Pain in an Interdisciplinary Context

1. Pain in an Interdisciplinary Context University of Alabama at Birmingham GEC Faculty Scholars Elizabeth Kvale, MD Assistant Professor of Medicine University of Alabama at Birmingham

2. UNDERSTANDING PAIN • Unpleasant sensory and emotional experience associated with actual or potential tissue damage. • Physical pathology does not need to be present • Pain is one of the most common reasons Americans 18+ seek medical attentions. • 25-50% community-dwelling older adult have pain • 45-80% nursing home residents have pain

3. Sensory-Discriminative Pain Perception Affective-Motivational Noxious Stimulus Autonomic & Motor Responses

4. Commons Myths Regarding Pain • In the presence of tissue damage there must be pain, and vice versa. • It is useful to classify pain as either organic (biological) or functional (psychogenic) • A placebo response verifies that pain is psychological in origin

5. BIOPSYCHOSOCIAL MODEL OF PAIN (and symptoms) BIOMEDICAL - Pathology - Injury - Nociception SOCIOCULTURAL PSYCHOLOGICAL - Age, Sex, Race - Income, Education - Social Milieau - Anxiety, Depression - Cognitive Factors - Behavioral Factors

6. Nociception Pain Behavior Suffering Pain

7. Pain Physiology Basicsdistinction between acute and chronic pain • Acute pain • identified event, resolves days–weeks • usually nociceptive • Chronic pain • cause often not easily identified, multifactorial • indeterminate duration • nociceptive and / or neuropathic

8. Pain Physiology BasicsTypes of Pain • Nociceptive – Arthritis, fracture, laceration • Visceral – Pancreatitis, M.I., Constipation • Neuropathic – Herpes zoster, diabetic neuropathy, • Complex Regional Pain Syndromes – RSD • Central Pain

9. Pain Assessment BasicsBelieve the Patient • Pain is a subjective experience – the patient is the best source of information about their pain • Pain History – site(s), intensity, temporality, character, exacerbating and alleviating factors

10. PATIENT ASSESSMENT • Comprehensive and ongoing assessment. • Medical history • Physical exam • Psychosocial • Family and culture • Pain history (including previous treatment) • Comprehensive medication history

11. ELEMENTS IN HISTORY • The nature and intensity of the pain. • Current and past treatments for the pain. • Underlying or coexisting diseases or conditions. • The effect of the pain on the physical and psychological function. • Documentation of a history of substance abuse. • Documentation of one or more recognized medical indications for the use of a controlled substance. • American Academy of Pain Medicine, Long-term Controlled Substances Therapy for Chronic Pain, July 2004

12. Pain Assessment BasicsBelieve the Patient, Use an Instrument The use of an instrument to assess pain allows you to know and document whether you have helped the patient

13. Pain Behaviors: Communication of Symptoms • Grimace, Groan, Rub, Guard, Brace • Can be observed and quantified

14. Pain Assessment INAdvanced Dementia - PAINAD

15. Pain Management Basics • Don’t delay for investigations or disease treatment • Unmanaged pain  nervous system changes • permanent damage • amplify pain • Treat underlying cause (eg, radiation for a neoplasm)

16. Mrs. Bellam (See Handout) • 74 yo with multiple medical issues, many of which contribute to pain • Multiple medications • Declining functional ability • Recent Falls • Lives alone, but with supportive family near

17. Developing an Interdisciplinary Care Plan Around Pain

18. Pain Management Strategies • Routine assessment and documentation • Patient and family education • Non-pharmacologic strategies • Serial Trial Intervention • Documentation

19. Non-pharmacologic Approaches • Heat • Cold • Positioning • Distraction • Relaxation • Massage • Controlled breathing and guided imagery • Music

20. Pharmacologic Interventions • Regular use of acetaminophen • Consider nonsteroidal anti-inflammatory • For intermittent pain • Many medical contraindications • Consider low dose pain medications • Oxycodone, morphine, hydromorphone • ? Use of combination medications • Re-evaluate

21. Pain Management Basics 3 severe • Match the medication to the amount of discomfort the patient is having • WHO 3-stepLadder 2 moderate Morphine Hydromorphone Methadone Levorphanol Fentanyl Oxycodone ± Adjuvants A/Codeine A/Hydrocodone A/Oxycodone A/Dihydrocodeine Tramadol ± Adjuvants 1 mild ASA Acetaminophen NSAIDs ± Adjuvants

22. Serial Trial Intervention • A structured approach to “let’s try it and see what happens”

24. Patient and Family Education • Patients and caregivers are essential team members in evaluating and managing pain • Caregiver resistance to pain management strategies ensures failure • Explore areas of concern or resistance to tailor education efforts most effectively

25. ASSESSING PAIN IN COGNITIVELY INTACT PATIENTS Use a standard scale to track the course of pain

26. DEVELOPMENT OF MANAGEMENT PLAN • Identify objectives that will be used to determine treatment success including but not limited to pain relief, improved physical function, and improved psychological function. • Documentation of the need for further diagnostic evaluations or other treatments which may be planned. • Adjustment of drug therapy based on the individual medical needs of each patient. • Consideration of other treatment modalities or rehabilitation programs depending on the extent and etiology of the pain.

27. NONPHARMACOLOGICPAIN MANAGEMENT • Encourage activity and self-care • Employ physical modalities: heat, cold, massage, acupuncture, transcutaneous electrical nerve stimulation • Recommend cognitive-behavioral interventions: relaxation and imagery, psychotherapy, structured support • Educate the patient

28. PHARMACOLOGIC PAIN MANAGEMENT • The risk of under treating pain is a greater concern than the risk of worsening delirium with medications • None systemic therapies, intra-articular steroid injections, lidocaine patches, topical preparations

29. USING OPIOIDS • Opioids are first-line therapy for severe acute pain and chronic moderate to severe persistent pain due to cancer, AIDS, and other advanced illnesses. • Consider the individual’s risk of drug abuse and addiction and provide appropriate and structured therapy. • Opioids are metabolized by the liver and excreted by the kidney

30. USING OPIOIDS • Peak plasma concentration is reached: • 60-90 minutes after oral dosing • 30 minutes after SC or IM dosing • 6 minutes after IV injection • Effective half-lives of 3–4 hours with normal renal clearance • Steady state achieved in 24 hours • Extended-release forms release over 8, 12, or 24 hours; fentanyl patch provides continuous relief for 48–72 hours

31. USING OPIOIDS • Use short-acting opioids to determine opioid requirements over 24 hours • If pain remains uncontrolled, increase doses by 25% to 50% for mild to moderate pain and by 50% to 100% for severe pain • Provide “rescue” analgesia for breakthrough pain or acute pain flares • 5% to 15% of the 24-hr dose • Offer every 1 hr orally; 30 min SC/IM; 10 min IV

32. REGULATORY ISSUES RELATED TO THE USE OF OPIOIDS • Urine drug screening (UDS) is recommended on initiation of therapy and randomly at subsequent visits • Implement as a global policy rather than a targeted policy • Evaluate for aberrant drug use and adherence to therapy you are providing • Interpretation of UDS results can be challenging

33. A TOOL TO HELP YOU – THE ALABAMA PRESCRIPTION DRUG MONITORING SYSTEM • Provides a report of all schedule 2 prescriptions filled by patient in state of Alabama • Results of report can be shared with patient, but you cannot give a copy of the report to the patient • Reports should not be placed in the medical record • http://pdmp.alabama.gov/index.html

34. REALISTIC GOAL SETTING • Reduce pain severity • Improved and or restore function • Improve mood and sleep patterns • Reduce misuse or overuse of medication • Return to productive activity • Increase ability to manage pain • Effective treatment should be as cost-effective as possible

35. Thank you