Transcript Pain Teleconference Presentation

Pain – An Introduction &
Opportunity for Social Work
Intervention
Terry Altilio LCSW
Department of Pain Medicine &
Palliative Care
Beth Israel Medical Center
CONVERGING CONTEXTS
Industry
Insurers
Pt/Family
Advocates
Litigators
Legislators
Clinicians
Media
Regulators
Supreme Futurology
NY Times 8/2005
William Stuntz, Harvard professor is 47 &
suffers from chronic back pain. “My
generation will include lots of very old
people who have more chronic pain than
middle-aged people and also get cancer at
higher rates, and both of these trends will
massively change the way the baby boom
generation thinks about drug policy.”
Impact
The annual cost of chronic pain in the United States,
including healthcare expenses, lost income, and lost
productivity, is estimated to be $100 billion.
More than half of all hospitalized patients experienced
pain in the last days of their lives and although therapies
are present to alleviate most pain for those dying of
cancer, research shows that 50-75% of patients die in
moderate to severe pain.
An estimated 20% of American adults (42 million people)
report that pain or physical discomfort disrupts their
sleep a few nights a week or more.
American Pain Foundation website for references
Incidence
An estimated 76.5 million Americans - report that they
have had a problem with pain of any sort that persisted
for more than 24 hours in duration. (excluding acute
pain).
More women (27.1%) than men (24.4%) reported that
they were in pain.
Non-Hispanic white adults reported pain more often than
adults of other races and ethnicities (27.8% vs. 22.1%
Black only or 15.3% Mexican).
Adults living in families with income less than twice the
poverty level reported pain more often than higher
income adult
American Pain Foundation website for references
Mandates
Ethical principles
– Justice, beneficence, nonmaleficence
Scientific standards & guidelines
JCAHO standards
Litigation
Emphasis on end of life care
Groups at Risk for Under-treatment
Babies, children, women, & frail elderly
Racial & ethnic minorities
Language & culture different from HCPs
Patients with
–Dementia
–Communication problems
–Emotional disturbance
–Cognitive impairment
–Substance abuse issues
When Patients Cannot Report
Pain
Assess with others
– Changes in behavior
Quiet when normally talkative
Restless
Sudden anger
Loss of appetite
– Watch for pain behaviors
Agitation / crying out
Rubbing
Confusion
Excessive sleep
Clinical / Systems Barriers to Managing
Pain
Lack of pain assessment skills
Lack of interdisciplinary collaboration
Absence of accountability
Absence of practical tools
Overstressed & desensitized staff
Mistrust – mutual
Barriers - Patient & Family
Fears
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Distracting HCP from survival efforts
Med side effects - confusion, sedation, hastening death
Painful interventions - injections
Addiction / tolerance
Upsetting family
Handling medication / “killing” the patient
Financial burden
Barriers - Patient & Family
Beliefs & Values
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Pain is inevitable
Pain is necessary / builds character
Requires stoic response
Represents sacrifice
Good patients do not complain
Intent of clinicians & medical system is suspect
Barriers - Patient & Family
Emotional Factors
– Distress, denial & / or depression impact
– Ability to assess & report pain
– Acknowledging pain means disease is worse
– Acceptance of need for treatment
Knowledge Factors
– No expectation for good treatment
– Do not know how to report pain
Pain & Substance Abuse
Some Considerations
Some Definitions
To enhance critical thinking & inform plan of care
– Addiction
– Physical dependence
– Chemical coping
– Tolerance
– Pseudoaddicton
Substance Abuse
Use of any drug outside accepted norms.
Labels any use of illicit drugs and misuse
of prescribed drugs as abuse.
ASAM, APS, AAPM (2003)
Addiction
A primary, chronic, neurobiological disease with
genetic, psychosocial & environmental factors
influencing its development & manifestation;
characterized by one or more of the following
– Impaired control over drug use
– Compulsive use
– Use despite harm
– Craving
ASAM, APS, AAPM (2003)
Tolerance
A state of adaptation in which exposure to the
drug induces changes that result in diminution of
one or more of the drug’s effect over time
ASAM, APS, AAPM (2003)
Physical Dependence
A state of adaptation that is manifested by a
drug class-specific withdrawal syndrome that
can be produced by abrupt cessation, rapid
dose reduction, decreasing blood level of the
drug &/or administration of an antagonist
ASAM, APS, AAPM (2003)
Pseudoaddiction
Term used to delineate the distress and drugseeking behaviors, similar to those of people with
the disease of addiction, that can occur in the
context of unrelieved pain
Weissman & Haddox (1989)
Chemical Coping
Most adults fall somewhere between the two
extremes of abstinence & addiction & therefore, one
needs to establish the degree of chemical coping &
the role of alcohol or drugs in the coping strategy of
the vast majority of cancer patients (self
medicating?)
Bruera (1998)
The Complexity
 Aberrant drug related behaviors
– Exist on a continuum
– Inadequate management of symptoms may
be the motivation for problem drug-taking
behaviors
– May reflect pseudoaddiction, psychiatric
disorders, family distress, criminal intent
Barriers & “Non-adherence”
The history & tradition of social work rests in the
embracing & overcoming of obstacles. It is
where we begin while for others, it is where they
end……..
Culture & Pain
Lasch, IASP (2002)
Culture of Pain
–Way in which society shapes meaning &
treatment of pain
Culture in Pain
–Way in which culture molds perceptions,
expression, coping responses, behaviors,
expectations & ascribed meanings
Rural / prisons…….
Some Things to Ponder
1993- NIH mandates inclusion of women in
research
1998- FDA requires drug companies to include
sex specific information on safety & efficacy
when applying for new drug approval
Some Things to Ponder
WEB MD (2002)
2001- IOM & DHHS recommend that sex & gender
differences be taken into account when designing &
analyzing studies
7/97 – 2/01- 8 of 10 prescription drugs taken off the
market caused more negative effects in women
then men.
Some Thoughts on Gender
Biological differences
– Reproductive hormones
– Stress induced analgesia responses
– Brain & central nervous system
Some Thoughts on Gender
Is more than physiology at work?
– Cognitive appraisal & meaning-making
Women more often experience pain as normal
biological process….sort normal from pathological
Hurt not equal to harm
– Communication
Women give contextual description - relationships
Men objectively report symptoms / limitations
– Which reporting style most consistent with medical
model????
Some Thoughts on Gender
Behavioral coping
Culture, gender & pain
The complex interplay between behaviors & values
systems impacts patients and clinicians
Gender of researcher has been shown to influence
male pain response
Some Thoughts on Gender
Are there differences in health care
provider’s perceptions?
– Sensitivity to pain
– Tolerance for pain
– Validity of self reports
– Objective, biological facts more credible
Pain
“An unpleasant sensory & emotional experience
associated with actual or potential tissue damage
or described in terms of such damage…”
“Pain is always subjective…”
“A sensation in a part or parts of the body,
but it is always unpleasant & therefore an emotional
experience.”
IASP Definition (1979)
Multidimensional Aspects of Pain
Multidimensional exploration of pain is not
a denial of physical pain but rather an
expression of interest, caring & concern
for the total person. Medical management
needs to be accompanied by efforts to
understand beliefs, thoughts, behaviors &
feelings that may contribute to pain,
suffering & distress.
Pain: a Multidimensional
Phenomenon
Integrates
– Knowledge of symptoms & treatments
– Individualized illness experience - patient &
family
Impacts
– Mood
– Function
– Quality of life
– Grief & bereavement
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Suffering
Distress brought about by the actual or
perceived impending threat to the integrity or
continued existence of the whole person.
Suffering can include physical pain but is by
no means limited to it - failure to understand
the nature of suffering can result in a medical
intervention that not only fails to relieve
suffering but becomes a source of suffering
itself.
Cassell (1982)
Impact of Unrelieved Suffering
Pain tolerance is diminished.
Medications might mask existential angst,
but they don’t resolve it.
Assess family suffering; respond to
discrepancies.
Explore possibility that pain behaviors have
become metaphors for unrelieved suffering
Multidimensional Assessment
Complements medical & pharmacologic
Engages & partializes pain experience
Includes clinical interview/tools & scales
Validates importance of patient perception
& information
May include input from family & health
care professionals
Traditional Biomedical Pain
Assessment
Diagnose underlying medical condition
If “organic” – physical
 Analgesics,
medical intervention
If “supratentorial”
Analgesics,
medical intervention discouraged
Pain
Experience
Pain
(Sensory)
Suffering
Biopsychosocial Spiritual Approach
to Pain (Revised)
Pain
Physical
Sensory
Nociception
(Tissue damage)
Social/Environmental
Family, Culture, Work,
Finances, Litigation
Psychological
Affective
Cognitive
Behavioral
Spiritual
Meaning, Purpose
Biopsychosocial Spiritual Pain
Assessment
Diagnose underlying medical condition
Assess
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Psychological status
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Pain behaviors
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Social environmental factors
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Spiritual aspects
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Cultural variables
Biopsychosocial Spiritual Pain
Assessment
Assess
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Mental status
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Cognitive response to pain condition
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Adjustment & coping
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Psychiatric history
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Substance use/abuse & dependence
Pain Behaviors
Verbal
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Pain complaints
Analgesic requests
Non Verbal
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Activity level and pattern
Complaints – grimacing, groans
Body posture
Social & Environmental Assessment
Work status
Economic status
Disability compensation?
Litigation?
Family & social support
Behavioral Interventions
Cognitive-Behavioral Therapy
Biofeedback
Relaxation Training/ Stress Management
Hypnosis
Imagery
Distraction Techniques
Psychotherapy
Bereavement / Loss
Altered self-identity
Anger management
Develop new sources of meaning,
Family/relationship issues
Behavior Therapy
Active coping responses to increase selfefficacy
Graded tasks & goal setting
Problem-solving skills
Contingency management
Modeling
Behavioral rehearsal
Cognitive Therapy
Cognitive restructuring, reinterpretation
Correct distortions, exaggerations
Distraction techniques
Education
Relaxation-Based Modalities
Muscle relaxation (passive & active)
Hypnosis
Autogenics
Imagery
Meditation
Integrative Techniques
Acupuncture
Exercise
Journaling
Massage
……….
Comprehensive Pain Management
Potential outcomes related to goals of care
Manage pain
Reduce anxiety & distress
Treat depression, mood disorders
Impact activity & participation in
meaningful activity
Increased feelings of self efficacy &
competence to manage symptoms
Response to Witnessed Distress
“Being alerted to reported or witnessed
distress begs an appropriate response by
the caregiver.”
Frager (1997)