Mount Auburn Hospital “The Nurses Role in Improving Pain Management” Julie O’Donnell, RN, BSN, BC

Objective: Distinguish the difference between nociceptive pain and neuropathic pain A.) Acute VS Chronic pain B.) Characteristics of nociceptive pain C.) Characteristics of neuropathic pain D.) Assessment findings E.) Pharmacologic interventions and non-pharmacologic interventions

Nurses know that… "Pain is what the person says it is and exists whenever he or she says it does." (McCaffery, 1968)

The definition of pain: Pain is "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, as described in terms of such damage". (The International Association for the Study of Pain)

Pain Experiences are… -unique to each patient -complex in nature -influenced by physical factors -influenced by psychological factors

Pain is the #1 reason patient’s visit their doctor… Pain is a public health problem that costs all of us.

Pain Transmission: Nociception The correct sequence of events in order… TRANSDUCTION PERCEPTION MODULATION

Pain: A Multimodal Issue

Physiological/Psychological Stressors Manifested in the Presence of Pain Escalated blood pressure, rapid heart rate, increased cardiac output, peripheral, systemic, and coronary vascular resistance, myocardial oxygen expenditure, coagulation, deep vein thrombosis Diminished cognitive performance, confusion, distorted disposition, high somatization, and anxiety Increased antidiuretic hormone, epinephrine, norepinephrine, aldosterone, glucagons, with decreased insulin and testosterone Cardiovascular Cognitive Endocrine

Physiological/Psychological Stressors Manifested in the Presence of Pain Gastrointestinal Genitourinary Quality of Life Metabolic Pulmonary Reduced gastric and intestinal motility Urinary retention, fluid burden, depression of immune responses Anxiety, depression Hyperglycemia, glucose intolerance, insulin resistance, protein catabolism Suppressed volume and flow, along sputum retention resulting in infection and atelectasis

Multidimensional Model of Pain Pain is multidimensional and complex. This is why single treatments are rarely effective.

Acute vs Chronic Pain Acute: -usually thought to resolve within a month (short duration) -pain that comes on quickly, can be severe but lasts a short time. -the cause is known -treatment typically with analgesics Chronic: -usually thought to last longer than six months (long duration) -“Pain that extends beyond the expected period of healing” -the cause may be known or idiopathic -treatment needs to be multidisciplinary

Characteristics of Nociceptive pain Nociceptive pain is causes by stimulation of the peripheral nerve fibers.

Nociceptive Pain: Somatic and Visceral -Somatic pain results from irritation or damage to the musculoskeletal system -Somatic pain may feel like a throbbing pain Examples: a cut to the finger, a stretching of a muscle Visceral pain results from the internal organs -Visceral pain is diffuse, poorly localized, and often referred. It is often described as generalized aching or squeezing. Examples: organ pain

Characteristics of neuropathic pain Neuropathic pain is a complex, chronic pain state that usually is accompanied by tissue injury. With neuropathic pain, the nerve fibers themselves may be damaged, dysfunctional or injured.

What symptoms would my patient show if they were having neuropathic pain? Symptoms may include: Shooting and burning pain Tingling and numbness

What causes neuropathic pain? ***Often time the cause is unknown Facial nerve problems HIV/AIDS MS Shingles Lower back pain Arthritis pain Fibromyalgia Migraine Sickle cell disease Malignant pain Neuropathic pain (trigeminal neuralgia, diabetic neuropathy, phantom limb pain, post herpetic neuralgia)

Referred pain: Pain that presents in an area other than its point of origin

Consequences of untreated pain: -impaired sleep -depression -anxiety -in older adults delirium and confusion -decreased socialization/loss of relationships -nutritional deficits -decline in ADL’s DECREASED QUALITY OF LIFE

Principles of Assessment Accept self report Use the same pain scale over time Assess when pain is both reported or suspected Re-assess routinely Consider the individual, the patient’s culture, values and beliefs

In summary… Nociceptive pain is greatly relieved when healing is complete, while neuropathic pain persists after healing is complete.

What happens if the pain is not relieved? Consequence of unrelieved pain is future pain. Failure to unrelieved pain may lead to future chronic pain syndromes

Treatments for Chronic Pain: Effective treatments for neuropathic/chronic pain: Currently there is no proven treatment to prevent or cure neuropathic pain (neuropathy or never pain). The primary goals of treatment are to reduce the pain as much as possible, balance the negative side effects of the treatment, and help patients manage any unresolved pain. Interdisciplinary approach Pain clinics

Pop Quiz Q: The least reliable tool for assessing pain in a cognitively intact adult is: a.) Changes in Vital signs b.) Observations of patients behavior c.) Assuming pain present with painful procedures d.) Patient’s self report

Non-pharmacologic interventions: -accupuncture -biofeedback -distraction -deep breathing -massage -guided imagery -hot and cold -laughter -music

Objective: Discuss the myths and misconceptions about pain C.) pseudoaddiction vs addiction D.) tolerance vs physical dependence E.) patient advocacy A.) providers misconceptions about pain B.) patients misconceptions about pain

Pain Questionnaire Handout True or False? Answers: 1.) F: Pain can increase myocardial demands 2.) F: It’s the patient 3.) F: Must manage tolerance 4.) True 5.) F: Indicates poor pain control 6.) F: Dose is not holding them for time frame ordered

Pain Questionnaire Handout True or False? 7.) F: Balanced analgesia 8.) F: Antacids blocks NSAID absorption 9.) F: no high when pain 10.) F: the antidepressants are used to treat certain types of pain and relieving depression is not the intent directly

Providers: Myths and Misconceptions about pain -Pain perception decreases with age -If the vital signs are good the patient isn’t in pain -If the patient is asleep they are free of pain

Patients: Myths and Misconceptions about pain -”Good” patients don’t report pain - Pain is punishment -Addiction is common -Strong pain medicine should be saved for later -The health care provider will know if I am in pain -No pain, no gain -Pain is normal part of aging

Myths about pain: Doctors and nurses are the experts about pain. THE REALITY: The older adult is the expert. Pain is a complex, subjective experience that is best described by the person who feels it. When the older adult cannot report pain because of cognitive impairment or stroke, the people who know the individual best should be consulted. These people usually include family members and nursing assistants.

Myths about pain: It’s important to be stoic about pain. THE REALITY: Stoicism can prevent health care providers from identifying and treating pain. Reference: http://www.geriatricpain.org/Content/Management/Pages/default.aspx

Pseudoaddiction vs Addiction According to the U.S. National Institute of Health, National Cancer Institute (2004), “The term pseudoaddiction was coined to depict the distress and drug-seeking that can occur in the context of unrelieved pain.

Pseudoaddiction vs Addiction The American Society for Addiction Medicine defines addiction as physical and/or psychological dependence on substances. Addiction is defined as the continued use of a addictive substance or behaviors despite adverse consequences.

Pseudoaddiction vs Addiction A person who is addicted to drugs also develops psychological dependence on the drug not just a physical dependence.

Pseudoaddiction vs Addiction Addiction can also be viewed as a continued involvement with a substance or activity despite the negative consequences associated with it.

Tolerance vs Physical dependence Physical dependence occurs when a person's body becomes accustomed to and dependent on the presence of a particular drug. When the dose is lowered or the drug is stopped, the person will begin to notice withdrawal symptoms.

Tolerance Normal biologic adaptation May develop at different rates Exposure to drug the effect of the drug over time NOT ADDICTION

What will my patient exhibit if they are showing signs of withdrawing? Some withdrawal symptoms feel like a flu bug.

Physical dependence A person can be physically dependent on a drug but not addicted to it. When a medication is stopped it is expected that our patients can show signs of withdrawal.

At Risk: People with addiction disorders Requests for pain meds are often perceived as addiction We cannot withhold meds due to past addictive disorders Relapse may be a consequence of undermedicating true pain Person may “self medicate” their pain

Guidelines for treating patients with addiction disorder: Define and treat pain syndrome Identify history of substance abuse Establish parameters/make contracts Discuss consequences of noncompliance Use adjuvant medications Use non-opiod treatments Use controlled release opiod agonists Close watch on behaviors and compliance with plan

Patient Advocacy When drug users become tolerant to a drug's effects, they must increase the dose to feel the same effects of the original dose. This is why it is important to teach our patients about slowly cutting down their pain medications when appropriate.

Objective: Identify the cultural barriers to providing acceptable pain management to patients. A.) Patient populations at risk for undertreatment of pain B.) How to perform a cultural pain assessment? C.) Knowledge of Self/Identify our own biases about pain D.) Evidence Based Practice

Which patient populations are at risk for undertreatment of pain? Minorities are three times as likely to be under treated. Patients receiving a poor pain assessment from an inexperienced health care provider. People with non-cancer pain.

Which patient populations are at risk for undertreatment of pain? People with "Good" performance status, such as someone who appears to be coping well and performing activities adequately. People over the age of 70.

HOW CULTURE AFFECTS THE PAIN EXPERIENCE People from cultures that value stoicism tend to avoid vocalizing with moans or screams when they are in pain. Other cultural groups tend to be more expressive about pain. They learned from childhood that when one is in pain, the appropriate response is to moan or cry.

Cultural Assessment Pop Quiz During your initial assessment of Mr. T’s pain he tells you that he is in terrible pain but just wants to endure it. The best response to this statement would be: A.) Tell him not to endure the pain B.) Further explore what he means by his statement C.) Provide information about the harmful effects of unrelieved pain. D.) Offer him analgesic medication

CULTURAL PROBLEMS COMPLICATING PAIN MANAGEMENT Language and interpretation problems Nonverbal communication problems Culturally or linguistically inappropriate pain assessment tools Underreporting Reluctance to use pain medications Providers' fears of drug abuse.

CULTURAL PROBLEMS COMPLICATING PAIN MANAGEMENT Prejudice and discrimination.

HOW CULTURE AFFECTS THE PAIN EXPERIENCE “People from different cultures conceptualize and describe pain using different cognitive frameworks. Being asked to characterize pain using an unfamiliar descriptive context may result in inadequate pain control.” Reference: (Green CR, et al,2003)

HOW CULTURE AFFECTS THE PAIN EXPERIENCE Culture also influences beliefs about what pain treatments are appropriate. In the Western biomedical culture, medications are the first line of defense, whereas Eastern cultures tend to prefer medicinal herbs, touch, and energy therapies such as acupuncture and yoga.

Examining our own biases… The tendency to feel that one's own cultural norms are correct and to evaluate others' beliefs in light of them is known as ethnocentrism. Most of us tend to believe that attitudes and behaviors that match our own are correct and those that don't are abnormal, wrong, or inferior.

HOW CULTURE AFFECTS PAIN ASSESSMENT AND MANAGEMENT As Nurses we need to first examine our own cultural beliefs about pain. As Nurses we need to remember that patients' diverse cultural patterns usually aren't right or wrong or normal or abnormal, just different that ours.

Activities that enhance pain management Show respect for other cultures Promote a feeling of acceptance Avoid stereotyping Understand individuals goals and expectations Use appropriate assessment tools Call an interpreter if we need to or use the interpreter phone

Evidence Based Practice The information obtained from a culturally sensitive assessment will allow nurses to develop a pain management plan that meets the professional standard of care and is culturally acceptable to the patient. To do this, nurses can group what they've discovered about how the patient's culture influences her or his pain and improve pain management.

In Summary: All patients have a right to effective pain management. Understanding the influences culture has on patients' pain experiences and attitudes regarding treatments will permit nurses to achieve better pain outcomes for all of them.

In Summary: Use the nursing process Gather pertinent objective and subjective data Accept self report Develop individual plans of care Reassessment is key in order to evaluate and revise the plan

THANK YOU SO MUCH FOR COMING TODAY! Please enjoy some candy!

References: 1.) McCaffery, M. (1968) Nursing Practice Theories Related to Cognition, Bodily Pain, and Environment. 2.) 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. 3.) National Centers for Health Statistics, Chartbook on Trends in the Health of Americans 2006, Special Feature: Pain. 4.) Results from the 2009 National Survey on Drug Use and Health (NSDUH): National Findings, SAMHSA (2010). 5.) Highlights of the 2009 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits, SAMHSA (December 2010). 6.) Vital Signs: Overdoses of Prescription Opioid Pain Relievers --- United States, 1999--2008, Centers for Disease Control and Prevention Analysis: Morbidity and Mortality Weekly Report (MMWR), November 4, 2011 / 60(43);1487-1492. 7.) Jacques, A. (1992) Do you believe I am in pain? Professional Nurse; 7: 4, 249-251. 8.) Frantsve, L.M., Kerns, R. (2007) Patient-provider interactions in the management of chronic pain: current findings within the context of shared medical decision-making. Pain Medicine; 8: 1, 25-35. 9.) Clarke, K., Iphofen, R. (2005) Believing the patient with chronic pain: a review of the literature. British Journal of Nursing; 14: 9, 490-493. 10.) Green CR, et al. The unequal burden of pain: confronting racial and ethnic disparities pain. Pain Med 2003

References: 10.) Green CR, et al. The unequal burden of pain: confronting racial and ethnic disparities pain. Pain Med 2003 11.) American Nurses Association. Position statement on discrimination and racism in health care. 1991 12.) International Study of Pain: An unpleasant experience that we primarily associate with tissue damage or describe in terms of tissue damage or both." Merskey, H. (1964), An Investigation of Pain 13.) Spanwick CC (editors) (2000). Pain management: an interdisciplinary approach. Churchill Livingstone, Edinburgh. Bulletin of the IACFS/ME