as a courtesy to those around you, please silence …

3/17/2016

1

AS A COURTESY TO THOSE AROUND YOU, PLEASE SILENCE YOUR CELL PHONE AND

OTHER ELECTRONIC DEVICES.THANK YOU FOR YOUR COOPERATION.

1© AMT Education Division

PAIN, THE FIFTH VITAL SIGNCHUCK GOKOO MD, CWSCHIEF MEDICAL OFFICER

AMERICAN MEDICAL TECHNOLOGIES


3/17/2016

2

The information presented herein is provided for educational and informational purposes only. It is for the attendees’ general knowledge and is not a substitute for legal or medical advice. Although every effort has been made to provide accurate information herein, laws change frequently and vary from state to state.

The material provided herein is not comprehensive for all legal and medical developments and may contain errors or omissions. If you need advice regarding a specific medical or legal situation, please consult a medical or legal professional. Gordian Medical, Inc. dba American Medical Technologies (AMT) and the AMT Education Division shall not be liable for any errors or omissions in this information

3

DISCLAIMER

© AMT Education Division

AAWC

ADAM

American Medical Directors Association (AMDA)

Medscape.com

4

ACKNOWLEDGEMENT


3/17/2016

3

PROGRAM OVERVIEW AND OBJECTIVES

5

Discuss the epidemiology of pain in the LTC

Discuss factors to improve pain management

Understanding pain management instead of reacting to a complaint of pain


© AMT Education Division 6

3/17/2016

4



3/17/2016

5

Pain

50 million Americans are disabled secondary to pain

The symptom most expected and most feared by dying residents

45% ‐ 83% of long‐term care residents experience some type of pain that impairs mobility, causes depression, and diminishes their quality of life

40% ‐ 45% of persons or more in nursing homes experience persistent pain, most of which is not recognized or treated

64% of facilities have an established protocol to diagnose and manage pain in the geriatric population

Cost of health care due to pain ‐ $560 B to $635 B (2010 dollars)National Nursing Home Survey, 2004

Trend reports, Annals of Long Term Care 2012

9

QUALITY OF CARE


10

QUALITY OF CARE

An unpleasant sensory and emotional experience

Induces stress and anxiety leading to a cascade of physiological events that inhibit

wound healing

No objective biological markers

Chronic pain is an abnormal condition

Pain is what the resident says it is


3/17/2016

6

ISSUES


Costly testing

Stoicism Burden for busy staff

Near death

Resident Beliefs

Sign of weakness

Attention seeking

Medication side affects

Addiction

Physician Factors


ISSUES Presuming patient expects prescription medication Prescribing

without sufficient

investigation or clinical situation

Unclear, complex

incomplete instructions;

not simplifying the regimen

Ordering automatic refills

Inappropriate prescribing

Lack of knowledge of geriatric clinical pharmacology

3/17/2016

7


ISSUES

Indicates the presence of a serious disease

Clinician’s View

High pain tolerance

Punishment for past actions

Leads to lossof

independence

Consequence of aging

Addictedto pain

medications

ISSUES


Pain signs or symptoms

Being treated for pain

Reasonable anticipation to cause pain

Possible indicators of

pain

Resident’s report of pain

Federal or State Surveyor

3/17/2016

8

Pain

Pulse

TemperatureRespiration

Blood pressure

PAIN THE FIFTH VITAL SIGN


Familiar with program goals


PAIN THE FIFTH VITAL SIGN

“Go to” person

Resident’s needs

Family members

Help with program

sustainability

Good with changes or

modifications

Staff members to serve in the champion role

Knowledge in pain

management or prevention practices

3/17/2016

9

PAIN


Sleep (increased or decreased)Mood (change)Appetite (malnutrition)

Mobility (gait or falls)Behavior (change)Relationships (socialization decreased)

Activities (socialization decreased)Cognitive functions (confusion, depression, anxiety)Quality of life (decreased)

PAIN


Manage or prevent

Evaluate

Identify

Recognize

Deliver interventions in a timely coordinated fashionCare consistent with the resident’s goals,

comprehensive assessment, plan of care, current clinical standards of practiceDocument

Existing pains and their causesChronic conditions requiring routine pain

managementEducation for families, legal surrogate, resident, staff

When pain can be anticipatedWound careOther treatments

Examine and question patient

When the resident is experiencing pain

3/17/2016

10

Screen

On Admission

‐Attending physician

‐Other healthcare professionals

‐Resident

‐Legal proxy

‐Family

Goal for Pain Management

‐Disease process

‐Nature of the pain

‐Approaches available to manage the pain

‐Need to report pain when it occurs

‐The need to evaluate the effectiveness of the interventions employed

19

RECOGNITION


Review the Resident’s Medication Record

With each change in pain medication

With a sudden change in status of the resident

Consultant Pharmacist

‐Any medication changes if recently admitted

‐Any recently discontinued pain medications

‐Drugs poorly tolerated OR giving less than optimal control

‐Any increase in pain related to worsening disease

‐When drug toxicity could be a problem

Pharmacogenomics

20

EVALUATION


3/17/2016

11

History and Physical

Existing diagnosis and conditions

‐Other diagnosis and conditions

Information from resident’s family or legal proxy

‐Conflicting reports

Prior treatment

‐Pharmaceuticals

‐Non pharmaceuticals

Medication history

‐Pharmacist

‐Previous medications

‐Reason for change

21

EVALUATION

Review of Systems

Neurological

‐Weakness

‐Numbness

Musculoskeletal

‐Tenderness

‐Inflammatories

‐Deformities

‐Decreased range of motion


Cause

Use an appropriate pain tool

‐Quantify the intensity of the resident's pain

Qualifiers

‐Aching, hurting, discomfort

Clarify specific causes of pain

‐History and physical examination

‐Most analgesics are non‐specific and may not address underlying causes

Diagnostic testing

‐No specific test for pain

‐Etiologies

Pharmacogenomics

22

EVALUATION


3/17/2016

12

Cognitively Intact Residents

‐Wong‐Baker Face Scale

‐Numeric Rating Scale

‐Visual Analog (Descriptor) Scale

‐Pain Map

‐Memorial Pain Assessment Card

‐McGill Pain Inventory

‐Brief Pain Inventory

‐Multidimensional Pain Inventory

‐Wisconsin Brief Pain Questionnaire

23

EVALUATION

Cognitively Impaired Residents

‐Pain Assessment in Advanced Dementia

(PAINAD)

‐Abby Pain Scale

‐Doloplus Scale

‐Discomfort Scale for Dementia of the Alzheimer’s type

‐Checklist of Nonverbal Pain Indicators

‐Non‐Communicative Patients Pain

‐Assessment Instrument (NOPPAIN)

Validated Pain Scales


EVALUATION


3/17/2016

13

WILDA

What does the pain feel like

Intensity of pain using valid tool (Numeric, VAS, Verbal)

Location (all sites)

Duration and frequency of pain (constant or intermittent)

Aggravating and alleviating factors (better or worse)

25

EVALUATION


Compilation

Complete upon admission

≤25 hours after admission

‐Immediately upon recognition of pain

Identify risk factors that could relate to pain

‐Cognitively intact and impaired residents

Identify and document characteristics of the pain

‐Including behavioral symptoms related to pain

Notify the practitioner

‐Presence of symptoms that may represent pain

‐Obtain appropriate treatment orders

26

IDENTIFICATION


3/17/2016

14

On‐going

Physician diagnosis, orders, and prognosis to ensure it is appropriate

Reassess the status of an resident’s pain

‐Weekly and upon change of pain related condition

‐Effectiveness and/or adverse consequences

Pain not responding adequately to selected interventions

‐Reevaluate and revise or adjust treatment approaches

Observation

‐Significant effects, side effects, and complications of pain medications

‐Nonspecific signs and symptoms that suggest pain

‐New medical conditions

27

MONITOR


Individualized

PoC

‐Pain management interventions

‐Clinical Standards of Practice

‐Responsibility

Interventions

‐Source(s), type(s) and severity of pain

‐Available treatment options

Approaches

‐Address underlying cause, when possible

‐Target strategies to source, intensity, nature of symptoms

‐Prevent or minimize anticipated pain cycle

28

PAIN MANAGEMENT


3/17/2016

15

Causes of Chronic Pain

Low back disorders

Arthritis

Knee pain

Muscle pain and/or stiffness

Osteoporosis with compression fractures

Headaches

Gout

Immobility or contractures

29

PAIN

Pressure ulcers

Chest pain

Degenerative Joint Disease

Oral or dental pathology

Diabetic neuropathy

Peripheral Vascular Disease

Improper positioning or use of restraints


Types

Acute

‐Abrupt onset and limited duration, associated with an adverse chemical, thermal or mechanical stimulus such as surgery, trauma and acute illness (nociceptor pain)

Background

‐Pain at rest (related to wound etiology, infection, ischemia)

Incident

‐Predictable and related to precipitating events (walking, coughing, transferring, dressing) or actions (ulcer care)

Breakthrough

‐Sudden flare ‐ up of severe pain, associated with inadequate pain medication levels

Persistent or Chronic

‐Prolonged period of time or recurs more than intermittently for months or years

30

PAIN


3/17/2016

16

Wound Dressings

Dried out/adherent

‐Irritate local nerve endings

‐Wet‐to‐dry (gauze)

‐Tissue in‐growth into product matrix

‐Premature release ‐ cause skin tears, damage tissue, cause pain

‐Gauze/Hydrocolloids

Frequency of dressing changes

‐Uncomfortable

‐Wound tissues ‐ hypothermic

31

PAIN

Dressing of choice

‐Non traumatic to tissues when removed

‐Low “peel” force

Non adherent dressings

‐Moisture retentive dressings

‐Hydrogels, hydrofibers, alginates and soft silicones

Enzymatic debriding agent

Medicate before, during and after as appropriate


Laboratory Tests

No specific blood tests for pain

Test to determine whether specific medical conditions associated with pain exist

‐Hemoglobin and hematocrit ‐ Anemia

‐Fasting Blood Glucose ‐ Diabetes

‐Blood Urea Nitrogen ‐ Renal function

‐Rheumatoid factor (RF) ‐ Rheumatoid arthritis

‐Uric acid ‐ Crystal ‐ induced arthropathy

‐Urinalysis ‐ Infection, urolithiasis, GU disease

‐Spine x‐ray ‐ Recurrent compression fracture

‐CT scan ‐ Spinal stenosis

32

PAIN


3/17/2016

17

Non‐Pharmacological Interventions

Physical modalities

‐Altering the environment (room or bed change)

‐Ice packs or cold compresses to reduce swelling and lessen sensation

‐Mild heat to decrease joint stiffness and increase blood flow

‐Transcutaneous Electrical Nerve Stimulation (TENS)

‐Rehabilitation therapy

‐Support group

33

PAIN

Cognitive interventions

‐Soothing, distracting verbal communication

‐Music therapy preferred by the resident

‐Reading to the resident

‐Activities or recreation


Complementary and Alternative Medicine (CAM)

50% facility usage

Physical, cognitive modalities, medications

Acupuncture

Acupressure (use with extreme care)

Reflexology

Chiropractic or osteopathic manipulation

Herbs

34

PAIN


3/17/2016

18

Neurocognitive Disorder

No evidence that older adults with neurocognitive disorder physiologically experience less pain than other adults Geriatric Society (AGS) 2002

‐Neurocognitive impaired like symptoms possible due to pain

‐May fail to interpret pain

‐Less able to recall their pain

‐Unable to verbalize

‐Verbal Descriptor Scale (VDS) not useful

‐Pain Assessment in Advanced Dementia Scale (PAINAD)

‐Analgesics

35

PAIN


Neurocognitive Impaired Like Symptoms

Treatment of neuropsychiatric symptoms

Agitation and aggression

Antipsychotic drugs (neuroleptics)

‐Chemical cash

‐Wean if possible

Pain assessment

Other causes

‐Infection, changes in medication, acute medical insult

Analgesics


PAIN

3/17/2016

19

Neurocognitive Impaired Assessment

Residents’ self report is still reliable

Report from caregivers or family members

Behaviors exhibited may indicate pain

Facial pain scale

Do not use cognitive pain scales and ask to recall information from past

37

PAIN


Observation

Vocalization of pain

‐Constant muttering

‐Moaning or groaning

Screaming/crying out

Breathing

‐Strenuous

‐Labored

‐Negative noise on inhalation or expiration

Pained facial expression

‐Clenched jaw

‐Troubled or distorted face

‐Crying

38

PAIN

Body language

‐Clenched fist

‐Wringing of the hands

‐Strained and inflexible position

Fetal position

‐Rocking

Movement

‐Restless

‐Altered gait

‐Forceful touching

‐Rubbing of body parts

‐Afraid to move© AMT Education Division

3/17/2016

20

PAINAD

39

J Am Med Dir Assoc. 2003;4:9‐15.

Pain Assessment in Advanced Dementia Scale


Pain and Fall Assessment

Injurious falls

ADR/ADE

Neurocognitive disorders

‐Assessment

Pain

‐Assessment

‐Agitation and aggression

‐Acetaminophen 2.6 g ‐ 3 g/day

PAIN


3/17/2016

21

NOPPAIN


42

RAI Manual, September 2010

7 direct measures of cognitive impairment, short and long term memory, recall or orientation items


3/17/2016

22

Substance Use Disorder

35% of adults ≥65yrs take 8 or more drugs daily

20% of elderly addicted

43

PAIN

Addiction

Drug use despite negative physical and social consequences (harm to self and others) and the craving for effects

other than pain relief

Pseudo‐addiction

Inadequately treated and un‐relieved pain leads to persistent or

worsening pain complaints, frequent office visits, requests for dose escalations

Dependence

The body's adaptation to a particular drug and

becomes use to receiving regular doses of a certain medication


Strong opiates (e.g. morphine) moderate ‐ severe pain

+/‐ Non‐opiod

Mild opiates (e.g. codeine) mild – moderate pain

+/‐ Non‐opiod

Mild pain

Non‐opiates (e.g. aspirin, acetaminophen)

HIERARCHY OF PAIN MEDICATIONS

Titrate 50%‐100% increase

Titrate 25%‐50% increase


3/17/2016

23

Inappropriate Medications (Long Term Care)

Aspirin >325 mg/d

Diclofenac

Diflunisal

Etodolac

Fenoprofen

Ketoprofen

Ibuprofen

Meclofenamate

Mefenamic acid

45

PAIN

Meloxicam

Nabumetone

Naproxen

Oxaprozin

Piroxicam

Sulindac

Tometin

Indomethacin

Ketorolac

Pentazocine

Carisoprodol

Chlorzoxazone

Cyclobenzaprine

Metaxalone

Methocarbamol

Orphenadrine


AGS Beers Criteria

Analgesics (Long Term Care)

Evaluate the resident’s overall medical condition and current medications regimen to determine the most appropriate pain therapy

Administer at least one analgesic medication regularly (not PRN)

Least invasive route of administration (swallowing or sublingual)

Acute pain ‐ begin with a low or moderate dose as needed and titrate more rapidly

Chronic pain ‐ begin with low dose and titrate carefully until comfort is achieved

Reassess and adjust the dose to optimize pain relief while monitoring and trying to minimize side affects

46

PAIN


3/17/2016

24

NSAID

Aspirin (acetaminophen)

‐Liver damage

‐Swelling

‐Difficulty breathing

Aspririn/Ibuprophen

‐Caution use (multisystem toxicity)

‐Adverse gastrointestinal problems

Cox 2 Inhibitors (adverse affects)

‐Hypertension

‐Renal impairment

‐Edema

‐Vascular disease

47

PAIN

NSAID

2005/2009 FDA warning

Moderate to severe pain control alone or adjunct

Side Affects

‐GI toxicity

‐Renal toxicity

‐Cardiovascular risk

‐Contraindication

‐Liver failure

‐Decrease renal function

‐Platelet dysfunction


Opiates

Pain related functional impairment

For both nociceptive and neuropathic pain

Diminished quality of life due to pain

Continual or frequent daily pain

“Around‐the‐clock” time‐contingent dosing

Rescue dose

‐10% ‐ 20 % of the 24 hour total

48

PAIN

Titrate ‐ no ceiling affect

Hyperglycemia

Respiratory depression

Constipation

Cardiac arrhythmias (Methadone)

Delirium, myoclonus, seizures


3/17/2016

25

Opiates

Morphine

‐Inexpensive, widely available

‐Administered by multiple routes and

schedules

Hydromorphone

‐More potent

‐Limited routes of administration

‐Advantages in renal insufficiency

49

PAIN

Oxycodone

‐Concentrated PO, but no IV

‐Possibly decreased risk of delirium in older

patients

Methadone

‐Inexpensive, available IV and PO

‐Prolonged QT interval – cardiac arrhythmias

Fentanyl patch

‐Convenient, conversion difficult, poor choice

when rapid titration is needed


Contraindicated as a Analgesic

Meperidine hydrochloride (Demerol)

‐Confusion or sedation

‐Lower seizure threshold (convulsions)

‐Severe weakness or dizziness

‐Feeling light‐headed or fainting

Pentazocine lactate (Talwin)

‐Delirium and hallucinations

‐Constipation or diarrhea

‐Nausea or vomiting

‐Withdrawal symptoms

50

PAIN

Opiates

Treatment of moderate pain

Timed

‐Codeine (short acting)

‐Hydrocodone (short acting)

‐Tramadol (short acting)

‐Hydromorphone short acting)

‐Morphine (short/long acting)

‐Oxycodone (long acting)

‐Oral mucosal fentynal citrate (long acting)

Acetaminophen and Hydrocodone (Lortab)


3/17/2016

26

PAIN

Opioid Use in Renal Failure

Avoid meperidine, codeine, dextropropoxyphene, morphine

Use with caution: oxycodone, hydromorphone

Safest: fentanyl, methadone

Opioid dosing by creatinine clearance:

>50 mL/min Normal dose

1050 mL/min 75% of normal dose

<10 mL/min 50% of normal dose


PAIN

Opioid Adverse Effects Common

Constipation

Dry mouth

Nausea/vomiting

Sedation

Sweats

Uncommon

Bad dreams/hallucinations

Dysphoria/delirium

Myoclonus/seizures

Pruritus/urticaria


Urinary retention

Hypogonadism

SIADH


3/17/2016

27

Opiate Side Affects


‐Uncommon when titrated in response to symptom

Nausea or vomiting

‐Consider treating with dopamine antagonists and/or promotility (metoclopramide, prochlorperazine, haloperidol)

Itch or rash

‐Worse in children; may need low‐dose naloxone infusion

‐May try antihistamines

Neurotoxicity‐Reduce opiate dose

‐Hydration

‐Benzodiazepines for neuromuscular excitation

53

PAIN


Constipation

Daily monitoring of bowel movement

Juices, fiber, bran, pudding

Laxative

‐Adjust as opioid is titrated

Physical exercise

No BM in 24 hour period

‐Sorbitol 30mL Q day or BID

No BM in 72 hours

‐Rectal exam and impaction

‐Phosphate enema or warm water enema

54

PAIN


3/17/2016

28

Transdermal Opiates (Fentanyl)

Around‐the‐clock pain control

Require 24 ‐ 72 hours to reach a “steady state”

Coverage for the first 48 ‐ 72 hours

Administered every 48 ‐ 72 hours

Absorption altered by temperature

Deposit of drug in excess adipose tissue

55

PAIN


Conversion from oral morphine to transdermal fentanyl ONLY‐Conversion from transdermal fentanyl to morphine could lead to overestimation of dose

PAIN


3/17/2016

29

Pain Management Strategies

Heat or cold

TENS units

Counseling

Spiritual support

NSAIDs or Acetaminophen

Agents for neuropathic pain

‐Tricyclic antidepressants, gabapentin

Opiates

57

END OF LIFE


Opiates

Use of multiple pharmacological agents is

often needed to provide optimal

management

‐NSAIDs

‐Tricyclic antidepressants

‐Corticosteroids

‐Anticonvulsants

Traditional rules discouraging

polypharmacy do not apply

Importance of individualized management

58

END OF LIFE

Opiates

Morphine (gold standard)

Codeine

Hydromorphine

Fentanyl

Methadone

Oxycodone


3/17/2016

30

Administration

Oral

IV/SC/SL route

Transdermal

‐Poor choice for rapid titration

‐Not optimal when limited adipose tissue

Rectal administration

‐Suppositories or liquid

‐Bioavailability is probably 90 ‐ 100% of oral route

‐First pass metabolism depends on site of absorption

59

END OF LIFE

Microcapsule formulations of morphine

‐Pudding/applesauce

‐PEG tube

‐Liquid formulations of methadone



IN CLOSING

Optimal pain control with minimal side

effects

Determine the best combination of pain

assessment tools to use

Comprehensive assessment

Assessment of benefits and risks of pain medications

Determine whether pain is episodic or

continuous

Meet residents needs and goals

Monitor for effectiveness and/or

adverse events

3/17/2016

31

American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. American Geriatrics Society JAGS, February, 2012.

American Pain Society at www.ampaisoc.org.

Borschert S. Side Effects Challenge Opioid Therapy for Acute Pain. Caring for the Ages. June 2012;13(6):19.

Cherny N, Ripamonti C, Pereira J, Davis C, Fallon M, McQuay H, et al. Strategies to manage the adverse effects of oral morphine: an evidence‐based report. J Clin Oncol. 2001;19:2542–54.

Cleeland CS. Undertreatment of cancer pain in elderly patients. JAMA. 1998;279(23):1914‐1915.

61

REFERENCES


Curr. Opin. Rheumatol. 2008;20:239‐45.

Goncalves ML, de Gouveua Santos VLC, de Mattos Pimenta CA, Suzuki E, Komagae KM. Pain in chronic leg ulcers. J Wound Ostomy Continence Nurs. 2004;31(5):275‐283.

Hareendran A. Bradbury A, Budd J, Geroulakos G, Hobbs R, Kenkre J, et al. Mesauring the impact of venous leg ulcers on quality of life. J Wound Care. 2005;14(2):53‐57.

Hutt E, Pepper GA, Vojir C, Fink R, Jones KR. Assessing the appropriateness of pain medications prescribing practices in nursing homes. J Am Geriatr Soc. 2001;54(2):213‐239.

Husebo BS, Ballard C, Sandvik R, Nilsen OB, Aarsland D. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes ith dementia: Cluster randomised clinical trial. GMJ2011;343:d4065doi:10.1136/bmj.d4065.

62

REFERENCES


3/17/2016

32

Hyochol A, Stechmiller J, Horgas A. Pressure ulcer‐related pain in Nursing home residents with cognitive impairment. Adv Skin and Wound Care. 2013;26(8):381‐382.

Ice packs vs. warm compresses for pain. The University of Chicago Medicine. www.uchospitals.edu/online‐library/content=P00918. Accessed November 14, 2013. ‐ See more at: http://www.annalsoflongtermcare.com/article/managing‐chronic‐pain‐older‐adult‐long‐term‐care#sthash.5mmHNOgi.dpuf

Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education: Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press, 2011.

Kaye AD, Baluch A, Scott JT. Pain management in the elderly population: a review. Oschner J. 2010;10(3):179‐187.


REFERENCES

Lapane KL, Quilliam BJ, Chow W, Kim MS. Pharmacologic management of non‐cancer pain among nursing home residents. J Pain Symptom Manage. 2013; 45(1):33‐42.

Morbidity and Mortality Weekly Report (MMWR), November 4, 2011 / 60(43);1487‐1492.

National Initiative on Pain Control at www.painedu.org Pain Management. Trend Reports, Annals of Long Term Care, December, 2012.

Pain management in the long‐term care setting. American Medical Directors Association. (2003).

Pharmacological Management of Persistent Pain in Older Persons. Special Article, JAGS, 2009. 57:1331‐1346.


REFERENCES

3/17/2016

33

Prevalence and Management of Pain, by Race and Dementia Among Nursing Home Residents: United States, 2004; NCHS Data Brief, Number 30, March 2010.

Quality Improvement Organizations at www.medqic.org.

Schappert SM. Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States,1997. National Center for Health Statistics. Vital Health Stat. 1999;13(143).

Shukla D, Tripathi AK, Agrawal S, Ansari MA RastogiA Shukla VK. Pain in acute and chronic wounds: a discriptive study. Ostomy Wound Management. 2005;51(11):47‐51.


REFERENCES

The TEDS Report, Changing Substance Abuse Patterns among Older Admissions: 1992‐2008; SAMHSA (2009).

Teno JM, Weitzen S, Wetle T, Mor V. Persistent Pain in Nursing Home Residents, JAMA 2001; 285(16):2081. Partners Against Pain web site at www.partnersagainstpain.com (Pain Management Center, Pain in the Elderly).

Vital Signs: Overdoses of Prescription Opioid Pain Relievers ‐ United States, 1999‐2008, Centers for Disease Control and Prevention Analysis.

Volochayev R. Pain management: acute and chronic. National Institute of HealthWebsite. http://clinicalcenter.nih.gov/ccc/nursepractitioners/pdfs/pain_managemen.... Accessed January 8, 2014.


REFERENCES

3/17/2016

34

WHO’s pain ladder for adults. World Health Organization Website. www.who.int/cancer/palliative/painladder/en. Accessed January 8, 2014.

Won AB, Lapane KL, Vallow S, Schein J, Morris JN, Lipsitz LA. Persistent nonmalignant pain and analgesic prescribing patterns in elderly nursing home residents. J Am Geriatr Soc. 2004;52(6):867‐874.

Woo KY, Exploring the Effects of Pain and Stress on Wound Healing. AdvSkin and Wound Care 2012;25(1):38‐44.


REFERENCES

as a courtesy to those around you, please silence …

Documents