“Pain Management Basics”

1. “Pain Management Basics” Maggie Buckley, MBA Patient Advocate With Special thanks to: Micke A. Brown, BSN, RN, Director of Advocacy American Pain Foundation

2. Albert Schweitzer “We must all die. But that I can save (someone) from days of torture, that is what I feel as my great & ever new privilege. Pain is a more terrible lord than even death itself”

3. What is Pain? • Pain is: • Biological “red flag” • COMPLEX • SUBJECTIVE • UNIQUE to every individual • Pain is NOT: • just a symptom • meant to “build character”

4. The Pain Experience • Common to most people • Remains a medical research challenge • Most frequent problem reported during hospital admissions • Significant undertreatment in minorities, women, children, and elderly

5. Medical Management of Pain • Strongly influenced by professional ethics, attitudes, and philosophies • Neurological Construct: • sensation perception due to neuroanatomical or physiological disorder; the unexplained is “psychiatric in origin” • Psychological Concept: • sensation with complex set of modulatory influences from emotional, environmental & psychophysiological factors

6. Specialty Definition • Pain is “an unpleasant sensory & emotional experience associated with actual or potential damage or described in terms of such damage”. (IASP, 1979) • Pain is “whatever the experiencing person says it is, existing whenever the person says it does”. (McCaffery, 1968)

7. COMMON MISCONCEPTIONS • Clinician • Educational deficits • Undermedication • Failure of adequate pain assessment • “Cookbook” therapies • Overestimation of risks • Patient • Regulatory agencies

8. PAIN TYPES • ACUTE • Duration of less than 3-6 months (6 week average healing time) • ANS (stress) response; initial effect until adaptation • Acute injury cascade (flare, wheal, hyperalgesia); strong neurohormonal effects

9. PAIN TYPES • CHRONIC (Benign) • Duration of greater than expected healing time; greater than 6 months • ANS usually depleted; psychological impact from prolonged suffering

10. PAIN TYPES • Combination: • Malignant (Cancer) • HIV/AIDS • Sickle Cell Disease • RA/OA • Diabetes Mellitus • Fibromyalgia • Ehlers-Danlos Syndrome

11. Common Types of Chronic Pain • Arthritis • Cancer (tumor or treatment-related) • Chronic Low Back • Headache • Neurogenic (Nerve pain disorders) • Psychogenic (Centralized)

12. Pain Transmission • Receptor cells: • Heat, cold, light touch, pressure • PAIN • Majority sense pain; minority sense cold • Injury stimulates chemical release: signals with use of “neurotransmitters” • Substance P, Prostaglandin's • Endorphins “morphine-like, Enkephalins “in the head”

13. Pain Transmission • Sensory pathways from nerve fibers -> spinal cord -> brain centers • All or nothing principal • Many opportunities to block pain before interpretation

14. PAIN ASSESSMENT • Clinical Practice Guidelines • “The FIFTH vital sign” • Assessment Tools • Numeric Scale (0-10) • Faces Scale • Intensity Rating (mild, moderate, severe) • Activity/Function Rating

15. Keep a Pain Diary • Keep a small notebook or tape recorder • Write what you need to write, do not worry about grammar or style • If too painful to write, have someone you trust help • Include: where it hurts, when it hurts, how it hurts • Plot relief measures & how the pain changes • Document effects of any medications good &/or bad • Add sleep, diet, work & pleasure interruptions

16. What to report • Location & movement of pain • When occurs, how long it lasts, predictability • How does it feel? Does it always feel the same? • Describe the sensations: • Sharp, dull, pressure, pulling, stabbing, burning

17. What to report • Is sleep interrupted? • Is your mood changed by the pain? • Is your appetite affected? • What makes it better? Worse? • What DO YOU think is the cause? • Have you tried to relieve the pain? HOW? • WHAT IS YOUR GOAL FOR RELIEF?

18. Drug Acetaminophen NSAID’s (Cox2) Opioids Steriods Tricyclic Antidepressants Muscle Relaxants Steroids Anticonvulsants Non-Drug Physical Psychosocial Sensory Pain Therapies

19. Non-Drug: Physical • Chiropractic maneuvers • Acupuncture/Acupressure • Reconditioning Program (PT/OT) • TENS • Pool therapy • Yoga; Tai Chi • Therapeutic Massage • Touch Therapy • Thermal Techniques • Counter-irritants

20. Non-Drug: Psychosocial • Relaxation & Breathing • Reframing (somatic re-education) • Biofeedback • Imagery: meditation, prayer, hypnosis • Walking meditation • Group ‘talk” therapies • Positive “self” talk

21. Non-Drug:Sensory • Aromatherapy • Nutrition: herbal, organic • Homeopathy • Art therapy • Music therapy • Humor therapy • Visualization

22. Where to go for help • Primary healthcare professional • Address acute problem if new onset • Active listener • Holistic approach • Specialist • Neither dismissive nor indulgent • Pain Specialist • Multi-disciplinary approach

23. External Resources • American Pain Foundation www.painfoundation.org • American Society of Pain Management Nurses www.aspmn.org (800) 34-ASPMN • International Association for the Study of Pain www.iasp-pain.org

24. Consumer-focused Resources • American Chronic Pain Association www.theacpa.org (916) 632-0922 • American Pain Society www.ampainsoc.org (708) 966-5595 • American Academy of Pain Management www.aapainmanage.org • UC Davis Division of Pain Medicine www.ucdmc.ucdavis.edu/pain/

25. Consumer-focused Resources • Dr. Andrew Weil www.pathfinder.com/drweil • NIH Complementary & Alternative Medicine Division www.nccam.nih.gov • National Headache Foundation www.headaches.org • National Fibromyalgia Association www.fmaware.org • CFIDS Association of America www.cfids.org • RSDS/CRPS Support Association www.rsdsa.org

26. The Q Factor