Implementation of Pain Management Standards 2009 Adapted from The - PDF document

Implementation of Pain Management Standards 2009 Adapted from The OSUMC Learning Resource System for The Medical Staff, The Ohio State University Medical Center, June 10, 2009, by Steven A. Severyn, MD, MBA Michael D. Adolph, MD Assistant Prof., Clinical Assistant Prof., Clinical Anesthesiology Palliative Medicine Learning Objectives � Recognize patient’s right to pain control � Evaluate pain screening tools across age spectrum � Assess techniques to identify various levels of pain and the appropriate intervention to address it � Provide education to the health care team on how to individually treat pain � Develop an interdisciplinary team to overview pain management from an institutional perspective � Identify risks involved for the patient and physician in the prescription of specific medications to control pain Implementation of Pain Management Standards 2009

Are our patients pain-free? It has been estimated that 11% of U.S. adults experience chronic non-cancer related pain. Just over half report that their pain is under control. (APS. (1999) Chronic Pain in America: Roadblocks to Relief.) In a published review of 53 studies (over 9000 patients) on the effectiveness of post-operative pain management, unrelieved moderate to severe pain was reported by the following: 66% of patients receiving IM pain medication 36% with PCA 21% with epidurals (Dolin, S. et al. (2002) Effectiveness of acute postoperative pain management: I. Evidence from published data. British Journal of Anesthesia 89 (3): 409-23.) Implementation of Pain Management Standards 2009 Why Do Patients Experience Unrelieved Pain? The most common reason for unrelieved pain in U.S. hospitals is the “failure of staff to routinely assess pain and pain relief.” in American Pain Society (1999). Principles of Analgesic use in the Treatment of Acute Pain and Cancer Pain, 4th edition. Uncontrolled pain interferes with: � Sleep � Immune System � Healing � Appetite � Daily Activities Implementation of Pain Management Standards 2009

Barriers to Effective Pain Management The Agency for Healthcare Research and Quality (1994) identified 3 main problem areas inhibiting effective pain management: � Health Care System � Health Care Providers � Patients Implementation of Pain Management Standards 2009 Barrier: Health Care System � Pain has not been recognized as an organizational priority � There has not been a focus on the joint responsibility across the spectrum of health care providers to assess and relieve pain. � There is a lack of recognition of the dangers of pain and the benefits of pain control for hospitalized patients which include reduction in complications and decreased length of stay. Implementation of Pain Management Standards 2009

Barrier: Health Care Provider � Lack of knowledge of evidence based pain control methods. � Inadequate pain assessments. � Misconceptions about opioid use and addiction potential. � Concern about administering pain medication to a patient who doesn’t really need it Resources Treatment of Cancer Pain, OSUMC Clinical Practice Guideline 2002 Agency for Healthcare Research and Quality, National Guideline Clearinghouse www.guideline.gov American Pain Society – Quality Improvement Guidelines for the Treatment of Acute Pain and Cancer Pain Clinical Practice Guideline for the Sustained Use of Sedatives and Analgesics in the Critically ill Adult. 92202) Critical Care Medicine (30), 1:119-141 International Association for the Study of Pain Implementation of Pain Management Standards 2009 Barrier: Patients � Attitudes (positive, negative) about use of analgesics, especially narcotics � Concern (or lack of concern) about addiction � Belief that acute and chronic pain cannot be relieved, and that pain is inevitable � Belief that acute and chronic pain can always be relieved, without compromising any other aspect of care Implementation of Pain Management Standards 2009

Barrier: Patients (continued) Patients with pain have the following rights: � to have their reports of pain accepted and acted on by health care professionals. � to have their pain controlled, regardless of cause or severity. � to be treated with respect at all times - and not as a drug abuser. Source: McCaffery and Pasero(1999). Pain:Clinical Manual. Implementation of Pain Management Standards 2009 Definitions of Pain “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” Mersky in Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. IASP(1979) “Pain is whatever the experiencing person says it is, existing whenever he says it does.” Margo McCaffery, 1968 Implementation of Pain Management Standards 2009

Types of Pain: Nociceptive Somatic - usually arises from bone, joint, muscle, skin, or connective tissue. Pain stimuli are from somatic Usually localized, or visceral structures. aching or throbbing. Visceral - arises from visceral organs, such as the GI tract. May be dull, diffuse, and referred to other sites. Usually not well localized. Source: McCaffery and Pasero (1999) Pain Clinical Manual Implementation of Pain Management Standards 2009 Types of Pain: Neuropathic Centrally generated - Results from abnormal � Associated with injury to the processing of sensory input peripheral or central nervous by the peripheral or central system. i.e. phantom pain nervous system. � Associated with abnormal activity of the autonomic nervous system - i.e. complex regional pain syndrome Peripherally generated Peripheral neuropathies (i.e. diabetic neuropathy; chemotherapy - associated; trigeminal) Source: McCaffery and Pasero (1999). Pain: Clinical Manual Implementation of Pain Management Standards 2009

Transduction When tissue damage occurs, the damaged cells release substances that activate nociceptors, generating an action potential . McCaffery and Pasero (1999). Pain:Clinical Manual Implementation of Pain Management Standards 2009 Transmission Occurs in three phases: � Injury site to spinal cord � Spinal cord to brain stem and thalamus � Thalamus to cerebral cortex McCaffery and Pasero (1999). Pain:Clinical Manual Implementation of Pain Management Standards 2009

Modulation Inhibition of transmission of nociceptive impulses by release of substances such as serotonin from the CNS through the spinal cord neurons. McCaffery and Pasero (1999). Pain: Clinical Manual Implementation of Pain Management Standards 2009 Tolerance � Tolerance means that “a larger dose of opioid analgesic is required to maintain the original effect.” APS, 1999 � Common in patients on chronic opioid analgesics � First sign may be a decrease in the duration of effective analgesia. � Tolerance may be delayed and analgesia continued by: – combining opioids with nonopioids – switch to an alternative opioid, selecting a lower starting dose McCaffery and Pasero (1999). Pain: Clinical Manual Implementation of Pain Management Standards 2009

Physical Dependence � Demonstrated in patients taking chronic opioids with an “abstinence syndrome” or withdrawal that occurs following abrupt discontinuation or administration of an opioid antagonist. APS, 1999 � Symptoms: anxiety, irritability, chills/ hot flashes, nausea, vomiting, abdominal cramps, diaphoresis, rhinorrhea. � Duration of abstinence syndrome is dependent on half life of the opioid. � Prevention: Slow withdrawal of chronically used opioids. McCaffery and Pasero (1999). Pain: Clinical Manual Implementation of Pain Management Standards 2009 Addiction � Defined as “a pattern of compulsive drug use characterized by a continued craving for an opioid and the need to use the opioid for effects other than pain relief.” APS 1999 � Most patients who take opioids several times daily for more than a month develop some tolerance or physical dependence. This is not an addiction. � Some patients may have an increased need based on a history of substance abuse, abnormal illness behavior, or other factors. � The fear of addiction should NOT be a primary concern in treating acute pain or cancer pain. McCaffery and Pasero (1999). Pain: Clinical Manual Implementation of Pain Management Standards 2009

Assessment of Pain Priorities The presence and severity of the pain are always what the patient tells you. First : Ask patients about their pain. Then: Record and intervene , based on what they tell you. Implementation of Pain Management Standards 2009 Case Example Case Example : The answer is yes. Research has demonstrated that: Female patient - age 56, 1 day post-op knee � A pain rating of 4-5 may significantly replacement - is visiting interfere with function. A rating of 6 or with family, laughing and above may indicate a need for talking. immediate intervention; � Patients behavioral and physiological When you ask her to rate responses to moderate to severe pain her pain, she tells you it is often adapt over time and may become an 8. minimal. Does she need pain medication? Source: McCaffery, Pasero (1999) Pain Clinical Manual Implementation of Pain Management Standards 2009