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Module 4:= Pain Management
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Pain
= Management
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&= #13;
The Education in Palliative and End-of-life Care Project = at Northwestern University’s Feinberg School of Medicine, created with the support of the American Medical Association and the Robert Wood Johnson Foundation
Additional material has been included from numerous
other sources.
For any questions related to the Education in Palliative and
End-of-Life Care you may contact the Program Co-Directors:
Kriste= ne K Gugliuzza, MD        = ;  Gary Kesling, PhD
Core materials in this Mod= ule developed from:
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Learning Objectives
•Recognize and address barriers to effective EOL pain care <= /div>
•Develop a better understanding of attitudes and beliefs about pain management
•Improve your knowledge and skills in assessing and treating pain
•Incorporate this content into your clini= cal teaching
•
Dealin= g with pain can be a pain.

This s= eminar will provide you with the basic tools to help make treating pain a source of satisfaction for you and your patients.



------=_NextPart_01C7BA5B.4F96ED70 Content-Location: file:///C:/A819918E/Module1_Pain_files/slide0119.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Module 4
Case of Mrs. Dolores = Long
Mr= s. Dolores Long is a 70-year old widowed African American female = who was recently diagno= sed with lung carcinoma and metastasis to bone. She is being admi= tted to the hospital for a round of chemotherapy.
A medical resident performs the admission H&P. Mrs. Long denies any symptoms. Physical examination is unremarkable. Mental status exam is significant for flat affect and poor eye contact.  The resident finishes the exam and leaves the room. Mrs. LongR= 17;s daughter steps outside with the resident and explains that her mot= her has complained of severe pain and has become sedentary and withdrawn. She has refused the acetaminophen with codeine that= was prescribed because she doesn’t want to “get hooked,” and the pills don’t help anyway.
The resident is surprised, as Mrs. Long did not appear to be in pain. <= /span>He explains that “nothing more can be done” for the pain, as strong narcotics like morphine might cause her to stop breathing and NSAIDs like ibuprofen could ca= use GI bleeding. However, psychiatry will be consulted to evaluate h= er depression.
Han= dout: Case of Mrs. Dolores Long
[Te= acher’s Note: Ask one learner to read the case aloud.]

What w= ould you be concerned about in this case? Do you see any red flags?
[Te= acher’s Note: You may want to tick off each of these with a red marker]

[Possi= ble responses might include:]

Is the= T#3 strong enough?

Needs = long-acting opioid

May no= t convert codeine to morphine

Attitu= des about opioids

May be= on medications that interfere with codeine

   Need to know more about her pain, her situation, etc.

These = are some of the challenges of treating pain that we will address in this seminar.




------=_NextPart_01C7BA5B.4F96ED70 Content-Location: file:///C:/A819918E/Module1_Pain_files/slide0151.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Module 4
Case of Mrs. Dolores = Long
What would yo= u be concerned about in this case?
Do you see an= y red flags?
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Case of Mrs. Dolores = Long
What would yo= u be concerned about in this case?
Do you see an= y red flags?
Is the T#3 strong enough?
She need long-acting opioid
May not convert codeine to morphine
Attitudes about opioids
May be on medications that interfere with codeine
Nee to know more about her pain, situation, etc= .
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Pain in the Hospitalized Seriously Ill
•50% of conscious patients were in moderate to severe pain at least half the time in the three days prior to death
•N =3D 9105 patients
A Controlled Trial to Improve Care for Seriously III Hospitalized Patients: The Study to Understand Prognoses and Prefer= ences for Outcomes and Risks of Treatments (SUPPORT).
JAMA. 274(20):1591-1598, November 22/29, 19= 95.
Studies show that pain is common at the end of life.

There is evidence that it is under-treated in all venues and all age groups.
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Pain in Nursing Home = Patients
=
=
•30% report= ed daily pain
•26% of the= se patients received no analgesia
<= span style=3D'font-size:75%;font-weight:normal'>•Only 26% of them received strong opioids
•What predi= cted inadequate pain management?
•Advanced a= ge: >85 years old
•Poor cogni= tive function
<= span style=3D'font-size:75%;font-weight:normal'>•Minority status
Bernabei R, Gambassi G, Lapane K, et al.  Management of pain in elderly patients with cancer.  JAMA 1= 998; 279 (23): 1877-1882
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General Principles for Prescribing Pain-Control Medication= s in the Long-Term Care Setting
1.Administer medication routinely (not PRN).
2.Use the least invasive route of administration fir= st.
3.Begin with a low dose. Titrate carefully until comfort is achieved. &= #13;
4.Reassess and adjust dose frequently to optimize &#= 13;
       pain relief while monitoring and managing side effects.
Source:
American Medical Directors Association = Published 199= 9, revised 2003
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Pain in Outpatients
=
•67% outpatients with metastatic CA were in pain
•42% of those not given adequate analgesic <= /span>therapy
•What predicted inadequate pain management?
Discrepancy between patient and MD assessment of pain
Advanced age: >70 years old
Female
Better performance status
Minorities
N =3D 1308
l
Cleeland CS, Gonin R, Hatfield AK, Edmon= son JH, Blum RH, Stewart JA, Pandya KJ.
(1994).  Pain and its trea= tment in qoutpatients with metesatic cancer. N Engl J Med 1994; 330:592-59= 6.
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•What makes pain so difficult to treat?
[Possible responses might include:]
   Not sure how to treat
   Afraid of Drug Enforcement Agency
   Fear of addiction
      [Ask “Who fears this?”]
   Patients
   Family members
   Medical and nursing staff
   Regulatory barriers=
   Side effects
   Emotionally difficult to d= eal with pain
   Patient don‘t want to complain, want to be ‘good’ patients, don’t think anyth= ing
      can be d= one
   Transcultural differences = in manifesting or ascribing meaning to pain
   Pain is difficult to measu= re
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•What makes pain so difficult to treat?
Not sure ho= w to treat
   Afraid of Drug Enforcement Agency
   Fear of addiction: Patients and/or Family members&= #13;
Medical and nursing staff &= #13;
   Regulatory barriers
   Side effects
   Emotionally difficult to de= al with pain
   Patient don‘t want to complain, want to be ‘good’ patients, don’t think anything
      can be done
   Transcultural differences in manifesting or ascribing meaning to pain
   Pain is difficult to measur= e
[Possible responses might include:]
   Not sure how to treat
   Afraid of Drug Enforcement Agency
   Fear of addiction
      [Ask “Who fears this?”]
   Patients
   Family members
   Medical and nursing staff
   Regulatory barriers=
   Side effects
   Emotionally difficult to d= eal with pain
   Patient don‘t want to complain, want to be ‘good’ patients, don’t think anyth= ing
      can be d= one
   Transcultural differences = in manifesting or ascribing meaning to pain
   Pain is difficult to measu= re
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Six Major Barriers to Adequate Pain Care
•Myth: That addiction is a common result of treating pain with opioids
•Regulatory and legal concerns
•System barriers
•Deficits in knowledge and education
•Fear of side effects
•Assessment challenges
These six major barriers have been cited in the literature.

Why do these barriers exist?

They reflect social realities.

[Teacher’s Note: Prompt for brief examples of how each myth might relate to the = case of Mrs. Long.]
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Definitions
=
=
<= span style=3D'font-size:88%;color:#CCCCFF;mso-color-index:6;font-weight:normal'= >•Addiction:<= span style=3D'font-size:88%'> Psychological dependence on <= span style=3D'font-size:88%'>a drug. Drug-seeking behavior despite adverse consequences
•Physical Dependenc= e: Development of physical withdrawal reaction upon discontinuation or antagonism of a drug
•Tolerance:<= span style=3D'font-size:88%'> Need to increase amount of drug to obtain the same effect <= /div>
•Pseudoaddiction: Behavior suggestive of addiction occurring as a result of <= span style=3D'position:absolute;top:91.54%;left:5.02%;width:82.01%;height:8.45%= '>undertreated pain
Han= dout: Definitions

Not al= l these barriers are specific to opioids. We’ll start with the myth about addiction, which is a big barrier for doctors and patients and their fami= lies alike.

What i= s your understanding of the concept of pseudoaddiction?

Who ha= s an example?

[Possi= ble responses might include:]

   Trying to act out acute pa= in to convince you of their real chronic pain and
      need for medication.
   Abnormal groaning
   ‘Doctor shoppingR= 17;
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Barrier #1: The Myth of Addiction
•Addiction differs from chemical dependence, tolerance, and = pseudoaddiction •Increased use of opioid analgesics for pain does n= ot appear to contribute to increases in opioid abuse (Joranson, 2000)
•Fears are exaggerated due to referral bias
•Pseudoaddiction complicates the picture
•Increased opioid requirement is usually related to= progression of disease, not tolerance
[Te= acher’s Note: Use of the word ‘myth’ is purposely ambiguous. Myths are based on some partial truth, e.g., opioids can become addictive.]

Mrs. L= ong was afraid of getting “hooked” on a pain killer.




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Barrier #2: Regulatory and Legal Concerns
•Physicians are wary of prescribing controlled substances for fear of criminal and/or licensing sanctions
Risk is very low if indication and response are properly documented
•Regulatory policies that control = opioids get in the way
Triplicates
Renewal policies
= l
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#3 System Barriers
•Lack of systemic use of practice guidelines •Pain management historically has not been incorporated into quality management structure •Many institutions still lack pain and/or palliative care services
Since the JCAHO requirement, we’re getting better with practice guideline= s.

Many institutions still lack pain or palliative care services, or are working = hard to initiate them.  This is challenging.
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Barrier #4: Deficits in Knowledge and Education
•In patients, families, physicians, and other health care professionals •Pain management is still rarely addressed in medical school <= span style=3D'position:absolute;top:67.87%;left:5.0%;width:81.69%;height:13.98%= '>curricula
In you= r own training, how much time did you spend learning to alleviate pain?<= br>

[Ask f= or a show of hands: “A course? Two hours?”]

Newer = physicians are beginning to get this, but many of us did not.
We don= ’t realize we’re missing it.




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Barrier #4: Deficits in Knowledge
<= span style=3D'mso-special-format:bullet;color:#FF3300;position:absolute;left:-4= .59%'>•It is rarely included in textbooks
< 2% medical textbook content =
        = ;            Rabow, JAMA. 2000;283:771-778.
< 5% nursing textbook pages
Ferrell, J. of  Palliative Care. 2000;16(1): 39-47.
•Physicians lack awareness of their own knowledge deficits in pain = = management
In you= r own training, how much time did you spend learning to alleviate pain?<= br>

[Ask f= or a show of hands: “A course? Two hours?”]

Newer = physicians are beginning to get this, but many of us did not.
We don= ’t realize we’re missing it.




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Barrier #5: Bad Side = Effects of Opioids - Key Points
•Pain is a partial antagonist to respiratory depression and CNS sedation
•Respiratory depression, sedation, and N&V relate more to changing blood serum levels of opioids than the steady state dose
•Pain management and constipation relate to steady state dosing, not the rising blood opioid level
Treat prophylactically and continually
As in = the case of Mrs. Long, many patients, families, and health care professionals = fear these things.

Side e= ffects can be managed.



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Barrier #6: Assessment Challenges
•Health care professionals are more comfortable measuring objective data
•We lack a scanner that is more accurate than patient report
•Compare, contrast nociceptive, neuropathic pain
•Know steps of analgesic management
How do= we know who really is in pain?

Blood = pressure, 02 saturation levels, and hematocrit are less open to interpretation or disp= ute.

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General principles . . .
•A= ssessment
•M= anagement
pharmacologic
nonpharmacologic
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. . . General principles
•Education – patient, family, all caregivers •Ongoing assessment of outcomes, regular review of plan of care •Interdisciplinary care, consultative expertise
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Pain pathophysiology
•A= cute pain
identified event, resolves days–weeks
usually nociceptive
•C= hronic pain
cause often not easily identified, multifactorial
indeterminate duration
nociceptive and / or neuropathic
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A Tool to Help Assess = Pain
=
=
•N - Number of pains?&#= 13;
•O - Origin/causes? = ;
•P - Palliates, potentiates?
•Q - Quality?
•R - Radiation?
•S - Severity, suffering?
•T - Timing, trend? = ;
•&= #13;
•<= span style=3D'mso-special-format:lastCR;display:none'>
Han= dout: NOPQRST: A Tool to Help Assess Pain

This i= s an adaptation from a time-honored mnemonic (Grey, 1977) to help differentiate what is going on when a patient is in pain.

Since = pain is subjective, we need to get the information through a patient-based subjec= tive history.



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quoted-printable Content-Type: text/html; charset="us-ascii" Module 4
Mnemonic
=
ABCDE for Pain Management and Assessment
Ask about pain regularly.
Assess pain systematically.
Believe the patient and family in their reports of pain and what
relieves it. <= /span>
Choose pain control options appropriate for the patien= t, family and setting. <= /span>
Deliver intervention in timely, logical and coordinated fashion.
Empower patients and their family.
Enable them to control their course to the greatest ex= tent possible.
<= i>Acute Pain Management: Operative . Publication 92-0032
 <= /span>
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Pattern Matching
Differences Between Acute and Chronic Pain
      Characteristics
      Acute Pain
     <= b> Chronic Pain
   
      Temporal features
   &nb= sp;  <= b>Recent onset and expected to last no
      longer than days or weeks=
      Remote, often ill-defined onset;
      duration unknown
 
      Intensity=
      Variable<= /b>&#= 13;
      Variable=
 
      Associat= ed affect
      Anxiety m= ay be prominent when pain is
      severe or cause is unknown; sometimes
      irritability
      Irritability or depressio= n
 
      Associated pain-
      related behaviors
      Pain behaviors (<= b>e.g.<= b>, moaning,
      rubbing, splinting) may be prominent
      when pain is severe
      <= b>May or may not give any indication
      of pain; specific behaviors (<= b>e.g.<= b>,
      assuming a comfortable position)
      may occur
 
<= span style=3D'mso-spacerun:yes'>      Associated
      features
      May have signs of sympath= etic
      hyperactivity when pain is severe
      (e.g<= b>., tachycardia, hypertension,
      sweating, mydriasis)
      <= b>May or may not have vegetative
      signs such as: lassitude, anorexia,
      weight loss, insomia, loss of libido;
      these signs may be difficult to
      distinguish from other disease-
      related effects.
 
Sou= rce: Portenoy RK and Kanner RM, Definition and assessment of pain. In Portenoy = RK and Kanner RM, eds. Pain = Management: Theory and Practice, Philadelphia: F A Davis; 1996; 7.
What w= ould an acute pain pattern look like?

Patter= n matching helps fit the appropriate treatment strategy to the pain pattern.<= br>

[Te= acher’s Note: Project this overhead or slide onto a white board.  Use a red marker for the pain pa= ttern and a blue one for treatment.]

We wan= t to understand and at least mentally graph the temporal pattern of pain in a given patient, then match this pattern with therapy.

This m= aximizes beneficial effect & minimizes toxicity, particularly when opioids are used.






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file:///C:/A819918E/Module1_Pain_files/slide0142.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Module 4
What Would a Acute Pain Pattern Look Like?
Maximize beneficial effects and minimize toxicity, particularly
when using opioids.
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Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Module 4
"Fifth Vital Sign"
Pain measurement, unlike other vital signs, is vulnerable to bias on the part of = both the patient and the caregiver. The patient self-report of pain is inherently subjective. However, healthcare workers often underestimate patients' pain for subjective reasons as well. A recent study by Marquié et al= . detected a "miscalibration&qu= ot; in the physician ratings for their patients and suggested such factors as physician gender, patient gender, = and "obviousness of the cause of pain" contribute to the discrepan= cy.
Marquié, L, Raufaste, E, Lauque, D, Mariné, C, Ecoiffier, M, Sorum, P. Pain rating by patients and physicians: evidence of systemic pain miscalibration. Pain. 2003; 102: 289     296.
3D-
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What Would a Chronic = Pain Pattern Look Like?
Most chronic pain has a basal component plus:
Spikes –breakthrough or incident pain
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f8LN8Sf89Yf++T/jR/ws3xJ/z1h/75P+NH/CzfEn/PWH/vk/41i+JvGGq67Yxw3xiZUlDAqpBzgj 196//9m= ------=_NextPart_01C7BA5B.4F96ED70 Content-Location: file:///C:/A819918E/Module1_Pain_files/slide0144.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Module 4
Treating Chronic Pain
•Basal pain medicine plus a different therapy for spikes:
l
Predictable spikes - Short-ac= ting agent
        = ;            &n= bsp;            = ;   prior to event
Unpredictable spikes - Short-= acting agent
        = ;            &n= bsp;            = ;    readily available
What t= herapy would you suggest for the chronic pain pattern?

If the= order says 10 mg morphine prior to dressing change, when is it likely to be given?  How would you want to write this order?

[Te= acher’s Note: Overlay this curve with a wavy line representing treatment.]

With o= pioids, give a long-acting opioid for basal pain relief and a short-acting opioid for predictable spikes.

Allow = enough time to allow maximal effect (45 minutes for most oral opioids).

------=_NextPart_01C7BA5B.4F96ED70 Content-Location: file:///C:/A819918E/Module1_Pain_files/slide0145.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Module 4
Case Discussion
•Chronic pain - escalating
Why might her pain be worse at night? <= /span>
Thinking back to Mrs. Long, let’s say she’s been getting better
pain control  but her p= ain is always worse at night.
Thinki= ng back to Mrs. Long, let’s say she’s been getting better pain control b= ut her pain is always worse at night.

Why mi= ght her pain be worse at night?
[Possi= ble responses might include:]
She ha= s time to think and focus on pain without distractions
Some p= ains worsened by recumbency, e.g., pressure on a bony metastasis
Restle= ssness, preoccupation
Vital = signs being taken
Deliri= um (sundowning) & agitation may worsen pain
Depres= sion may become apparent
Taking= only short-acting medication which wears off 4 hours after going to bed=
Caregi= ver who gives short-acting medication is not available - asleep or busy
She ma= y not be able to ask for medication
Patien= t has to get up frequently to urinate

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Case Discussion
•Chronic pain - escalating
Why might her pain be worse at night? <= /span>
P= ossible responses might include:
She = has time to think and focus on pain without distractions
Some pains worsened by recumbency, e.g., pressure on a bony metastasis
Rest= lessness, preoccupation
Vital signs being taken 
Deli= rium (sundowning) & agitation may worsen pain
Depr= ession may become apparent
Taki= ng only short-acting medication which wears off 4 hours after going to bed= 3;
Care= giver who gives short-acting medication is not available - asleep or busy
She = may not be able to ask for medication
Pati= ent has to get up frequently to urinate
Thinki= ng back to Mrs. Long, let’s say she’s been getting better pain control b= ut her pain is always worse at night.

Why mi= ght her pain be worse at night?
[Possi= ble responses might include:]
She ha= s time to think and focus on pain without distractions
Some p= ains worsened by recumbency, e.g., pressure on a bony metastasis
Restle= ssness, preoccupation
Vital = signs being taken
Deliri= um (sundowning) & agitation may worsen pain
Depres= sion may become apparent
Taking= only short-acting medication which wears off 4 hours after going to bed=
Caregi= ver who gives short-acting medication is not available - asleep or busy
She ma= y not be able to ask for medication
Patien= t has to get up frequently to urinate

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•How might we treat Mrs. Long’s pain?
What a= pproaches might we take to alleviate these problems?

[Possi= ble responses might include:]

Consid= er giving a larger dose or a long-acting medication at night
A seda= tive, neuroleptic, or antidepressant may help if she is agitated, confused, or depressed
This m= ay also be an opportunity to discuss what is bothering her
Discus= s options for urinary frequency (diapers, Foley catheter)
Provid= e stimulation, recreation, or counseling (as appropriate) during the day
If pat= ient has an internal locus of control, biofeedback or the relaxation response can hel= p


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•How might we treat Mrs. Long’s pain?
P= ossible responses might include:
C= onsider giving a larger dose or a long-acting medication at night <= /div>
A sedative, neuroleptic, or antidepressant may help if she is agitated, confused, or depressed
T= his may also be an opportunity to discuss what is bothering her
D= iscuss options for urinary frequency (diapers, Foley catheter)
P= rovide stimulation, recreation, or counseling (as appropriate) during the day = ;
If patient has an internal locus of control, biofeedback or the relaxation response can help
=
What a= pproaches might we take to alleviate these problems?

[Possi= ble responses might include:]

Consid= er giving a larger dose or a long-acting medication at night
A seda= tive, neuroleptic, or antidepressant may help if she is agitated, confused, or depressed
This m= ay also be an opportunity to discuss what is bothering her
Discus= s options for urinary frequency (diapers, Foley catheter)
Provid= e stimulation, recreation, or counseling (as appropriate) during the day
If pat= ient has an internal locus of control, biofeedback or the relaxation response can hel= p


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Nociceptive pain . . .
•D= irect stimulation of intact nociceptors
•T= ransmission along normal nerves
•s= harp, aching, throbbing
somatic
easy to describe, localize
visceral
difficult to describe, localize
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Nociceptive Pain
=
•Origin:
Tissue damage
•Palliates/potentiates:
Worse with stress, pressure= 3;
Responds better to opioids, NSAIDs
•Quality:
Sharp, dull, stabbing, pressur= e, ache, throbbing
•Radiation:
Occasionally radi= ates (less well-defined), but not along an obvious nerve distribution
Nociceptive pain is adaptive: The pain fibers are working as they are supposed to.

Consider psychological, spiritual, and cultural factors that may either exacerbate= or relieve pain.
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Neuropathic pain . . .
•Di= sordered peripheral or central nerves
•C= ompression, transection, infiltration, ischemia, metabolic injury
•V= aried types
peripheral, deafferentation, complex regional syndromes
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. . . Neuropathic pain
•P= ain may exceed observable injury
•D= escribed as burning, tingling, shooting, stabbing, electrical =
•M= anagement
opioids
adjuvant / coanalgesics often required
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Visual Analog Scale
•1-3     Tolerable <= /span>
•4-6     Change therapy soon
•7-10   Emergency SOS - change therapy now
JCAHO requires that intensi= ty of pain be assessed and that the results are documented. Pain Assessment F= orms are the best tool to measure and document the intensity of pain. Ensuring clear communication between the patient and the care team. <= /span>
JCAHO requires that intensi= ty of pain be assessed and that the results are documented. Pain Assessment F= orms are the best tool to measure and document the intensity of pain. Ensuring clear communication between the patient and the care team. <= /span>
JCAHO requires that intensi= ty of pain be assessed and that the results are documented. Pain Assessment F= orms are the best tool to measure and document the intensity of pain. Ensuring clear communication between the patient and the care team. <= /span>
JCAHO requires that intensity of pain be assessed and that the results are <= /span>documented. Pain Assessment scales are the best tool to measure and document the intensity of p= ain. Ensuring clear communication between the patient and the care team. <= /span>
It is = important to use a consistent way of recording pain.&= nbsp; There are many different scales.

Use of= the 0-10 Visual Analog Scale or similar tool is recommended.  Studies have demonstrated reliab= ility (McDowell, 1996)

Most p= eople can communicate through a pain scale at least what they would like us as clinicians to do.

Where = is pain relief on the scale?

There = may be considerable variation between individuals.

It is = important to ask if pain relief is adequate or not.

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Scale
Advantages
Disadvantages
Comments
Numeric rating scale (NRS) =
Easy to use Simple to describe
High rate of adherence Flexible administrat= ion = (including by telephone)
Validated for numerous settings and pain = types (acute, cancer, CNCP)
Less reliable for some patien= ts (very young or old; patients with visual, = = hearing, or cognitive impairment)
Most commonly used = rating scale
Visual analog scale (VAS) =
Efficient to administ= er
Valid in patients with chronic pain, older = than age 5 years, rheumatic disease
Time-consuming scoring
Controversial validity
Can cause patient confusion
Poor reproducibility with cognitive = = dysfunction
FPS generally = = preferred to the VAS for assessment in the = elderly
Faces pain scale (FPS) =
Perceived as easier t= han NRS or VAS
No influence of culture, gender, or ethnici= ty
Useful in individuals with difficulty = communicating (e.g., children, elderly, individuals with limi= ted language fluency or education)
Potential for distort= ed assessment (i.e., patients’ tendency to point to= = the center of such scales)
Need for instrumentation (i.e., a = printed form)
Good alternative for = = patients with difficulty communicating

CNCP: chronic noncancer pain; FPS: Faces Pa= in Scale; NRS: numeric rating scale; VAS: visual analog scale. <= span style=3D'color:white;mso-color-index:0;mso-special-format:lastCR;display:n= one'>
Pain Assessment Tools
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Pain management
•D= on’t delay for investigations or disease treatment
•U= nmanaged pain ® nervous system changes
permanent damage
amplify pain
•Tr= eat underlying cause (eg, radiation for a neoplasm)
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Suffering
•“A state of severe distress associated with events that threaten= the intactness of the person” •Cassell, E. J. , "The nature of suffering and= the goals of medicine," in= The New England Journal of Medicine, 306:639-645,1982.
<= span style=3D'font-weight:normal'>•Subjective: No way to measure it
<= span style=3D'font-weight:normal'>•Significantly diminish= es quality of life
Suf= fering often results from pain, but they are not the same:

Suffer= ing blends past experiences and anticipation of future.

How do= es the pain affect the person?
Change= s in activities, sleep, movement
Signif= icant diminution of quality of life
Change= s in mood and thoughts
Increa= sed perception of pain

These = things may be amenable to change.






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(1) Finding strength
     Inquire about the patient's resources:       "When bad thing have happened to you before, how have you coped?"
      "Whom will you turn to for support?"
Prescribe resources available to the patient:
      Regular physician follow up
      Psychologist, social worker, chaplain, h= ome care referral
      Reading material, videos
      Specific organisations (for example, the National Colitis Association)
      Internet news groups, bulletin boards, c= hat rooms
      Support groups
Strategies for clinicians= to help patients who suffer
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2) Enhancing growth
I= nquire about compensatory pleasures and skills:
    =   "Even though there are some things you can no longer do, what activities can you still enjoy?"
=       "Are there things about you this disease does not affect?"
Prescribe steps toward growth:
    =   Identify times when patient has grown in the past
&= nbsp;     Research what has been possible for others
    =   Encourage volunteering
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(3) Embracing the moment
I= nquire about current feelings and desires:
    =   "What do you feel like doing right now?"
&= nbsp;     "Is there something you've always wished you could do? What is stopping you from doing it?"
Prescribe a redirection toward current reality:
&= nbsp;     Coordinate disease treatment with personal goals
&= nbsp;     Help set priorities
T= each or encourage meditation
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(4) Searching for meaning in suffering
I= nquire about the patient's disease model and illness meaning:
    =   "What does this news mean to you?"
&n= bsp;     "Does this news scare you in any way?"
&n= bsp;     "What do you think caused your illness?"
Prescribe life examination exercises:
&n= bsp;     Journal writing, autobiography, life review
    =   Revisiting the past through photos, people, travel
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(5) Seeking acceptance and reconciliation=
I= nquire about personal dissatisfaction and estranged relationships:
&= nbsp;     "Where are you hardest on yourself ?"
&= nbsp;     "Do you have any regrets in life?"
&= nbsp;     "Is there anyone you really want to talk to before you = die?"
&= nbsp;     "Is there someone you've never been able to forgive?"
P= rescribe steps toward self-acceptance and reconciliation:
&= nbsp;     Advance care planning
&= nbsp;     Distribution of personal possessions
&= nbsp;     Communication by letter, telephone, e-mail
&= nbsp;     Meetings, goodbyes
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6) Achieving transformation
I= nquire about spiritual and religious beliefs:
&= nbsp;     "Are you a spiritual or religious person?"
&= nbsp;     "Has illness ever changed you in a fundamental way in the past? If so, how?"
&= nbsp;     "Do you know anyone who was transformed in a positive way by illness?"
&= nbsp;     "Where do you think things are headed?"
P= rescribe movement toward transcendence:
&= nbsp;     Spiritual mentor
&= nbsp;     Prayer
&= nbsp;     Letters to loved ones
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Total Pain
•P - Physical pain
•A - Affective distress
•I - Interpersonal distress
•N - Non-acceptance, or spiritual distress
Perception of physical stimul= i can be magnified
or diminished by physical, cognitive, emotional
or spiritual experiences.=
Pain i= ncludes complex aspects of human functioning.

Here i= s another mnemonic, coined by Cicely Saunders, to encompass this complexity. (197= 6)

The pe= rception of physical stimuli can be magnified or diminished by physical, cognitive and emotional, social, or spiritual experience.

Total = pain needs to be treated in a total way.




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Placebos
•&= #13;
•The use of placebos in clinical practice is unethical, and there is n= o place for their use in the management of persistent pain. <= /span>
•<= span style=3D'mso-special-format:lastCR;display:none'>
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General Principles for Alleviating Pain
•Assess with NOPQRST
•Identify types(s) and location(s) of pain
•Correct underlying cause, if possible <= /span>
•Consider special circumstances <= /div>
Avoid specific toxicities =
Look for ‘two-fers’= ;
Medication routes <= /div>
Self-administered or by others=
Now we= ’ll address pharmacologic strategies for alleviating pain.

Once y= ou’ve answered the NOPQRST questions, here are some useful general principles to follow.


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WHO 3-step
Ladder
<= b>1 <= b>mild
<= b>2<= b> moderate
<= b>3 <= b>severe
Morphine
Hydromorphone
Methadone
Levorphanol
Fentanyl
Oxycodone
± Adjuvants=
A/Codeine
A/Hydrocodone
A/Oxycodone
A/Dihydrocodeine
Tramadol
± Adjuvants=
ASA
Acetaminophen
NSAIDs
± Adjuvants=
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Acetaminophen
•S= tep 1 analgesic, coanalgesic
•S= ite, mechanism of action unknown
minimal anti-inflammatory effect
•H= epatic toxicity if > 4 g / 24 hours
increased risk
hepatic disease, heavy alcohol use
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NSAIDs . . .
•S= tep 1 analgesic, coanalgesic
•I= nhibit cyclo-oxygenase (COX)
 vary in COX-2 selectivity
•A= ll have analgesic ceiling effects
effective for bone,  inflammatory pain
individual variation, serial trials
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. . . NSAIDs
•H= ighest incidence of adverse events
•G= astropathy
gastric cytoprotection
COX-2 selective inhibitors
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NSAID adverse effects
•R= enal insufficiency
maintain adequate hydration
COX-2 selection inhibitors
•I= nhibition of platelet aggregation
assess for coagulopathy
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Opioid pharmacology . . .
•Conjugated in liver= 3;
•Excreted via kidney (90%–95%)
•First-order kinetics
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Opioid pharmacology . . .
•C= max after
po »  1 h
SC, IM » 30 min
IV » 6 min = ;
•h= alf-life at steady state
po / pr / SC / IM / IV » 3-4 h
=
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. . . = Opioid pharmacology
•S= teady state after 4–5 half-lives
steady state after 1 day (24 hours)
•D= uration of effect of “immediate-release” formulations (except methadone)
3–5 hours po / pr
shorter with parenteral bolus
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3D"Text
Plasma Concentration
0
Half-lif= e (t1/2<= /b>)
Time
IV
po / pr
SC / IM
Cmax
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Routine oral dosing
immediate-release preparation= s
•C= odeine, hydrocodone, morphine, hydromorphone, oxycodone =
dose q 4 h
adjust dose daily
mild / moderate pain é 25%–50%
severe / uncontrolled pain é 50%–100%
adjust more quickly for severe uncontrolled pai= n
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Routine oral dosing
extended-release preparations=
•Im= prove compliance, adherence
•D= ose q 8, 12, or 24 h (product specific)
don’t crush or chew tablets
may flush time-release granules down feeding tubes
•A= djust dose q 2–4 days (once steady state reached)
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Routine oral dosing
long-half-life opioids=
•Dose interval for methadone is variable (q 6 h or q 8 h usually adequate)
<= span style=3D'font-weight:normal'>•Adjust methadone dose q 4–7 days
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Breakthrough dosing
•U= se immediate-release opioids
5%–15% of 24-h dose
offer after Cmax reache= d
po / pr = » q 1 h = ;
SC, IM <= span style=3D'font-family:Symbol;mso-char-type:symbol'>» q 30 min&= #13;
IV » q 10̵= 1;15 min
•Do NOT use extended-release opioids
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Clearance concerns
•C= onjugated by liver
•9= 0%–95% excreted in urine
•D= ehydration, renal failure, severe hepatic failure
¯ dosing interval, ¯ dosage size
if oliguria or anuria
STOP routine dosing of morphine = ;
use ONLY prn
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Not recommended . . .
•M= eperidine
poor oral absorption
normeperidine is a toxic metabolite
longer half-life (6 hours), no analgesia
psychotomimetic adverse effects, myoclonus, seizures
if dosing q 3 h for analgesia, normeperidine builds up
accumulates with renal failure
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Not recommended . . .
•P= ropoxyphene
no better than ASA, acetaminophen
low efficacy at commercially available <= span style=3D'position:absolute;top:35.01%;left:17.55%;width:74.08%;height:7.94= %'>doses
toxic metabolite at high doses
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. . .= Not recommended
•M= ixed agonist-antagonists
pentazocine, butorphanol, nalbuphine, dezocine
compete with agonists ® withdrawal
analgesic ceiling effect
high risk of psychotomimetic adverse effects with pentazocine, butorphanol
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Addiction . . .
•Psychological dependence
•Compulsive use
•Loss of control over drugs
•Loss of interest in pleasurable activities
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Addic= tion . . .
•C= ontinued use of drugs in spite of harm
•A rare outcome of pain management
particularly, if no history of substance abuse
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. . . Addiction
•C= onsider
substance use (true addiction)
pseudoaddiction (undertreatment of pain)
behavioral / family / psychological disorder
drug diversion
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Tolerance
•Reduced effectiveness to a given dose over time •Not clinically signifi= cant with chronic dosing •If dose is increasing, suspect disease progression
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Physical dependence
•A process of neuroadaptation
•A= brupt withdrawal may &re= g; abstinence syndrome
•If dose reduction required, reduce by 50% q 2–3 days =
avoid antagonists
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Substance users
•Can have pain too =
•Treat with compassion
•Protocols, contracting
•Consultation with pain = or addiction specialists
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Pain poorly responsive
to opioids
•If dose escalation &r= eg; adverse effects
more sophisticated therapy to counteract adverse effect
alternative
route of administration
opioid (“opioid rotation”)
adjuvant
use a nonpharmacologic approach
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Ongoing assessment
•Increase analgesics until pain relieved or adverse effects unacceptable
•Be prepared for sudden changes in pain
•D= riving is safe if
pain controlled, dose stable, no adverse effects
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E
P
E
C
= Module 1, Part 2
Equianalgesic Dosing