cancer pain chapter 13. last class: discuss the goals of chemotherapy. discuss the goals of...
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Last Class:Last Class:
• Discuss the goals of chemotherapy.Discuss the goals of chemotherapy.• Describe the agents used in Describe the agents used in
chemotherapy, including classification, chemotherapy, including classification, methods of administration and side methods of administration and side effects.effects.
• Describe the nursing management of side Describe the nursing management of side effects of chemotherapyeffects of chemotherapy
Today’s Objectives:Today’s Objectives:
• Describe radiation as a modality for cancer Describe radiation as a modality for cancer treatment, and the uses of radiotherapytreatment, and the uses of radiotherapy
• Identify factors affecting cell response to Identify factors affecting cell response to radiotherapy.radiotherapy.
• Discuss the principles of radiation protectionDiscuss the principles of radiation protection• Describe the types of radiation therapy and Describe the types of radiation therapy and
related nursing care.related nursing care.• Discuss side-effects of radiation therapy and Discuss side-effects of radiation therapy and
nursing care.nursing care.
Today’s Class:Today’s Class:
Define painDefine painOutline the pathophysiology of painOutline the pathophysiology of painDiscuss the concept of “total pain”Discuss the concept of “total pain”Compare and contrast acute and chronic pain Compare and contrast acute and chronic pain Discuss the different classifications of pain and Discuss the different classifications of pain and common descriptors.common descriptors. Describe the WHO analgesic ladderDescribe the WHO analgesic ladderDescribe common assessments and Describe common assessments and interventions for paininterventions for painRead Chapter 13 TextRead Chapter 13 Text
Pain DefinitionPain DefinitionDifficult to describe b/c it is such a multi-Difficult to describe b/c it is such a multi-dimensional phenomenon. According to dimensional phenomenon. According to International Association for the Study of International Association for the Study of Pain:Pain:
““An unpleasant sensory and emotional experience An unpleasant sensory and emotional experience associated with actual or potential tissue associated with actual or potential tissue
damage, or described in terms of such damagedamage, or described in terms of such damage””
Pain DefinitionPain Definition
McCaffrey’s McCaffrey’s definition addresses definition addresses the subjectivity of the subjectivity of pain ….pain ….
““whatever the whatever the experiencing person experiencing person
says it is and says it is and existing whenever existing whenever the person says it the person says it
is”is”
Facts About Pain:Facts About Pain:
Pain is always subjective.Pain is always subjective.The severity of pain is not in linear relation The severity of pain is not in linear relation to the amount of tissue damageto the amount of tissue damageMany factors influence a person’s Many factors influence a person’s perception of pain, including:perception of pain, including:
FatigueDepressionAngerFear & anxiety (including past experience with pain)Feelings of helplessness and hopelessness.Pain tolerance
Total PainTotal Pain
Seven “P’s”:Seven “P’s”:
Physical PainPhysical Pain
Intellectual PainIntellectual Pain
Emotional painEmotional pain
Interpersonal painInterpersonal pain
Spiritual PainSpiritual Pain
Financial PainFinancial Pain
Bureaucratic PainBureaucratic Pain
Pathophysiology of PainPathophysiology of Pain
TransductionTransduction – initial pain stimulus – initial pain stimulus triggers action potentialtriggers action potential
TransmissionTransmission – action potential travels – action potential travels from the site of damage to spinal cord and from the site of damage to spinal cord and brainbrain
PerceptionPerception – the conscious perception of – the conscious perception of painpain
ModulationModulation – – inhibition of pain impulse inhibition of pain impulse
Pathophysiology of PainPathophysiology of Pain
http://www.bayareapainmedical.com/http://www.bayareapainmedical.com/nervanim.htmlnervanim.html
Types of PainTypes of Pain
May be Acute or Chronic
Acute Pain– Short duration (<6 mths)– Immediate, identifiable onset
(surgery)– Limited & often predictable duration– Often described as “sharp”,
stabbing”, “shooting” SharpStabbingShooting
Chronic Pain
Three types: Three types:
chronic non-malignantchronic non-malignant (low back pain),(low back pain), chronic chronic intermittentintermittent (migraine headaches),(migraine headaches), chronic chronic malignantmalignant (cancer-related pain)(cancer-related pain)
Characteristics of Characteristics of chronic pain:chronic pain:– Lasts long periods of time(months to years)Lasts long periods of time(months to years)– Is not readily treatableIs not readily treatable– Pain that is constant, continuous, & moderate Pain that is constant, continuous, & moderate
is described as is described as “difficult to bear””– Often associated with withdrawal & Often associated with withdrawal &
depressiondepression
Cancer-Related PainMalignant pain has characteristics of both acute & Malignant pain has characteristics of both acute & chronic pain.chronic pain.Moderate to severe pain occurs in 30% of clients Moderate to severe pain occurs in 30% of clients receiving treatment and in receiving treatment and in 60-90% in clients with 60-90% in clients with advanced diseaseadvanced diseaseSources of pain in persons with cancer:Sources of pain in persons with cancer:– The cancer itself 46-92%The cancer itself 46-92%– Related to cancer or debility (i.e. muscle spasms, Related to cancer or debility (i.e. muscle spasms,
constipation) 12-29%constipation) 12-29%– Related to treatment (i.e. mucositis, incisional Related to treatment (i.e. mucositis, incisional
pain) 5-20%pain) 5-20%– Concurrent disorder (i.e. arthritis) 8-22% Concurrent disorder (i.e. arthritis) 8-22%
Remember that…..Remember that…..
A A receptorreceptor is any functional macromolecule in a is any functional macromolecule in a cell to which a drug binds to produce an effectcell to which a drug binds to produce an effect
The term The term affinityaffinity to a receptor means the to a receptor means the strength of attraction between receptor and drugstrength of attraction between receptor and drug
Pain:Pain:
Pain Pain - is a perceptual interpretation of nerve - is a perceptual interpretation of nerve activity that reaches consciousness.activity that reaches consciousness.
Pain can be classified according to Pain can be classified according to pathophysiologic mechanism:pathophysiologic mechanism:
Nociceptive pain:Nociceptive pain: pain that pain that arises directly from chemical, arises directly from chemical, thermal or physical stimulation thermal or physical stimulation of normal nerve endings.of normal nerve endings.http://www.youtube.com/http://www.youtube.com/watch?v=PMZdkac4YLkwatch?v=PMZdkac4YLkNeuropathic pain:Neuropathic pain: results from results from injury to a nerve or from injury to a nerve or from abnormal nerve function at abnormal nerve function at any point along the line of any point along the line of neuronal transmission from neuronal transmission from the most peripheral tissues to the most peripheral tissues to the CNS.the CNS.
Nociceptive PainNociceptive Pain
Types: – Somatic (superficial)– Visceral (deep)
Somatic pain originates in skin, bone, joints, muscles, or connective tissue.
Visceral (deep) originates in the organs (lungs, GI, GU tract)
Somatic PainSomatic Pain
Originates in bones, joints, muscles, skin or Originates in bones, joints, muscles, skin or connective tissueconnective tissue
Usually localized & non-radiatingUsually localized & non-radiatingOften described as sharp, deep, dull, aching, throbbingOften described as sharp, deep, dull, aching, throbbingConstant or intermittentConstant or intermittentOften worse with movementOften worse with movementPalpation of area usually elicits painPalpation of area usually elicits painNSAIDs should be considered in any patient with bone NSAIDs should be considered in any patient with bone pain. Often combined with opioidspain. Often combined with opioidsExamples bee sting, sunburnExamples bee sting, sunburn
Visceral painVisceral pain
Originates in cardiac, lung, GI or GU tract Originates in cardiac, lung, GI or GU tract tissuestissues
Is more diffuse over the viscera involvedCramping, gnawing or colicky pain associated with
obstruction of hollow viscusOften referred to cutaneous sitesOther visceral tissues, pain described as aching,
stabbing, or throbbing, spasm, cramping, pressure.Ex. Acute appendicitis, cholecystitis, bowel
obstruction
Neuropathic PainNeuropathic Pain
Results from abnormal sensory processing which occurs Results from abnormal sensory processing which occurs after damage to a nerve, the spinal cord or brainafter damage to a nerve, the spinal cord or brain
Burning, deeply aching that may be accompanied by sudden, sharp, lancinating painOften distributed along a dermatome or peripheral nerveNumbness or tingling over the skinHyperesthesia over an area of the skinSevere pain from the slightest pressure or touchEx. Phantom limb pain
http://www.youtube.com/watch?v=qq5VsVf3CzA
Pain relief can be accomplished by:Pain relief can be accomplished by:
1.1. Preventing activation of Preventing activation of nociceptive receptors in nociceptive receptors in the peripherythe periphery
2.2. Preventing transmission Preventing transmission of electrical signal along of electrical signal along a pathwaya pathway
3.3. Preventing transfer of Preventing transfer of the signal from one the signal from one neuron to anotherneuron to another
Methods for Pain ControlMethods for Pain ControlNonopioid analgesicsNonopioid analgesicsOpioid analgesicsOpioid analgesicsAdjuvant drug therpyAdjuvant drug therpyRadiation therapyRadiation therapyChemotherapyChemotherapyHormonal therapyHormonal therapyAnesthetic proceduresAnesthetic proceduresNeurosurgical proceduresNeurosurgical proceduresPsychosocial interventionsPsychosocial interventions
RadiationRadiation
Good to excellent relief in:Good to excellent relief in:– Painful bone metastasesPainful bone metastases– Acute spinal cord Acute spinal cord
compressioncompression– Chest pain 2ndary to Chest pain 2ndary to
bronchial carcinomabronchial carcinoma– Dysphagia due to Dysphagia due to
esophageal canceresophageal cancer
ChemotherapyChemotherapy
May provide excellent pain relief in May provide excellent pain relief in responsive tumorsresponsive tumors
Usually administered in oral formulations Usually administered in oral formulations when possiblewhen possible
Single agents with lowest toxicity are usedSingle agents with lowest toxicity are used
Administered in short coursesAdministered in short courses
Hormonal therapyHormonal therapy
Is used primarily for cancers arising in cells that have an endocrine function (breast, endometrium, prostate)Hormonal therapy to relieve pain is most likely to be effective in carcinoma of the prostrate. Bilateral orchidectomy brings relief of bone pain in 60-80% of clients within hours of surgery & may last up to 2 years
Palliative surgeryPalliative surgery
Indicated for:Indicated for:
Stabilization of long bone Stabilization of long bone with mets to prevent a with mets to prevent a pathological fracturepathological fracture
Decompression of the Decompression of the spinal canal to prevent spinal canal to prevent impending paralysisimpending paralysis
Relief of bowel obstruction Relief of bowel obstruction in selected patientsin selected patients
Anesthetic & Neurosurgical Anesthetic & Neurosurgical ProceduresProcedures
Anesthetic procedures are most helpful Anesthetic procedures are most helpful in treating well-localized somatic or in treating well-localized somatic or visceral pain.visceral pain.
Procedures include injections, inhalation Procedures include injections, inhalation of nitrous oxide, epidural infusion with of nitrous oxide, epidural infusion with opioids or local anesthetics. opioids or local anesthetics.
Neuroablation involves interruption of Neuroablation involves interruption of specific nerve tractsspecific nerve tracts
Physical/non-pharmaceutical Physical/non-pharmaceutical MethodsMethods
Local heatLocal heat
Local cold Local cold applicationsapplications
MassageMassage
TENSTENS
Vibration therapyVibration therapy
AcupunctureAcupuncture
ExerciseExercise
Psychosocial InterventionsPsychosocial Interventions
The goal of most psychosocial The goal of most psychosocial interventions is to help the client regain a interventions is to help the client regain a sense of control that has been under-sense of control that has been under-mined by illness and pain. These mined by illness and pain. These include:include:
– Education and accurate information Education and accurate information about pain, pain control, & common about pain, pain control, & common misconceptions about the use of misconceptions about the use of opioids (fear of addiction, side opioids (fear of addiction, side effects..)effects..)
Psychosocial Interventions Con’tPsychosocial Interventions Con’t
Relaxation Relaxation techniques (focused techniques (focused breathing, meditation)breathing, meditation)
Guided imageryGuided imagery
HypnosisHypnosis
MusicMusic
HumorHumor
Therapeutic touchTherapeutic touch
ABCDE’s of PainABCDE’s of Pain AA- - AskAsk about the pain regularly. Assess pain about the pain regularly. Assess pain
systematicallysystematically
BB- - BelieveBelieve the patient and family in their reports of the patient and family in their reports of pain and what relieves it.pain and what relieves it.
CC- - ChooseChoose pain control options appropriate for the pain control options appropriate for the patient and family, and setting.patient and family, and setting.
DD- - Deliver Deliver interventions in a timely, logical , and interventions in a timely, logical , and coordinated fashioncoordinated fashion
EE- - EmpowerEmpower patients and their families. Enable patients and their families. Enable them to control their course as much as possiblethem to control their course as much as possible
Pay Attention to Detail:Pay Attention to Detail:
Take nothing for grantedTake nothing for grantedBe precise in history takingBe precise in history takingExplore the client’s “total pain”Explore the client’s “total pain”Determine what the person knows about Determine what the person knows about the situation, what s/he believes and fears the situation, what s/he believes and fears about pain and the things that can relieve about pain and the things that can relieve ititMake sure instructions are precise and Make sure instructions are precise and written downwritten down
Pain AssessmentPain Assessment
““Tell me about your pain”Tell me about your pain”Why is it important to pay attention to the Why is it important to pay attention to the
words the patient uses to describe the words the patient uses to describe the painpain
Pain AssessmentPain Assessment
How intense is your pain? How intense is your pain?
Use a pain scaleUse a pain scale
Where is your pain?Where is your pain?
How long does it last?How long does it last?
What makes it better or worse?What makes it better or worse?
How does the pain affect your sleep, How does the pain affect your sleep, appetite, energy, mood, relationships, appetite, energy, mood, relationships, daily activities?daily activities?
Pain AssessmentPain Assessment
Are you having any other symptoms?Are you having any other symptoms?What do you think is causing the pain?What do you think is causing the pain?What medications are you taking for the What medications are you taking for the pain?pain?Do have any concerns about medications?Do have any concerns about medications?What are you doing to try to relieve the What are you doing to try to relieve the pain?pain?Do you have support from family and Do you have support from family and friends?friends?
Pain AssessmentPain Assessment
What investigations have been done?What investigations have been done?
X-raysX-rays
CT scanCT scan
Bone scanBone scan
Blood workBlood work
Subjective tools such as the Subjective tools such as the Visual Analog Scale (VAS) Visual Analog Scale (VAS) and the Faces Scale are and the Faces Scale are used to assess pain.used to assess pain. The VAS is a straight The VAS is a straight horizontal 100 mm line horizontal 100 mm line anchored with "no pain" on anchored with "no pain" on the left end and "worst the left end and "worst possible pain" or "pain as possible pain" or "pain as bad as it could possibly be" bad as it could possibly be" on the right. Clients are on the right. Clients are asked to choose a position asked to choose a position on the line that represents on the line that represents their pain.their pain.The Faces Scale depicts The Faces Scale depicts facial expression on a scale facial expression on a scale of 0-6, with 0=smile, and of 0-6, with 0=smile, and 6=crying grimace. Clients 6=crying grimace. Clients should choose a face that should choose a face that represents how the pain represents how the pain makes them feel. makes them feel.
The African-American The African-American version of the Oucher version of the Oucher was developed and was developed and copyrighted by Mary J. copyrighted by Mary J. Denyes, PhD, RN, Denyes, PhD, RN, Wayne State Wayne State University School of University School of Nursing, and Antonia Nursing, and Antonia M. Villarruel, PhD, RN, M. Villarruel, PhD, RN, currently of the currently of the University of University of Pennsylvania. Pennsylvania.
Behavioral CuesBehavioral Cues
Non-verbal cues include:Non-verbal cues include:– Decreased activity or restlessnessDecreased activity or restlessness– Furrowed browFurrowed brow– GrimacingGrimacing– Crying, moaningCrying, moaning– Withdrawal from interacting with each otherWithdrawal from interacting with each other– Guarded or stiffened postureGuarded or stiffened posture– irritabilityirritability
Physical Physical signs include increased BP, rapid signs include increased BP, rapid pulsepulse
WHO General Principles of Pain WHO General Principles of Pain ManagementManagement
By mouthBy mouth
By clockBy clock
By the ladderBy the ladder
For the individualFor the individual
Use of adjuvantsUse of adjuvants
Attention to Attention to detailsdetails
WHO 3-step Analgesic LadderWHO 3-step Analgesic LadderThe WHO has developed a three-step The WHO has developed a three-step analgesic ladder to guide the use of analgesic ladder to guide the use of drugs in treating cancer paindrugs in treating cancer pain
First stepFirst step: non-opioid drug with/without : non-opioid drug with/without adjuvant drug as requiredadjuvant drug as required
Second stepSecond step:: add a weak opioid for add a weak opioid for mild to moderate pain, with adjuvant mild to moderate pain, with adjuvant drugs as requireddrugs as required
Third stepThird step:: a strong opioid should be a strong opioid should be substituted for the weak. substituted for the weak.
A Stepped ApproachA Stepped Approach
Step OneMild pain(1-2 / 10)Acetaminophen, NSAIDs ±adjuvants
Step TwoModerate pain(3-5 / 10)Acetaminophen with codeine, acetaminophen or ASA with oxycodone ± adjuvants ± nonopioid analgesics
Step ThreeSevere pain(6-10 / 10)Morphine, hydromorphone, methadone, fentanyl, oxycodone ± adjuvants ± nonopioid analgesics
Nonopioid Analgesics –Nonopioid Analgesics – AcetaminophenAcetaminophen
Effective for mild painEffective for mild pain
No anti-inflammatory effectNo anti-inflammatory effect
Usual adult dose 325-1000 mg po q4h Usual adult dose 325-1000 mg po q4h (maximum 4000 mg daily)(maximum 4000 mg daily)
Often combined with opioidsOften combined with opioids
Nonopioid Analgesics – NSAIDsNonopioid Analgesics – NSAIDs
Act by inhibiting prostaglandinsAct by inhibiting prostaglandinsAnalgesia and anti-inflammatory actionAnalgesia and anti-inflammatory actionAppropriate for mild to moderate painAppropriate for mild to moderate painEffective adjuvants for bone painEffective adjuvants for bone painSide effect profiles vary between agents within the Side effect profiles vary between agents within the classclassGastroprotectants may be necessaryGastroprotectants may be necessaryUse cautiously in patients with renal insufficiency Use cautiously in patients with renal insufficiency Due to ↓ platelet aggregation, NSAIDs should be Due to ↓ platelet aggregation, NSAIDs should be avoided in patients at risk of thrombocytopeniaavoided in patients at risk of thrombocytopenia
Opoid Opoid AnalgesicsAnalgesicsAct primarily by stimulation of receptors in the Act primarily by stimulation of receptors in the brainbrainAre the mainstay of cancer pain management of Are the mainstay of cancer pain management of moderate to severe intensitymoderate to severe intensityUse the oral route whenever possibleUse the oral route whenever possible
Use the SC or IV route for rapid pain relief or if Use the SC or IV route for rapid pain relief or if the patient is not able to take medications orallythe patient is not able to take medications orally
All parenteral opioids can be given SCAll parenteral opioids can be given SC
IM injections not recommended IM injections not recommended
Opioid Analgesics – Opioid Analgesics – Choice of Choice of AgentAgent
Start with morphine (unless contraindicated) as Start with morphine (unless contraindicated) as most patients will achieve pain control and it is most patients will achieve pain control and it is easily available in multiple doses and dosage easily available in multiple doses and dosage routes routes
Hydromorphone and fentanyl may be preferred Hydromorphone and fentanyl may be preferred in the elderlyin the elderly
Oxycodone, fentanyl and methadone may be Oxycodone, fentanyl and methadone may be safer in patients with renal failuresafer in patients with renal failure
Avoid meperidine/DemerolAvoid meperidine/Demerol
Useful for short term acute care.Useful for short term acute care.Has a long half-life Has a long half-life The metabolite of meperidine is associated with The metabolite of meperidine is associated with many adverse effects and may reach toxic levels, many adverse effects and may reach toxic levels, leading to CNS excitation or even seizures.leading to CNS excitation or even seizures.
Sphincter of Oddi is sensitive to all Sphincter of Oddi is sensitive to all narcotics.narcotics.
The sphincter of Oddi is a muscular valve that controls the flow of digestive juices (bile and pancreatic juice) through the ampulla of Vater into the first part of the small intestine (duodenum).
Narcotics cause spasms of the spinchter of oddi. The spasms cause a back-up of these digestive juices the result being episodes of severe abdominal pain.
Sphincter of Oddi: Sphincter of Oddi: is sensitive to narcoticsis sensitive to narcotics
Equianalgesic Doses and Half-Lives of Equianalgesic Doses and Half-Lives of Selected Morphine-Like Agonists Selected Morphine-Like Agonists
For the IndividualFor the Individual
Requirements vary deeplyRequirements vary deeplyTThe average person will require 60 to
120mg of oral morphine per day
Some will require less opioid
A small % may require very high doses (>2000mg/day)
The dose of analgesic must be titrated against the particular patient pain
Use of AdjuvantsUse of Adjuvants
Enhances the analgesic effect (steriods, Enhances the analgesic effect (steriods, anticonvulsants)anticonvulsants)
Controls the adverse effects of opiods Controls the adverse effects of opiods (e.g. antiemetics, laxatives)(e.g. antiemetics, laxatives)
To manage symptoms that are To manage symptoms that are contributing to the client’s pain (anxiety, contributing to the client’s pain (anxiety, depression, insomnia)depression, insomnia)
1.1. Aim for graded reliefAim for graded relief
2.2. Start with a specific drug for a Start with a specific drug for a specific painspecific pain
3.3. Choose an appropriate route of Choose an appropriate route of administrationadministration
4.4. Titrate the dosage of opioidsTitrate the dosage of opioids
5.5. Provide for rescue dosesProvide for rescue doses
6.6. Anticipate and treat side effectsAnticipate and treat side effects
Attention to DetailAttention to Detail
Take nothing for grantedTake nothing for grantedBe precise in history takingBe precise in history takingExplore the client’s “total pain”Explore the client’s “total pain”Determine what the person knows about Determine what the person knows about the situation, what s/he believes and fears the situation, what s/he believes and fears about pain and the things that can relieve about pain and the things that can relieve ititMake sure instructions are precise and Make sure instructions are precise and written downwritten down
Initiating An OpioidInitiating An Opioid
Assess the level of painAssess the level of pain
Start with an immediate-release preparation, q4h Start with an immediate-release preparation, q4h around the clockaround the clock
Follow a titration schedule to establish pain Follow a titration schedule to establish pain controlcontrol
Breakthrough doses of the same opioid Breakthrough doses of the same opioid (immediate-release only) should be provided(immediate-release only) should be provided
When pain is controlled, convert to a sustained-When pain is controlled, convert to a sustained-release product release product
Side Effects of OpioidsSide Effects of Opioids
CommonCommon Less FrequentLess Frequent RareRare
ConstipationConstipation
NauseaNausea
GI UpsetGI Upset
SedationSedation
Dry MouthDry Mouth
Urinary retentionUrinary retention
PruritusPruritus
Severe myoclonusSevere myoclonus
ConfusionConfusion
Hallucinations, Hallucinations, nightmaresnightmares
Postural hypotensionPostural hypotension
VertigoVertigo
Respiratory depressionRespiratory depression
AllergyAllergy
Use of AdjuvantsUse of Adjuvants
Enhances the analgesic effect (steriods, Enhances the analgesic effect (steriods, anticonvulsants)anticonvulsants)
Controls the adverse effects of opiods Controls the adverse effects of opiods (e.g. antiemetics, laxatives)(e.g. antiemetics, laxatives)
To manage symptoms that are To manage symptoms that are contributing to the client’s pain (anxiety, contributing to the client’s pain (anxiety, depression, insomnia)depression, insomnia)
Ongoing AssessmentOngoing Assessment
Pain is a dynamic process and may Pain is a dynamic process and may change from hour to hour!change from hour to hour!
New pains, disease progression, a New pains, disease progression, a treatable acute problem may arise.Pain treatable acute problem may arise.Pain assessment must be documentedassessment must be documented
Assess for tolerance:the need to increase Assess for tolerance:the need to increase dosage of a drug over time to maintain a dosage of a drug over time to maintain a given level of analgesia. (rare)given level of analgesia. (rare)
Factors Affecting PainFactors Affecting Pain
Situational factorsSituational factorsSociocultural factorsSociocultural factorsAgeAgeGenderGenderMeaning of painMeaning of painAnxietyAnxietyPast experience with painPast experience with painExpectations & placebo effectExpectations & placebo effect
Rural clients (access)Rural clients (access)
Elderly (natural part of aging? Difficulty Elderly (natural part of aging? Difficulty describing pain?describing pain?
Cultural differencesCultural differences
Ethnic minorities, lower income bracketsEthnic minorities, lower income brackets
Gender - womenGender - women
Religious beliefs (positive & negative Religious beliefs (positive & negative impact)impact)
Barriers to Pain ManagementBarriers to Pain Management HCPs & FamiliesHCPs & Families
Lack of education about pain management from Lack of education about pain management from health professionals.health professionals.Poor communication (subjectivity)Poor communication (subjectivity)
Personal BarriersPersonal BarriersStigma associated with use of narcoticsStigma associated with use of narcoticsFear of addictionFear of addictionSide effectsSide effectsNeed to be “good patient”Need to be “good patient”Fear it will impede progressFear it will impede progressFear of injectionsFear of injections
Barriers to Pain ManagementBarriers to Pain Management
Health Care System FactorsHealth Care System Factors
Pain not recognized as a major Pain not recognized as a major management priority in pastmanagement priority in past
Lack of prescription drug coverage for Lack of prescription drug coverage for many peoplemany people
Restrictions on prescriptions for narcoticsRestrictions on prescriptions for narcotics
Health Care ProfessionalsHealth Care Professionals
Lack of educationLack of education
Fear of regulatory scrutinyFear of regulatory scrutiny
Concerns about addiction and respiratory Concerns about addiction and respiratory depression from opioidsdepression from opioids
Poor pain assessment skillsPoor pain assessment skills
Concerns about people seeking drugs for Concerns about people seeking drugs for illicit useillicit use
Patients and FamilyPatients and Family
Fears about the meaning of the painFears about the meaning of the pain
Strong views on the use of opioidsStrong views on the use of opioids
The belief that pain is a “normal” part of the The belief that pain is a “normal” part of the illnessillness
Past experiences with painPast experiences with pain
Cultural, or religious beliefsCultural, or religious beliefs
Denial of disease or disease progressionDenial of disease or disease progression
Fears about constipation, addiction, sedation, Fears about constipation, addiction, sedation, cognitive changescognitive changes
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