Lisa Stephenson QIPP Lead Pharmacist NEE CCG 26th January 2016 Pain Management Lisa Stephenson QIPP Lead Pharmacist NEE CCG 26th January 2016

What is Pain? Pain is a very individual experience; only the person feeling the pain can describe it properly. Pain can be:- Acute or short-term pain Indication of injury Chronic or longstanding pain Longer than 3 months mild or severe It is not well understood either in humans or animals and since it is complex and cannot be directly measured. For example two people may undergo the same unpleasant experience but each will have a different description of the pain. This makes it difficult to define and treat. Acute or short-term pain This can be intense and short-lived and is usually an indication of impending danger (for example touching a sharp object, or something cold or hot) or an indication of an injury. When the danger is removed, or the injury heals, the pain usually goes away. Chronic or longstanding pain This lasts for much longer (at least 3 months) and can be mild or severe. When pain lasts for a long time, it can affect every part of a person's life. It can affect their ability to work, their relationships with family and friends, activity levels, sleep and independence. All of this can become overwhelming and can cause a vicious circle of pain and distress. It is now widely accepted that longstanding pain and disability can only be understood and managed within a biopsychosocial model. Since people's beliefs about pain, disease and/or disability are the largest predictors of pain-associated disability, treatment needs to address the role of biological, psychological and social factors as obstacles to recovery.

Signs of Pain Verbal Non – verbal The person affected tells us Facial Expressions Vocalizations Body Movements Social Interaction Facial Expressions -Clenched teeth, Wrinkled forehead, Biting lips, Scowling, Closing eyes tightly, Widely opened eyes or mouth Vocalizations – Crying, Moaning, Gasping, Groaning, Grunting Body Movements –Restlessness, Protective body movement, Muscle tension, Immobility, Pacing, Rhythmic movement Social Interaction – Silence, Withdrawal, Reduced attention span, Focus on pain relief measures

Dementia & Pain Non – verbal Facial Expressions Vocalizations Body Movements Behavioural changes Emotional changes Facial expressions When you look at the person’s face, are they telling you they are in pain e.g. frowning, looking frightened? Verbal expressions Is the person making unexplained/different noises e.g. groaning, crying? Body movements Is the person’s body language telling you they are in pain e.g. pacing, rocking? Behavioural changes Are there changes in their behaviour e.g. sleeping, eating or not wanting to get out of bed? Emotional changes Have you noticed any emotional changes e.g. irritability or distress?

Non-pharmacological Interventions Comfort measures Hot water bottle Blanket Pillows for support Movement and changing position Some positions may can less pain Massage Distraction Massage provide pain relief and comfort Distraction may work for some people with acute pain. This involves doing something they enjoy e.g. listening to music, playing board games

Pharmacological Treatment Paracetamol - OTC Ibuprofen - OTC Naproxen Codeine Morphine orally Patches

Patches Where on the body to apply patches? Intact skin on your upper arm, outer arm, upper chest, upper back or side of the chest. Apply to a relatively hairless or nearly hairless skin site. If no suitable hair free sites are available the hairs should be cut off with a pair of scissors. Do not shave them off. Avoid skin which is red, irritated or has any other blemishes, for instance large scars. After a hot bath or shower, wait until the skin is completely dry and cool. The area of skin you choose must be dry and clean. If necessary, wash it with cold or lukewarm water. Do not use soap, alcohol, oil, lotions or other detergents. Do not apply lotion, cream or ointment to the chosen area. This might prevent your patch from sticking properly. A new patch should then be applied to a different skin site after removal of the previous transdermal patch. Several days should elapse before a new patch is applied to the same area of skin.

Warnings associated with opiate patches All patients should be advised to avoid exposing the patch site to direct external heat sources such as heating pads, hot water bottles, electric blankets, prolonged hot baths while wearing the patch, since there is potential for temperature dependent increases in release of drug from the patch. Patients with fever should be monitored for opioid side effects.

Removal and Disposal of Patches Breathing difficulties Increased drowsiness Confusion Dizziness Impaired speech Patches should be disposed of by folding in half and seal all edges then place in clinical waste Remove patch immediately and seek medical attention

Recap Non-pharmacological and pharmacological treatment may be used Patches must be applied to hairless area of skin Avoid hot baths while wearing patch Remember people with dementia express pain non-verbally

Questions