2NN3 - Managing Chronic Pain

Collaborate with the person to...

identify their goals for pain management and suitable strategies to ensure a comprehensive approach to the plan of care.

Establish a comprehensive plan of care that incorporates the goals of the person and the interprofessional team and addresses:

Assessment findings

The person's beliefs and knowledge and level of understanding

The person's attributes and pain characteristics.

Reassess the person's response to the pain management interventions consistently using the same re-evaluation tool. The frequency of reassessments will be determined by:

Presence of pain

Pain intensity

Stability of the person's medical condition

Type of pain e.g. acute versus persistent

Practice setting

Pain is defined as an unpleasant _______ and ________ experience associated with actual or potential damage or described in terms of damage.

sensory and emotional

This definition recognizes both the physiologic and affective nature of the pain experience.

Pain can be classified by these types:

nociceptive and neuropathic

Nociceptive pain

considered a warning signal that results from actual or threatened damage to non-neural tissue resulting in the activation of nociceptors in a normal functioning nervous system

Neuropathic pain

clinical description of pain thought to be caused by damage from a lesion or disease of the somatosensory nervous system that is confirmed by diagnostic investigations.

Also, pain categories can be based on...

the location of lesion (somatic, visceral), diagnosis (headache) or duration (acute, persistent).

The Canadian Pain Coalition's Pain in Canada Fact Sheet (2012) says...

1/5 Canadians have moderate to severe persistent (chronic pain), and one-third of those people have lost the ability to work because of the significant impact of pain on their health and quality of life.

The prevalence of persistent pain has been shown to _____________ with age, and persistent pain has been identified in approximately 65 percent of the older adult population (> 65 years of age) living in the community and in 80 percent of older adults living in long-term care

increase

t or f - Inadequate pain management is evident across all ages

true

Not everyone is able to talk about their pain. People who are unable to talk or self-report may include:

Neonates, infants and preverbal children

Older adults with cognitive impairment (such as advanced dementia)

Persons with intellectual disability

Critically ill or unconscious persons;

Persons who are terminally ill

Here are the steps to follow when someone cannot report their pain:

Attempt to have the person self-report

If a person is unable to self-report, rely on behavioural indicators or behavioural pain scales

Obtain proxy reporting from family or caregivers about potential behaviour that may indicate pain

Minimize emphasis on vital signs because they do not discriminate pain from other sources of distress.

Vital signs such as heart rate, blood pressure and respiratory rate should not be the sole source of information on the presence of pain.

Validated behavioural tools are also only one component of a comprehensive pain assessment

proxy reporting

Proxy reporting from people who know the person well can help the nurse detect changes in behaviour that may indicate the presence of pain.

However, family and caregivers' proxy reports of pain intensity (i.e., 0 - 10 Numerical Rating Scale - NRS) have been shown to be inaccurate .

Therefore, it is important to combine proxy pain assessments with other evidence such as the results of direct observation with validated behavioural pain scales, the person's diagnosis, findings from their health history and physical examination

People with pain have

certain beliefs about pain-related practices shaped by their past pain experiences, age, education, culture or ethnicity, and gender.

A person's beliefs about pain often influence whether

they will seek help for it and what strategies they will accept to manage it

Difficulties arise when a person makes decisions based on erroneous beliefs formed by a lack of understanding and incomplete knowledge of pain.

Eight pain-related beliefs and concerns that prevent persons with cancer from reporting pain and taking medication:

1) fear of addiction

2) concern about drug tolerance

3) belief that adverse effects from analgesics are even more bothersome than pain

4) fatalism (i.e., a resigned attitude) about the possibility of achieving pain control

5) belief that ''good'' patients do not complain about pain

6) fear of distracting a physician from treating the disease

7) belief that pain signifies disease progression

8) fear of injections.

Nurses need to ask questions to uncover a person's

beliefs and concerns about pain

People and their families or caregivers need help to understand that...

unrelieved severe acute pain can cause long-term pain problems that affect body functioning (systemic, hormonal, metabolic, immunologic, physiological, cardiovascular and pulmonary function responses)

People need to be encouraged to communicate moderate to severe post-surgical pain because it...

interferes with deep breathing and limits movement, which can lead to other health issues such as pneumonia and delayed recuperation

Read assumptions of RNAO pain

k

Nurses need to recognize the ____________ in each person's response to opioid analgesics

variability

________________ can be a common adverse effect when initiating opioids and when increasing opioid doses for pain management

sedation

________________ generally precedes significant respiratory depression.

Gradual increase in _____________ is an early warning sign and a particularly sensitive indicator of impending respiratory depression in the context of opioid administration.

sedation

Regular serial systematic ___________________ and ________________ assessments are recommended to evaluate the person's response during opioid therapy

sedation and respiratory assesment

When children receive opioid medications it is very important to assess their

alertness

This allows health-care providers to recognize when a child is approaching over-sedation.

Nurses and interprofessional teams must frequently monitor...

a person's response to opioids to ensure the person's safety and avoid unintentional sedation and respiratory depression, particularly for people with no prior use of opioids.

The National Opioid Use Guideline Group (NOUGG) (2010) recommends

monitoring for misuse of opioids on implementation for pain management.

Signs of misuse include

escalating doses, use of alternative routes of delivery and engagement in illegal activities.

Physical interventions such as

physiotherapy and exercise and application of heat or cold should be considered along with pharmacological interventions to reduce pain, improve sleep, mood and general well-being.

When using more specialized interventions

(TENS, acupuncture) consult the appropriate interprofessional team member such as physical therapist or occupational therapist for assistance.

t or f - Non-pharmacological approaches should not be used as a substitute for adequate pharmacological management

true

Psychological (psychosocial) interventions such as

cognitive behaviour therapy, music, distraction, relaxation techniques and education should be considered in pain management because these interventions affect the way a person thinks feels and responds to pain

Psychological interventions related to education have been shown to...

assist with coping and enhancing the person's ability to self-manage to lessen pain (post-operative pain).

t or f - The effectiveness of non-pharmacological interventions should not be generalized for use in all persons and only be proposed based on the best evidence of their effectiveness for the person's population group

true

misbelief: Infants' nervous systems are immature and not capable of

pain perception

fact: Infants have the anatomical and functional requirements for

pain processing by mid to late gestation. Newborn infants are

capable of the sensory-discriminative aspects of pain experience

misbelief: Infants are less sensitive to pain than older children and adults

Term neonates have the same sensitivity to pain as older infants

and children. In fact preterm neonates have a greater sensitivity

to pain than term neonates or older children.

Infants are incapable of

remembering therefore pain

should have no lasting effects.

Repetitive exposure to pain may have cumulative effects and

early exposure to significant pain may permanently affect

children's perceptions of, and reactions to, subsequent pain

misbelief: Infants must learn about pain from experience.

fact: Pain requires no prior experience and is not learned. Pain is

present with the first insult.

misbelief: Infants and young children are incapable of expressing pain. If they are able to express pain, their pain cannot be assessed.

fact: Although infants cannot verbalize pain they respond with

behavioural cues and physiological indicators that can be

accurately assessed. The most reliable approach in infants is

facial expression. The most valid approach is through the use of

a composite pain measure. Children as young as 3 years of age

can use pain scales and by 4 years of age they can accurately

point to the body area that hurts

misbelief: Opioids are more dangerous for

infants and children than they

are for adults (termed 'opioid

phobia').

fact: Infants older than one month of age metabolize drugs in the

same manner as older infants and children. Careful selection

of appropriate dose and dosing schedule, as well as frequent

monitoring for desired and undesired effects, can minimize the

potential adverse effects of. Addiction to opioids used to treat

pain is extremely rare in children.

misbelief: People should expect to have considerable unrelieved pain

with procedures such as surgery.

fact: Unrelieved severe acute pain has pathophysiological consequences involving respiratory, cardiovascular, gastrointestinal, immune, neurological, musculoskeletal systems

misbelief: People who are in pain always have observable signs that are more reliable than their own

self-reports.

fact: Physiological adaptations occur quickly and should not be used instead of self-report when the latter is available

misbelief: People will tell us when they are in pain and will use the

term "pain".

People will not necessarily tell us when they are in pain and may

not use the word pain

misbelief: People who use opioids for pain are addicts.

Opioids are a standard management intervention for moderate to severe pain with surgery, cancer, and persistent non-cancer pain (PNCP).

misbelief: Pain is directly proportional to the tissue injury.

fact: Pain is multidimensional and influenced by many factors so each

person's response to the same type of surgery, trauma or disease

is individual and variable

misbelief: Pain is a normal part of getting older and can never be very intense, pain sensation decreases with age.

fact: Persistent pain is not a normal part of aging. The intensity

and sensation of pain does not decrease in older persons.

Inadequate pain management of potential or actual pain in

older persons has numerous consequences

t or f - Pain cannot be assessed

with older persons who are

cognitively impaired

fact: Older people with mild to moderate cognitive impairment are

able to use scales adapted for their needs such as categorical

numerical scales

Pain in special pop: preterm and newborn infants

Preterm and sick infants are exposed to numerous painful procedures during their

hospitalization. Prevention and consistent management of pain is important to reduce adverse effects affiliated with repeated painful procedures. When planning

drug dose, infant weight must be taken into consideration.

pain in special pop: Infants and young children

Both sick and healthy infants and young children are exposed to multiple painful procedures during hospitalization and early childhood immunizations.

Young children lack understanding and coping skills and often exhibit high levels of pain, distress and fear.

Consistent effective management of pain caused by needles has the potential to reduce subsequent fear of medical care.

Strategies are available to reduce pain and distress associated with immunization in infants and children.

pain in special pop: older adult

The older adult may experience communication challenges associated with:

■ Under reporting of pain,

■ Speaking a different language, and

■ Communication barriers (aphasia, cognitive impairments such as dementia, visual and hearing impairments).

When planning pharmacological interventions, the impact of age-related changes such as co-morbidities, co-existent diseases and use of multiple medications must be considered, as they put the older adult at high risk for medication-related adverse events

pain in special pop: critically ill

Many critically ill patients are unable to self-report due to multiple factors such as mechanical ventilation, administration of high doses of sedative agents, and altered levels of consciousness.

In addition to their reason for admission often related to pain, they are exposed to many painful procedures during hospitalization in a critical care unit.

A high proportion of critically ill patients experience moderate to severe pain.

Therefore, pain management includes the use of opioids, mainly through parenteral route.

Continuous monitoring of physiologic parameters is necessary to ensure adequate surveillance of patients.

Moreover, multi-modal approaches are strongly recommended but have to be carefully established taking according to the complex patient's condition and use of other

medications.

Non-pharmacological interventions are also suggested to maximize

pain relief.

Look at different pain assesments!

RNAO

unintentional death related to prescription opioids has been identified as a public health crisis, owing in part to such factors as...

insufficient professional training and medication overprescription, misuse, and diversion

Chronic pain, also known as persistent pain, is...

any pain that continues beyond the period over which healing would normally occur (generally three to six months) and affects a person's function or quality of life

While chronic pain can be alleviated through effective and compassionate treatment, it is rarely...

eliminated entirely

treatment options for chronic pain include

nonpharmacologic modalities, such as physical therapy and cognitive-behavioral training; nonopioid analgesics; adjuvant medications, such as anticonvulsants and antidepressants; injection therapies, including trigger-point injections, large joint injections, and epidural steroid injections; central nervous system

for carefully selected patients whose chronic pain and functional status does not improve with nonopioid therapies, we give....

opiods

Although prescription opioids have been associated with misuse, abuse, diversion, and unintentional death, this is in part owing to such factors as...

insufficient provider education and professional training.

pain..

Acute pain alerts the patient to risk of tissue damage or injury.

Chronic pain may start with an acute pain episode that persists long beyond the time of expected healing, or it may occur spontaneously, as is the case with fibromyalgia and various types of neuropathy

t or f - Patients with chronic pain are often socially isolated and stigmatized; they have more disability than the general population, and their pain is often inadequately managed

true

t or f - Opioids remain a necessary option for managing chronic pain in selected patients and that they should be used not as monotherapy, but as part of a comprehensive multimodal plan of care that includes nonpharmacologic interventions and nonopioid medications as first-line therapy

true

What is the goal of chronic pain management?

to achieve improvements in both pain intensity and functional status, with the emphasis on functional improvement.

chronic pain ppl

People with chronic pain commonly report having difficulty falling asleep and maintaining sleep

They often experience fatigue and daytime drowsiness.

Patients who report poor quality of sleep also tend to report significantly higher pain intensity

Early recognition of sleep problems can minimze the risk of medication misuse

Improved function and quality of life is the focus of follow-up visits

alid and reliable assessment tools can help nurses

identify the effects of pain on the patient; track progress during treatment; evaluate adherence to medications; and recognize misuse, overuse, or illicit use

When patients report unrelieved pain, the possibility of a

new or progressive problem should be considered and fully evaluated

Opioid-induced ______________ is nearly universal

constipation

For most patients, management requires regular use of a stimulant or osmotic laxative as well as a stool softener

Patient teaching should include a plan to prevent and treat constipation

Sedation, nausea, and urinary retention may also occur when opioid therapy is initiated, but

these diminish with time

Long-term opioid use may cause some patients to exhibit symptoms of ...

hypogonadism or to become more sensitive to painful stimuli, a condition known as opioid-induced hyperalgesia.

Decreases in testosterone and estrogen may adversely affect sexual drive and function and have long-term negative effects on muscle mass and bone density

Physical depedence

an adaptation to a drug that manifests in withdrawal symptoms upon the drug's abrupt cessation or rapid dose reduction

Physical dependence is an expected effect of opioid therapy

If a person taking opioids stops the medication abruptly, symptoms of withdrawal will occur within approximately 12 hours.

Slowly tapering off dose prevents withdrawl

Opioid tolerance

Tolerance to sedation, nausea and vomiting, euphoria, and anxiolytic effects of opioids develops rapidly

Tolerance develops more slowly to the analgesic effects of opioids, but when it occurs, it results in less analgesic efficacy

Ask the patient whether there is a new problem causing the pain, if the pain has worsened, or if the opioid is being used for purposes other than analgesia

Opioid Withdrawal

Any person taking opioids for several weeks or longer may experience symptoms of withdrawal (also called opioid abstinence syndrome) if the opioid dosage is rapidly decreased or if opioids are abruptly stopped

Opiod withdrawal

characterized by sympathetic arousal with elevated heart rate and blood pressure, pupillary dilation, goose bumps, anxiety, jittery behavior, and additional symptoms such as nausea, diarrhea, runny nose, yawning, myalgia, and insomnia.

Symptoms of withdrawal are treated by...

resuming opioid therapy at a lower dose and providing a less drastic tapering schedule, or with an α-blocking agent, such as clonidine

Opiod-induced hyperalgesia

occurs when repeated or prolonged exposure to opioids makes the person increasingly sensitive to painful events or causes the chronic pain to intensify, spread, change in quality, or increase in frequency.

The treatment for opioid-induced hyperalgesia is to gradually reduce the opioid dose while transitioning the patient to an effective nonopioid alternative.

Advise patients of the risks of mixing opioids with other _______________drugs, such as benzodiazepines, carisoprodol (Soma), zolpidem (Ambien and others)

sedating

for chronic pain, opioid therapy should be administered only to patients whose pain is...

moderate to severe and unmanageable without it.

It's necessary to conduct a thorough risk assessment of the patient's ability to

use opiods safely

t or f - Opioid risk screening tools, such as the Opioid Risk Tool (ORT), may be helpful in determining the type and intensity of monitoring the patient requires and the patient's need for referral to additional supportive services.

true

The ORT is a

simple, validated, five-question survey that may be used to stratify patients into categories of low, moderate, and high risk before starting therapy

The patient's initial risk category should always be modified to incorporate actual behavior over the course of opioid therapy, as ORT results may be misleading

Ex. patients who are initially assessed as low risk on the ORT but demonstrate high-risk behaviors over the course of opioid therapy should be monitored more frequently.

opiod agreements

Both the prescriber and patient review and sign the agreement, which serves as an educational tool, a written reminder of mutual expectations, and a way to build patient and provider trust

Random urine drug testing

used to determine whether patients are taking prescribed medications as directed and not illicit or prescription drugs that have not been prescribed.

Pill counts

Pill or patch counts performed at regular visits or at random are another means of monitoring adherence. For the count, patients should bring their medications in the containers in which they were dispensed

t or f - Medication safety, storage, and disposal. Patient education should include proper security and disposal of unused medication

true

t or f - Saving medications for later" also increases the risk of misuse and intentional or accidental ingestion by another person

t

T of F- flush opiods in toilet

no dont do that

when selecting an opiod

the prescriber considers the patient's health status, age, and previous exposure to opioids; the potential for drug-drug interactions; and the treatment plan

The oral or transdermal routes are preferred for

chronic pain opiods

Opioid-naïve patients should never begin therapy with

long-acting or extended-release opioids

extra info

If a patient has had prior opioid treatment, morphine equivalency ratios may be considered (ex. 15mg codeine=2.25 mg morphine)

Methadone dosing is unique and dose dependent. For example, 10 to 20 mg of methadone is considered the equivalent of 40 to 80 mg of morphine

Older adults and pain

- Nonsteroidal antiinflammatory drugs are often contraindicated or used with caution in this age group.

- Metabolic changes that occur with aging may slow drug metabolism and excretion, potentially leading to higher than expected serum drug levels

- Oversedation= falling

patients with renal problems

Patients with significant liver dysfunction should avoid products containing acetaminophen

Certain opioids, such as morphine and codeine, should be avoided in the treatment of patients with renal dysfunction, as they have active and potentially toxic metabolites that tend to accumulate in the presence of impaired renal clearance

safe opiod- not given renally

pregnant women and opiods

Both opioid physical dependence and opioid withdrawal during pregnancy are associated with adverse perinatal outcomes.

Childbearing age women should be aware of this

Effective birth control is essential when opioid therapy is considered in a woman of childbearing age

It is critical to refer women who discover a pregnancy while using opioid therapy to a high-risk obstetric program

At present, supervised opioid maintenance therapy for women taking opioids for any reason during pregnancy is the recommended treatment approach

patients with sleep prob

Raises concerns since the combined effects of obstructive apnea due to airway collapse and central apnea due to opioid use could increase the risk of hypoventilation or respiratory depression during sleep

patients with symptoms of obstructive sleep apnea who are using opioid therapy should be referred for appropriate sleep evaluation

Patients with depressed mood or anxiety

Chronic pain may adversely affect mood; conversely, depressed or anxious mood can increase pain perception.

Identifying and treating depression and anxiety are part of a comprehensive pain management plan

patients with adverse health behaviors

- smoking?

alcohol use is contraindicated in patients using opioid therapy, as alcohol greatly increases the risk of adverse outcomes, including central nervous system and respiratory depression, aspiration, overdose, and death

-obesity

- substance use history

for patients with an active substance use disorder or a history of diverting drugs, chronic pain is best treated by a...

pain management and addiction specialist

_________ assessment is essential for effective management

routine

Unrelieved pain after surgery or injury results in ...

more complications, longer hospital stays, greater disability, and potentially long-term pain.