Transcript Heidi White - Indiana Society for Post-Acute and Long

Assessing and Treating Pain
Heidi K. White, MD, MHS, MEd, CMD
Speaker Disclosures
Dr. White has no relevant financial relationships.
Learning Objectives
By the end of the session, participants will be able to:
• Recognize categories and components of pain
• Routinely utilize pain assessment techniques
• Describe ways to assess and manage pain in patients with
cognitive impairment.
• Identify indications for specific approaches to pain
management.
• Identify potential resources to help manage pain.
• Evaluate and reassess the effectiveness and adverse
consequences (e.g., sedation, respiratory suppression,
constipation) of pain interventions in accordance with
patient goals and preferences.
Pain Management
Case Study
Mr. S has been admitted after a hospitalization for
pneumonia with a new diagnosis of metastatic lung
cancer prior to this he had lived in the nursing home due
to disability stemming from severe COPD. The nurses tell
you they think he is depressed. When you go to visit Mr.
S he forces a smile but appears tentative in his
movements and grimaces when he coughs. When you
ask about pain he shakes his head no. You reframe the
question and use the term discomfort. He finally tells you
that all of this is part of ‘getting old.’ Besides, he did not
live a good life and God is ‘paying him back’.
Difficulties in post-acute/long-term care…
• Multiple concurrent illnesses
• Under-reporting of symptoms
• Expect pain with aging
• Do not want to bother their physician
• Do not want to be viewed as a “bad” patient
•
•
•
•
Do not think their pain can be alleviated
Pain means serious illness or death is near
Fear diagnostic tests
Fear addiction
• Cognitive impairment
• Poorly validated pain-assessment instruments
Pain effects…
• Physical
– Sleep disturbance
– Impaired ambulation  deconditioning   fall risk
– Anorexia and malnutrition
• Psychological
– Depression
• Social-role loss, isolation, economic burden
• Spiritual-punishment?, harbinger of death
Pain pathophysiology
• Nociceptive Pain
– Tissue injury stimulates specialized pain receptors
– Somatic pain—skin, muscle bone, soft tissue
• Trauma, inflammation, neoplastic infiltration
– Visceral pain—internal organs and cavities
• Distention, ischemia, inflammation
• Neuropathic Pain
– Abnormal function of the central or peripheral nervous system
– Degeneration, compression, inflammation, ischemia, metabolic
derangements, toxin, trauma
– Descriptors: burning, shooting, and tingling
– Signs: heightened sensitivity to non-painful stimuli and
exaggerated sensitivity to noxious stimuli
PAIN ASSESSMENT
Case study
• With careful questioning Mr. S indicates that he has
two different pains. One has been going on for weeks,
is in the right chest, dull, aching and mostly bothers
him at night making it difficult to sleep. He also has
sharp, fleeting but intense left chest pain when he
coughs or takes a deep breath. This started yesterday
after a coughing episode. You explain that both the
pneumonia and the cancer in his right lung along with
a fluid collection around the lung may cause some of
his dull aching pain but you want to get a chest X-ray
and suspect a rib fracture related to the coughing and
cancer that has spread to his ribs may be causing the
more intermittent and intense pain.
Pain Assessment
• Pain History
–
–
–
–
–
Location
Duration
Frequency
Intensity
Quality
• Scales
–
–
–
–
Visual analog scale
Numeric rating scales
Pain thermometer
Facial pain scale
Pain Assessment in Advanced
Dementia Scale (PAINAD)
Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain
Assessment in Advanced
Dementia (PAINAD) scale. J Am Med Dir Assoc. 2003;4(1):9-15.
Pain Assessment Checklist for Seniors with
Limited Ability to Communicate-II (PACSLAC-II)
Facial Expressions
1. Grimacing
2. Tighter face
3. Pain expression
4. Increased eye movement
5. Wincing
6. Opening mouth
7. Creasing forehead
8. Lowered eyebrows or frowning
9. Raised cheeks, narrowing of the eyes
or squinting
10. Wrinkled nose and raised upper lip
11. Eyes closing
Verbalizations and Vocalizations
12. Crying
13. A specific sound for pain
(e.g., ‘ow’, ‘ouch’)
14. Moaning and groaning
15. Grunting
16. Gasping or breathing loudly
Body Movements
17. Flinching or pulling away
18. Thrashing
19. Refusing to move
20. Moving slow
21. Guarding sore area
22. Rubbing or holding sore area
23. Limping
24. Clenched fist
25. Going into foetal position
26. Stiff or rigid
27. Shaking or trembling
Changes in Interpersonal Interactions
28. Not wanting to be touched
29. Not allowing people near
Changes in Activity Patterns or Routines
30. Decreased activity
Mental Status Changes
31. Are there mental status changes that are due to pain and are not explained by another condition (e.g.,
delirium due to medication, etc.)?
Case Study
- After talking with Mr. S for a while you explain that you are
concerned about his discomfort and feel that it should be
treated with medication. You explain the 0 to 10 numeric pain
scale and ask him to rate his current level of discomfort.
- You also explain that the nurses will be administering
acetaminophen regularly but that you will also provide a
medication that is stronger that he can ask for when his pain is
not adequately controlled with the scheduled medication.
They will be asking him to use the pain scale so that you can
monitor how well the medication is working and know how to
make adjustments.
- You also ask if you can arrange for a chaplain to come and
speak with Mr. S since he is still adjusting to the implications
of this new diagnosis on his quality and length of life.
Physician role in pain assessment
•
•
•
•
•
•
Historical context
Physical examination
Developing a differential diagnosis
Establishing a working diagnosis
Determining a treatment plan
Availability for follow up and readjustment of
the plan based on continued assessment of
response
Pitfalls to be Avoided by Providers
• Reporting by staff may be
– Superficial
– Without sufficient chronology
– Lacking reports of response to treatment
• Patients, families and staff may request specific
interventions that may not be the most
appropriate response
• Chronic pain necessitates pain relief goals that
include functional targets rather than intensity
scale targets alone
Ballantyne JC & Sullivan MD. NEJM 2015;373(22):2098-99
NONPHARMACOLOGIC
APPROACHES
Transcutaneous Electrical Nerve
Stimulation (TENS)
Condition
Evidence
Outcomes
Comment
Back Pain
Small RCTs** Conflicting
Against
PHN*
Case reports
one RCT
Positive
Insufficient
PDN*
Small RCTs
Positive
For
*PHN: Postherpetic Neuralgia; PDN: Painful Diabetic Neuropathy
**RCTs: Randomized Controlled Trials
Dubinsky et al. Neurology 2010;74;173-176
Khadilkar A et al. Cochrane Collaboration, 2008, DOI: 10.1002/14651858.CD003008.pub3
Acupuncture
Condition
Evidence
Outcomes
Back Pain
Meta-Analysis Positive
For
PHN
Case reports
Insufficient
OA*
Meta-Analysis Positive
Positive
Comment
For
*OA: Osteoarthritis
Vickers AJ et al. Archives of Internal Medicine. 2012;172:1444-53
Furlan AD et al. Cochrane Collaboration, 2005 DOI: 10.1002/14651858.CD001351.pub2
Manheimer E Cochrane Collaboration, 2010 DOI: 10.1002/14651858.CD001977.pub2
Percutaneous Electrical Nerve
Stimulation (PENS)
Condition
Evidence
Outcomes
Comment
Back Pain
Small RCTs
Positive
Consider
PHN with
myofascial
pain
Case Reports Positive
Consider
Weiner DK et al. Pain 2008;140:344-57.
Weiner DK & Schmader KE. Pain Med 2006;7(3):243-9
Cognitive Behavioral Therapy*
Condition
Evidence
Outcomes
Comment
Back Pain
Meta-analysis
Positive
For
PHN
None
N/A
Insufficient
Arthritis
Meta-analysis
Positive
For
*Patients attend 6–12 sessions to learn and practice pain-management
skills, including relaxation, distraction, activity pacing, cognitive
restructuring, problem solving
Keefe FJ et al. Br J Anaesthesia 2013;111:89–94
Dixon KE et al. J Pain Sympt Manage 2007;26:241–50
Hoffman BM et al. Health Psychol 2007;26:1–9
Eccleston C, et al. Cochrane Collaboration 2009; CD007407.
Cipher DJ, et al. Clin Gerontol 2007;30:23–40.
Cook AJ. J Gerontol B Psychol Sci Soc Sci 1998;53:51–9.
Tried and true…
•
•
•
•
•
•
Distraction
Relaxation
Heat/Cold
Repositioning
Rest/Pacing activities
Muscle strengthening
•
•
•
•
•
Getting restful sleep
Physical therapy
Chiropractic care
Self management
Avoiding postures and
positions that provoke
pain
PHARMACOLOGIC APPROACHES
Pharmacologic Changes with Aging
Concern
Normal Aging
Common Disease Effects
GI
Slowing of transit
(i.e., Enhanced dysmotility with
opioids)
Surgical alterations reduce
absorption
Distribution
Increased fat to lean increases volume
of distribution fat soluble drugs (i.e.,
diazepam)
Obesity longer effects of
drugs
Liver
metabolism
Oxidation may decrease and increase
drug half life
Cirrhosis, hepatitis, tumors
may disrupt oxidation,
Renal excretion
Reduced GFR leads to decreased
excretion
Chronic kidney disease
exacerbates
Active
metabolites
Reduced GFR prolongs effects of
metabolites
Chronic kidney disease
increases half life
Anticholinergic
effects
Multiple age related changes lead to
greater sensitivity to confusion,
constipation, incontinence, movement
disorders
Enhanced by neurological
disease
Topical Therapies for Chronic Pain in
Older Adults
Condition
Topical NSAIDs Capsaicin Lidocaine Patch
Back Pain
No trials
Off Label
Post Herpetic Case reports
Neuralgia
Off Label
Osteoarthritis Positive RCTs
FDA Label
No trials
Off Label
Case reports,
small trials
Off Label
RCTs
FDA Label
(8% patch)
Positive
RCTs
FDA Label
Positive RCTs
FDA Label
Case reports,
small trials
Off Label
RCT- Randomized Controlled Trials
Derry S. Cochrane Collaboration 2012;9:CD010111. doi: 10.1002/14651858.CD010111.
Derry S. Cochrane Collaboration 2013;2:CD007393. doi: 10.1002/14651858.CD007393.pub3
Acetaminophen
• First line therapy for mild to moderate musculoskeletal pain
• Better safety profile than NSAIDs
• Randomized controlled trials confirm acetaminophen is
effective for musculoskeletal pain, equal to and sometimes
superior to NSAIDs in many patients
• Often greater effectiveness with scheduled dosing
• Extended release preparation may decrease pill burden
• Maximum dose to avoid hepatic toxicity 4000mg/24 hours
*AGS Panel on Pharmacological Management of Persistent Pain, JAGS
2009;57:1331-1346
**British Geriatrics Society Guidance on the Management of Pain in Older People,
Age and Ageing 2013;42:i1–i57
Adjust Acetaminophen Dosing in Older Adults at
Risk for Hepatotoxicity
• Reduce maximum dose 50% to 75% in
patients with
– Hepatic insufficiency
– Alcohol abuse
– Malnutrition
– Concomitant use of enzyme-inducing drugs e.g.,
carbamazepine, phenytoin, barbiturates,
AGS Guidelines, JAGS 2009;57:1331-1346
British Geriatrics Society Guidelines, Age and Ageing 2013;42:i1–i57
Acetaminophen Special Uses
Type
Scheduled oral
Intravenous
Oral non-fixed
combination with
opioids
Patients
Dementia with
behavioral
disturbances
Surgical patients in
perioperative period
Moderate to severe
pain
Husebo BS et al. BMJ 2011;343:d4065
Apfel CC et al. Pain 2013;154:677–689
Outcome
Reduced agitation
Reduced pain,
nausea and vomiting
Greater analgesic
effect than APAP or
higher doses of the
opiate alone
Non-Steroidal Anti-Inflammatory Drugs
(NSAIDs)
Congestive Heart
Failure
Peptic Ulcer
Disease
Chronic Kidney
Disease
Non-Steroidal Anti-Inflammatory Drugs
• More appropriate for acute pain management
• Selective use in persistent pain
• Topical NSAIDs (↓ systemic levels) may be
safer but no long-term studies
Mitigate the Risk of GI Bleeding from NSAIDs
• Proton pump inhibitor use for individuals at
risk for GI bleeding
– Medical conditions, e.g., peptic ulcer disease
– Antiplatelet agents, Corticosteroids, Warfarin
• Eradication of Helicobacter pylori
• Consider use of non-acetylated salicylates,
e.g., Salsalate
– Safer choice for GI bleed risk
AGS Panel on Pharmacological Management of Persistent Pain, JAGS 2009;57:1331-1346
Opioids
• Moderate to severe acute or chronic pain
– significant effect on function and quality of life
• Selections depends on…
– severity, location, and causes of pain
– expected duration of the pain syndrome (acute
versus chronic)
– desired duration of drug activity
– route of administration
– adverse effect profile
Opioids
Selection
Adverse Effects
•
• Constipation (need stimulant
laxatives, not bulk-forming)
• Nausea and vomiting
• Sedation
• Psychomotor and cognitive
impairment, delirium
• Pruritis
• Urinary retention
• Respiratory Depression
(usually preceded by sedation)
• At high dose, myoclonus and
hallucinations
•
•
Weak Full Agonists
•
Codeine
•
Hydrocodone
Weak Agonist/Reuptake Inhibitor
•
Tramadol
•
Tapentadol
Strong Full Agonist
•
Morphine
•
Oxycodone
•
Hydromorphone
•
Fentanyl
•
Methadone
•
Oxymorphone
Opioid Risk
• Side effects are common
– Nausea, sedation, constipation, urinary retention, sweating
• Addiction
– Low for older adults when treating chronic pain
– Exceedingly low (<1%) when treating acute pain
– Personal history of substance abuse, family history of substance
abuse, younger age, mental illness, preteen sexual abuse increase risk
– Physical dependence
• Over Treatment
• Overdose
– at high doses
– when combined w/ other sedatives
– Illness may effect clearance
Monitoring Opioids
General
• Effectiveness
• Adherence
• Diversion
Adverse Effects
• Time is your ally: tolerance
develops to many side effects:
not to constipation
• Multimodal therapy (non-drug
therapies, combining drugs
that work by different
mechanisms)
• Dose reduction or route
change
• Opioid rotation: side effects
may be less with one drug
than another
• Symptom management
Are Opioids the answer for chronic pain?
• Systematic reviews have not found sufficient
evidence that long-term opioid use controls
non-cancer pain more effectively than other
treatments
• when risks outweigh benefits, as will often be
the case for chronic pain, opioid use should be
avoided in favor of other treatments
• the risk of opioids stems primarily from these
drugs, not from patients
CDC Guidelines for Chronic Pain
Benefits out way Risks/Multimodal Treatment Plan
Establish Pain and Function Goals
Shared Decision-Making and Responsibility
CDC Guidelines for Chronic Pain
Start with immediate release opioids
Use the lowest effective dose
Prescribe short courses for acute pain
Re-evaluate early and routinely
CDC Guidelines for Chronic Pain
EVALUATE Risks for HARM
Review the history of opioid use
Urine drug screening
Avoid Benozodiazapines
Offer treatment for Opioid Use Disorder
TREATMENT PLAN
Prescribing Principles
• Start low and go slow…
– BUT monitor frequently
• Increase in gradual increments
• Combine medications so doses can be decreased minimizing
side effects “rational polypharmacy”
• Choose agents that work on different points for additive or
synergistic results
• Use Scheduled pain medications rather than prn especially for
patient who are unable or unwilling to ask for medication
• Follow up and Reassess
Rational Polypharmacy: Exploiting Synergism
N Engl J Med. 2005 Mar 31;352(13):1324-34.
Provider Pitfalls in Pain Treatment
• Overemphasis on under-treatment of pain in the nursing
home can lead to
– Excessive treatment of pain that replaces pain with adverse
effects
– Nonspecific treatment without consideration of the type or
severity of pain
– Inappropriate treatment (e.g., opioids for chronic abdominal
pain)
• Patients new to long-term care need to have their pain
regimen reassessed
• If a medication is not providing any significant pain relief, a
higher dose may not be the best answer
• Older adults change over time; they may require less pain
medication as their function and physical activity decline
Interdisciplinary team
Pain assessment and management
includes all members of the IDT
• Physician/Advanced
Practice Provider
• Licensed nurses
• Nurse aides
• Therapist-physical,
occupational, speech
• Nutritionist
• Pharmacist
Common Pitfalls
• Inadequate recognition
– Pain behaviors
– Adverse effects of medication
• Communication
– Delays in provider notification
– Delays in provider response
– Dissemination of plan to the
team
• Medication procurement
– Delays due to lack of a written
prescription
– Delays due to formulary issues
– Delays due to allergy resolution
Buhr GT. White HK. Quality improvement initiative for chronic pain assessment and
management in the nursing home: a pilot study. J Am Med Dir Assoc 2006;7(4):246-
Case Study
- It will take time to gather more history about the location, quality, frequency
and intensity of Mr. S’s pain. He may have more than one type of pain. It may
require additional diagnostic testing to determine the etiology of his pain and
the interventions that may help to alleviate it.
- For example, X-rays may reveal bone metastases that would be amenable to
radiation. The physician should include the patient, nurses, therapists and
family in a collaborative plan of care. In addition to an array of pharmacologic
and non-pharmacologic interventions, it will be important to outline the plan
for continued assessment both by the nursing staff and you to determine
response to these interventions and make further adjustments.
Resources
www.geriatricpain.org
The Geriatric Pain website was created to provide nurses who work in long-term care
environments with access to free best-practice pain assessment tools and resources
to help manage pain in older adults, including quality improvement processes
focused on pain management. The web site is made possible by generous funding
from The Mayday Fund. Additional support was provided by The University of Iowa,
Golden Living and in part by a grant from the RWJ Executive Nurse Fellows program
http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinic
al_guidelines_recommendations/2009/
AGS Clinical Practice Guideline:
Pharmacological Management of Persistent Pain in Older Persons (2009)
Consultant Pharmacist—Utilizing your pharmacist can be a effective way of engaging
the team in pain assessment and management.
AMDA Pain Management in the Long Term Care Setting Clinical Practice Guideline–
This guideline provides the framework for a team approach in nursing facilities
References
Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain
Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc 2003;4(1):9-15
Chan S et al. Evidence-based development and initial validation of the Pain Assessment Checklist
for Seniors with Limited Ability to Communicate-II (PACSLAC-II). The Clinical Journal of
Pain 2014;30(9):816-24
Ballantyne JC & Sullivan MD. NEJM 2015;373(22):2098-99
Dubinsky et al. Neurology 2010;74;173-176
Khadilkar A et al. Cochrane Collaboration, 2008, DOI: 10.1002/14651858.CD003008.pub3
Vickers AJ et al. Archives of Internal Medicine. 2012;172:1444-53
Furlan AD et al. Cochrane Collaboration, 2005 DOI: 10.1002/14651858.CD001351.pub2
Manheimer E Cochrane Collaboration, 2010 DOI: 10.1002/14651858.CD001977.pub2
Weiner DK et al. Pain 2008;140:344-57.
Weiner DK & Schmader KE. Pain Med 2006;7(3):243-9
Keefe FJ et al. Br J Anaesthesia 2013;111:89–94
Dixon KE et al. J Pain Sympt Manage 2007;26:241–50
References
Hoffman BM et al. Health Psychol 2007;26:1–9
Eccleston C, et al. Cochrane Collaboration 2009; CD007407.
Cipher DJ, et al. Clin Gerontol 2007;30:23–40.
Cook AJ. J Gerontol B Psychol Sci Soc Sci 1998;53:51–9.
Derry S. Cochrane Collaboration 2012;9:CD010111. doi: 10.1002/14651858.CD010111.
Derry S. Cochrane Collaboration 2013;2:CD007393. doi: 10.1002/14651858.CD007393.pub3
Dowell D, et al. Opioid analgesics: risky drugs not risky patients. JAMA 2013; 309(21); 2219-20.
Chou R, et al. The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain. Ann Intern Med
2015;162(4):276-86.
AGS Panel on Pharmacological Management of Persistent Pain, JAGS 2009;57:1331-1346
British Geriatrics Society Guidance on the Management of Pain in Older People, Age and Ageing
2013;42:i1–i57
Husebo BS et al. BMJ 2011;343:d4065
Apfel CC et al. Pain 2013;154:677–689
N Engl J Med. 2005 Mar 31;352(13):1324-34.
Buhr GT. White HK. Quality improvement initiative for chronic pain assessment and management in the
nursing home: a pilot study. J Am Med Dir Assoc 2006;7(4):246-53.
Post-Test
• Same as pretest