral pain. August 2003. <= span style=3D'font-family:Arial;font-size:75%;text-shadow:auto;color:white; mso-color-index:0'>End-of-Life Physician Education Resource Center w <= /span>
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Module 4
Patient
Controlled Analgesia in Palliative Care
&=
#13;
Author(s): E=
ric
Prommer
Module 4
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Module 4
Module 4
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Module 4
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Module 4
Cultural
aspects of pain management
&=
#13;
Author(s):
Bidar-Sielaff, Shiva; Gordon, Deborah; Weissman, David E
• ACGME
Competencies: Interpersonal and Communication Skills,
Patient Care
Module 4
Module 4
Module 4
To
be Culturally Competent, you must:
• Be aware of your perso=
nal
biases and assumptions about people with
• Be aware and accept
cultural differences between yourself and
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• References:
•Bates
M.S., Rankin-Hill, L., & Sanchez-Ayendez, M. (1997) The Effects of the Cultural Context of Health Care on Treatment of and Response =
to
Chronic Pain and Illness. Soc=
ial
Science and Medicine, 45(9). 1433-1447.
=
;•Berlin EA Fowkes WC. <=
/span>A teaching framework for cross-cultural health care.=
WJMed 1983;139:934=
-938.
•Kleinman AK, Eisenberg L, Good B. Culture illness and care. Clinical lessons from =
Anthropologic and cross-cultural research. Ann Int Med 1978;88:251-=
258.
•Morrison RS, Wallenstein S, Natale DK, Senzel RS, Huang=
LL.
"We don't carry that"-failure of pharmacies in predominantly nonwhite
neighborhoods to stock opioid ana=
lgesics.
N Engl J Med 2000;342:1023-1026.
• University of Wisconsin
Hospital & Clinics, Pain Patient Care Team.
•
•Citation for referenci=
ng.
Fast Facts and Concepts #78 Cultural aspects of pain management. Weissman D Gordon D, and Bidar-Sielaff S.
October 2002. End-of-Life Physic=
ian
Education Resource Center
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Promoting Pain Acts; 2001.&n=
bsp;
http://www.fsmb.org <=
/span>.
of opioid analgesics and implications for
diversion control: 1997-2002. Journal of Pain & Symptom =
=
http://ww=
w.medsch.wisc.edu/painpolicy/publicat/04jpsm/index.htm Gilson AM, Joranson DE, Maurer MA, Ryan KM,
Garthwaite JP. Progress to a=
chieve
balanced state policy relevant to pain management and palliat=
ive
care: 2000-2003. Care Pharmacotherapy<=
/span>Gilson AM, Joranson DE, Maurer MA. Improving state medical board
policies: Influence of a model. Journal of Law, Medicine
& Ethics. 2003; 31(1):119-129. http://ww=
w.medsch.wisc.edu/painpolicy/publicat/03jlme/index.htm
Controlled
substances and pain management: Changes in knowledge =
&nb=
sp;
Journal of Pain & Symptom Management. =
21(3):227-237. &nb=
sp;
http://ww=
w.medsch.wisc.edu/painpolicy/publicat/01jpsm/index.htm
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------=_NextPart_01C7C2FD.FC563110
Content-Location: file:///C:/14882234/Module1.PainManagement_files/script.js
Content-Transfer-Encoding: quoted-printable
Content-Type: application/javascript; charset="us-ascii"
function LoadSld()
{
var sld=3DGetObj("SlideObj")
if( !g_supportsPPTHTML ) { =09
sld.style.visibility=3D"visible"
return
}
if( MakeNotesVis() ) return
runAnimations =3D _InitAnimations();
=09
if( IsWin("PPTSld") )
parent.SldUpdated(GetSldId())
g_origSz=3DparseInt(SlideObj.style.fontSize)
g_origH=3Dsld.style.posHeight
g_origW=3Dsld.style.posWidth
g_scaleHyperlinks=3D(document.all.tags("AREA").length>0)
if( g_scaleHyperlinks )
InitHLinkArray()
if( g_scaleInFrame||(IsWin("PPTSld") && parent.IsFullScrMode() ) )
document.body.scroll=3D"no"
_RSW()
if( IsWin("PPTSld") && parent.IsFullScrMode() )
FullScrInit();
=09
MakeSldVis();
ChkAutoAdv()
if( runAnimations )
{
if( document.all("NSPlay") )
document.all("NSPlay").autoStart =3D false;
if( sld.filters && sld.filters.revealtrans )
setTimeout( "document.body.start()", sld.filters.revealtrans.duration * =
1000 );
else
document.body.start();
}
}
function MakeSldVis()=20
{
var fTrans=3Dg_showAnimation && SldHasTrans()
if( fTrans )=09
{
if( g_bgSound ) {
idx=3Dg_bgSound.indexOf(",");
pptSound.src=3Dg_bgSound.substr( 0, idx );
pptSound.loop=3D -(parseInt(g_bgSound.substr(idx+1)));
}
SlideObj.filters.revealtrans.Apply()=09
}
SlideObj.style.visibility=3D"visible"
if( fTrans )
SlideObj.filters.revealtrans.Play()
}
function MakeNotesVis()=20
{
if( !IsNts() ) return false=20
SlideObj.style.display=3D"none"
nObj =3D document.all.item("NotesObj")
parent.SetHasNts(0)
if( nObj ) {=20
nObj.style.display=3D""
parent.SetHasNts(1)
}
return 1
}
function ChkAutoAdv()
{
if(SldHasTrans())
SlideObj.onfilterchange=3DAutoAdv
else
AutoAdv()
}
function AutoAdv()
{
if(!IsWin("PPTSld") || !gUseSldTimings )return
var sld=3DGetCurSld()
if( (sld.mAdvDelay>0) && !parent.IsFramesMode() )
setTimeout("parent.GoToNextSld()",sld.mAdvDelay)
}
function GetObj(id)
{
if(g_supportsPPTHTML) return document.all(id);
else return document.getElementById(id);
}
function SldHasTrans() { return SlideObj.style.filter !=3D ""; }
function GetSldId() { return sId=3Dlocation.href.substring(location.href.la=
stIndexOf('/')+1) }
function HideMenu() { if( frames["PPTSld"] && PPTSld.document.all.item("ctx=
tmenu") && PPTSld.ctxtmenu.style.display!=3D"none" ) { PPTSld.ctxtmenu.styl=
e.display=3D'none'; return true } return false }
function IsWin( name ) { return window.name =3D=3D name }
function IsNts() { return IsWin("PPTNts") }
function IsSldOrNts() { return( IsWin("PPTSld")||IsWin("PPTNts") ) }
function SupportsPPTAnimation() { return( navigator.platform =3D=3D "Win32"=
&& navigator.appVersion.indexOf("Windows")>0 ) }
function SupportsPPTHTML()
{
var appVer=3Dnavigator.appVersion, msie=3DappVer.indexOf("MSIE "), ver=3D0
if( msie >=3D 0 )
ver=3DparseFloat( appVer.substring( msie+5, appVer.indexOf(";",msie) ) )
else
ver=3DparseInt(appVer)
return( ver >=3D 4 && msie >=3D 0 )
}
function _RSW()
{
if( !g_supportsPPTHTML || IsNts() ||
( !g_scaleInFrame && (!IsWin("PPTSld") || !parent.IsFullScrMode()) ) )
return
var padding=3D0;
if( IsWin("PPTSld") && parent.IsFramesMode() ) padding=3D6
cltWidth=3Ddocument.body.clientWidth-padding
cltHeight=3Ddocument.body.clientHeight-padding
factor=3D(1.0*cltWidth)/g_origW
if( cltHeight < g_origH*factor )
factor=3D(1.0*cltHeight)/g_origH
newSize =3D g_origSz * factor
if( newSize < 1 ) newSize=3D1
s=3DSlideObj.style
s.fontSize=3DnewSize+"px"
s.posWidth=3Dg_origW*factor
s.posHeight=3Dg_origH*factor
s.posLeft=3D(cltWidth-s.posWidth+padding)/2
s.posTop=3D(cltHeight-s.posHeight+padding)/2
if( g_scaleHyperlinks )
ScaleHyperlinks( factor )
}
function _InitAnimations()
{
animRuntimeInstalled =3D ''+document.body.localTime !=3D 'undefined';
isFullScreen =3D (window.name =3D=3D "PPTSld") && !parent.IsFramesMode();
g_animUseRuntime =3D g_showAnimation && animRuntimeInstalled && !(isFullSc=
reen && parent.IsSldVisited());
if( g_animUseRuntime ) {
collSeq =3D document.all.tags("seq");
if( collSeq !=3D null ) {
for(ii=3D0;ii numSlds )
gSldJumpIdx =3D numSlds;
if ( gSldJumpIdx >=3D 0 ) {
if ( gSldJumpIdx =3D=3D 0 )
gSldJumpIdx =3D 1;
var jumpTo =3D parseInt(gSldJumpIdx);
gSldJump =3D 0; gSldJumpIdx =3D "";
win.GoToSld( parent.GetSldList().mList[jumpTo-1].mSldHref )
}
}
}
function _KDH()
{
if( event.keyCode =3D=3D 8 ) {
event.returnValue =3D 0;
parent.GoToPrevSld();
}
}function DocumentOnClick()
{
if( IsNts() || parent.HideMenu() ) return;
if( ( g_allowAdvOnClick && (window.name=3D=3D"PPTSld") && !parent.IsFrames=
Mode() ) ||
(event && event.keyCode=3D=3D32) ) {
=09
if( g_animUseRuntime && g_animMainSequence && g_animMainSequence.cangonex=
t )
return;
parent.GoToNextSld();
}
}
var g_supportsPPTHTML =3D SupportsPPTHTML(), g_scaleInFrame =3D 1, gId=3D""=
, g_bgSound=3D"",
g_scaleHyperlinks =3D false, g_allowAdvOnClick =3D 1, g_showInBrowser =
=3D 0, gLoopCont =3D 0, gUseSldTimings =3D 1;
var g_showAnimation =3D g_supportsPPTHTML && SupportsPPTAnimation() && ( (w=
indow.name=3D=3D"PPTSld" && !parent.IsFramesMode()) || g_showInBrowser );va=
r g_animManager =3D null;
var g_animUseRuntime =3D false;
var g_animItemsToHide, g_animInteractiveItems, g_animSlideTime;
var g_animMainSequence =3D null;
var ENDSHOW_MESG=3D"End of slide show, click to exit.", SCREEN_MODE=3D"Fram=
es", gIsEndShow=3D0, NUM_VIS_SLDS=3D39, SCRIPT_HREF=3D"script.js", FULLSCR_=
HREF=3D"fullscreen.htm";
var gCurSld =3D gPrevSld =3D 1, g_offset =3D 0, gNtsOpen =3D gHasNts =3D gO=
tlTxtExp =3D 0, gHasNarration =3D 0, gOtlOpen =3D true
window.gPPTHTML=3DSupportsPPTHTML()
var gMainDoc=3Dnew Array(new hrefList("slide0056.htm",1,-1,1),new hrefList(=
"slide0169.htm",1,-1,1),new hrefList("slide0170.htm",1,-1,1),new hrefList("=
slide0171.htm",1,-1,1),new hrefList("slide0172.htm",1,-1,1),new hrefList("s=
lide0173.htm",1,-1,1),new hrefList("slide0174.htm",1,-1,1),new hrefList("sl=
ide0175.htm",1,-1,1),new hrefList("slide0176.htm",1,-1,1),new hrefList("sli=
de0177.htm",1,-1,1),new hrefList("slide0178.htm",1,-1,1),new hrefList("slid=
e0179.htm",1,-1,1),new hrefList("slide0180.htm",1,-1,1),new hrefList("slide=
0181.htm",1,-1,1),new hrefList("slide0182.htm",1,-1,1),new hrefList("slide0=
183.htm",1,-1,1),new hrefList("slide0184.htm",1,-1,1),new hrefList("slide01=
85.htm",1,-1,1),new hrefList("slide0186.htm",1,-1,1),new hrefList("slide018=
7.htm",1,-1,1),new hrefList("slide0188.htm",1,-1,1),new hrefList("slide0189=
.htm",1,-1,1),new hrefList("slide0190.htm",1,-1,1),new hrefList("slide0191.=
htm",1,-1,1),new hrefList("slide0192.htm",1,-1,1),new hrefList("slide0193.h=
tm",1,-1,1),new hrefList("slide0194.htm",1,-1,1),new hrefList("slide0195.ht=
m",1,-1,1),new hrefList("slide0196.htm",1,-1,1),new hrefList("slide0197.htm=
",1,-1,1),new hrefList("slide0198.htm",1,-1,1),new hrefList("slide0199.htm"=
,1,-1,1),new hrefList("slide0200.htm",1,-1,1),new hrefList("slide0201.htm",=
1,-1,1),new hrefList("slide0202.htm",1,-1,1),new hrefList("slide0203.htm",1=
,-1,1),new hrefList("slide0204.htm",1,-1,1),new hrefList("slide0205.htm",1,=
-1,1),new hrefList("slide0206.htm",1,-1,1));
/*********************************************
Frameset functions
These functions control slide navigation
and state of the frameset.
**********************************************/
function FullScrInit()
{
g_allowAdvOnClick =3D GetCurSld().mAdvOnClk
document.body.style.backgroundColor=3D"black"
document.oncontextmenu=3Dparent._CM;
document.onkeydown =3D _KDH;
document.ondragstart=3DCancel
document.onselectstart=3DCancel
self.focus()
}
function Redirect( frmId )
{=09
var str=3Ddocument.location.hash,idx=3Dstr.indexOf('#'), sId=3DGetSldId()
if(idx>=3D0) str=3Dstr.substr(1);
if( window.name !=3D frmId && ( sId !=3D str) ) {
obj =3D GetObj("Main-File")
window.location.href=3Dobj.href+"#"+sId
return 1
}
return 0
}
var MHTMLPrefix =3D CalculateMHTMLPrefix();=20
function CalculateMHTMLPrefix()
{
if ( document.location.protocol =3D=3D 'mhtml:') {=20
href=3Dnew String(document.location.href)=20
Start=3Dhref.indexOf('!')+1=20
End=3Dhref.lastIndexOf('/')+1=20
if (End < Start)=20
return href.substring(0, Start)=20
else=20
return href.substring(0, End)=20
}
return '';
}
function GetTags(base,tag)
{
if(g_supportsPPTHTML) return base.all.tags(tag);
else return base.getElementsByTagName(tag);
}
function UpdNtsPane(){ if(frames["PPTNts"]) PPTNts.location.replace( MHTMLP=
refix+GetHrefObj( gCurSld ).mNtsHref ) }
function UpdNavPane( sldIndex ){ if(gNavLoaded) PPTNav.UpdNav() }
function UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() }
function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() }
function SetHasNts( fVal )
{
if( gHasNts !=3D fVal ) {
gHasNts=3DfVal
UpdNavPane()
}
}
function ToggleOtlText()
{
gOtlTxtExp=3D!gOtlTxtExp
UpdOtlPane()
}
function ClearMedia()
{
// Clear any sounds playing before launching another browser window. Other=
wise,
// in fullscreen mode, you'll continue to hear the sound in the frames mod=
e.
if (PPTSld.pptSound) PPTSld.pptSound.loop =3D 0;
}
function FullScreen()
{=20
if ( PPTSld.g_animUseRuntime )
PPTSld.document.body.pause();
ClearMedia();
var href =3D ( document.location.protocol =3D=3D 'mhtml:') ? FULLSCR_HREF =
: FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref;
if(PPTNav.event.ctrlKey) {
var w =3D (window.screen.availWidth * 1.0) / 2.0
var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW
win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top=
=3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h );
if( win.document.body && PPTSld.g_animUseRuntime )
win.document.body.PPTSldFrameset=3Dwindow;
}
else
{
win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" );
if( win.document.body && PPTSld.g_animUseRuntime )
win.document.body.PPTSldFrameset=3Dwindow;
}
}
function ToggleVNarration()
{
rObj=3DPPTSld.document.all("NSPlay")
if( rObj && !PPTSld.g_animUseRuntime ) {
if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) )
rObj.Play()
else if( rObj.playState =3D=3D 2 )
rObj.Pause()
else
return;
}
else if( PPTSld.g_animUseRuntime )
{
narObj =3D PPTSld.document.all("narrationID")
if( narObj )
narObj.togglePause()
}
}
function GetCurSldNum()
{ =20
obj=3DGetHrefObj(gCurSld)
if( obj.mOrigVis =3D=3D 1 )
return obj.mSldIdx
else =20
return gCurSld
}
function GetNumSlds()
{ =20
if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 )
return GetSldList().mNumVisSlds;
else
return GetSldList().mList.length
}
function GetSldNum( href )
{
for(ii=3D0; ii 1 )
PopSldList();
else if( !IsFramesMode() ) {
if( gLoopCont )
GoToFirst()
else
EndShow()
}
}
function GoToPrevSld()
{
ii=3DgCurSld-1
if( ii > 0 ) {
obj=3DGetHrefObj(ii)
while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) )
obj=3DGetHrefObj(--ii)
if( ii =3D=3D 0 ) ii=3D1
GoToSldNum(ii)
}
}
function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) }
function GoToLast()
{
ii=3DGetSldList().mList.length
if( ii !=3D gCurSld )
GoToSld( GetHrefObj(ii).mSldHref )
}
function GoToSldNum( num )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
obj =3D GetHrefObj( num )
obj.mVis=3D1
gPrevSld=3DgCurSld
gCurSld =3D num;
PPTSld.location.replace(MHTMLPrefix+obj.mSldHref)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function GoToSld( href )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
GetHrefObj( GetSldNum(href) ).mVis=3D1
PPTSld.location.replace(MHTMLPrefix+href)
}
function SldUpdated( id )
{
if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return
gPrevSld=3DgCurSld
gCurSld=3DGetSldNum(id)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) }
function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO=
bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) }
function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) }
function CloseWindow() {
if( HideMenu() ) return;
=09
var event =3D PPTSld.event;
if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D=
=3D32 || event.type=3D=3D"click" ) )
window.close( self );
CatchNumKeys( self, event );
}
function Unload() { gIsEndShow=3D0; }
function SetupEndShow() {
gIsEndShow=3D1;
PPTSld.document.body.scroll=3D"no";
PPTSld.document.onkeypress=3DCloseWindow;
PPTSld.document.onclick=3DCloseWindow;
PPTSld.document.oncontextmenu=3D_CM;
}
function EndShow()
{
if( IsFramesMode() ) return
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
doc=3DPPTSld.document
var dir =3D doc.body.dir
if( dir !=3D "rtl" ) dir =3D "ltr";
doc.open()
doc.writeln(' 0) {
PushSldList(sldList,fEnd);
gCurSld =3D 1;
}
else
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
}
function PushSldList(arr,fEnd) {
var ii =3D gSldStack.length;
gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd);
GoToSld( gSldStack[ii].mList[0].mSldHref );
}
function PopSldList() {
if (gSldStack[gSldStack.length-1].fEndShow)
EndShow()
else {
gCurSld =3D gSldStack[gSldStack.length-1].mCurSld;
gSldStack[gSldStack.length-1] =3D null;
gSldStack.length--;
var sldList =3D gSldStack[gSldStack.length-1];
GoToSld( sldList.mList[gCurSld - 1].mSldHref );
}
}
var custShowList=3Dnew Array();
/*********************************************
Navigation button implementation
There are 2 types of buttons: ImgBtn, TxtBtn
implemented as function objects. They share
a similiar interface so the event handlers
can call SetActive, for example, on a button=20
object without needing to know exactly=20
what type of button it is.
**********************************************/
//----------------------------------
function ImgBtn( oId,bId,w,action )
//----------------------------------
{
var t=3Dthis
t.Perform =3D _IBP
t.SetActive =3D _IBSetA
t.SetInactive=3D _IBSetI
t.SetPressed =3D _IBSetP
t.SetDisabled=3D _IBSetD
t.Enabled =3D _IBSetE
t.ChangeIcon =3D null
t.UserAction =3D action
t.ChgState =3D _IBUI
t.mObjId =3D oId
t.mBorderId=3D bId
t.mWidth =3D w
t.mIsOn =3D t.mCurState =3D 0
}
function _IBSetA()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _IBSetI()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0=20
}
}
function _IBSetP()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 )
obj.style.posLeft+=3D1; obj.style.posTop+=3D1
}
}
function _IBSetD()
{ =20
obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 )
obj.style.posTop=3D0=20
}
function _IBSetE( state )
{
var t=3Dthis
GetObj( t.mBorderId ).style.visibility=3D"visible"
if( state !=3D t.mIsOn ) {
t.mIsOn=3Dstate
if( state )
t.SetInactive()
else
t.SetDisabled()
}
}
function _IBP()
{
var t=3Dthis
if( t.mIsOn ) {
if( t.UserAction !=3D null )
t.UserAction()
if( t.ChangeIcon ) {
obj=3DGetObj(t.mObjId)
if( t.ChangeIcon() )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth
else
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth
}
t.SetActive()
} =20
}
function _IBUI( clr1,clr2,nextState )
{
var t=3Dthis
SetBorder( GetObj( t.mBorderId ),clr1,clr2 )
obj=3DGetObj( t.mObjId )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj=
.style.posTop
t.mCurState=3DnextState
return obj
}
//-----------------------------------------
function TxtBtn( oId,oeId,action,chkState )
//-----------------------------------------
{
var t=3Dthis
t.Perform =3D _TBP
t.SetActive =3D _TBSetA
t.SetInactive=3D _TBSetI
t.SetPressed =3D _TBSetP
t.SetDisabled=3D _TBSetD
t.SetEnabled =3D _TBSetE
t.GetState =3D chkState
t.UserAction =3D action
t.ChgState =3D _TBUI
t.mObjId =3D oId
t.m_elementsId=3D oeId
t.mIsOn =3D 1
}
function _TBSetA()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gHiliteClr,gShadowClr,0,0 )
}
function _TBSetI()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
}
function _TBSetP()
{
if( this.mIsOn )
this.ChgState( gShadowClr,gHiliteClr,1,1 )
}
function _TBSetD()
{ =20
this.ChgState( gFaceClr,gFaceClr,0,0 )
this.mIsOn =3D 0
}
function _TBSetE()
{
var t=3Dthis
if( !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
else
t.ChgState( gShadowClr,gHiliteClr,1,1 )
t.mIsOn =3D 1
}
function _TBP()
{
var t=3Dthis
if( t.mIsOn ) {=20
if( t.UserAction !=3D null )
t.UserAction()
if( !t.GetState )
return
if( t.GetState() )
t.SetPressed()
else
t.SetActive()
} =20
}
function _TBUI( clr1,clr2,lOffset,tOffset )
{
SetBorder( GetObj( this.mObjId ),clr1,clr2 )
Offset( GetObj( this.m_elementsId ),lOffset,tOffset )
}
function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle=
ft }
function SetBorder( obj, upperLeft, lowerRight )
{
s=3Dobj.style;
s.borderStyle =3D "solid"
s.borderWidth =3D 1=20
s.borderLeftColor =3D s.borderTopColor =3D upperLeft
s.borderBottomColor=3D s.borderRightColor =3D lowerRight
}
function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] }
function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() }
function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() }
function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() }
function BtnOnUp()
{
b=3DGetBtnObj()
if( b !=3D null )
b.Perform()
else
Upd()
}
function GetNtsState(){ return parent.gNtsOpen }
function GetOtlState(){ return parent.gOtlOpen }
function GetOtlTxtState(){ return parent.gOtlTxtExp }
function NtsBtnSetFlag( fVal )
{
s=3Ddocument.all.item( this.m_flagId ).style
s.display=3D"none"
if( fVal )
s.display=3D""
else
s.display=3D"none"
}
function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etActive() }
function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etInactive() }
function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etPressed() }
function _BSetA_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]=20
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _BSetI_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0
}
}
var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"=
THREEDFACE"
var gBtnArr =3D new Array()
gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan=
e,GetOtlState )
gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt=
lPane,GetOtlState )
gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN=
tsPane )
gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg;
gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg;
gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.=
ToggleNtsPane,GetNtsState )
gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To=
ggleNtsPane,GetNtsState )
gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n=
b_prevBorder",30,parent.GoToPrevSld )
gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n=
b_nextBorder",30,parent.GoToNextSld )
gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent=
.FullScreen )
gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa=
rent.FullScreen,null )
gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent=
.FullScreen,null )
gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice=
","nb_voiceBorder",18,parent.ToggleVNarration )
gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT=
xt","nb_otlTxtBorder",23,parent.ToggleOtlText )
gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts"
gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag
gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState
/*********************************************
Context menu implementation
_CM() is the function that's hooked up to
the oncontextmenu event. Once we're asked to
show the menu, we first build it by creating
DIVs on-the-fly. Then we position it=20
within the screen area so it doesn't get
clipped.
Creating the DIVs using createElement() means
we don't have to write out any extra HTML
into the slide HTML files.
**********************************************/
var sNext=3D"Next",sPrev=3D"Previous",sEnd=3D"End Show",sFont=3D"Arial",sAr=
row=3D"Arrow",sFreeform=3D"Freeform",sRect=3D"Rectangle",sOval=3D"Oval"
function ShowMenu()
{
BuildMenu();
var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y=
=3DPPTSld.event.clientY+doc.scrollTop
m =3D PPTSld.document.all.item("ctxtmenu")
m.style.pixelLeft=3Dx
if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) )
m.style.pixelLeft=3Dx-m.scrollWidth
m.style.pixelTop=3Dy
if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) )
m.style.pixelTop=3Dy-m.scrollHeight
m.style.display=3D""
}
function _CM()
{
if( !parent.IsFullScrMode() ) return;
if(!PPTSld.event.ctrlKey) {
ShowMenu()
return false
} else
HideMenu()
}
function BuildMenu()
{
if( PPTSld.document.all.item("ctxtmenu") ) return
var mObj=3DCreateItem( PPTSld.document.body )
mObj.id=3D"ctxtmenu"
mObj.style.visibility=3D"hidden"
var s=3DmObj.style
s.position=3D"absolute"
s.cursor=3D"default"
s.width=3D"120px"
SetCMBorder(mObj,"menu","black")
var iObj=3DCreateItem( mObj )
SetCMBorder( iObj, "threedhighlight","threedshadow" )
iObj.style.padding=3D2
CreateMenuItem( iObj,sNext,M_GoNextSld,M_True )
CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld )
=09
CreateSeparator( iObj )
CreateMenuItem( iObj,sEnd,M_End,M_True )
mObj.style.visibility=3D"visible"
}
function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa=
lue=3Dfalse }
function Highlight() { ChangeClr("activecaption","threedhighlight") }
function Deselect() { ChangeClr("threedface","menutext") }
function Perform()
{
e=3DPPTSld.event.srcElement
if( e.type=3D=3D"menuitem" && e.IsActive() )
e.Action()
else
PPTSld.event.cancelBubble=3Dtrue
}
function ChangeClr( bg,clr )
{
e=3DPPTSld.event.srcElement
if( e.type=3D=3D"menuitem" && e.IsActive() ) {
e.style.backgroundColor=3Dbg
e.style.color=3Dclr
}
}
function M_HasPrevSld() { return( parent.HasPrevSld() ) }
function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() }
function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();=
PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() }
function M_True() { return true }
function M_End() { window.close( self ) }
function CreateMenuItem( node,text,action,eval )
{
var e=3DCreateItem( node )
e.type=3D"menuitem"
e.Action=3Daction
e.IsActive=3Deval
e.innerHTML=3Dtext
if( !e.IsActive() )
e.style.color=3D"threedshadow"
e.onclick=3DPerform
e.onmouseover=3DHighlight
e.onmouseout=3DDeselect
s=3De.style;
s.fontFamily=3DsFont
s.fontSize=3D"9pt"
s.paddingLeft=3D2
}
function CreateSeparator( node )
{
var sObj=3DCreateItem( node )
SetCMBorder(sObj,"menu","menu")
var s=3DsObj.style
s.borderTopColor=3D"threedshadow"
s.borderBottomColor=3D"threedhighlight"
s.height=3D1
s.fontSize=3D"0px"
}
function CreateItem( node )
{
var elem=3DPPTSld.document.createElement("DIV")
node.insertBefore( elem )
return elem
}
function SetCMBorder( o,ltClr,rbClr )
{
var s=3Do.style
s.backgroundColor=3D"menu"
s.borderStyle=3D"solid"
s.borderWidth=3D1
s.borderColor=3DltClr+" "+rbClr+" "+rbClr+" "+ltClr
}
------=_NextPart_01C7C2FD.FC563110
Content-Location: file:///C:/14882234/Module1.PainManagement_files/fullscreen.htm
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Module 4
------=_NextPart_01C7C2FD.FC563110--
Contra=
indications
to these procedures include bleeding diathesis and local infection. Side effects referable to loss of sympathetic
tone may include transient
hypotension and increased intestinal motility. Complications include needle injury to visceral, neural and vascular structur=
es,
pain at the injection site, and
failure to obtain an analgesic response.
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Crucial to t=
he
success of sympatholysis is professional expertise, in terms of both patient selection and technical excellence.
=
;
Sympathetic blocks are not a panacea and
generally do not obviate the need f=
or
ongoing pharmacological management of the remaining nociceptive and neuropathic pain components.
However, they can substantially improve analgesia and
quality of life, and may allow for opioid dosage reduction.
<=
span
style=3D'position:absolute;top:59.75%;left:16.85%;width:84.64%;height:3.5%=
'> Note: attempts at post-block opioid reduction should be done=
wi=
th
care to avoid unmasking existing nociceptive/neuropathic pa=
in and
precipitating opioid withdrawal.
Potential advantages of a neurolytic procedure, compare=
d to
spinal and epidural anesthetic
techniques, include cost savings and avoidance of hardware (e.g. catheters, tubes, pump), which can be
cumbersome and are subject =
to
malfunction, and pose an infection risk.
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REFERENCES
Waldman SD (ed.): Intervent=
ional
Pain Management. 2nd ed. Philadelphia: WB Saunders
Company, 2001.
<=
span
style=3D'font-family:Arial;font-size:75%;text-shadow:auto;color:white;
mso-color-index:0'>De Leon-Casasola OA: Critical
evaluation of chemical neurolysis of the <=
span
style=3D'font-family:Arial;font-size:75%;text-shadow:auto;color:white;
mso-color-index:0'>sympathetic axis for cancer pain. Cancer Control. 2000;7(2):142-148.
=
Plancarte R, Velazquez R, Patt RB: Neurolytic blocks of the sympathetic axis=
. In: Patt RB. = Citation for referencing: Reisfield GM and Wilson GR. F= ast Facts and Concepts #97. Blocks of the sympathetic axis for visceral pain. August 2003. <= span style=3D'font-family:Arial;font-size:75%;text-shadow:auto;color:white; mso-color-index:0'>End-of-Life Physician Education Resource Center w <= /span>
ACGME Competencies: Medic=
al
Knowledge, Patient Care
Keyword(s): Pain
treatment
Patient Controlled Analgesia<=
/span> (PCA) is the technique whereby patients can self administer parenteral analgesics.
The primary advantage of PCA is to shorten =
the
interval from patient-defined need, to the time of actual analgesic administration. PCA is an
effective, safe and well accept=
ed
treatment for post-operative pain, sickle cell crisis pain (as young as age
4), and cancer pain.
In general, PCA will provide the same degre=
e of
analgesia compared to other delivery systems with=
the
same or less total amount of medication.
PCA allows for more immediate relief of
incident (breakthrough) pain and can provide =
patients with a greater sense of personal control over
their pain.
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Indications: The primary indication for PCA is the patient who =
re=
quires
parenteral analgesia (e.g. severe pain and/or or=
al/transdermal/rectal
route not useable) and
PCA is also indicated for use as a method of rapid dose
titration and dose finding in acute
severe pain.
&#=
13;
ha=
s incident pain or other pa=
in
patterns that are not predictable.
=
Relative
contraindications include patients who
a) do not=
have
the cognitive ability to understand how to use a
PCA devic=
e,
or
b) have an
anticipated need for parenteral opioids less than 24
&nbs=
p;
hours.
PCA devices: most devices have a drug reservoir and infusion system
whereby PCA administration can occ=
ur
with or without a background continuous infusion. Thus, PCA devices need the following orders;
1) PCA dose<=
/b> in mg or ug (aka Patient Initiated Dose or Patient Demand
Dose),
2) Delay
Interval (aka Lockout) ? in minutes (period du=
ring
which the patient cannot o=
btain
additional medication),
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3)=
Continuous infusion (CI) Rate in mg/hr or ug /hr (if CI is used) and
4)=
Hour Limit - Maximum
amount of drug to be dispensed in a defined period of time; set th=
e one
hour limit to deliver 3-5 times the estimated required dos=
e.
(N=
ote:
due to the need for frequent dose adjustments, the Hour Limit is of=
ten
omitted in Palliative Care). Most palliative care patients will need bo=
th PCA
demand and CI dosing.
UTMB
Policies:
Dosing: Opioid naive patient: T=
he
following information is for Morphine, the drug of fi=
rst
choice for most patients. Note: Dosing and Delay interval information will
differ with other opioids.
Start dosing: PCA
demand dose =3D 1-3 mg MS;
Delay Interval =
=3D 8-10
min. The total dose given over 4 hours is calculated and an hourly rate determin=
ed
(e.g. if 16 mg is given over four hours =3D 4 mg/hour).
A new PCA
demand dose is then calculated at 50% of the hourly =
continuous infusion rate (4m=
g/hr /
2 =3D 2 mg PCA demand dose,
Delay Interval 8=
-10
min). Non IV patients: Convert the current total oral/transdermal dose to a =
total
24 hour IV dose; divide by 24 to give the hourly
Continuous Infusion r=
ate
(mg/hour, IV/SQ).
The PCA demand dose =
is
initially calculated at 50% of the hourly rate.
Risk of
Overdose The patient who is pushing his or her own PCA button w=
ill
fall asleep before serious signs of overdose occ=
ur
as long as only the patient pushes the bu=
tton
(Note: special care is needed for patients with sleep apnea as they will b=
e mo=
re
sensitive to opioids)
NOTE: these dosing recommendations are rough guidelines:
clinicians need to take i=
nto
account patient age, renal and pulmonary function, co-morbid illness and other psychoactive medication.
<=
/span>When in doubt, it is advised to use a lower continuo=
us
infusion rate (with upward do=
se
adjustments of the CI rate no more frequently than every 8 hours), while adjusting the PCA dose at frequent
intervals (q30-60 minutes).=
<= /span>
<= /span>
References:
Bruera E., Ripamonti Carla. Current Status of Patient-Controlled Analgesia <=
/span>in cancer patients. Oncology 1997; 11:
373-384 1997
Citron ML.,.
Ripamonti-Bruera article reviewed. Oncology<=
/u> 1997; 11: 384-386
1997.
Principles of analgesic=
use
in the treatment of acute pain and cancer pain. American =
Pain
Society 4th Ed. Pgs 39-43.
Pain Clinical Manual 2nd =
Ed.
McCaffery M and Pasero C (eds) Mosby 1999.
Citation for
referencing. Prommer, E. Fast Facts and Concepts #92 PATIENT CONTROLLED ANALGESIA IN PALLIATIVE CARE June 20=
03.
End-of-Life Physician Education
Resource Center
<=
span
style=3D'font-family:Arial;font-size:58%;color:yellow;text-shadow:auto'>•<=
/span> Keyword(s): culture, pain
Studies have
shown that patients from ethnic minorities and cultures different from the health care professionals treating them, receive
inadequate pain management.
Each of us has the impression that people from distinct
cultures are more or less likely=
to
express their pain experience in a manner that is somewhere between quietly enduring (stoic) or very expressive.
Just ask yourself this question-what
populations do you regularly encounter that are =
more likely to be stoic, to be expressive? Now ask your=
self
a second question-do you treat su=
ch
patients who are stoic differently from those who are expressive? <=
/span>Ideally, the answer would be no, we should treat everyo=
ne
the same. However, in truth, we are
likely to provide more attentive and compassionate care to the patient who is stoic compared to the expressive patient. This is
because the culture of pain in Wes=
tern
Civilization tends to honor the stoic person (no pain =3D no gain; the football player who makes a touchdown despite a broken
leg).
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What is it a=
bout
people that directs them to express their pain experience in different ways?
Culture is the framework that directs human
behavior in a given situation. The meaning
and expression of pain are influenced by people's cultural background. =
3;
Pain is not just a physiologic response to tissue damage
but also includes emotional and
behavioral responses based on individuals' past experiences and perceptions of pain (e.g. when you were a child was your
expressive behavior tolerated or
were you expected to be stoic).
Note: Not everyone in every cul=
ture
conforms to a set of expected behaviors or beliefs, so trying to categorize a person into a partic=
ular
cultural stereotype (e.g. all North Da=
kota
farmers are stoic) will lead to inaccuracies. On the other hand, knowledge of a patient's culture may help you better
understand their behavior.
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Even more
important than understanding the culture of others, is understanding how your own upbringing effects your atti=
tude
about pain.
We are likely to believe that our reaction to pain is
"normal" and that other reacti=
ons
are "abnormal".
Thus a doctor or nurse from a stoic family may not know=
how
to react to a patient who responds =
to
pain by loud verbal complaints (or discount the
pain because of the apparent mismatch between the injury and the verbal response).
Even subtle cultural and individual
differences, particularly in nonver=
bal,
spoken, and written language, between health care providers and patients impact care.
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<=
span
style=3D'font-family:Arial;font-size:75%;color:white;mso-color-index:0;
text-shadow:auto'>•Be aware of your own
cultural and family values
different
values than yours
individual
patients
<=
span
style=3D'font-family:Arial;font-size:75%;color:white;mso-color-index:0;
text-shadow:auto'>•Be capable of
understanding the dynamics of the difference
<=
span
style=3D'font-family:Arial;font-size:75%;color:white;mso-color-index:0;
text-shadow:auto'>•Be able to adapt to
diversity
•You
must
• Listen =
with empathy to the patient's perception of their pain;
• Explain your perception of the pain problem;
• Acknowledge the differences and similarities in perceptions=
;=
• Recommend treatment; and
• Negotiate agreement. Questions that staff can use to help assess=
=
cultural differences include:
•What do
you call your pain? Do you have a name for it?
•What do
you think caused your [pain]?; Why do you think it started <=
span
style=3D'position:absolute;top:55.75%;left:11.79%;width:79.77%;height:4.0%=
'>when it did?
•What d=
oes
your [pain] do to you?; How does it work?
•
•What a=
re
the most important results you hope to receive from the treatment?
•
•What a=
re
the main problems your [pain] has caused you?
•What do
you fear most about your [pain]?
=
;
From Pain and Policy Stud=
ies
Group, University of Wisconsin.
Joranson DE, Gilson AM. Legal and regulatory issues in the
management of pain. In: Grah=
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Joranson DE, Gilson AM,
Dahl JL, Haddox JD. Pain
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Journal of Pain & Symptom Management =
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