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Core Curriculum
Pain Management
MODULE 2
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Section I: Introduction to Pain Management
Definition of painMultidimensional approachBarriers to pain assessment and managementReview a case study
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Pain Is…
“An unpleasant sensory and emotional experience associated with actual or potential tissue damage”
“What the person says it is…”
Biopsychosocial/spiritual/existential model
IASP, 2017
Pasero & McCaffery, 2011
Paice, 2016, 2017, & 2019
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Cancer and Pain
~80% of patients with advanced cancer have moderate to severe pain
Challenges to pain management: Fear pain may mean disease progression/recurrence Not wanting to appear ‘weak’ & have treatment reduced Not wanting to ‘distract’ their provider Not wishing to appear to be drug‐seeking Patients may believe anything that everything is being done
for their pain
NCI, 2018
Coyne et al., 2018
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Non‐Malignant Diseases & Pain
Assess for co‐morbidities that could cause pain
More research needed
Fink et al., 2019; Paice, 2019
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Effects of Unresolved Pain
Pain associated with depression in patients with heart failure
Inadequate pain relief may hasten death by: Increased physiological stress Decreased immunity Decreased mobility Increased possibility of pneumonia and or
thromboembolism Increased workload of heart and lungs
Paice, 2019
Pantilat et al., 2016
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Barriers to Pain Relief
Specific barriers Professionals Healthcare systems Patients/families
Coyne et al., 2018
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Strategies to Overcome Challenges in Pain Management
Education of healthcare professionalsOvercoming system‐based issuesManagement Use current guidelines Use appropriate analgesicsMonitor outcomes Attend to adverse effects
Education of patients and families Set realistic goals—most pain can be alleviated
Provide psychosocial support
Research
Coyne et al., 2018; Kwon, 2014
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Clinical Practice Guidelines for Quality Palliative Care: Issue of PainInterdisciplinary careAssessment should be regular and on‐goingPain level should be acceptable to patient and familyDocument responseIdentify and address barriersFor controlled substances, implement a risk management plan
Consider cultureEducate the family/caregiverAddress sufferingRefer to providers with specialized skill
NCP, 2018
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Goals of Pain Management
Providing adequate pain and symptom controlDecrease distress caused by pain in the patient and familyProvide an acceptable sense of controlRelieve caregiver burdenStrengthen relationshipsOptimize quality of life (QOL)Enhance meaning of life and illness, providing personal growth
NCCN, 2018
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Pain vs Suffering at the End of Life
Existential distress: spiritual/religiousDimensions of quality of life (QOL)Requires interdisciplinary approach
Ferrell & Coyle, 2008
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Patients at Risk for Undertreatment
Children and older adultsNon‐verbal or cognitively impairedPatients who deny painNon‐English speakingCultural considerationsHistory of additive disease
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Sound Familiar?
Lee is 62 years‐old and has just returned home after having his right shoulder ‘pinned’, due to his fallHas a history of CHF, emphysema & Type II diabetesHis homecare nurse notes various sites and types of pain (pain score): At the incision site (7/10) Phantom pain from LBKA due to diabetes (8/10) Residual post‐herpetic neuropathy (PHN) from shingles (5/10)
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What Role Does Culture Play in Pain Assessment and Management?
Preferred languageHealth literacyFear of pain medicationsConcept of pain and sufferingCorrect labeling of pain: Pain versus hurt
Cormack et al., 2019; NCP, 2018
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Ethical Responsibilities of Providing Excellent Pain Assessment and Management
Assessment and treatment of pain is a basic human right, yet: 80% experience acute unrelieved postoperative pain25% of residents in nursing homes receive no intervention for pain reliefUnrelieved pain: Does it correlate with euthanasia or physician‐assisted suicide?
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Your Ethical Responsibility
Assessing and managing pain is an ethical and legal principle everyone must adhere to.Ethical tenets: Beneficence: Duty to benefit Nonmaleficence: Duty to do no harm Autonomy: The right to self‐determination Justice: Equal and fair access to pain management
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Section II: Pain Assessment
Pain history Acute Chronic
Physical examinationLaboratory/diagnostic evaluation
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Goals of Pain Assessment
Determine pain diagnosis Etiology of pain Nociceptive or neuropathic pain Acute, chronic, acute on chronic Response to pain interventions
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Pain Assessment Vignette
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Pain Experience
Patient’s description of painLanguage used: Ache Hurt Pain
Location(s), intensity, quality, timing, aggravating/alleviating factorsMeaning of painHow pain impacts quality of life
Fink et al., 2019; NCCN 2018; Paice, 2019
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Pain Experience (cont.)
Cultural considerations for painMedication use history Current Past
Psychosocial historySubstance use historyGoals of care
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Physical Examination
ObservationPalpation AuscultationPercussion
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Functional Assessment
Muscle toneCoordinationReflexesAbility to perform self‐careWalkingCookingWhat are the patient’s goals?
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Laboratory/Diagnostic Evaluation
Rule out potentially treatable causes
Need for additional laboratory or radiographic evaluation is directed by the goals of care
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Reassess
Changes in pain
Response to analgesics Relief Adverse effects
Make pain visible
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Communicating Assessment Findings
Communication improves pain managementDescribe location, intensity, limitations, and response to treatmentsDescribe effect on functionDocument medications, efficacy, and adverse effectsAsk for suggestions, but be ready to make recommendationsBe objective Fink et al., 2019;
Paice, 2016
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Section III: Pharmacological Therapies
NonopioidsOpioidsAdjuvantsRoutes of administration
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Nonopioids
Acetaminophen Analgesic and antipyretic High doses can cause liver dysfunction Use cautiously with older adults
Paice, 2016; Paice, 2019
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Nonopioids: Role of NSAIDs
Antipyretic, anti‐inflammatory, and analgesic
Toxicity
Adverse effects
Paice, 2019
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Opioids: Most Commonly Used in Palliative Care
BuprenorphineCodeineFentanylHydrocodoneHydromorphoneMethadone
MorphineOxycodoneOxymorphoneTapentadolTramadol
Mechanism of action: Opioids block the release of neurotransmitters that are involved in the processing of pain
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Opioids: Adverse Effects
Respiratory depression ConstipationSedationUrinary retentionNausea/vomitingPruritusMyoclonus
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Opioids: Definitions
Substance‐use disorder AddictionTolerancePhysiologic dependence
Paice, 2019; Volkow et al., 2016
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Opioid Epidemic
Drug overdose: Leading causes of death among those < 50 years of age in US
Challenge: How do we reduce pain/suffering and contain the toll of harm caused by the misuse of opioids?
How do we prevent unintended consequences of efforts to control misuse and protect access to opioids for those with life‐threatening illness?
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Adjuvant Analgesics: Antidepressants
Tricyclic antidepressants (TCAs)
Serotonin‐norepinephrine reuptake inhibitors (SNRIs)
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Adjuvant Analgesics: Anticonvulsants (AKA Antiepilepsy Medications)
Used for neuropathic pain
GabapentinDose: 100 mg po TID and titrate gradually
PregabalinDose: 50 mg TID x 1 wk then 100 mg BID or TID
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Adjuvant Analgesics: Local Anesthetics
Topical: Lidocaine gel, lidocaine/prilocaine creamand lidocaine 5% patch
Intravenous
Spinal
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Adjuvant Analgesics: Corticosteroids
Indications
Activates/increase appetite
Proximal muscle wasting
Administer ‐ q am
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Cannabis: A Few Words
33 US states and DC legally permit use for medicinal use10 US states legalized for recreational usePros/consClinical practice recommendations Research is limited
Berke & Gould, 2019
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Routes of Administration
OralTransmucosal Buccal Sublingual Nasal
RectalTransdermalTopical
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Routes of Administration (cont.)
Parenteral Intravenous Subcutaneous Intramuscular
Spinal Epidural Intrathecal
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Lets Practice: A Case Study
Ms. T is 86‐years‐oldTwo days ago, she fell and broke her hip and had surgery yesterday Many co‐morbidities (e.g. diabetes, CHF, renal failure), and diagnosed with stage III colon cancer 10 months agoMorphine 1 mg/hr continuous rate with no breakthrough dosageAssessment: Multiple sites of pain with pain score of “8” for incisional pain Surgeon “I'm afraid of overdosing her” Your response?
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Section IV: Principles of Pain Management
Opioid dose titrationLong‐acting medicationsOpioid rotation/equianalgesiaAddictive diseaseInterventional therapiesNon‐pharmacological techniquesYour role
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Principles of Opioid Dose Titration
Sustained release medications
Immediate‐release for breakthrough pain
Distinguish types of breakthrough pain
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Principles: Use of Opioid Rotation
Use when one opioid is ineffective, even with adequate titration
Use when adverse effects are unmanageable
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Principles of Equianalgesia
Determine equal doses when changing drugs or routes of administration
Reduce by 25% when changing drugs
Use of oral morphine equivalents(OME)
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Treatment of Pain in Persons With Addictive BehaviorsTeam meetings with interdisciplinary approachSet realistic goalsSet limitsUse nonopioids as ableConsider tolerance
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Treatment of Pain in Persons With Established Addictive Disease (cont.)
Avoid parenteral injections, if possible
Prevent withdrawal
Treat depression and other psychiatric disorders
Use alternate opioid if on methadone for maintenance
Universal precautions
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Cancer Therapies to Relieve Pain
Radiation
Surgery
Chemotherapy
Hormonal therapy
Bisphosphonates
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Interventional Therapies
Neurolytic blocks
Neuroablative procedures
Vertebroplasty/kyphoplasty
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Non‐Pharmacologic Strategies
Physical
RehabilitationExerciseHeat or coldTENS (transcutaneouselectrical nerve stimulation)Cognitive‐behavioral therapy
Psychosocial
RelaxationMeditationHypnosisMusicBiofeedbackSystematic desensitization
Complementary & Integrative
AcupunctureQigongTherapeutic massageReiki
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Summary
Pain relief is contingent on adequate assessment and use of both drug and non‐drug therapiesPain extends beyond physical causes to other causes of suffering and existential distressInterdisciplinary care
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