Implementation of Pain Management Standards 2009 Adapted from The - - PDF document

Implementation of Pain Management Standards 2009

Adapted from The OSUMC Learning Resource System for The Medical Staff, The Ohio State University Medical Center, June 10, 2009, by Steven A. Severyn, MD, MBA Michael D. Adolph, MD

Assistant Prof., Clinical Assistant Prof., Clinical Anesthesiology Palliative Medicine

Implementation of Pain Management Standards 2009 Learning Objectives

Recognize patient’s right to pain control Evaluate pain screening tools across age spectrum Assess techniques to identify various levels of pain and the

appropriate intervention to address it

Provide education to the health care team on how to

individually treat pain

Develop an interdisciplinary team to overview pain management

from an institutional perspective

Identify risks involved for the patient and physician in the

prescription of specific medications to control pain

Implementation of Pain Management Standards 2009 Are our patients pain-free?

It has been estimated that 11% of U.S. adults experience chronic non-cancer related pain. Just over half report that their pain is under control. (APS. (1999) Chronic Pain in America: Roadblocks to Relief.) In a published review of 53 studies (over 9000 patients) on the effectiveness of post-operative pain management, unrelieved moderate to severe pain was reported by the following: 66% of patients receiving IM pain medication 36% with PCA 21% with epidurals (Dolin, S. et al. (2002) Effectiveness of acute postoperative pain management: I. Evidence from published data. British Journal of Anesthesia 89 (3): 409-23.)

Implementation of Pain Management Standards 2009 Why Do Patients Experience Unrelieved Pain?

The most common reason for unrelieved pain in U.S. hospitals is the “failure of staff to routinely assess pain and pain relief.”

in American Pain Society (1999). Principles of Analgesic use in the Treatment of Acute Pain and Cancer Pain, 4th edition.

Uncontrolled pain interferes with: Sleep Immune System Healing Appetite Daily Activities

Implementation of Pain Management Standards 2009 Barriers to Effective Pain Management

The Agency for Healthcare Research and Quality (1994) identified 3 main problem areas inhibiting effective pain management: Health Care System Health Care Providers Patients

Implementation of Pain Management Standards 2009 Barrier: Health Care System

Pain has not been recognized as an

• rganizational priority

There has not been a focus on the joint responsibility across the spectrum of health care providers to assess and relieve pain. There is a lack of recognition of the dangers of pain and the benefits of pain control for hospitalized patients which include reduction in complications and decreased length of stay.

Implementation of Pain Management Standards 2009 Barrier: Health Care Provider

Lack of knowledge of evidence based pain control methods. Inadequate pain assessments. Misconceptions about opioid use and addiction potential. Concern about administering pain medication to a patient who doesn’t really need it

Resources Treatment of Cancer Pain, OSUMC Clinical Practice Guideline 2002 Agency for Healthcare Research and Quality, National Guideline Clearinghouse www.guideline.gov American Pain Society – Quality Improvement Guidelines for the Treatment of Acute Pain and Cancer Pain Clinical Practice Guideline for the Sustained Use of Sedatives and Analgesics in the Critically ill Adult. 92202) Critical Care Medicine (30), 1:119-141 International Association for the Study of Pain

Implementation of Pain Management Standards 2009 Barrier: Patients

Attitudes (positive, negative) about use of analgesics, especially narcotics Concern (or lack of concern) about addiction Belief that acute and chronic pain cannot be relieved, and that pain is inevitable Belief that acute and chronic pain can always be relieved, without compromising any other aspect of care

Implementation of Pain Management Standards 2009 Barrier: Patients (continued)

Patients with pain have the following rights: to have their reports of pain accepted and acted on by health care professionals. to have their pain controlled, regardless of cause or severity. to be treated with respect at all times - and not as a drug abuser.

Source: McCaffery and Pasero(1999). Pain:Clinical Manual.

Implementation of Pain Management Standards 2009 Definitions of Pain

“Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”

Mersky in Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. IASP(1979)

“Pain is whatever the experiencing person says it is, existing whenever he says it does.”

Margo McCaffery, 1968

Implementation of Pain Management Standards 2009 Types of Pain: Nociceptive

Pain stimuli are from somatic

• r visceral structures.

Somatic - usually

arises from bone, joint, muscle, skin, or connective tissue. Usually localized, aching or throbbing.

Visceral - arises

from visceral organs, such as the GI tract. May be dull, diffuse, and referred to other

• sites. Usually not

well localized.

Source: McCaffery and Pasero (1999) Pain Clinical Manual

Implementation of Pain Management Standards 2009 Types of Pain: Neuropathic

Results from abnormal processing of sensory input by the peripheral or central nervous system. Peripherally generated Peripheral neuropathies (i.e. diabetic neuropathy; chemotherapy - associated; trigeminal)

Source: McCaffery and Pasero (1999). Pain: Clinical Manual

Centrally generated - Associated with injury to the peripheral or central nervous

• system. i.e. phantom pain

Associated with abnormal activity

• f the autonomic nervous system
• i.e. complex regional pain

syndrome

Implementation of Pain Management Standards 2009 Transduction

When tissue damage occurs, the damaged cells release substances that activate nociceptors, generating an action potential.

McCaffery and Pasero (1999). Pain:Clinical Manual

Implementation of Pain Management Standards 2009 Transmission

Occurs in three phases: Injury site to spinal cord Spinal cord to brain stem and thalamus Thalamus to cerebral cortex

McCaffery and Pasero (1999). Pain:Clinical Manual

Implementation of Pain Management Standards 2009 Modulation

Inhibition of transmission of nociceptive impulses by release of substances such as serotonin from the CNS through the spinal cord neurons.

McCaffery and Pasero (1999). Pain: Clinical Manual

Implementation of Pain Management Standards 2009 Tolerance

Tolerance means that “a larger dose of opioid analgesic is required to maintain the original effect.” APS, 1999 Common in patients on chronic opioid analgesics First sign may be a decrease in the duration of effective analgesia. Tolerance may be delayed and analgesia continued by: – combining opioids with nonopioids – switch to an alternative opioid, selecting a lower starting dose

McCaffery and Pasero (1999). Pain: Clinical Manual

Implementation of Pain Management Standards 2009 Physical Dependence

Demonstrated in patients taking chronic

• pioids with an “abstinence syndrome” or

withdrawal that occurs following abrupt discontinuation or administration of an

• pioid antagonist. APS, 1999

Symptoms: anxiety, irritability, chills/ hot flashes, nausea, vomiting, abdominal cramps, diaphoresis, rhinorrhea. Duration of abstinence syndrome is dependent on half life of the opioid. Prevention: Slow withdrawal of chronically used opioids.

McCaffery and Pasero (1999). Pain: Clinical Manual

Implementation of Pain Management Standards 2009 Addiction

Defined as “a pattern of compulsive drug use characterized by a continued craving for an opioid and the need to use the opioid for effects other than pain relief.” APS 1999 Most patients who take opioids several times daily for more than a month develop some tolerance or physical dependence. This is not an addiction. Some patients may have an increased need based

• n a history of substance abuse, abnormal illness

behavior, or other factors. The fear of addiction should NOT be a primary concern in treating acute pain or cancer pain.

McCaffery and Pasero (1999). Pain: Clinical Manual

Implementation of Pain Management Standards 2009 Assessment of Pain Priorities

The presence and severity of the pain are always what the patient tells you. First: Ask patients about their pain. Then: Record and intervene, based on what they tell you.

Implementation of Pain Management Standards 2009 Case Example The answer is yes.

Research has demonstrated that: A pain rating of 4-5 may significantly interfere with function. A rating of 6 or above may indicate a need for immediate intervention; Patients behavioral and physiological responses to moderate to severe pain

• ften adapt over time and may become

minimal. Source: McCaffery, Pasero (1999) Pain Clinical Manual Case Example: Female patient - age 56, 1 day post-op knee replacement - is visiting with family, laughing and talking. When you ask her to rate her pain, she tells you it is an 8. Does she need pain medication?

Implementation of Pain Management Standards 2009 Assessment of Pain – When Is It Done? Initial pain assessment for all inpatients is done on admission to the patient unit and documented on the Admission Data Base.

Note: For ambulatory pain assessment routine, see department policy.

Implementation of Pain Management Standards 2009 Assessment of Pain – What is Assessed and Documented?

Patient’s verbal description of pain Chronic pain conditions and current treatment plan Note current pain medications Effect of pain on quality of life

Implementation of Pain Management Standards 2009 Assessment and Reassessment

As a part of ongoing patient assessment Within an hour after analgesic intervention Prior to surgery At regular intervals post-op Post procedure With every new report of pain Note: Document above assessments on 24 hour Flow Sheet or appropriate ambulatory form

Implementation of Pain Management Standards 2009 What to Ask: P Q R S T

Palliating and Provoking factors: causes; what makes it better or worse? Time: onset, duration, rhythms Severity: rating scales, is the pain tolerable or intolerable? Region or site: where is the pain? (May help to mark on figure drawing.) Quality: throbbing, sharp, aching, cramping, etc.

Note: Assessment is documented on Patient Data Base, 24 hour flowsheet, or appropriate ambulatory form

Implementation of Pain Management Standards 2009 Pain Assessment Tools

Patient self report with a verbal analog scale (VAS). Pain or symptoms are documented using a 0-10 pain scale, for those patients who are able to identify their pain in this way. Faces Scale Can be used with patients who have difficulty with numerical scales, such as children, the elderly, or those with language differences or communication barriers. Descriptive Scale Mild, moderate, moderately severe, severe.

Implementation of Pain Management Standards 2009 Assessment of Pain – Objective Signs

• Behaviors - facial expressions, physical movements,

vocalizations (may not be present)

• Emotional expressions - anger, irritability
• Physiological responses (Least sensitive indicators of pain.)

Implementation of Pain Management Standards 2009 Examples of Pain Assessment Documentation

Better documentation would be: Does this documentation give enough information about the patient’s pain? Patient c/o constant pain RUQ. Patient describes sharp constant pain in his RUQ, 7/10. Onset 30 minutes ago when he got up to BR. Accompanied by nausea, denies

• vomiting. Appears pale, skin moist.

Implementation of Pain Management Standards 2009 Purpose of Pain Rating Scale

The pain rating scale evaluates the effectiveness of the pain plan of care, according to the patient’s baseline pain assessment.

Implementation of Pain Management Standards 2009 Pain Plan of Care

• 1. The Pain Plan of Care is individualized through a

collaborative process with consideration of the following:

• age
• developmental status
• physical, emotional, cognitive level
• cultural beliefs
• treatment preferences
• source of pain
• concurrent medical conditions and drug interactions

Reference: OSUH (11/2000) Pain Management Policy and Procedure

Implementation of Pain Management Standards 2009

Pain Plan of Care 2. Goals should address pain relief adequate to perform recovery activities, i.e. to cough and deep breathe following surgery. Nursing identifies Pain Management as a goal on the “Priority Patient Needs List” section of the Patient Flowsheet or Appropriate Outpatient form.

Implementation of Pain Management Standards 2009

Pain Plan of Care

• 3. Pain/discomfort is reassessed and the plan of care

re-evaluated based on the patient’s condition and the severity of the pain. Nursing evaluates achievement

• f pain management goals every 24 hours on the 24

hour Patient Flowsheet or during each outpatient visit. i.e. Patient has utilized PCA to maintain self-reported pain level below 4/10. Self initiated use of visualization also employed by patient and rated as useful as adjunct to pain medication.

Implementation of Pain Management Standards 2009 Interventions for Treating Pain

Patients who are experiencing pain can be helped using one or a combination of the following: Pharmacological interventions Non-pharmacological interventions Providing information and education about pain management

Implementation of Pain Management Standards 2009 Pharmacological Interventions

There are three main categories of analgesics used to treat pain. Opioids Non-opioids Adjuvants Selection of pain medication depends on severity and type of pain, and underlying patient conditions.

Implementation of Pain Management Standards 2009 Keys to Analgesic Administration

Stay ahead of pain by administering analgesic to patients At scheduled times Prior to painful procedures Breakthrough medication should be ordered

• n all patients receiving around the clock

analgesics.

Implementation of Pain Management Standards 2009 Opioids

Considered the mainstay of pain management Used to treat moderate to severe pain Provide analgesia by binding to opioid receptors inside and

• utside the CNS

Morphine, hydromorphone and fentanyl are examples of frequently prescribed opioids

• Remember: To properly dispose of fentanyl patches,

fold adhesive sides together, flush down commode, and document witnessed disposal according to policy.

Implementation of Pain Management Standards 2009 Opioids (continued)

Opioids may be administered by a PCA pump Patient-controlled analgesia promotes patient participation in pain management PCA pumps can be programmed to provide a continuous infusion of pain medication and/or a patient bolus. Only the patient should administer the pain medication and it is important to educate the patient and family about this process. Verify correct drug, concentration and dosage.

Implementation of Pain Management Standards 2009 Considerations with Opioids

Oral route is preferred when feasible IM route should be avoided Adverse effects:

• Constipation
• Respiratory depression
• Nausea
• Sedation
• Urinary retention
• Pruritus
• Confusion

Implementation of Pain Management Standards 2009 Considerations with Opioids (continued)

An equi-analgesic dose chart should be used as a guideline for converting pain medication dosages. Auto-prompt provided in many hospital EMR programs.

(For example, IV dilaudid is typically considered 7 times more potent than IV morphine.)

Morphine 1mgIV = Morphine 3mg PO Dilaudid 1mg IV = Morphine 20mg PO Dilaudid 1mg IV = Morphine 7mg IV

Implementation of Pain Management Standards 2009 Non-opioids

Used to treat mild to moderate pain Can be used in combination with an opioid Inhibit synthesis of prostaglandins 2 categories Acetaminophen Nonsteroidal antiinflamatory drugs (NSAIDS)

• Ibuprofen and Toradol are commonly prescribed NSAIDS

Implementation of Pain Management Standards 2009 Side Effects of NSAIDS

GI symptoms such as heartburn, nausea, abdominal pain occur up to 15% and mucosal lesions may occur in up to 80% of patients Serious GI complications such as perforated ulcers and catastrophic bleeding result in death 10% of time when it occurs. (Singh, 1998) NSAIDS inhibit COX-1 & 2. Inhibition of COX-1 is thought to be responsible for GI side effects

Implementation of Pain Management Standards 2009 Considerations with Non-Opioids

Adverse effects can occur at any time

• Hepatic and renal dysfunction
• Adverse GI effects

Heartburn Mucosal lesions Nausea, vomiting Perforated ulcers Abdominal pain

Risk factors increase with: – Advanced age, higher NSAID dose, hx GI problems, duration of use, concurrent corticosteroid & anticoagulant use

Implementation of Pain Management Standards 2009 Adjuvant Medications

Are used in combination with opioids and non-opioids to enhance action or reduce side effects May be used as a primary therapy in certain pain treatment Include antidepressants, anticonvulsants, anti-anxiety agents, corticosteroids, local anesthetics

Implementation of Pain Management Standards 2009 Considerations with Adjuvants

Selection of the adjuvant is based on pain characteristics Response varies widely from patient to patient Adverse effects vary with type of adjuvant administered Monitor the patient for pain control and side effects

Implementation of Pain Management Standards 2009 Non-Pharmacologcial Interventions

Address mind, body, spirit connection Consist of 2 main modalities –Physical Interventions Massage Heat & cold Exercise Therapeutic touch Referrals to PT, OT, massage therapists –Cognitive/behavioral Patient education Relaxation/guided imagery Biofeedback Diversion: music/humor

Implementation of Pain Management Standards 2009

Non-Pharmacological Intervention Considerations

Most often used in conjunction with analgesics Decrease the emotional components of pain and increase sense of control and ability to cope with the pain Variable outcomes are seen in pain management among patients

Implementation of Pain Management Standards 2009

Patient/Family Education

Patient and family fear of addiction and failure to report pain may be a barrier to pain relief Patient and family often lack knowledge on how to administer pain medication Caregiver’s attitudes influence efficacy of pain interventions Patients and family are usually eager to add non-drug interventions

Implementation of Pain Management Standards 2009

Patient/Family Education (continued)

Does education make a difference in pain management? In a randomized controlled trial, patients who were educated to report pain and contact health care practitioners to request medication experienced better pain control than patients who did not receive education (De wit, et al. Pain, 1997; 73:55-56).

Implementation of Pain Management Standards 2009

Materials for Pain Education

Patient education handout “About Pain and Pain Control” Contains facts about pain control Dispels common myths Contains pain rating scales for self-report To be distributed to all patients/families who access OSUMC system

Implementation of Pain Management Standards 2009

Materials for Pain Education

How to find patient education pain handouts? –Located on OSUMC Intranet –Go to OneSource –Go to Clinical Applications –Go to Patient Information –Go to Patient Education –Go to Pain and Symptom Management

Implementation of Pain Management Standards 2009 Special Populations

Pain management interventions must meet the needs of special populations Special populations at the Medical Center include: – Older adults – Patients with cognitive impairments – Patients from other cultures

Implementation of Pain Management Standards 2009 Older Adults

Tend to underreport their pain –Assume pain is part of aging –Believe “good” patients don’t complain –Fear more pain signals the progression of disease Take multiple drugs and are at risk for drug-drug interactions Rely on their families to make health care decisions

Implementation of Pain Management Standards 2009 Older Adults – Pain Management

Critical to assess and reassess pain – Use simple tool such as FACES or numerical scale and educate the family to use same tool at home – Due to slower reaction time and visual impairments, provide adequate time and lighting for assessment Aging alters how drugs are metabolized – NSAIDS more likely to cause renal & gastric toxicity – Opioids are metabolized more slowly and remain in the body longer and at higher concentrations

• Same metabolic pathways are utilized as in the young
• Consider initial lower doses and titration

Implementation of Pain Management Standards 2009 Cognitive Impairment

Observe changes in behavior (see Module #2 Pain Assessment) – Some patients may become quiet or agitated and restless when in pain – Family or significant other may be able to identify behaviors that indicate the patient may be experiencing pain Don’t rule out the use of a pain scale – Patients with substantial impairment can use a scale when given adequate time Reports indicate “unconscious” patients do recall experiencing pain – 60% remember moderate to severe pain once they regain consciousness Puntillo, 1990

Implementation of Pain Management Standards 2009 Cultural Considerations

• People from different cultures exhibit different behavioral responses

to pain and have different treatment preferences and beliefs.

• Three terms -pain, hurt and ache-appear to go across cultures to

describe intensity. – “Pain” is most intense followed by “hurt” then “ache”

• Pain scales may need modification

– For example, a Chinese patient may better understand a vertical instead of a horizontal line representation.

Implementation of Pain Management Standards 2009 Resources

Considerations for hospital intranet accessibility

• Clinical Care
• Patient Information
• Patient Education
• Pain and Symptom Management
• Spanish Materials Listing
• Patient Teaching Resources & Other Language Documents

–Information About Various Cultures

• Staff Resources
• Pain Resource Information

Implementation of Pain Management Standards 2009 Medications: Patient Risks Specific to Opioids

Consent form for regular prescribing in management of non-cancer

chronic pain (SMBO 4731-21-02)

Risks to include: Sedation, confusion, reaction time, balance, coordination Respiratory depression Unintended rapid absorption of some sustained release delivery

products (OxyContin, Duragesic)

Exaggerated effects of concurrent sedating medications Poisoning Development of tolerance Withdrawal Cardiac arrhythmia (methadone) Addiction, abuse, diversion, theft

Implementation of Pain Management Standards 2009 Implementing an Interdisciplinary Team

Develop an interdisciplinary team to overview pain management

from an institutional perspective

Empowerment considerations Committed resources Physician, NP/PA, RN, Pharmacist, Hospital Administration,

Information Management, Patient Advocate