Special%20Management%20Challenges

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• Special Management Challenges

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Biopsychosocial Dimensions of Pain
Culture, Social interactions, Sick role
SOCIAL
PSYCHOLOGICAL
Neurophysiological changes Physiological
dysfunction
BIOLOGICAL
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Chronic Pain Definition

• No international standard definition
• Persists gt 90 days ( gt 3-6 months)
• Often unrelated to time of initial injury
• Poor/no response to treatments effective in
  acute pain
• Complex structural and functional changes in the
  nervous system
• Generally purposeless, often irreversible
• Estimated incidence worldwide 2025

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Chronic Pain Definition

• Chronic pain is a disease Acute pain is a
  symptom
• Poor understanding of the mechanisms implicated
  in the transition from acute injury to chronic
  pain

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Differences Acute versus Chronic

• Acute
• Simple assessment(s)
• Unidimensional tools
• Usually responds to analgesics and/or treatment
  of the underlying cause
• Often resolves spontaneously

• Chronic
• Complex assessment(s)
• Multidimensional tools
• Underlying causes may be difficult to identify or
  isolate
• Often refractory to analgesics
• May never resolve

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Chronic Pain Assessment

• Absence of abnormal findings on exploration
  cannot rule out pain and does not mean normal
  physiology
• Changes in vital signs and behavior are
  unreliable
• Assess multiple dimensions of pain experience
  with emphasis on function and mood
• Establish a pain diagnosis when possible, and
  determine the type of pain and contributing
  factors

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Case Study

• 55 year old black female
• History of low back pain all her adult life
• Described as continuous, severe, localized, and
  interfering with her ability to work
• No relevant findings on physical exam and imaging
• Treated with increasing doses of opioid therapy
  for the past 2 years
• Declined to try an antidepressant
• Requesting an increase dose of morphine

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Chronic Pain Assessment

• A body diagram colored by the patient may be
  helpful to determine location(s) and assess
  quality and type of pain, as well as help
  establish and adequate treatment plan

Yellow Aching Blue Burning Red
Stabbing Black Numbness Green Tingling pins
needles Orange hurts to touch Purple Other
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Predictors of Pain Chronicity
Sociodemographic, Clinical Psychological Factors Sociodemographic, Clinical Psychological Factors
Age gt 50 Fear avoidance
Previous history of back pain Catastrophising
Nerve root pain Pain behaviour (non-physical illness behaviour)
Pain intensity / functional disability Job dissatisfaction
Poor perception of general health Duration of sickness absence
Distress depression Expectations about return to work
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Transition from Acute to Chronic Pain

• Predicting Factors

• cumulative trauma exposure (LBP)
• acute pain intensity, duration, and disability
• level of education, female sex, older age
• early use of prescription opioids (acute LBP)
• negative beliefs on chronic pain severity
  disability
• high baseline fear, anxiety, depression
• repeated environmental stress

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Differences in Pain Treatment

• Acute
• Medical-treatment model
• Primary goal Reduce pain intensity
• Prevent chronic pain
• Generally successful
• Treatment ends when pain resolves

• Chronic
• Rehabilitation-disease management model
• Primary goal Improve function
• Physical
• Psychological
• Social
• Patients must actively participate

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Case continued

• Non-steroidal anti-inflammatory drugs (NSAIDs)
  and heat have not been helpful
• She has self-increased her morphine from 15mg (5
  tablets a day) to doses of 45mg as often as every
  3 hrs
• She seems depressed
• Sleep is poor
• Smokes tobacco
• Her mother was an alcoholic

Does the patient have a job?
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Chronic Pain Analgesic Management

• A multimodal approach using a combination of
  drugs may be necessary
• Combine drugs of different groups and with
  different mechanisms
• Frequently assess how the patient is taking the
  analgesic medication, the level or degree of pain
  relief and side effects
• Start with the lowest effective dose
• Discontinue if side effects are intolerable or if
  treatment is not helpful
• Consider cost of treatment

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Chronic Pain Opioids

• Chronic opioid therapy remains controversial due
  to misconceptions, regulatory barriers, and
  uncertainty about effectiveness / safety
• Ongoing investigations into potential negative
  effects on quality of life and endocrine adverse
  events

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Use of Scheduled versus PRN Opioids

• It is unclear whether scheduled around-the-clock
  opioid therapy is better than PRN dosing
• Assess the need for additional rescue doses
• Are they being taken for psychological reasons ?
• Do increased doses of the long-acting opioid
  eliminate the need for some of the rescues doses?
• Evaluate the risk / benefit (improvement in
  function) that the additional doses will produce

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Types of Episodic or Increased Pain

• Breakthrough pain
• Transitory flare of moderate-to-severe pain
  occurring in patients with persistent pain
  otherwise controlled by analgesics (often
  opioids). May be incident related, due to
  end-of-dose failure, or idiopathic
• Flare pain
• Term used in chronic non-cancer pain to describe
  an exacerbation of pain that may last days to
  weeks
• Treatment may have to be adjusted, often adding
  other drugs, in order to control pain and other
  symptoms

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Chronic Pain Treatment Goals

• Restore function
• Physical, emotional, social
• Decrease pain
• Treat underlying cause where possible
• Correct secondary consequences of pain
• Postural deficits, weakness, muscle overuse
• Maladaptive behavior, poor coping

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Chronic Pain Treatment Approach

• Together with the patient, set realistic goals
  about pain control
• Brief motivational interviewing
• Acknowledge feelings (e.g., grief, loss,
  frustration)
• Use a multimodal approach
• Medication, exercise, sleep, nutrition,
  counseling
• Flare plan

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Chronic Pain Exercise

• Many patients are fearful of movement and
  exercise
• Improves physical functioning, decreases
  secondary sources of pain, and improves general
  health and wellbeing
• Different types of exercise each with specific
  goals
• For example strengthen, stretch, preserve range
  of motion, recondition
• Recommend a consult with a physical therapist

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Exercise and Chronic Pain

• Common Misperceptions

• Exercise should fix my problem! or Ive tried
  physical therapy (PT) and it didnt help or
  Activity makes my pain worse!
• 30 minutes/day of exercise will not overcome 16
  hours/day of poor posture and poor body mechanics
• Repetitive practice and lifestyle change are
  crucial

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Chronic Pain
it is not clear what a flairis. Would be good
to provide an example

• How to Manage Flares

• Short term increase in usual level of pain
• Temporary, may last hours to days or weeks
• Distinct from breakthrough pain how?
• Look into what triggered the flare
• Stress, injury, lack of sleep, exercise, hormonal
  changes, additional / new pathology
• Use a flare plan
• Medication, ice or heat, increase or decrease
  activity, distraction, other coping skills

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Case continued Treatment Plan

• Diagnostic Impression
• Low back pain, acute flare
• Major or moderate depression, single episode
• Tobacco abuse
• Goal Increase Functional Activity
• Counsel on stretching, strengthening and
  endurance exercises, supervised physical therapy
  if available initially
• Help with development of pain coping
  strategies/skills, brief motivational interview,
  counselor or health psychologist if available

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Case continued Treatment Plan

• Goal Reduce Pain by 25 or more
• As self-increased doses of morphine have not
  helped to reduce pain or improve function, reduce
  as previously prescribed
• It should be made clear that morphine should not
  be self-increased under any circumstances
• Consider re-introduction of NSAID or paracetamol.
  
• Consider if they were not effective before,
  might not improve pain now.
• If there is a neuropathic component in her LBP,
  gabapentin or antidepressants could be added to
  the opioid
• Trial of tricyclic antidepressant to reduce pain
  why TCA ?

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Case continued Treatment Plan

• Goal Diminish Psychological/Social Disruption
• Depression counseling
• Reduce anxiety, facilitate sleep
• Smoking cessation counseling
• Goal Reduce Interference with Work
• Attempt modification in work flow and body
  mechanics
• Give examples of how to modify body mechanics,
  e.g. position, bearing, sitting

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Summary Chronic Pain

• Chronic pain is a complex biopsychosocial
  condition that differs widely from the symptom of
  acute pain
• A multidimensional assessment is essential to
  establish a pain diagnosis to guide the treatment
  plan

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Summary Chronic Pain

• The goals of chronic pain treatment are to
• Maintain or restore function, diminish
  psychological/social disruption.
• Often only partial pain relief can be achieved.
• A disease management model that aims to empower
  the patient to self-manage pain with less
  reliance on medications and on invasive
  procedures seeking cure is likely best suited.

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Chronic Pain Take Home Messages

• Involves complex changes in the brain and nervous
  system that lead to dysfunction
• May be difficult to detect underlying mechanisms
• Assessment and treatment address al dimensions of
  the biopsychosocial experience
• Complete relief and cure often unrealistic
• Treatment is aimed on empowering the patient to
  manage the pain using positive coping skills,
  lifestyle changes and judicious use of
  medications.

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Addiction Definition

• Substance dependence is defined as
• When an individual persists in use of alcohol or
  other drugs despite problems related to use of
  the substance, substance dependence may be
  diagnosed. Compulsive and repetitive use may
  result in tolerance to the effect of the drug and
  withdrawal symptoms when use is reduced or
  stopped.

Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV)
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Addiction A Neurobiological Disease

• Involves the brains reward (limbic) center
• An area of the brain that is associated with the
  affective responses to pain
• Involves dopamine and neurochemical stimulation
  What does it mean?
• Susceptible individuals may have an alteration of
  the limbic or related systems that causes
  sensitization to the reinforcing effects
• Genetic factors account for about half the
  likelihood of developing addiction

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Prevalence of Substance Abuse in Pain Management
Populations

• Prevalence studies reveal variable results based
  on non-uniform definitions of abuse and addiction
• Reported as less prevalent in cancer pain (0 -
  5)
• More prevalent in the chronic non-cancer pain
  population (0 - 50 depending on criteria used)
  
• (confirm figures)

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Prevalence of Substance Abuse in Pain Management
Populations

• Risk factors include high opioid doses,
  concomitant use of alcohol or benzodiazepines,
  younger age, previous depression and low
  educational level
• Fear and misunderstanding about addiction are
  barriers to adequate pain management

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Addiction

• Physical dependence
• Tolerance
• Pseudoaddiction
• Pseudotolerance
• Are NOT addiction

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Physical Dependence - Definition

• Physical dependence is a state of physical
  adaptation that is manifested by a drug-class
  specific withdrawal syndrome. Withdrawal can be
  induced by abrupt cessation or rapid dose
  reduction decreasing blood level of the drug,
  and/or administration of an antagonist.
• Dependence is an expected manifestation of opioid
  administration
• Manifested by withdrawal symptoms

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Tolerance - Definition
These concepts may be difficult to grasp unless
an example is given e.g. opioids

• Tolerance is a state of adaptation in which
  exposure to a drug induces changes that result in
  diminution of one or more of the drugs effects
  over time.
• Tolerance is an expected manifestation during
  opioid administration
• Opioid tolerance is manifested by a decrease in
  analgesia that requires increasing the doses to
  obtain a similar effect.
• In cancer pain, the most common need for
  increased dosage is disease progression, rather
  than drug tolerance

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Pseudoaddiction is

• Manifested by behaviors similar to addiction
• Clock watching
• Focus on obtaining the drug
• Illicit behaviors can occur
• Associated with the under-treatment of pain
• Behaviors resolve when the pain is effectively
  managed

• these behaviours could be included in the
  description of addiction

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Pseudotolerance

• Need to increase the dose that is not related to
  the development of tolerance such as
• Disease progression
• New disease
• Increased activity
• Lack of drug adherence
• Addiction ? For opioids, addicted subjects are
  tolerant

slide not clear
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Precautions

• Differential diagnosis
• Screen for risk of addiction (simple clinical
  interview /or screening tool)
• Obtain informed consent (explain risk and
  benefits)
• Use a treatment agreement (verbal or written /
  signed)
• Regularly assess the Four As Analgesia,
  Activity, Adverse Reactions, and Aberrant
  Behavior
• Periodically re-assess the pain diagnosis and
  co-morbid conditions including addictive
  behaviour

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The Four As Patient Level Outcomes

• Used to Guide Treatment Goals and to Reassess
  for Development of Addiction

• Analgesia
• Improve analgesia or Comfort
• Activities of Daily Living
• Physical and emotional function should be
  preserved or improved
• Adverse Events
• Should be minimized
• Aberrant Drug-taking Behaviors
• Potential aberrant drug-taking behaviors should
  be monitored

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Aberrant Behaviors observed during the
development of addiction

• Drug hoarding when symptoms are improved
• Acquiring drugs from multiple medical sources
• Aggressive demands for a higher dose
• Unapproved use of a drug to treat a symptom, e.g.
  use of an opioid to treat anxiety
• Unsanctioned dose escalation (1-2x)
• Reporting psychic effects
• Requesting specific drugs

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More Obvious Aberrant Behaviors

• Selling prescription drugs
• Forgery of prescriptions
• Concurrent illicit drug use
• Multiple prescription/medication losses
• Ongoing unsanctioned dose escalations
• Stealing and borrowing drugs
• Obtaining prescription drugs from nonmedical
  sources
• Repeated resistance to changing drug type
  inflexibility

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Aberrancy Risk Factors

• Family history of substance abuse
• Legal problems
• Drug or alcohol abuse
• Mental health problems
• Multiple motor vehicle accidents
• Cigarette smoker
• Fewer adverse events of what ?
• High opioid dose

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Differential Diagnosis When Aberrant Behavior is
Observed

• Addiction
• Pseudoaddiction
• Psychiatric pathology
• Encephalopathy
• Personality disorder
• Depression, anxiety, high level of stress
• Chemical coping (give examples)
• Criminal intent (give examples)

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Take Home Message Pain Management in Patients
with Risk of Substance Abuse

• Fear of addiction hinders pain management in all
  patient populations
• Risk screening should must be performed at onset
  of opioid therapy and aberrant behaviors
  repeatedly assessed
• Goals of pain management similar to thoose for
  chronic pain include improving analgesia
  activities of daily living, and controlling
  adverse events and aberrant behaviors
• Patients with addiction also present tolerance,
  and usually require higher doses of opioids to
  obtain effective analgesia

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Pregnancy and Substance Use

• Neonates exposed to heroin, prescription opioids,
  methadone, or buprenorphine during pregnancy are
  monitored closely for symptoms and signs of
  neonatal withdrawal (neonatal abstinence syndrome)

• ADD signs and symptoms of neonatal withdrawal

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Pregnancy and Chronic Pain

• Almost all drugs cross the placenta
• Where possible, non-pharmacologic treatment
  options should be considered first
• Exercise reduce back and pelvic pain during
  pregnancy.
• Paracetamol and codeine are generally considered
  safe
• NSAIDs and aspirin should be used with caution in
  the last trimester of pregnancy and avoided after
  the 32nd week

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Pregnancy and Chronic Pain

• Most adjuvant anticonvulsants are associated with
  birth defects
• At best, chronic opioids provide mild to moderate
  analgesia and are associated with lower Apgar
  scores (and potential newborn withdrawal)
• explain why this is so, analgesia is
  dose-dependent regardless if a patient is
  pregnant or not.

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Lactation and Analgesics

• The choice of drugs should be based on transfer
  in human milk and likely effects on the infant
• The lowest possible effective maternal dose of
  analgesic is recommended
• Breastfeeding is best avoided at times of peak
  drug concentration in milk, and the infant should
  be observed for effects of medication transferred
  in breast milk.
• Lactating women having surgery are generally
  advised to discard their milk for 24hours after
  operation

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Lactation and Analgesics

• Local anaesthetics, paracetamol and several
  non-selective NSAIDs, in particular ibuprofen,
  are considered safe in the lactating patient
• Morphine and fentanyl are considered safe in the
  lactating patient and are preferred over
  pethidine
• SSRIs and TCAs can be used in postnatal
  depression
• See specific information on use of
  anticonvulsants ?

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Pain in Older Adults

• Aging affects every aspect of health
• risk
• mechanisms
• symptoms
• psychosocial adaptation
• treatment efficacy
• survival

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Misconceptions about Pain in Older Adults

• Pain is a natural outcome of aging
• Pain perception or sensitivity decreases
• The elderly cannot use pain rating scales
• Opioids are too dangerous in the elderly

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Pain Prevalence with Age

• Measurement in the community is difficult and may
  be underestimated
• Regional and widespread pain conditions are
  common in older persons
• Reports of increases, decreases, and no change
  for musculoskeletal pain
• Increased prevalence of neuropathies with age
• Pain is more prevalent in women
• Result of combination of constitutional,
  lifestyle, mechanical and psychosocial factors

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Common Conditions Causing Pain in Older Adults

• Low back pain from facet joint arthritis and
  spondylosis
• Osteoarthritis
• Osteoporosis
• Previous bone fractures
• Rheumatoid arthritis
• Polymyalgia rheumatica
• Pagets disease
• Peripheral neuropathies

• Neuropathic pain associated with stroke
• Shingles, postherpetic neuralgia
• Diabetes
• Trigeminal neuralgia
• Nutritional neuropathies
• Peripheral vascular disease
• Coronary artery disease

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Challenges in Older Adults Reporting Pain

• May not use word pain but endorse aching,
  hurting, soreness or other descriptors
• Reliable pain assessment can be obtained in
  patient with mild to moderate cognitive
  impairment using standardized pain assessment
  measures
• A strong relationship exists between pain and
  function in the older adult
• physical function
• psychosocial function
• cognitive function

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Age Appropriate Strategies

• Screen for cognitive impairment
• Use direct query and standard scales (e.g. verbal
  or visual analogue or descriptor)
• Ensure understanding
• Simplest, clear explanation, use examples
• Give time to grasp task and respond
• Repetition is important
• Modify assessment according to sensory deficits
• Use visual cues, large print, adequate ambient
  light
• Eliminate distractions and assure aids are in
  place
• Vigilance and inquiry into functional changes

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Behavioral Pain Assessment in the elderly

• Physiological indicators (changes in heart rate,
  blood pressure, respiratory rate), are not
  reliable or sensitive for discriminating pain
  from other sources of distress
• Common validated pain behaviors
• Negative Vocalizations (in words and not in
  words)
• Facial expressions
• Body language (movement or immobility)
• Changes in interpersonal interactions or routines

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Behavioral Pain Assessment in the elderly

• Use behavioral assessment tools at rest and
  movement or during known painful procedures
• Behavioral scores do not equate pain intensity
• For complete list of behavioral scales see
• http//prc.coh.org/PAIN-NOA.htm

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Pharmacokinetic Considerations in Older Adults

• Absorption
• Distribution
• Protein binding
• Metabolism
• Excretion
• End result is higher peak levels and longer
  duration of action (delayed clearance and higher
  incidence of side effects)

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Older Adults and Analgesics

• NSAIDs more likely to suffer adverse gastric,
  renal and CV side effects, and also be more
  likely to develop cognitive dysfunction
• Opioids require less opioid than younger
  patients to achieve the same degree of pain
  relief though large inter-patient variability
  still exists
• TCAs more prone to side effects including
  sedation, confusion, orthostatic hypotension, dry
  mouth, constipation, urinary retention and gait
  disturbances which may increase the risk of falls
• ECG abnormalities may be a contraindication

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Older Adults and Analgesics

• Anticonvulsants gabapentin and topiramate may be
  less likely to result in adverse effects
• Drug interactions with routine medication

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Non-pharmacologic Interventions older adults

• Distraction-TV, music, storytelling
• Relaxation-music, touch, warmth
• Cold/Heat on the affected site.
• Be cautious not to damage skin
• Repositioning-body alignment
• Movement/exercise glider activity
• Sensory stimulation pet therapy, gardening
• Cognitive therapy-reminiscing, reading, visiting

McDonald Sterling, 1998 Kovach et al., 1999
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Take Home Messages Older Adults

• Older adults with cognitive impairment are more
  likely to be under treated
• There are age related decreases in analgesic
  requirements, though inter-patient variability
  exists

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This talk was originally prepared by

• Debra Gordon, RN, DNP, FAAN
• Seattle, USA

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International Pain School
Talks in the International Pain School include
the following
Physiology and pathophysiology of pain Nilesh Patel, PhD, Kenya
Assessment of pain taking a pain history Yohannes Woubished, M.D, Addis Ababa, Ethiopia
Clinical pharmacology of analgesics and non-pharmacological treatments Ramani Vijayan, M.D. Kuala Lumpur, Malaysia
Postoperative low technology treatment methods Dominique Fletcher, M.D, Garches Xavier Lassalle, RN, MSF, Paris, France
Postoperative high treatment technology methods Narinder Rawal, M.D. PhD, FRCA(Hon), Orebro, Sweden
Cancer pain low technology treatment methods Barbara Kleinmann, MD, Freiburg, Germany
Cancer pain high technology treatment methods Jamie Laubisch MD, Justin Baker MD, Doralina Anghelescu MD, Memphis, USA
Palliative Care Jamie Laubisch MD, Justin Baker MD, Memphis, USA
Neuropathic pain - low technology treatment methods Maija Haanpää, MD, Helsinki Aki Hietaharju, Tampere, Finland
Neuropathic pain high technology treatment methods Maija Haanpää, M.D., Helsinki Aki Hietaharju, M.D., Tampere, Finland
Psychological aspects of managing pain Etleva Gjoni, Germany
Special Management Challenges Chronic pain, addiction and dependence, old age and dementia, obstetrics and lactation Debra Gordon, RN, DNP, FAAN, Seattle, USA
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International Pain School
The project is supported by these organizations