Criterios para otorgar los beneficios

The experience of pain includes the patient’s emotional reaction to it and is influenced by many factors, including the patient’s prior experiences with pain, meaning given to the pain, emotional stresses, and family and cultural influ- ences. Pain is a subjective phenomenon, and clinicians cannot reliably detect its existence or quantify its severity without asking the patient directly. A useful means of assessing pain and evaluating the effectiveness of analgesia is to ask the patient to rate the degree of pain along a numeric or visual pain scale (Table 5–1).

General guidelines for management of pain are recom- mended for the treatment of all patients with pain. Clini- cians should ask about the nature, severity, timing, location, quality, and aggravating and relieving factors of the pain. Distinguishing between neuropathic and nociceptive (somatic or visceral) pain is essential to proper tailoring of pain treatments (see below). The goal of pain management is properly decided by the patient. Some patients may wish to be completely free of pain even at the cost of significant sedation, while others will wish to control pain to a level that still allows maximal functioning.

Chronic severe pain should be treated continuously. For ongoing pain, a long-acting analgesic can be given around the clock with a short-acting medication as needed for “breakthrough” pain. Whenever possible, the oral route of administration is preferred because it is easier to adminis- ter at home, is not painful, and imposes no risk from needle exposure. Patient-controlled analgesia (PCA) of intrave- nous medications can achieve better analgesia faster with

Table 5–1. Pain assessment scales.

A. Numeric Rating Scale No pain

0 1 2 3 4 5 6 7 8 9 10

Worst pain

B. Numeric Rating Scale Translated into Word and Behavior Scales

Pain Intensity Word Scale Nonverbal Behaviors

0 No pain Relaxed, calm expression

1–2 Least pain Stressed, tense expression

3–4 Mild pain Guarded movement, grimacing

5–6 Moderate pain Moaning, restless

7–8 Severe pain Crying out

9–10 Excruciating pain Increased intensity of above C. Wong Baker FACES Pain Rating Scale1

1_{Especially useful for patients who cannot read English and for pediatric patients.}

Reprinted, with permission, from Hockenberry M, Wilson D, Winkelstein ML. Wong’s Essentials of Pediatric Nursing, ed. 8. Copyright © 2009, Mosby, St. Louis. 0 No hurt Hurts1 Little Bit 2 Hurts Little More 3 Hurts Even More 4 Hurts Whole Lot 5 Hurts Worst

less medication use, and its principles have been adapted for use with oral administration.

The underlying cause of pain should be diagnosed and treated, balancing the burden of diagnostic tests or thera- peutic interventions with the patient’s suffering. For exam- ple, radiation therapy for painful bone metastases or nerve blocks for neuropathic pain may obviate the need for ongo- ing treatment with analgesics and their side effects. Regard- less of decisions about seeking and treating the underlying cause of pain, every patient should be offered prompt relief.

PAIN MANAGEMENT FOR PATIENTS WITH

SERIOUS ILLNESS

»Definition & Prevalence

Pain is what many people say they fear most about dying, and it is consistently undertreated. Up to 75% of patients dying of cancer, heart failure, COPD, or other diseases experience pain. The Joint Commission reviews of health- care organizations include pain management standards.

»Barriers to Good Care

One barrier to good pain control is that many clinicians have limited training and clinical experience with pain management and thus are reluctant to attempt to manage severe pain. Lack of knowledge about the proper selection and dosing of analgesic medications carries with it

attendant and typically exaggerated fears about the side effects of pain medications, including the possibility of respiratory depression from opioids. Most clinicians, how- ever, can develop good pain management skills, and nearly all pain, even at the end of life, can be managed without hastening death through respiratory depression. In rare instances, palliative sedation may be necessary to control intractable suffering as an intervention of last resort.

A misunderstanding of the physiologic effects of opi- oids can lead to unfounded concerns on the part of clini- cians, patients, or family members that patients will become addicted to opioids. While physiologic tolerance (requiring increasing dosage to achieve the same analgesic effect) and dependence (requiring continued dosing to prevent symptoms of medication withdrawal) are expected with regular opioid use, the use of opioids at the end of life for relief of pain and dyspnea is not generally associated with a risk of psychological addiction (misuse of a sub- stance for purposes other than the one for which it was prescribed and despite negative consequences in health, employment, or legal and social spheres). The risk for problematic use of pain medications is higher, however, in patients with a history of addiction or substance abuse. Yet even patients with such a history need pain relief, albeit with closer monitoring. Some patients who demonstrate behaviors associated with addiction (demand for specific medications and doses, anger and irritability, poor coop- eration or disturbed interpersonal reactions) may have

pseudo-addiction, defined as exhibiting behaviors associ- ated with addiction but only because their pain is inade- quately treated. Once pain is relieved, these behaviors cease. In all cases, clinicians must be prepared to use appro- priate doses of opioids in order to relieve distressing symp- toms for patients at the end of life.

Harms from the use of opioid analgesics, including medication diversion or death from accidental or intentional overdose, are known and significant risks. Some clinicians fear legal repercussions from prescribing the high doses of opioids sometimes necessary to control pain at the end of life. The US Food and Drug Administration (FDA) offers a Risk Evaluation and Management Strategy for long-acting and extended-release opioids to inform clinicians about appropriate prescribing and to promote safe use of opioids for patients who require them (http://www.fda.gov/Drugs/ DrugSafety/InformationbyDrugClass/ucm163647.htm). Some states have special training, licensing, and documenta- tion requirements for opioid prescribing. However, govern- mental and professional medical groups, regulators (including the FDA), and the US Supreme Court have made it clear that appropriate treatment of pain is the right of the patient and a fundamental responsibility of the clinician. Although clinicians may feel trapped between consequences of over- or under-prescribing opioids, there remains a wide range of practice in which clinicians can safely and appropri- ately treat pain. Referral to pain management or palliative care experts is appropriate whenever pain cannot be con- trolled expeditiously or safely by the primary clinician. In the field of chronic noncancer pain (CNCP) management, many clinicians are using pain medication contracts and urine drug testing to help decrease the chance of abuse and diversion (see “Opioids for Chronic, Noncancer Pain”). Clinicians who are caring for patients earlier in the course of life-threatening illness and are concerned that their patient may be misusing opioids (with serious negative conse- quences) can conduct periodic urine toxicology screening to confirm that the patient is taking the medication as pre- scribed and not using other medications.

PHARMACOLOGIC PAIN MANAGEMENT