Treating Pain: Modalities, Opportunities and Safe Opioid Use

1. Treating Pain: Modalities, Opportunities and Safe Opioid Use

2. Learning Objectives • Begin to understand pain, pathophysiology and clinical implications • Provide a framework for assessment, diagnosis and treatment planning for pain management • Engage with members of the health care team to evaluate opportunities and outcomes of pain interventions

3. Pain: Fact or Fiction Positive thinking about pain can reduce pain-related activity in the brain

4. Pain: Positive Thinking Fact • Thinking positively can be an important part of managing chronic pain • Researchers found that what people think can affect their pain • People who expect less pain may feel less pain • Intense feelings of love can also provide pain relief similar to the effects of painkillers, according to a Stanford study

5. Pain: A Practical Primer

6. Pain: A Definition Pain defined: • “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Pain is: • “A subjective and entirely individual personal experience influenced by learning, context and multiple psychosocial variables” • Definitions from the International Association for the Study of Pain

7. Pain: A Personal Experience • Pain is whatever the experiencing person says it is, existing whenever and wherever the person says it does. • Margo McCaffery, RN, MS, FAAN 1968

8. Pain: A Very Personal Experience • People have to feel the pain, share it with others and then tuck it in a pocket to carry it with them forever.  • Steve Hartman, CBS News, “Vietnam veterans honor a fallen soldier 50 years later” (19 July 2019)

9. Fundamental Principles of Pain Management • Pain is an experience that cannot be separated from a patient’s mental state, environment or cultural background • Pain is complex and therefore requires a structured patient assessment to determine the cause and triggers • Assessment of pain and documentation of the effectiveness of any intervention are fundamental to successful pain management • Both non-pharmacological and pharmacological treatments should be used to minimize the patient’s experience of pain • The adverse effects of unrelieved pain can be physiological, emotional, spiritual, economic and socio-cultural, affecting every part of a patients well-being • There is no physical, imaging, behavioral or laboratory test that can identify or measure pain • Until now?

10. New Research: Blood Test Acts as an Objective Pain Measure • Dr. Alexander Niculescu, Indiana University School, discusses the results of a pain blood test in a July 2019 study: • The team found pain markers in the blood that act like pain fingerprints • The pain fingerprints are in different quantities in the blood when patients are in pain • Eventually, providers could use the information to pinpoint precise pain treatments

11. New Research: EEG Acts as an Objective Pain Measure • Dr. Carl Saab, Brown University, discusses the results of an electroencephalography-based test to objectively measure pain in a November, 2018 study: • The team reported the pain in rodents can be determined by looking at brain waves called “theta” waves • The theta waves increased in rodents experiencing mild pain and decreased when the rodents were given a clinical dose of the painkiller Lyrica

12. New Research: Nonpharmacologic Research • According to the American Pain Society there are: • “Advances in nonpharmacologic treatments that activate endogenous pain modulatory systems with minimal adverse effects” • Examples: • Transcranial magnetic stimulation • Direct current stimulation • Neurofeedback can help train patients to directly control their own pain

13. Potential Clinical Impact • Dr. Niculescu and Dr. Saab both believe their research could eventually have a significant impact on the treatment of pain and the nation’s opioid crisis: • “Given the massive negative impact of untreated pain on quality of life, the current lack of objective measures to determine appropriateness of treatment, and the severe addiction gateway potential of existing opioid-based pain medications, the importance of approaches such as ours cannot be overstated.” • Alexander Niculescu • “We want to help patients with chronic pain and their physicians get into agreement about pain level so it is better managed and diagnosed, which may reduce the over-prescription of opioids.” - Carl Saab

14. Pain: Classifications

15. Pain Classification: Duration • Acute Pain • Less than three months duration • Chronic Pain • More than three months duration • Acute-on-Chronic Pain • Acute pain flare superimposed on underlying chronic pain

16. Pain Classification: Physiology • Nociceptive Pain • Normal response to an injury of tissues • Neuropathic Pain • Pain caused by a primary lesion or disease in the somatosensory nervous system • Inflammatory • Activation and sensitization of nociceptive pain pathway by a variety of mediators released at a site of tissue inflammation

17. Pain: Nociceptive and Neuropathic

18. Pain: Types of Pain

19. Structural Remodeling Sensitization CNS Neuroplasticity Hyperactivity Peripheral Nociceptive Fibers Peripheral Nociceptive Fibers Sustained currents Transient Activation Sustained Activation Long-Term Consequences of Acute Pain: Potential for Progression to Chronic Pain Surgeryorinjurycausesinflammation CHRONIC PAIN ACUTE PAIN

20. Pain: Quick Quiz The essential feature of pain that can be used to differentiate it from other somatic sensations is its: • Intensity • Threshold • Chronicity • Unpleasantness

21. Pain: The Assessment

22. Pain Assessment: Best Practices “Lack of proficient and uniform pain assessment is one of the most challenging barriers in achieving adequate pain control” • Diane Glowacki, RN, MSN, CNS, CNRN-CMC

23. Pain Assessment: Best Practices • Recognize a patient’s perception of pain, previous experiences with pain, current knowledge of pain, spiritual and religious beliefs and sociocultural components • Scheduled, routine screening for all assessments • Designate minimum frequency • Document clearly and consistently to facilitate tracking • Levels of pain that trigger assessment and intervention/planning • Scheduled reassessment for efficacy • Plan based on individual needs and assessment

24. Pain Assessment: An Option A = ask regularly, assess systematically, use standard rating scale B = believe the patient’s report of pain C = choose best treatment options D = deliver interventions in coordinated, timely manner E = evaluate effectiveness and reassess

25. Pain Assessments: Evidenced Based Choices

26. Pain Assessment: More to Consider Objectives: • Evaluate, select and use valid, reliable tools appropriate to the needs of the individual • Be aware of language, cognitive ability, age, culture and disability factors • Assess all aspects of pain: sensory, cognitive, cultural, behavioral, affective • Genetic, age and gender differences may be seen • Know vulnerable populations: infants and children, elderly, racial and ethnic groups, people with current or past history of substance abuse/addiction • Cognitively impaired, non-verbal persons

27. Pain Assessment: Common Misconceptions A comprehensive approach to pain assessment includes evaluating the patients beliefs about pain and treatment: • Pain is a part of my life… I just need to live with it • I shouldn’t take my pain medication until I really need it or else it won’t work later • I don’t want to become an addict • I don’t want to get constipated so I’d better not take my pain medication • I don’t want to bother the doctor or nurse; they’re busy with other patients • My family thinks I get confused on pain medication; I’d better not take it • Discussing misconceptions: • Helps legitimize patients’ concerns • Provides an opportunity to educate patients and families about pain medications and how they work

28. A Word About Non-Verbal Persons • Observe behavioral changes • Understand the baseline behavior/function • Solicit input from family members and caregivers for help about person’s behavior or unusual vocalizations • Understand if the situation is typically painful (bone marrow biopsy) it would be the same for the non-verbal person • Use of visual aides or having the person write their responses may be useful • Talk with person, they may understand even if they cannot verbalize

29. Pain: Barriers to Assessment • Patient and family attitudes and knowledge • Health care providers’ attitudes and knowledge • Health care system and access to care • Regulatory concerns • Patient safety • Patient’s reluctance to report pain • Fear of meaning of pain • Fear of addiction

30. Pain: Barriers to Assessment • Belief that pain is inevitable or deserved • Negative experiences and attitudes about analgesics • Fear of distracting health care team from treating the disease • Belief that pain cannot be managed • Negative attitudes about pain and time constraints of provider • Respiratory depression, adverse reactions

31. Pain: Treatment Planning

32. Pain: The Goal and the Expectation • Care Team Goal: • Get rid of all your pain? • Make you forget you have pain? • Decrease your pain and improve your function! • Patient Expectation: • Decrease my pain and improve my function? • Make me forget I have pain? • Get rid of my pain! What is the best way to align the care team goal and the patient expectation?

33. Pain: Treatment Goals Alignment: Care Team and Patient • Early intervention and assessment • Prevention if possible • Prompt adjustments in therapy for poorly controlled pain • Reduce pain to acceptable levels • Facilitate recovery from injury, surgery or disease • Minimize pharmacologic side effects • Prevent development of chronic pain

34. Pain: Setting Realistic Goals • Reduce pain, improve comfort short, long term and improve quality of life • Maximize medications for effect and minimize side effects • Improve strength endurance • Improve psychological status • Discharge patient in better health than upon admission • If patient is discharged on opioids, ensure proper education, provide resources about concepts of dependence, addiction and tolerance • Engage the case management team to schedule appropriate follow-up appointments prior to discharge

35. Pain: Essentials of Successful Treatment • Understand pain through the eyes of the patient • Take time for a comprehensive pain assessment: • History and physical • Previous treatment • Psychosocial concerns • Past pain history • Comorbidities • Family history of addiction or pain challenges • Listen for common misconceptions about pain, treatment or fears • Engage patient in developing pain treatment plan • Ask the patient about a personal recovery goal

36. Pain: Multimodal Treatment Options Pharmacotherapy: ALTOs - check nonopioid therapies in the Pain Pathways Opioids Interventional Approaches: Injections Neurostimulation Physical Medicine and Rehabilitation: Assistive devices Electrotherapy Strategies for Pain: Acute, Chronic, Acute-on-Chronic Psychological Support: Psychotherapy group support Complementary and Alternative Medicine: Massage Supplements Lifestyle Change: Exercise/weight loss

37. Pain: Treatment Strategy Multimodal Options: • Pharmaceutical • ALTOs first choice • Society of Hospital Medicine Pain Pathways • Opioids as a rescue drug • Nonpharmaceutical Options: • Therapies • Rehabilitation • Integrative therapies • Psychological • Spiritual • Vocational • Occupational interventions • Education for patient and family

38. Pain: Treatment Close Treatment comes to a close when: • Goals are met in the eyes of the patient • Treatment plans have not worked in spite of changes in plans • Other treatments may be used in its place • Patient is unable or unwilling to participate in meeting goals • Treatment goals are not met, are not considered achievable and/or the maximum possible progress toward those goals has been accomplished • Patient needs referral to another care provider • Suspected substance use disorder • Suspected behavioral health disorder • Comorbidity

39. Groups At Risk for Poor Pain Control/Management • Infants and children • Elderly • Racial and ethnic groups • Women • People with current or past history of substance abuse/addiction • Cognitively impaired, non-verbal people

40. Pain: Fact or Fiction Growing pains are real

41. Pain: Growing Pains Fact • Doctors think about 20% of children aged two to 12 have mild to severe pain in their legs at night • Although these pains are commonly called “growing pains,” that's a little misleading since growth itself doesn’t hurt • The leg pain could be a sign of overused muscles • Some children who have these pains might be more sensitive to pain

42. Take Home Points • Pain is best treated with a combination of pharmacologic and non-pharmacologic strategies • Pain is a complex response requiring proper assessment and management • Pain is more than a sensory experience having affective, cognitive, sociocultural and spiritual dimensions • Pain management can be optimized when each patient is thoroughly assessed, reassessed and engaged in treatment planning • Consider patient preferences when selecting treatments and adapt for age, cultural considerations and developmental stage • Recognize there are pain specialists and recourses to determine the best course of treatment • Check the Society of Hospital Medicine Pain Pathways for treatment guidelines

43. References • Cox S. (2010) Nursing Standard. Basic Principles of Pain Management: assessment and intervention. (Vol 25, Issue 1). Retrieved from: https://pdfs.semanticscholar.org/e7e6/423e73ce5696e2a2f1e2596258736fb2f486.pdf • Dmitry, A.M., Fleming, A., (2019, April). Pain Assessment: Review of Current Tools. Practical Pain Management. Retrieved from: https://www.practicalpainmanagement.com/resource-centers/opioid-prescribing-monitoring/list-clinically-tested-validated-pain-scales • Fink. R. (2000, July). Pain assessment: the cornerstone to optimal pain management. Baylor University Medical Center Proceedings, 38 (3), 236-239. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1317046/ • Gereau IV, R. W., Sluka, K. A., Maixner, W., Savage, S. R., Price, T. J., Murinson, B. B., Sullivan, M. D. … Fillingim, R. B. (2014, December). The Journal of Pain 12: 1203-1215. http://americanpainsociety.org/uploads/about/positionstatements/APS_Pain_Research_Agenda_White_Paper.pdf • Hartman, S. Vietnam veterans honor a fallen soldier 50 years later. (2019, July 19). CBS News. Retrieved from:. https://www.cbsnews.com/news/vietnam-veterans-honor-fallen-soldier-leonard-nitzsche-50-years-later-2019-07-19/ • International Association for the Study of Pain: https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698 • Macintyre PE, Schug SA. (2007) Acute Pain Management." A Practical/Guide. Third edition. Saunders Elsevier, Edinburgh. • McCaffery M. (1972) Nursing Management of the Patient with Pain. Lippincott, Williams & Wilkins, Philadelphia, PA. • Miller, F. H., Choi, M. J., Angeli, L. L., Harland, A. A., Stamos, J. A., Thomas, S. T., . . . Rubin, L. H. (2009). Web site usability for the blind and low-vision user. Technical Communication, 57, 323-335.

44. References continued • National Pharmaceutical Council, INC, Joint Commission on Accreditation of Healthcare Organizations. (2001, December). . Barriers to the Appropriate Assessment and Management of Pain. Pain: Current Understanding of Assessment, Management, and Treatments. (15-16). Retrieved from: https://www.npcnow.org/system/files/research/download/Pain-Current-Understanding-of-Assessment-Management-and-Treatments.pdf • Niculescu, A. B., Le-Niculescu, H., Levey, D. F., Roseberry, K., Soe K. C., Rogers, J., Khan, F., … White, F. A., (2019, February 12). Towards precision medicine for pain: diagnositic biomarkers and repurposed drugs. Molecular Psychiatry 24:(501–522). Retrieved from: https://www.nature.com/articles/s41380-018-0345-5 • Otis, J.A., Macone, A., (2019, April). When to Use Opioids: What I Didn’t Learn in Medical School. Practical Pain Management. Retrieved from: https://www.practicalpainmanagement.com/resource-centers/opioid-prescribing-monitoring/when-use-opioids-what-didnt-learn-medical-school • Riberio-Pinho, F. A., Verri Jr., W. A., Chiu, I. M., (2017, January). Nociceptor Sensory Neuron-Immune Interactions in Pain and Inflammation. Trends Immunol. 38(1) 5-19. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5205568/pdf/nihms821842.pdf • University of Wisconsin School of Medicine and Public Health: Pain Management (2010). Retrieved from: http://projects.hsl.wisc.edu/GME/PainManagement/index.html • Waller C. (2018). Colorado Hospital Association Opioid Safety Summit: The Addiction Treatment Ecosystem. • Wilensky, B. Adapted from Woolf CJ. Ann Intern Med. 2004;140:441-451. https://annals.org/aim/article-abstract/717288/pain-moving-from-symptom-control-toward-mechanism-specific-pharmacologic-management?volume=140&issue=6&page=441 • Chong MS, Bajwa ZH. J Pain Symptom Manage. 2003;25:S4-S11. • Younger J, Aron A, Parke S, Chatterjee N, Mackey S (2010) PLOS ǀ ONE “Viewing Pictures of a Romantic Partner Reduces Experimental Pain: Involvement of Neural Reward Systems. Retrieved from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0013309