Transcript Special Management Challenges

International Pain School
Special
Management Challenges
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Biopsychosocial Dimensions of Pain
Culture, Social interactions,
Sick role
SOCIAL
PSYCHOLOGICAL
Neurophysiological
changes +
Physiological
dysfunction
BIOLOGICAL
Chronic Pain Definition
• No international standard definition
• Persists > 90 days ( > 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 20–25%
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
Differences: Acute versus Chronic
Acute
Chronic
• Simple assessment(s)
• Complex assessment(s)
– Unidimensional tools
• Usually responds to
– Multidimensional tools
– Underlying causes may
analgesics and/or treatment
be difficult to identify or
of the
isolate
underlying cause
• Often resolves
spontaneously
• Often refractory to
analgesics
• May never resolve
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
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
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
Predictors of Pain Chronicity
Sociodemographic, Clinical & Psychological Factors
Age > 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
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
Differences in Pain Treatment
Acute
Chronic
• Medical-treatment model
• Rehabilitation-disease
• Primary goal: Reduce pain
intensity
– Prevent chronic pain
management model
• Primary goal: Improve
function
• Generally successful
– Physical
• Treatment ends when pain
– Psychological
resolves
– Social
• Patients must actively
participate
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?
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
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
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
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
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
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
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
Exercise and Chronic Pain
Common Misperceptions
• „Exercise should fix my problem!“
or „I‘ve tried physical therapy (PT) and it didn‘t 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
Chronic Pain
it is not clear what a “flair”is.
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
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
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 “selfincreased” 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 ?
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
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
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.
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.
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)
Addiction – A Neurobiological Disease
• Involves the brain’s 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
Prevalence of Substance Abuse in Pain
Management Populations
• Prevalence studies reveal variable results based on nonuniform 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)
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
Addiction
• Physical dependence
• Tolerance
• Pseudoaddiction
• Pseudotolerance
… Are NOT addiction
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
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 drug’s 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
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
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
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
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
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
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
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
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)
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
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
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
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.
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
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 ?
Pain in Older Adults
• Aging affects every aspect of health
– risk
– mechanisms
– symptoms
– psychosocial adaptation
– treatment efficacy
– survival
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
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
Common Conditions Causing Pain
in Older Adults
• Low back pain from facet
joint arthritis and
spondylosis
• Neuropathic pain
associated with stroke
• Shingles, postherpetic
• Osteoarthritis
neuralgia
• Osteoporosis
• Diabetes
• Previous bone fractures
• Trigeminal neuralgia
• Rheumatoid arthritis
• Nutritional neuropathies
• Polymyalgia rheumatica
• Peripheral vascular
• Paget‘s disease
• Peripheral neuropathies
disease
• Coronary artery disease
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
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
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
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
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)
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 interpatient 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
Older Adults and Analgesics
• Anticonvulsants: gabapentin and topiramate may be less
likely to result in adverse effects
• Drug interactions with routine medication
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
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
This talk was originally prepared by:
Debra Gordon, RN, DNP, FAAN
Seattle, USA
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
International Pain School
The project is supported by these organizations: