Title: Pain and its Management
1Pain and its Management
Adherence
2What are we going to talk about today?
- Pain
- Definition, assessment, pain management
- Adherence to medical advice
- Prevalence of nonadherence
- Costs of nonadherence
- Causes of nonadherence
- Solutions
3- The pain usually starts with nausea and a vague
headache. The real attack follows after somewhere
between one and six hours. It is as if a burning
nail is being pushed inside my head, not once,
but all the time, day and night. The only thing I
can do is lie on my bed with a wet cloth on my
forehead and a bole next to me. I do not want
anyone near to me, no one can help me anyway. And
that is the worst thing of migraine the
loneliness. Pain is such a lonely feeling. - Ria Weteling (56)
- In Libelle (2001, 44)
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9Examples of pain
- Headache
- Musculoskeletal problems
- Rheumatoid arthritis
- Neuropathic pain
- Herpes zoster (shingles)
- Abdominal pain
- Postoperative pain
- Pain caused by cancer
10Consequences of pain
- Work
- Household
- Leisure time activities
- Social activities
- Sleeping problems
- Family / marital problems
- Emotional problems (depression, anxiety)
http//www.sbtv.com/Partners/Fibro/
11Physiological significance of pain
- Pain hurts and so it disrupts our lives
- Pain is critical for survival
- Minor pains provide low-level feedback
- Shift posture, uncross legs
- Roll over when asleep
- Medical consequences
- Pain is the symptom most likely to lead an
individual to seek treatment
12Psychological significance of pain
- Depression and anxiety worsen the experience of
pain - Patients fear pain when undergoing treatments
- Inadequate relief from pain is the most common
reason for euthanasia requests
13The elusive nature of pain
- Pain is a psychological experience
Behaviour
Experience
Nociception
Perception
Loesers Onion-model
14Definition of pain(1994)
- An unpleasant sensory and emotional experience
associated with actual or potential tissue
damage, or described in terms of such damage. - Note pain is only associated with actual or
potential tissue damage, or described in terms of
such damage
15The elusive nature of pain
- Interpretation of the pain influences
- The degree to which it is felt
- How incapacitating it is
- Beechers study of WWII injuries
- To soldiers, pain means, Im alive
- To civilians it interrupts activities
- Pain is influenced by
- Context, culture, and gender
http//www.mdialog.com/videos/16391-apf---debunkin
g-pain-myths
16Epidemiology
- Acute Pain Annually 15-20 of approximately 31
million Canadians have acute pain warranting
clinical care the cardinal symptom of disease! - Chronic pain (CP) pain that is persistent in
either continuous or intermittent forms - CP associated with terminal illness (cancer,
HIV/AIDS, etc.) estimated that as many as 80
of us will die in pain (Salter, 2002) - CP nonmalignant
- 25-30 have chronic pain
- Pain a lifelong experience
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18Measuring Pain - Verbal Reports
- Large informal vocabulary
- Throbbing pain? Shooting pain? Dull ache?
- Questionnaires
- Nature of pain (throbbing, shooting, dull)
- Intensity of pain
- Psychosocial components
- Fear
- Degree to which it has been catastrophized
19The McGill Pain Questionnaire
20Pain is what the person says it is and exists
whenever he or she says it does (McCaffery, 1968)
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22Parent Ratings of Pain
Pain expression did not differ across 2, 4, 6,
and 12 months
23Self-report measures of pain
- Serious limitations
- speech only partially reflects complexities of
thought - cognitive and communication competence crucial
- inevitably selective reflects perceived best
interests, context driven, audience effects
24Facial activity during pain
- Highly visible
- Faces are very plastic remarkable array
- Stereotypic display
- Acute pain (injury, exacerbation of disease)
- Sensitive, relatively specific
- Vigour reflects intensity of distress
- Moderately correlated with self-report
25Pain in children with autism
- reduced pain sensitivity, not feeling pain as
intensely as others, indifference to pain, a
high threshold for pain, etc. (DSM-IV TR, 2000
Wing, 1996 Bettelheim, 1967 Peeters, 1999,
etc.) - anecdotal and clinical impressions
- Nader, R., Oberlander, T.F., Chambers, C.T.,
Craig, K.D. (2004). Expression of pain in
children with autism. The Clinical Journal of
Pain, 20, 88-97
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27Revised definition of pain
- Revised definition of pain
- Definition of pain(1994) An unpleasant sensory
and emotional experience associated with actual
or potential tissue damage, or described in terms
of such damage. - Added note (2002) The inability to communicate
verbally in no way negates the possibility that
an individual is experiencing pain and is in need
of appropriate pain relieving treatment
28Physiology of Pain
- Pain is protective
- Brings into consciousness the awareness of tissue
damage - Pain doesnt feel protective
- It is accompanied by motivational and behavioural
responses - Crying
- Fear
- Withdrawal
29Physiology of Pain
- Pain perception is called Nociception
- Three kinds of pain perception
- Mechanical nociception
- Mechanical damage to body tissue
- Thermal nociception
- Damage due to temperature exposure
- Polymodal nociception
- General category
- Pain triggers chemical reactions from tissue
damage
30Physiology of pain
- http//fora.tv/2008/07/30/Dr_Sean_Mackey_on_Pain_M
anagementDr_Mackey_Explains_Pains_Physiology
31Acute Pain
- Typically results from a specific injury
- Wound or broken limb
- Disappears when damaged tissue is repaired
- By definition, acute pain goes on for six months
or less - During acute pain, there is an urgent search for
relief
32Chronic Pain
- Chronic Pain
- Typically begins with an acute episode
- Pain does not decrease with treatment
- Pain does not decrease as time passes
- Three types of chronic pain
- Chronic benign pain
- Recurrent acute pain
- Chronic progressive pain
33Chronic Pain
- Chronic benign pain
- Persists more than 6 months
- Varies in severity
- Example Chronic low back pain
- Recurrent acute pain
- Intermittent episodes of acute pain
- Chronic because the condition lasts more than 6
months - Example Migraine headaches
- Chronic progressive pain
- Increases in severity over time
- Persists longer than 6 months
- Typically associated with malignancies or with
degenerative disorders - Example Rheumatoid arthritis
34Chronic pain must be thought of not as a
particular pain that simply goes on for a long
period of time, but as an unfolding
physiological, psychological, and behavioural
experience that evolves over time (Flor,
Birbaumer Turk, 1990)
35Acute vs. Chronic Pain
- Acute and chronic pain present different
psychological profiles - Chronic pain often produces depression
- Pain present in 2/3 of patients seeking care from
physicians with primary symptoms of depression
(Bair et al) - Pain control techniques work well with acute pain
but less successfully with chronic pain - Chronic pain involves more secondary gain role
of the social environment is key
36Who Becomes a Chronic Pain Patient?
- All chronic pain patients were once acute pain
patients - Patients for whom pain interferes with life
activities make the transition to chronic pain - Chronic pain may result from a predisposition to
respond to a bodily insult with a specified
bodily response - Chronic jaw pain by tensing jaw can be aggravated
by stress and poor coping
37The effects of chronic pain
- Lifestyle of chronic pain
- Can entirely disrupt a persons life
- Little social or recreational life
- Difficulty performing simple tasks
- Goals are set aside self esteem suffers
- Toll on relationships
- Communication is inadequate
- Sexual relationships deteriorate
- Chronic pain behaviours emerge
38Pain and Personality
- Pain-Prone Personality
- Constellation of personality traits predisposing
a person to experience chronic pain (neuroticism,
introversion, passive coping) - This hypothesis is simplistic because
- Pain alters personality
- Individual experiences of pain are too complex to
be explained by a single personality profile
39Psychological risk factors of chronic pain
- Excessive emotional reactions
- Stress
- Debilitating fear of pain or depression
- Destructive thinking
- Catastrophizing Magnification, rumination,
helplessness - Behavioural maladjustment
- Excessive avoidant behaviour and inactivity
- Deteriorating social relationships
- Stress and strain in relationships
- Reinforcement for pain/illness behaviour
- Social isolation
40Protective psychological factors of chronic pain
- Self-efficacy
- Confidence in ones ability to follow a course of
action that will accomplish desired outcomes
(e.g., control pain) - Pain coping strategies
- Relaxation, distraction, commitment, redefinition
- Readiness to change
- Willingness to take an active role
- Acceptance
- Patients lives often consumed by unsuccessful
effort to eliminate pain
41Pain control techniques
- Pain control can mean a person
- No longer feels anything in an area that once
hurt - Feels sensation but not pain
- Feels pain but is no longer concerned about it
- Is hurting but is able to stand it
42Pain management
- Biomedical
- Pharmacological anti-inflammatories (e.g.,
acetaminophen), opioids, etc. - Other somatic physiotherapy, massage, exercise,
transcutaneous electrical nerve stimulation,
acupuncture, surgery, etc. - Psychosocial
- Environmental/operant interventions
- Cognitive/behavioural relaxation, exercise,
coping strategies, operant control, placebos,
etc. - Family and marital therapy
43Pharmacological control of pain
- Most common method of controlling pain through
drugs - Morphine has been the most popular painkiller for
decades - Any drug that influences neural transmission is a
candidate for pain relief - Main concern with using drugs Potential for
addiction - This threat is lower than once thought
44Surgical control of pain
- Cutting pain fibers at various points so pain
sensations cant be conducted - Effects are often short-lived
- Regenerative powers of the nervous system mean
that blocked pain impulses reach the brain
through different neural pathways - Can worsen the problem due to damage of the
nervous system
45Sensory control of pain
- Counterirritation
- Inhibiting pain in one part of the body by
stimulating or mildly irritating another area - Example Scratching a part of the body near the
part that hurts - Dorsal Column Stimulation
- Electrodes near the nerve fibers from the painful
area deliver a mild electrical stimulus, thus
inhibiting pain
46Biofeedback an operant learning process
- A method whereby an individual is provided with
- Ongoing specific information about a particular
physiological process by a machine - So that s/he can learn how to modify that process
- Once patients can control this process, they can
usually make the changes on their own without the
machine - http//www.youtube.com/watch?v6qocxopS5fc
47Relaxation
- Relaxation techniques
- Enable patients to cope with stress and anxiety,
reducing pain - What is relaxing?
- A person shifts his/her body into a low state of
arousal - Progressively relaxing different parts of the
body - Controlled breathing using long, deep breaths
- Meditation focusing attention fully on a very
simply, unchanging stimulus
48Hypnosis
- An old and misunderstood technique
- How does it work?
- Hypnosis involves relaxation, reinterpretation,
distraction, and drugs - Hypnotherapy has successfully controlled
- Irritable bowel syndrome
- Acute pain due to surgery, childbirth, dental
procedures, burns, headaches - Pain due to laboratory procedures
- Chronic pain, such as pain due to cancer
http//www.youtube.com/watch?vF8zhqQAzuIo
49Acupuncture
- Technique of healing developed in China over
2,000 years ago - Long, thin needles are inserted into designated
areas of the body to reduce discomfort in a
target area of the body - How acupuncture controls pain is unknown
- Sensory method?
- Expectations? Relaxation?
- Endorphins released?
50Distraction
- Attention is redirected in order to reduce pain
- May involve focusing on some stimulus irrelevant
to the painExample Singing O Canada backwards
while the dentist drills - May involve reinterpreting the pain
experienceExample Im a secret agent and the
dentist is trying to get me to reveal secrets! - Effective for acute pain and low-level pain
51Coping techniques
- Coping skills training is used to help chronic
pain patients manage pain - Is any particular coping technique more effective
for managing pain? - It depends on how long the patient has had the
pain - Recent Onset Avoidant styles work
- Chronic Pain Attending directly to the pain is
effective
52Guided imagery
- Person conjures up a picture and holds it in mind
during painful experiences - Used to induce relaxation
- Controls slow-rising pains
- May be used as aggressive imagery
- Chemotherapy treatment was a cannon blasting the
cancer dragon apart - What does guided imagery do?
- Relaxing or aggressive imagery both induce
positive mood states (relaxation or excitement)
53Other cognitive techniques
- Reconceptualize the problem from overwhelming to
manageable - Enhance expectations that this training will be
successful - Clients role is to be active, resourceful, and
competent (not passive) - Clients monitor maladaptive cognitions and stop
negative self-talk
54Psychological interventions with chronic pain
- No longer treatment as a last resort (after
biologically-based treatment failed) - Should be considered soon after injury or onset
of pain for those vulnerable to chronicity - Systematic reviews show they work for low back
pain, arthritis pain, cancer pain, tension
headache and migraine headache, mixed chronic
pain syndromes - Variety of contexts multidisciplinary,
independent practice, outpatient or inpatient,
individually or in groups, with or without family
55CAREGIVER
PERSON
Biological substrates Personal History
Sensitivity Knowledge, Attitudes (biases)
Motor programs
Pain Expression
Assessment or attribution of pain
Action dispositions
Pain Experience
Tissue Trauma (real or Perceived)
(self-report, nonverbal display, physiological rea
ctivity
(pharmacological, cognitive/ behavioural,
environmental)
(thoughts, feelings, sensations)
(decoding)
Relationship
Social display rules
Context, social and physical
The World of a Person in Pain A
Sociocommunications Model
56Summary
- What is pain?
- Assessment of pain
- Acute vs. chronic pain
- Pain management
57What are we going to talk about today?
- Pain
- Definition, assessment, pain management
- Adherence to medical advice
- Prevalence of nonadherence
- Costs of nonadherence
- Causes of nonadherence
- Solutions
58Adherence
59Definitions
Compliance
The extent to which a patient follows medical
instructions
Adherence
The extent to which a persons behaviour taking
medication, following a diet, and/or executing
lifestyle changes corresponds with agreed
recommendations from a health care provider
Sources Haynes RB. Determinants of compliance
the disease and the mechanics of treatment.
Baltimore Johns Hopkins University Press
1979. Adherence to Long-Term Therapies Evidence
for action. World Health Organization 2003.
60Adherence is a worldwide issue that will grow as
populations age and chronic diseases increase
In developed countries, adherence among patients
suffering chronic diseases averages only 50
percent.
World Health Organization 2003Adherence to
Long-Term Therapies Evidence for Action
Adherence to Treatment for Hypertension
United States 51 China 43 Gambia 27
Dual burden of disease in developing countries
infectious and chronic
Sources Adherence to Long-Term Therapies
Evidence for action. World Health Organization
2003. Available at http//www.who.int/chronic_con
ditions/adherencereport/en/. American Medical
Association. The Patients Role in Improving
Adherence. Available at http//www.ama-assn.org/a
ma/pub/article/12202-8427.html. Magee M.
Attacking Chronic Diseases in Developing
Countries. . Available at http//www.healthpoliti
cs.com/program_info.asp?pprog_55.
61Types of nonadherence Prescription drug use
- Not having prescription filled
- Taking too much or too little medication
- Erratic dosing
- Stopping medication too soon
- Using medications without a prescription
- Combining a prescription with
- Incorrect over the counter medication
- Alcohol, illicit drugs
62Types of nonadherence Lifestyle changes
- Not following
- Dietary recommendations
- Exercise recommendations
- Activity Limitations
- Following surgery
- During pregnancy
- Following diagnosis (e.g., osteoporosis)
- Rates of nonadherence are highest with lifestyle
changes, particularly over time
63Patients arent the only ones who are noncompliant
- 5 of hospital patient deaths are estimated to
be due to failure of health care providers to
wash their hands properly. - Reasons cited for noncompliance
- Soaps are skin irritants
- Repeated need becomes tedious
- Centres for Disease Control do not track these
deaths
64Typical Published Nonadherence Rates for
Medications
- Medication Type Ley Food Barofsky (1976)
Drug (1980) (1979) - Antibiotics 49 48 52
- Psychiatric 39 42 42
- Hypertensive --- 43 61
- Tuberculosis 38 42 43
- Other Medications 48 54 46
- SourceLey (1982)
65New patients remaining on cholesterol-lowering
medications since first prescription (n11,000)
66Bottom line
- Only 5 of patients requiring cholesterol-lowering
therapy in Canada are actually receiving it.
67Is investing in adherence worth it?
U.S. Annual Costs of Poor Adherence
- 75 billion 100 billion
- 125,000 deaths
- 10 25 of hospital and nursing home admissions
Better adherence will not threaten health care
budgets. On the contrary, adherence will result
in a significant decrease in the overall health
budget. This is due to the reduction in the need
for more costly interventions, unnecessary use of
emergency room services and highly expensive
intensive care services.
Eduardo SabatéMedical Officer, WHO
Source Adherence to Long-Term Therapies
Evidence for action. World Health Organization
2003.
68Rising health care costs
SourceCIHI (1999)
69Total Health Expenditure as a Percentage of GDP,
Canada 1960 - 1997
SourceCIHI (1999)
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73Health Care Expenditures in Canada (total 95B)
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75Medications 15 of Canadian health care costs
(and growing)
- There is a need to control costs without
degrading health care quality - Few methods available to do this
- Improving medication use is one way
- Treatment unit costs are lower with medication
than most other treatments - Medication is constantly improving
76Problems with randomized clinical trials for
assessing effectiveness of treatment
- Medical research is based on the double-blind,
randomized clinical trial (RCT) - Patients are randomly assigned to
- treatment or
- placebo group
- Double blind
- Neither Pt or Dr knows what group it is
77Randomized clinical trials
- RCTs attract highly motivated Pts, noncompliant
ones tend to be dropped from analysis - RCTs are essential science tools, but we must be
cautious in conclusions drawn.
78Problems with RCTs
- RCTs measure the efficacy of the molecule
- How well it works in the body under optimal
conditions - Effectiveness is different
- How well the medication works in the real world,
by the average patient - Many medications are not being used to their full
effectiveness - Key problem is noncompliance
79Measuring adherence is problematic, but
technology and partnerships may help
There is no gold standard for measuring
adherence behavior measurement of adherence
remains only an estimate of a patients actual
behavior.
World Health Organization 2003Adherence to
Long-Term Therapies Evidence for Action
- Technology Smart delivery systems to release
medicine in the body - Cross-sector partnerships deliberately attacking
behavioral change and chronic diseases
Sources Adherence to Long-Term Therapies
Evidence for action. World Health Organization
2003. Available at http//www.who.int/chronic_con
ditions/adherencereport/en/. American Medical
Association. Facilitating Adherence with
Technology. Available at http//www.ama-assn.org/
ama/pub/article/12202-8430.html. Pfizer Clear
Health Communication Initiative 2003-2004.
80In addition to the financial benefits of
adherence, the medical benefits are real
Medical Benefits of Patient Adherence
- Fewer medical complications
- Better quality of life
- Decreases in drug resistance
- Wiser use of health resources
- Decreases in pain and intervention
- Increases in work productivity
When we are sick, working is hard and learning
is harder still. Illness blunts our creativity,
cuts out opportunities.
Kofi AnnanSecretary-General, United Nations
Sources Adherence to Long-Term Therapies
Evidence for action. World Health Organization
2003. Family Medicine NetGuide. Patient
Adherence Explained. Available at
http//www.fmnetguide.com/vo2iss1/feature.html.
81Canada Cost of nonadherence
- In Canada, patient nonadherence and physician
inappropriate prescribing combined have been
estimated to cause - 20,000 deaths per year
- one million hospitalizations per year
- (McLean et al., 1998)
82Why is there such poor adherence?
83- Video on nonadherence
- http//www.youtube.com/watch?vqxvT9sqVBnQ
84Ex of Hypertension Most people have had their
blood pressure checked
- Blood pressure is a vital sign (heart rate,
respiration, temperature, blood pressure) - Hypertension (high blood pressure) is strongly
linked to mortality and morbidity - 4.1 million hypertensive individuals in Canada,
many die each year - 98 had had their blood pressure tested at least
once - 73 had had their BP tested in the last year
85The Problem of HypertensionWhy dont patients
get treated?
- Of those with high Blood Pressure (BP) who
were18-34 of age - 64 of males 19 of females did not know that
they had high blood pressure - Only 16
- Were in treatment for their condition, and
- Had brought their BP to acceptable levels
- Most people with high BP who die do not have
their condition under control
86The Problem of hypertension
- How can it happen that checking blood pressure is
a standard part of medical care, - YET, so many people with high BP are unaware of
the problem?
87The ecology of the medical consult
- Approx. 25,000 active General Practitioners
(GPs) and Family Practitioners (FPS) in Canada - Each responsible for approximately 1200 patients
(30 million Canadians /25,000 GP/FPs) - Average visit lasts approximately 12 min
- Check-ups are longer
- Physician sees 30-35 patients/day
88Preconditions for the medical consult
- Pt identifies health problem Breast lump?
Baldness? - Self-assessment of medical problem occurs
- Health care professional is chosen visited
- Power relationship is established
- Who is the agent of change, patient or Dr?
- How will power be shared?
- When is cure achieved?
89 The consult timeline
- Dr asks for patient to report problem
- Patient presents 1 or more problem(s)
- Dr tries to focus on most important
- Diagnosis made (or not)
- Treatment prescribed, instructions given
- Case notes made (or not)
- Consult ends
- Patient makes notes (or not)
- Treatment plan followed (or not)
90Problems in the consult 1
- Patient often has not done enough to prevent the
condition (e.g., smoking, previous noncompliance) - Ignorance
- Incorrect personal risk assessment
- Perceived personal immunity
- Patient is passive about treatment
- Patient wants too much in one visit
- Physician does not centre on patient needs
- Inadequate diagnosis
91Problems in the consult 2
- Patient does not attend properly to physician
instructions, notes seldom taken - Approximately 50 of information is forgotten
shortly after the consult - Patient often does not
- Fill Rx, take Rx, or continue Rx
- Adhere to other treatment recommendations
- Report treatment problems and concerns to doctor
92Medical communication problems
- Patients are not being informed adequately
- Patients are forgetful
- Patients are noncompliant with lifestyle
interventions - Patients are noncompliant with medications
- Patients do not feel sufficiently empowered to
take care of their own health
93Adherence
- Adherence is lower when
- Recommendations do not seem medical
- Lifestyle modification is needed
- Complex self-care regimens are required
- Patients have private and conflicting theories
about the nature of their illness or treatment. - Adherence is increased when
- Patients have decided to adhere
- They feel the provider cares about them
- They understand what to do
- Good communication is used
- They have received clear, written instructions.
94Factors affecting adherence
- Demographic Factors
- Gender, ethnicity and age
- Treatment regimen complexity, duration,
disruptive effects, cost - Side effects
- Avoidant Coping Strategies
- People with avoidant coping strategies are less
likely to adhere? - Presence of Life Stressors
- Other problems affect adherence
- Lack of time
- No money
- Problems at home
95Some determinants of adherence to treatment
regimens and care
96The Modern Patient-Physician Relationship Is
Becoming Horizontal
Evolving Patient-Physician Relationship
- Paternalism
- One-on-one strategies
- Knowledge gap
- Doctors orders
- Intervention
Partnership Team approaches Educational
empowerment Mutual decision-making Prevention
Sources Magee M, DAntonio M. The Best Medicine.
New York Spencer Books 2001. Magee M.
Relationship Based Health Care in the United
States, United Kingdom, Canada, Germany, South
Africa, and Japan. Presented at the World Medical
Association Annual Meeting. Helsinki, September
11, 2003.
97How do we improve adherence?
- Teach providers how to communicate
- Spend some time in conversation about non-medical
issues - Train providers Patient-centred communication
- Listen to the patient and ask them to repeat what
has to be done - Gear the frequency of visits to adherence needs
- Involve the patients spouse/partner
- Avoid medical jargon Give clear instructions on
exact treatment and why it is so
98Improving adherence contd
- Postcard reminders or telephone calls reminding
them to come back in - Reduce time spent in waiting room
- Repeated presentation of treatment regimen
- Providers personal authority can be used to
instill compliance - Provider must probe for potential adherence
barriers or obstacles What are the patients
worries? - Adopt a friendly, less business like attitude
99Reasons for poor adherence are understood
Solutions are taking shape
Questions to Generate Information
Adherence Requires
- How much medication is needed?
- How often? Same time every day?
- Empty the bottle? Refills? Side effects?
Addiction? Interactions? - Information? Phone number?
- 1) Understanding the plan
- 2) Agreement on course of action
- 3) Commitment to execution
Realities
- No single strategy known to be effective
- Interventions must be tailored to the individual
- Peer, family and community support helps
(especially peer support, according to the WHO)
Sources Adherence to Long-Term Therapies
Evidence for action. World Health Organization
2003. Available at http//www.who.int/chronic_con
ditions/adherencereport/en/. Family Medicine
NetGuide. Patient Adherence Explained. Available
at http//www.fmnetguide.com/vo2iss1/feature.html
.
100What did we talk about today?
- Pain
- Definition, assessment, pain management
- Adherence to medication
- Prevalence of nonadherence
- Costs of nonadherence
- Causes of nonadherence
- Solutions