Learning Objectives
At the conclusion of this lesson, you will be able to:
• Define pain.
• Describe the four components of pain.
• Identify two tools to assess pain.
• Describe the five components used in the history and physical to describe pain.
• Describe the basic treatments for the four components of pain.
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Learning Objectives Learning Objectives Learning Objectives
To be able to define pain
To describe the 4 components of pain
To identify 2 tools to assess pain
To describe the 5 components used in the history and physical to describe pain
To describe the basic treatments for the 4 components of pain
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An unpleasant sensory or emotional experience that can be acute, recurrent or persistent
Highly subjective
No biological makers
3
Definition of Pain Definition of Pain Definition of Pain
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4 Components of Pain 4 Components of Pain 4 Components of Pain
4
Physical
Social
Total
Pain Emotional
Spiritual
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Pain Pathways Summary Pain Pathways Summary Pain Pathways Summary
Pain receptors (nociceptors) originate signals
Signals travel through peripheral nerves to spinal cord and brain
Signals gather in dorsal (back) part of spinal cord
Transmitted to thalamus and then to cerebral cortex, where pain is “felt”
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Fast Pathway
Pain receptors sense injury and release chemical messengers
Chemicals travel through very fast nerve pathways
Signals directly to thalamus and cerebral cortex
Brain identifies and sends message to react
Slower Pathway
Pain signals enter dorsal (back) part of the spinal cord
Signals transfer back and forth between nerves that regulate pain message
Signals go to cerebral cortex
Entire nervous system may be reprogrammed
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May have both acute and chronic components
Multiple simultaneous causes
Some causes may be more modifiable than others
May benefit from cause-specific and general interventions
Requires skilled clinical assessment to differentiate
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COMMUNICATION
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What are your hopes (your expectations, your fears) for the future?
What has been most difficult about this illness?
How is treatment going for you (your family)?
What makes life most worth living for you?
Given the severity of your illness, what is most important for you to achieve?
The answers can change as the illness progresses
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Ask patients about pain
At scheduled assessments and whenever change in patient status noted
Phrase as: “Does it hurt anywhere?” “Do you have any aching or soreness?”
If patient cognitively impaired, also ask questions of family members, where feasible
Observe patient for signs and symptoms that suggest pain
Nonspecific symptoms
Grimacing, agitated, restless, etc.
May have other or multiple causes
Pain Assessment Scales
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Pain Assessment Scales Pain Assessment Scales Pain Assessment Scales
Partners against pain.com
Visual Analog Scale
Number Pain Intensity Scale
Simple Descriptive Pain Intensity Scale
Graphic Rating Scale
Verbal Rating Scale
Pain Faces Scale
Numeric Pain and Pain Distress Scale
Brief Pain Inventory
Dosage and Frequency of Pain Medications
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Epigastric, Right Upper Quadrant or Suprapubic
Cramping, Burning, Gnawing
Does the pain move anywhere or does it stay in one spot
Constant or Intermittent Scale of 1 to 10;
Worsening or Improving
When did the pain start?
How long does it last?
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Abdominal Pain (cont.) Abdominal Pain
Abdominal Pain (cont.)(cont.)
Aggravating
What makes it worse?
Alleviating Factors
What makes it better?
Dosage and Frequency of Pain Medications
How often are you taking pain medications, if any?
Natural remedies
Hot water bottle
A practitioner may need to evaluate patient to:
Get details of symptoms
Review existing diagnoses and conditions that may cause or contribute to pain
Discuss with family members and other members of interdisciplinary team
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In end-of-life patients, try to identify most likely causes using clinical evaluation instead of diagnostic testing
Often, careful review of symptom details and likely causes will → best possible approach
Review current medications as possible causes
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Summarize characteristics and causes of patient's pain
Assess impact of pain on individual
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Depression Dyspnea Constipation
Nausea Anxiety Delirium Anorexia/Cachexia
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Symptoms (cont.)
Symptoms
Symptoms (cont.)(cont.)
Symptom Assessment Treatment
Depression NOT normal
SIGECAPS
Psychostimulants (e.g. Ritalin)
SSRI (e.g. Paxil)
NO TCAs (Elavil)
Dyspnea Cause
Symptoms (cont.)(cont.)
Symptom Assessment Treatment
Nausea Medication
Delayed Gastric Emptying
Symptoms (cont.)(cont.)
Symptom Assessment Treatment
Is patient troubled by it?
Medications (e.g.
dexamethasone,
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Symptoms (cont.)
Symptoms
Symptoms (cont.)(cont.)
Symptom Assessment Treatment
Delirium Cause (e.g.
Electrolytes,
Oxygen dependency + dyspnea + history of chronic obstructive pulmonary disease (COPD) = impaired gas exchange
Impaired gas exchange → chest pain
Antidepressant + antinausea medication +antisecretion medication + antianxiety agent = adverse drug reaction (ADR)
ADR → severe intestinal ileus
Severe ileus → abdominal pain
Abdominal pain → narcotic analgesic
Narcotic analgesic → more ileus
More ileus → more pain → miserable death
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Questions
What is prognosis?
What are overall goals for this individual?
How will specific treatments and services help achieve those goals?
Goals should be:
Specific for that individual
Relevant to underlying causes and risk factors
Otherwise, hardly better than guesswork!
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Discuss findings and develop treatment plan with physician, interdisciplinary team, patient and family
Identify patient's preferences, wishes and goals
Consider complementary (nonpharmacologic) treatments
Prescribe appropriate medications
Where relevant, address underlying causes
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Objective
Develop or refine plan to address relevant issues and problems
Based on recognition of causes and consequences
Identify specific roles/responsibilities of various individuals and disciplines
Care plan should be
Specific for that individual
Relevant to underlying causes and risk factors
Otherwise, hardly better than guesswork!
Relieve low back pain due to muscle spasms by repositioning more frequently and applying heat
Reduce abdominal pain due to ileus by reducing medications affecting GI motility
Relieve left shoulder pain due to osteoarthritis by giving acetaminophen and anti-inflammatory medication
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Relieve back pain by giving pain medications
Treat abdominal pain by increasing MS-Contin, Haldol, Reglan, etc.
Give Duragesic patch for left shoulder pain
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Important to incorporate both nonpharmacologic and pharmacologic Approaches
Provide a comforting, supportive environment
General comfort measures may reduce need for high analgesic doses
Don’t do harm while trying to do good – evaluate the risks of benefits of all interventions
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Intervention Details
Rehabilitation/physical therapy
Can improve stretching, strengthening,&
mobility
Massage Family members can be taught Many hospice programs have trained, certified massage therapists Transcutaneous/
percutaneous nerve stimulation
Evidence of support with persistent low back and knee pain
Acupuncture Popular therapy for cancer and other end stage pain
Studies showing benefits on COPD, dyspnea, asthma
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Patient’s underlying diagnosis and co-existing conditions
Past patient experience with therapy
Availability of skilled, experienced providers
Patient or advocate preferences
Advance directives
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Non-Opioids
Acetaminophen
NSAIDs
Topical analgesics
Opioids
Adjuvant Analgesics
Disease Modifying Therapies
Relieving symptoms more important than treating causes
But cause-specific pain management may be more beneficial with fewer side effects
Side effects don’t matter
But they often do
May be as unpleasant or problematic as pain
May prevent individual from spending quality time at end of life
Pain management is desirable
It is, but it’s a means to an end
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WHO’s Pain Relief Ladder
Pain persisting or increasing Opioid for mild to moderate pain +/- Non-Opioid
+/- Adjuvant Non-opioid +/- Adjuvant Pain persisting or increasing
Freedom from Cancer Pain Freedom from Cancer Pain Freedom from Cancer Pain Opioid for moderate to severe pain +/- Non-Opioid
Acetaminophen: 1stchoice in those without significant liver disease or ETOH intake
Example: 500 or 650 mg q4h 8AM–8PM and q4h PRN 8PM–8AM
Topical agents: possible additional relief for those with musculoskeletal, neuropathic pain
Counterirritants (e.g., menthol, methylsalicylate, trolamine salicylate): Supplied as liniments, creams, ointments, sprays, gels or lotions
Can cause skin injury, especially when used with heat or with an occlusive dressing
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Non-Steroidal Anti-Inflammatory drugs (NSAIDs)/ Cyclooxygenase-2 (COX-2) inhibitors
Risk in frail elderly: GI bleeding and renal impairment
“Ceiling effect”: point after which increasing dose offers no additional pain relief and may produce added side effects
Frequency of more serious side effects
Tramadol
Centrally acting analgesic
May be added to NSAIDs or acetaminophen
Watch for drug-drug Interactions
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Combining smaller doses of drugs from different classes
If maximizing acetaminophen dosage fails to achieve pain relief
May reduce risk of side effects associated with higher doses of a single medication
Add an opioid
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Discontinue/transition from a mixed opioid to a pure opioid
Opioid analgesics gaining wider acceptance as an important component of comfort care
Examples: Codeine, oxycodone, hydrocodone, morphine and fentanyl: commonly used opioids
When starting patient on opioids, begin with immediate-release preparation
After establishing amount needed daily to control pain, convert daily dose to sustained-release preparation given routinely every 12 hours
May still need doses of immediate-release drug for
“breakthrough” pain
About 10% of daily dose may be as often as every 1 to 2 hours PRN for breakthrough pain
Transdermal patch another option for patients requiring around-the-clock pain control for moderate to severe pain
Administer opioids at regular intervals rather than PRN
Use bowel regimens to avoid constipation
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Opioids that should be avoided in the elderly:
Meperidine
Propoxyphene
Mixed Opioid Antagonists
For instance, Pentazocine
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Medications with a primary indication other than pain that have analgesic properties
Examples:
Individualize administration of medications to meet patient needs
Identify events or activities that may exacerbate pain
Medication may be more effective if given before such activities
Use regular notPRN (as needed) administration if
Frequent PRN use for relief
Pain persists with PRN approach
Use least invasive route of administration first
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Begin with low dose
Reassess and adjust dose frequently to optimize pain relief while monitoring and managing side effects
Elderly, chronically ill more likely to have adverse drug reactions
Identify treatment goals: decrease pain, improve functioning, mood, sleep, etc.
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Appropriate Nonpharamcologic Approaches
Topical analgesics
Acetaminophen
NSAIDs (short-term, low-dose preferred)
Tramadol (if patient or advocate wishes to avoid opioids)
Opioids
If related to diabetes, establish control of blood glucose levels
Topical analgesics
Anticonvulsant or antidepressant
Acetaminophen
NSAIDs
Tramadol (if patient or advocate wishes to avoid opioids)
Opioids
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Review and reassess regularly
Frequency and intensity of pain
Ability to perform activities of daily living
Sleep pattern
Mood, cognition and behavior
Participation in usual activities
Treatment plan and effectiveness of current medications and complementary treatments
Side effects of analgesics
Conditions/diagnoses associated with pain
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Constipation: a laxative should be started at the time of prescribing an opioid
Sedation: Residents may experience drowsiness and should decrease in a couple of days
Nausea with/without vomiting: Check for impaction! Usually subsides within 3-4 days
Delirium: Opioids can precipitate or aggravate confusion, delusions and hallucinations. Also make sure to r/o other medical issues
Respiratory Depression: rare in opioid tolerant, yet more in common in opioid naive
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Revise treatment plan as necessary
Options for unresponsive pain after above measures—referral to:
Pain clinic
Physician certified in palliative medicine or psychiatrist experienced in care of elderly patients
Pain specialist
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50 y.o. male with terminal cancer
Admitted for hospice inpatient
Out-of-control pain
Family
Son about to graduate from high school
Patient to retire from the Navy
Extended family lived in the Philippines
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What To Do Next?
What To Do Next?
What To Do Next?
Reviewed pain medicines
Patient at optimum (WHO)
Patient taking the medicines appropriately
Patient asked “Given the severity of your illness what is most important for you to achieve?”
He wanted to say goodbye to his extended family
He grieved not being able to attend his son’s graduation
His career was incomplete without a formal retirement ceremony
Sacraments of his church
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Social Worker
Arranged special visas for his family
With his son’s high school principal, they re-enacted his son’s graduation
50 Navy colleagues joined the patient’s commanding officer in a retirement ceremony in the hospice conference room
Chaplain provided sacraments of anointing of the sick and communion
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Pain persisting or increasing Opioid for mild to moderate pain +/- Non-Opioid
+/- Adjuvant Non-opioid +/- Adjuvant Pain persisting or increasing
Freedom from Cancer Pain Freedom from Cancer Pain Freedom from Cancer Pain Opioid for moderate to severe pain +/- Non-Opioid
+/- Adjuvant
I 3
2
WHO’s Pain Relief Ladder
What Happened to his Pain?
What Happened to his Pain?
What Happened to his Pain?
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Views about management of pain have changed
Widespread concern about untreated pain and adequate pain management
Pain can and should be addressed
Cannot always be eliminated, given less-than-ideal options we have
People should die as comfortably as possible
Don’t do harm while trying to do good
Indiscriminate symptom-chasing can do harm
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Summary (cont.)
Summary
Summary (cont.)(cont.)
However, available treatments are only sometimes effective, often problematic
May cause as many or more unpleasant effects as they relieve
Pain in dying individuals should be treated as best as possible
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Questions?
Questions?
Questions?
Notes Page
Basic Hospice, November 2008 Student Manual