What’s the deal with Pain?

Useful Pain Management in

the post-acute setting.

Mary Kofstad, APRN, MSN, FNP-BC

Vice President Clinical Operations Signature Home Health, Hospice &

NP2U

Objectives

Review pathophysiology, mechanism of action and

classifications of pain.

Discuss pharmacologic and non- pharmacologic

interventions.

Describe multimodal pain management including

evidence based tools and assessments for use in the

post-acute setting.

Case Study: you are consulted for

pain management

43 year old male status post lumbar discectomy

On Dilaudid, Fentanyl, Soma & Ativan

Not ambulating

Skipping therapy- has PT & OT

Describes pain with ambulation- shooting down left leg some foot drop bilateral leg weakness

Has been on chronic opioids for 18 months

Vital signs stable, no new or worsening complaints or symptoms.

CLINICAL QUESTIONS:

What can we do to get him moving with therapy?

Non-medication strategies?

What more do you want to know about assessment and history?

Case Study # 2 Consulted for pain

management 86 year old female C6 fracture- quadriplegic after fall

Pain in neck and shoulders, describes as shooting, aching.

Participating in Therapy, PT, OT, Speech

Has been inpatient rehab for 4 weeks

Has Tylenol ordered, takes BID, has morphine not using nurse told her “it

effects your breathing.”

Interested in stopping therapy

CLINICAL QUESTIONS:

What non medication therapies could we consider?

What other issues may be effecting decision making?

What other information and history do you need on this case?

Definitions of Pain:

An unpleasant sensory and emotional experience

associated with actual or potential tissue damage or

described in terms of such damage

IASP 1979

Whatever the experiencing person says it is existing

whenever he says it does

Margo McCaffery

1968

Pathophysiology of Pain:

Mechanism of Action

Nociception

-perception of pain

Nociceptors

-bare nerve endings in skin, muscle, joints, arteries, and the

viscera that respond to chemical, mechanical, and thermal

stimuli

-detect a wide range of stimuli

Pathophysiology of Pain:

Transduction of Pain

• Noxious Stimuli

– Mechanical

– Thermal

– Chemical

• Peripheral Soup

– Histamine - Antihistamines

– Substance P - Capsaicin

– Prostaglandins – Corticosteroids,

– NSAIDS

– Bradykinin

– Serotonin

Pain Classifications: ACUTE

The normal, predicted physiological response to an adverse chemical,

thermal or mechanical stimulus…

SURGERY

INFECTION

BURN

TRAUMA

ACUTE ILLNESS

TIME: Less than 1 month but can be longer than 6 months

Initiation phase: persistent nociceptive and behavioral cascade triggered by

tissue injury

This cascade has the potential to rapidly evolve into chronic pain

Acute Pain Classifications :

SOMATIC

Well localized

Aching, throbbing, gnawing

Activation of nociceptors in cutaneous

and deep tissues

Bone mets, soft tissue injuries

Acute Pain Classifications:

VISCERAL

Poorly localized

Deep aching, cramping,

pressure, referred

Activation of nociceptors

resulting from stretch,

distention or inflammation

Bowel obstruction, biliary

colic

CHRONIC PAIN

Purposeless, cyclical. Irreversible

Persists> 3-6 months

Vegetative, depressive signs

Autonomic adaption

Tissue damage may not be evident

Unpredictable

Scope of the Chronic Pain Problem

IN 2011

Chronic pain conditions affect approximately 10 million U.S. adults

Cost $560 - $635 billion annually or about $2,000 for every person living in the U.S.

Direct treatment costs $261-300 billion

Loss of productivity $297-336 billion

Medicare bears ¼ of the costs for pain or 14% of all Medicare costs

IN 2016

100 Million Americans live with Chronic Pain

IOM, 2011

Opioids: American Epidemic

OPIOIDS: 55 billion

in health and social

costs

20 billion in ED visits

78 people a day die

from an opioid

related overdose

Acute on Chronic Pain

Acute exacerbation of chronic pain condition

Preoperative assessment & formulated perioperative plan is essential.

Physical dependence means that a postoperative baseline opioid requirement is necessary to prevent withdrawal.

Postoperative opioid requirements may be more or less than preoperative levels, depending on the effect of surgery.

Consequences of Uncontrolled Pain

Delays healing

Noxious stimuli

can lead to enhanced sensitivity to subsequent noxious stimuli

(hyperalgesia)

can sensitize the pathway of previously nonpainful stimuli

(allodynia)

enhance the response of the spinal neurons

Overall result is sensitization of the central nervous system also

known as “windup”

Mayer et al., 2015; Belfer, 2013

Why So Much Pain?

AGING

Cancer

Traumatic Injury

Autoimmune

Disease

RA

Lupus

Scleroderma

MS

Fibromyalgia

Chronic Disease

Diabetes

Osteoarthritis

Obesity

HIV

Headaches

Muscle tension

Migraine

Cluster

Perception

Occurs in the cortex

Thalmus relays information=e

limbic system where affective

responses

“EMOTIONAL CENTER”

Influenced by psychological,

biological, social, and spiritual

dimensions

The Brain Shows Pain

Neurologic brain

signature for pain

Standard map can be

employed for patients

experiencing pain

Yellow areas predictive

of higher levels of pain

Blue areas predict lower

levels of pain

NEJM, 2013.

Individual Response to Pain: Biology

Extent of illness or injury

whether the person has other

illnesses, is under stress,

specific genes

Predisposing factors that

affect pain:

TOLERANCE

THRESHOLDS

Individual Response to Pain: Psychological

Anxiety,

Fear,

Guilt,

Anger,

Depression,

Thinking pain represents

something worse helpless

to manage.

Individual Response to Pain: Social

Response of significant other

or family

Support, criticism, enabling

behavior or

Withdrawal—the demands of

the work environment,

Access to medical care,

culture family attitudes &

beliefs.

Stress

Comprehensive Assessment of Pain

Location

Duration

Intensity

Quality

Timing

Aggravating and alleviating factors

Nonverbal cues

Objective findings: changes in

Pulse, BP, Gait

Other symptoms

Current therapies

Prior treatment and response

Functional changes

Risk of substance abuse

Risk of diversion

NCCN Guidelines, 2012

4 A’s

• Analgesia

• ADLs

• Adverse Events

• Aberrant

Behaviors

Pain Assessment tools

One-dimensional

Verbal descriptor scale (VDS)

Numerical rating scale (NRS)

Visual analog scale (VAS)

Multidimensional

McGill Pain Questionnaire (MPQ)

Brief Pain Inventory (BPI)

Neuropathic Pain Questionnaire (NPQ)

Points for clarification

Rate your pain

Concerns about saying a high number-

Addresses a true barrier in pain management

Describe your pain- OUCH

This all comes down to:

COMMUNICATION

Visual Pain Scales

Pain Scales for Assessment:

CNPI-used for patients that are nonverbal

Pain Scales for Assessment:

PAINAD-used for advanced dementia or cognitive

impairment

Barriers to Pain Assessment:

PATIENT BARRIERS

Lack of knowledge about pain

and pain relief.

Cultural differences

Language barriers

Socioeconomic status

Physical and psychological

condition of patient

Age

COMMUNICATION- Health

literacy levels, diseases, age

Professional

BIAS/PROFESSIONAL BARRIERS

Lack of knowledge

Low priority

Values & beliefs

TIME

SYSTEM BARRIERS

Lack of systemic approach to pain

Lack of accountability

Points for clarification

Non verbal- hand in the

face

Not my patient

Timing

Emotions

Communication

Communication

Therapeutic communication, the sender, or nurse seeks to illicit a

response from the receiver, or patient that is beneficial to the patients

mental and physical health.

Some of the emotions associated with therapeutic communication

include but are not limited to the following: Professionalism,

Confidentiality, Courtesy, Trust, Availability, Empathy, and

Sympathy.

The process of learning is active , open and honest.

Promotes mutual understanding

RESPECT

Likely to influence human behavior

Factors influencing communication:

Perceptions

Values

Emotions

Socio-cultural background

Knowledge

Role and relationships

Environment

Gender

Physical dependence: body relies on a external

source to prevent withdrawal. Physical dependence is

predictable, easily managed with medication, and is

ultimately resolved with a slow taper off

Tolerance: body’s adaption over time to a substance

resulting in a decrease effects over time

Pseudoaddiction- under treatment of pain,

manifested by behaviors similar to addiction (clock

watching, focus on obtaining drug, aberrant

behaviors), behaviors resolve once the pain is

effectively managed

A Neurobiological Disease

ADDICTION

Involves the brain’s reward (limbic) center

An area of the brain that is associated with the affective responses

to pain

Involves dopamine

Susceptible individuals may have an alteration of the limbic or

related system that causes sensitization to the reinforcing effects of

drugs

Treatments

MEDICATIONS

Opioid Agonists

Codeine

Hydromorphone

Propoxyphene

Morphine

Oxycodone

Oxymorphone

Hydromorphone

Fentanyl

Methadone

NSAIDS NON- OPIOIDS

Aspirin

Acetaminophen

Ibuprofen (Advil®, Motrin, Nuprin)

Naproxen (Anaprox, Naprosyn)

Etodolac (Lodine)

Ketorolac (Toradol)

Nambumetone (Relafen)

Celecoxib (Celebrex)

Meloxicam (Mobic)

Treatment Tailored to Quality

Somatic

• Dull

• Aching

• Well-localized

Direct stimulation of nociceptors

• Bone metastases

• Arthritis

• Musculoskeletal pain

• Acetaminophen

• NSAIDS

• Opioids

Visceral

• Cramping

• Diffuse

• Poorly localized

Diffuse pain

• Bowel

• Lymphedema

• Ascites

• NSAIDS

• Corticosteroids

• Opioids

Neuropathic

• Burning

• Lancinating

• Shooting

Changes in the peripheral or

central nervous system

• Brachial plexopathy

• CIPN

• Opioids

• Antiepileptics

• Antidepressants

• Corticosteroids

• Local anesthetics

• NMDA antagonists

Multimodal Pain Therapy

Opioids, non opioids, NSAIDs, Regional anesthesia or Local peripheral nerve block,

ICE, HEAT, MASSAGE

POSITIVE EFFECTS: with different mechanisms of action

Improved pain relief with reduced side effects

DECREASES OPIOID USE(30%–50%)

Continuous coverage with LESS sedation

Improved patient outcomes: SHORTER LOS, REHAB; may allow earlier discharge

Potential drawbacks

Multimodal techniques can be technical and labor-intensive: TIME

Increased number of drugs increases the number of potential adverse effects

MULTIMODAL APPROACH

Avoid multiple drugs from same

class that have the same

mechanism of action: Maximize

treatment before abandoning

Use lowest effective dose or

intervention

Discontinue if intolerable side

effect or adverse effect or if

treatment is not helpful

PATIENT: Pharmacy, Therapy,

Physician, Nurse, Aide,

Chaplain= TEAM

Nonpharmacological Interventions:

NO PILLS

Strategies other than medications

Types of non pharmacologic interventions

Basic comfort measures

Cutaneous stimulation techniques

Cognitive and behavioral strategies

Rationale for Nonpharmacologic

Treatment of Pain

Pain is more than just a sensory

experience.

Pain has affective, cognitive,

behavioral, sociocultural and

spiritual dimensions.

Most pain is best treated with a

combination of pharmacologic

and nonpharmcologic strategies

MULTIMODAL PAIN

MANAGEMENT

Primary vs Adjunctive Treatment

Type of pain

Pain intensity

Duration

Patient preference

Additional Benefits of

Nonpharmacologic Interventions

Reduced anxiety

Improved mood

Increased sense of control

over pain

Improved sleep

Decreased fatigue

Improved function

Restored hope

Improved quality of life

Barriers to Nonpharmacological

Pain Management

Lack of knowledge

Belief that nonpharmacologic interventions are

not effective

Perceptions that patients won’t be receptive

Lack of time & equipment

Lack of support from colleagues, administrators

Basic Comfort Measures

Positioning

Environmental

conditions

Lighting

Noise

Temperature

Pacing activities / rest

Supportive devices

Cutaneous stimulation

Stimulation of the skin and underlying tissues

Locations:

Directly over or around pain

Proximal to the pain (between pain and the

brain)

Distal to pain (beyond the pain)

Contralateral to pain (opposite side)

Heat/Cold

HEAT: Vasodilation

Decreases sensitivity to pain,

releases muscle tension, and

provides a competing

sensory experience

Useful for muscle tension or

spasm, neck and back pain,

arthritis, postoperative pain

NOT FOR ACUTE PAIN

OR INJURY

COLD: Vasoconstriction

Decreases sensitivity to pain,

reduces muscle spasms, and

provides a competing sensory

experience.

Useful for muscle spasms,

back pain, arthritis, headache,

trauma and surgical incision

pain

Cold may be more effective

than heat

Vibration

Changes the quality of pain sensations (e.g., sharp to dull)

Useful for muscle pain, tension headache, phantom limb pain,

postoperative pain

High frequency (fine motion) vibrations more effective than low

frequency

Duration: Up to 30 minutes, 2- 3 times / day

Contraindicated

Thrombocytopenia

Thrombophlebitis / DVT

Burned, cut, or fragile skin

Massage

Rubbing, kneading,

tapping or manipulating

soft tissue

Produces physical and

mental relaxation,

improves circulation

and may reduce edema

Useful for low back

pain, cancer pain,

fibromyalgia, headache,

musculoskeletal pain,

post-exercise pain and

soreness

Traditional massage: gentle kneading

strokes

Site of pain, back, neck, scalp, hands,

feet

Duration: 5 minutes – 1 hour

Contraindications

Thrombocytopenia

Fragile skin

Superficial thrombophlebitis or

DVT

Acute inflammation or skin

infection

Superficial tumor sites

TENS

Skin stimulation through

mild electrical current

Various modes:

conventional, brief-intense,

strong low-rate

(acupuncture-like)

Electrodes placed directly

over or near the site of pain

or at an acupuncture point

Useful for musculoskeletal

pain, low back pain,

rheumatoid arthritis,

postoperative pain,

phantom limb pain, and

headache

Requires a physician’s order

Contraindications

On-demand pacemakers

Implanted electrical

devices

Reserved for moderate –

severe pain due to cost

Physical Exercise

Aerobic exercise, resistance training

ROM, passive exercise in debilitated patients

Useful for low back pain, osteoarthritis, neck pain,

general musculoskeletal pain

Supervised by trained professional

Practiced on a regular basis

Intensity, frequency, duration should be

individualized to avoid exacerbation of pain

Active lifestyle change

Cognitive and Behavioral Strategies

Change the way pain is interpreted and experienced

Modify thoughts that prevent coping with pain effectively

Divert attention away from pain

Increase personal sense of control over pain

Relaxation

Release of stress and tension

associated with pain

Decreased autonomic

nervous system activity

Useful for:

Pain caused by muscle

tension

Arthritis, procedural pain,

postoperative pain, cancer

pain

Cognitive and affective

components of pain

Relaxation Techniques

Jaw Relaxation

Rhythmic breathing

Heartbeat breathing

Progressive muscle relaxation

Stretch-based relaxation

Meditation

Prayer

Music therapy

Distracts attention from pain,

stimulates relaxation, or

changes attitude / mood

Useful for procedural pain,

postoperative pain, cancer

pain, arthritis pain

Use patient preference for

music selection

Encourage tapping out

rhythm, singing, dancing

Give patient control over

volume and length of

intervention

Imagery/Distraction

IMAGERY

Using one’s imagination to

create sensory images that

decrease pain

Distraction / Relaxation

Imagery (pleasant scene)

Pain-focused (image of pain

itself)

Useful for back pain,

postoperative pain, arthritis

pain, headache, cancer pain

DISTRACTION

Directing attention away from pain

Requires:

Mental capacity to concentrate

Physical ability / energy to engage in

distracting activities

Useful for brief pain episodes,

procedural pain

Awareness of pain may return when

distraction ends

Complementary / Alternative

Medicine

Energy Therapies

Therapeutic Touch

Reiki

Qi Gong

Magnet Therapy

Dietary supplements

Herbal therapy

Homeopathy

Aromatherapy

Accupuncture

Caregiver Fatigue: Don’t get there

# 1 Solution: Set realistic

Expectations

If Chronic Pain establish

baseline

Okay to take meds

Okay to medicate –

especially prior to exercise

Patient satisfaction

Patient’s are informed

Time Management

Side effects matter

Case Study: you are consulted for

pain management

43 year old male status post lumbar discectomy

On Dilaudid, Fentanyl, Soma & Ativan

Not ambulating

Skipping therapy- has PT & OT

Describes pain with ambulation- shooting down left leg some foot drop bilateral leg weakness

Has been on chronic opioids for 18 months

Vital signs stable, no new or worsening complaints or symptoms.

CLINICAL QUESTIONS:

What can we do to get him moving with therapy?

Non-opioid strategies?

What more do you want to know about assessment and history?

Case Study # 2 Consulted for pain

management 86 year old female C6 fracture- quadriplegic after fall

Pain in neck and shoulders, describes as shooting, aching.

Participating in Therapy, PT, OT, Speech

Has been inpatient rehab for 4 weeks

Has Tylenol ordered, takes BID, has morphine not using nurse told her “it

effects your breathing.”

Interested in stopping therapy

CLINICAL QUESTIONS:

What non medication therapies could we consider?

What other issues may be effecting decision making?

What other information and history do you need on this case?

Take Away

Pain is Subjective

Patient Perception and communication styles matter

Patient expectations critical to our overall assessments,

treatment & management

Multimodal therapy is the best way to treat

Lots of tools exist

Patient Preference for care and treatment MATTERS

Acute Pain: Symptom

Chronic Pain: Disease

TAKE AWAYS

Multimodal- not multi medications

ASSESS- RIGHT TOOL

EDUCATE- EXPECTATIONS: TEACH BACK

EmPathy

Proactive

Patience

PARTICIPATING- TheraPy, ADL’s

COMMUNICATE

Questions??