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The Basics of Good Pain Control: Understanding and Assessment

The Basics of Good Pain Control: Understanding and Assessment. Dr. Leah Steinberg. On Monday you go to work:. Meet Mr. Peters 52 yr old patient with lung cancer Holding his chest “It feels like I ’ m being squeezed and it is burning” “I can’t sleep…” His wife is crying at his side….

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The Basics of Good Pain Control: Understanding and Assessment

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  1. The Basics of Good Pain Control: Understandingand Assessment Dr. Leah Steinberg

  2. On Monday you go to work: • Meet Mr. Peters • 52 yr old patient with lung cancer • Holding his chest • “It feels like I’m being squeezed and it is burning” • “I can’t sleep…” • His wife is crying at his side…

  3. Your Learning Objectives: • Appreciate the prevalence of pain in patients with advanced cancer and other medical illnesses; • Describe the basic mechanism of pain; • Define the elements of a complete pain assessment;

  4. Pain 84% Fatigue 69% Weakness 66% Anorexia 65% Dyspnea 50% Nausea 36% Delirium 21% How common are symptoms? Walsh et al, Supportive Care Cancer 2006 N= 922 patients with advanced cancer

  5. What about non-malignant illness? Congestive Heart Failure Emphysema (COPD) ALS Renal failure Advanced liver disease • PAIN • FATIGUE • ANOREXIA • DYSPNEA

  6. Objective 2: What is pain? • An unpleasant sensation – a feeling • Created by stimulation of receptors on nerve endings -- nociceptors

  7. Mechanism of pain transmission: • Cancer damages tissue • Releases neurotransmitters • Pain signal • We now know: • Cancer itself releases inflammatory mediators • Inflammatory mediators trigger pain receptors • Don’t always “see” damage on imaging; size doesn’t matter

  8. Types of pain simplified: Nociceptive pain Intact nervous system Visceral - describe? Somatic – describe? Neuropathic pain Damaged nervous system Describe? If it sounds weird…

  9. Back to Mr. Peters: Sitting in front of you, looking for help… What have we learned so far?

  10. We now know: • Common • His disease is causing pain signals • But before we know what to do for him, we need a good assessment

  11. Objective 3: How do we assess pain? • Thoughts?

  12. How do we assess pain? Physical Domain + Psychosocial Domain TOTAL PAIN

  13. Physical Domain: find etiology • Location of pain • Timing of pain • Nature (quality): ache, dull, burning, skin • Radiation of pain • Aggrevating/Relieving factors • Severity (use a pain rating scale) • Treatment so far and effect

  14. Past/current medical status • May assist or complicate assessment: Assist: Location of cancer: pain syndromes, neuropathic Complicate: Delirium, dementia, infection, renal function, chronic pain

  15. Mr. Peters: Physical Domain Now you can start asking some questions!

  16. Physical Domain: Another example • Mrs. C. presented with pain from locally advanced breast cancer -- • Her physical domain assessment: • Sharp, burning, chest wall pain • Started 4 days ago • Worse with movement of arm, dressings • Redness increased • PMH: LABC x 4 yrs, no other illnesses

  17. Mrs. C: What is her pain from? • What is our going on in this case?

  18. How do we assess pain? Physical Domain + Psychosocial Domain TOTAL PAIN

  19. Psychosocial Domain • Understanding of disease • Fears, ideas, expectations • History of depression/anxiety • Fears of opioid use • Family support/awareness • Cultural/religious factors Affects how your patient perceives and expresses his pain

  20. Mr. Peters: Psychosocial domain Now you can ask more questions!

  21. Psychosocial Domain: Another example • 90 yr old female with bony metastatic disease to manubrium (lung ca) • Clearly bone (somatic) pain • Clearly uncomfortable • Always said pain was acceptable, never wanted pain medication – family quite upset • Assessment revealed fear of sedation and confusion – therefore under expressed pain

  22. Why it is important? Or, how I understand TOTAL PAIN NOCICEPTION PERCEPTION EXPRESSION Pain receptors and neurotransmission; this is where opioids work Thalamus and cortex Psychosocial Domain

  23. Total Pain • Our patients express pain • Opioids work and they work well • But, remember, it is EXPRESSION of PAIN • If you are having trouble with managing pain with opioids, think about the other inputs…

  24. Complete Assessment • Physical understanding: • Gives you likely etiology and medical complications • Psychosocial understanding: • Gives you understanding of how your treatments will likely work and what other components you need to add to have effect

  25. Summary Prevalence of pain Mechanisms of pain First (and hardest) step in treatment: A good pain assessment Once you have that, you know the path to treatment

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