PAIN MANAGEMENTPAIN MANAGEMENT

TRACY CULKINTRACY CULKIN & &

SARAH BUSHELL SARAH BUSHELL

WHAT IS PAIN ?WHAT IS PAIN ?

Pain is described as an unpleasant Pain is described as an unpleasant sensory and emotional experience sensory and emotional experience

(IASP 1979)(IASP 1979)

Pain is what the patient says Pain is what the patient says it is and exists when he/she says it it is and exists when he/she says it does (McCaffrey 1989)does (McCaffrey 1989)

There are two types of painThere are two types of pain

AcuteAcuteChronicChronic

Acute painAcute pain

Acute pain is suddenAcute pain is sudden and short lasting (less and short lasting (less than 3mths) than 3mths) It is associated with actual or potential tissue It is associated with actual or potential tissue damage, trauma, surgery or disease damage, trauma, surgery or disease

It is thought that acute pain should It is thought that acute pain should

subside after injury or disease has been subside after injury or disease has been resolvedresolved

Chronic painChronic pain

Chronic pain is persistent pain Chronic pain is persistent pain which remains after the normal which remains after the normal healing time (3mths) healing time (3mths) It is also caused by injury, It is also caused by injury, surgery, disease and poor pain surgery, disease and poor pain managementmanagement This pain can lead to alterations in This pain can lead to alterations in receptors and transmitters in the receptors and transmitters in the spinal cord and brain spinal cord and brain Causing pain which may last for Causing pain which may last for months or years to the suffering months or years to the suffering personperson

What influences pain ?What influences pain ?Emotional stateEmotional statePersonality Personality Cultural backgroundCultural backgroundAgeAgeSexSexSocial factorsSocial factorsEducationEducationPrevious experiencePrevious experienceStaff attitudes Staff attitudes Lack of informationLack of informationType of analgesia Type of analgesia

The WHO Analgesic LadderThe WHO Analgesic Ladder

Step 1 Non-opioid

•NSAIDs•aspirin

Paracetamol

± adjuvant

Step 2Weak opioid

•codeine•oxycodone

(combination; low dose)

•tramadol

± non-opioid

± adjuvant

Step 3Strong opioid

•morphine•oxycodone

•hydromorphone•methadone

± non-opioid

± adjuvant

The Five Families of Analgesia are:The Five Families of Analgesia are:

OpiatesOpiatesNon-opiatesNon-opiatesNSAID’SNSAID’SAdjuvantsAdjuvantsLocal anaestheticLocal anaesthetic

Acute painAcute pain

Why do we have acute pain Why do we have acute pain services?services?

It was recommended in a government It was recommended in a government green paper that all hospitals should have green paper that all hospitals should have an acute pain servicean acute pain serviceThe purpose for this service is to reduce the The purpose for this service is to reduce the severity of postoperative or post-traumatic severity of postoperative or post-traumatic pain (NAPP,2006)pain (NAPP,2006)

Acute pain can be influenced byAcute pain can be influenced by

HeadacheHeadacheMigraineMigrainePostoperative painPostoperative painTraumaTraumaDysmenorrhoeaDysmenorrhoealabourlabour

Where culture and pain intersectWhere culture and pain intersect

Nurses interpret pain Nurses interpret pain behaviour through their behaviour through their own cultural lensown cultural lensOften making culturally Often making culturally learned judgements about learned judgements about patients by the behaviour patients by the behaviour they displaythey display

Get to know your patientsGet to know your patientsHindus believe pain must be enduredHindus believe pain must be enduredIt is part of preparing for a better life in the next It is part of preparing for a better life in the next cyclecycleThe devout Hindu who senses imminent death The devout Hindu who senses imminent death prepares for a ‘good death’ by remaining conscious prepares for a ‘good death’ by remaining conscious in order to experience the events to come in order to experience the events to come

Asking for pain medication, especially with somnolent side effects, is generally avoided.”

Cont…Cont…Members of the Jewish culture Voice their pain Members of the Jewish culture Voice their pain openlyopenlyThey believe pain must be shared recognised and They believe pain must be shared recognised and validated by othersvalidated by others

Jewish patients’ intense complaining Jewish patients’ intense complaining

doesn’t necessarily mean intense pain. Rather, it doesn’t necessarily mean intense pain. Rather, it may relate to the need for the presence of others may relate to the need for the presence of others to listen to them and affirm their experience.”to listen to them and affirm their experience.”

Role of the acute pain nurseRole of the acute pain nurse

Assess patientAssess patientCheck documentationCheck documentationPlan appropriate pain reliefPlan appropriate pain reliefImplement appropriate analgesiaImplement appropriate analgesiaEvaluate drug efficiencyEvaluate drug efficiencyReduce patient hospital stayReduce patient hospital stayLiaise with the multidisciplinary team Liaise with the multidisciplinary team Educate staff/patient on analgesic reliefEducate staff/patient on analgesic reliefFacilitate patient to make informed choiceFacilitate patient to make informed choiceEncourage patient mobility and independence Encourage patient mobility and independence

Acute pain assessment involvesAcute pain assessment involves

Regular pain scoringRegular pain scoringRegular medicationRegular medicationRegular observation Regular observation Communication staff/patientCommunication staff/patientCorrect documentation Correct documentation Non-judgemental attitude Non-judgemental attitude

Acute Pain Assessment ToolAcute Pain Assessment ToolScore 0Score 0 No pain at rest No pain at rest No pain on movementNo pain on movement

Score 1Score 1 No pain at rest No pain at rest Slight pain on movementSlight pain on movement

Score 2Score 2 Intermittent pain at rest Intermittent pain at rest Moderate pain on movementModerate pain on movement

Score 3Score 3 continuous pain at rest continuous pain at rest Severe pain on movementSevere pain on movement

Pain scoring should be done routinely along with pulse, BP Pain scoring should be done routinely along with pulse, BP and temperature (NAPP, 2006)and temperature (NAPP, 2006)

REMEMBER…REMEMBER…

If it is not documented it is not done!If it is not documented it is not done!

Methods used to treat acute Methods used to treat acute painpain

Oral, Rectal, Buccal, Sub-Oral, Rectal, Buccal, Sub-lingual, Inhalationlingual, InhalationSub-cut, IM Sub-cut, IM IvIvEpiduralEpiduralIntrathecalIntrathecalPhysiotherapyPhysiotherapy

Equipment used for acute painEquipment used for acute painBaxter PumpsBaxter PumpsPatient Controlled Analgesia Patient Controlled Analgesia (PCA)(PCA)Patient Controlled Epidural Patient Controlled Epidural Analgesia (PCEA)Analgesia (PCEA)

Cannula AttachmentCannula AttachmentCheck patencyCheck patencyNeed for drugs e.g. PCANeed for drugs e.g. PCADo not give blood with PCADo not give blood with PCAMust have cannula if Must have cannula if epidural in progressepidural in progressDo not take blood from the Do not take blood from the same cannulasame cannula

What to look out for!What to look out for!Respiratory depression if Respiratory depression if this happens;this happens;Stop analgesiaStop analgesiaAdminister oxygenAdminister oxygenNaloxoneNaloxoneVentilateVentilate

When treating painWhen treating pain

Oral is always the best routeOral is always the best routeMedication must be given regular to Medication must be given regular to

work effectivelywork effectively

UnresolvedUnresolved pain causes pain causes

SicknessSicknessConstipation Constipation ThrombosisThrombosisDeterioration in mental stateDeterioration in mental stateHeart problemsHeart problemsMuscle wastageMuscle wastageImmobilityImmobilityPressure soresPressure soresStressStress

Impact Impact Increase patient hospital stayIncrease patient hospital stayIncrease the ever-growing cost to the Increase the ever-growing cost to the NHS NHS Increase the possibility of acute pain Increase the possibility of acute pain becoming chronic…becoming chronic…

Chronic painChronic pain

Chronic painChronic pain

More than 750,000 people suffer from chronic More than 750,000 people suffer from chronic pain in the UK every year (Hoffman et pain in the UK every year (Hoffman et al,1997)al,1997)

A fifth of those patients who suffer A fifth of those patients who suffer from chronic pain will contemplate suicide from chronic pain will contemplate suicide (Simon et al,2004)(Simon et al,2004)

What influences chronic pain?What influences chronic pain?

Age Age Illness Illness Lack of education Lack of education Emotional state Emotional state Social and cultural backgroundSocial and cultural backgroundLack of supportLack of supportPoor mobility Poor mobility Poor pain managementPoor pain management

Chronic pain cycleChronic pain cycle

Psychological

Sociological

Biological

Consequences of persistent pain Consequences of persistent pain

Depression Depression Mood and behaviour changes Mood and behaviour changes Social withdrawalSocial withdrawalSleep disturbance Sleep disturbance Decline in economic statusDecline in economic statusDisabilityDisabilitySuicide Suicide

So how does chronic pain effect So how does chronic pain effect the working person?the working person?

Take time off work

Feel the need for care

Visit GP Medication

Social isolation

Depression

Fear job loss

Pain

Impact on societyImpact on society

The TUC reported that British The TUC reported that British businesses lose an estimated 4.9 businesses lose an estimated 4.9 million days to employee million days to employee absenteeism through work related absenteeism through work related back painback painThe All Party Parliamentary Group The All Party Parliamentary Group on Endometriosis revealed the on Endometriosis revealed the average woman with this condition average woman with this condition loses 55 working days per yearloses 55 working days per yearThe National Rheumatoid Arthritis The National Rheumatoid Arthritis Society estimated that 9.4 million Society estimated that 9.4 million working days are lost through working days are lost through Rheumatoid Arthritis Rheumatoid Arthritis

Aim of the GovernmentAim of the GovernmentThe public health White Paper aims to The public health White Paper aims to strengthen the ongoing Government strengthen the ongoing Government programmes such as “Back in Work” to programmes such as “Back in Work” to tackle the problemtackle the problemAs part of the healthy workplace As part of the healthy workplace initiativeinitiativeBy encouraging companies to adopt By encouraging companies to adopt “back in work” friendly policies“back in work” friendly policiesOver 300 business organisations have Over 300 business organisations have already registered and have been short-already registered and have been short-listed with a chance of receiving a grant listed with a chance of receiving a grant of up to £50.000 of up to £50.000 Although the money is incentive for Although the money is incentive for businesses, the government aims to businesses, the government aims to improve health by making it everybody's improve health by making it everybody's business.”business.”

Chronic pains services Chronic pains services suffersuffer

CINDERELLA SERVICE STILL?CINDERELLA SERVICE STILL?There is still a wide variation in the availability of chronic pain There is still a wide variation in the availability of chronic pain services services Both funding and staffing levels vary greatly between district Both funding and staffing levels vary greatly between district hospitals, from hospital to hospital and from region to region hospitals, from hospital to hospital and from region to region within the UK within the UK Many services fall short of the recommended levels of 10 Many services fall short of the recommended levels of 10 consultant sessions per 10,000 peopleconsultant sessions per 10,000 people

The Clinical Standards Advisory Group The Clinical Standards Advisory Group recommends consultants provide three dedicated sessions per recommends consultants provide three dedicated sessions per week – 10% of services failed on this standardweek – 10% of services failed on this standard

Cont…Cont…GP referrals vary taking between 4-110 weeks to GP referrals vary taking between 4-110 weeks to see a chronic pain consultant see a chronic pain consultant Consultant referrals take between 4-133 weeks to Consultant referrals take between 4-133 weeks to get patients’ on pain management programmesget patients’ on pain management programmesWith only 58% of clinics offering outpatient Pain With only 58% of clinics offering outpatient Pain Management ProgrammesManagement ProgrammesDemand is so great for chronic pain services that 8 Demand is so great for chronic pain services that 8 services have closed their GP referral lists services have closed their GP referral lists

However treatment to alleviate chronic However treatment to alleviate chronic pain is a human right (WHO,2000)pain is a human right (WHO,2000)

Pain scalePain scale

Numerical pain scaleNumerical pain scale

0 1 2 3 4 5 6 7 8 9 100 1 2 3 4 5 6 7 8 9 10

Visual analogue scaleVisual analogue scale

NoNo ______________________________ ______________________________ WorstWorstpainpain possible possible

painpain

Biopsychosocial assessment of Biopsychosocial assessment of chronic painchronic pain

Effect of pain on behaviour, lifestyle Effect of pain on behaviour, lifestyle and relationshipsand relationshipsDegree of disability related to pain, Degree of disability related to pain, e.g. depressione.g. depressionManner of expressing painManner of expressing painUnderstanding of painUnderstanding of painCoping and adaptive skillsCoping and adaptive skillsInterpersonal and family support Interpersonal and family support systemssystemsMotivationMotivationSleep, appetiteSleep, appetiteFinancial aspectsFinancial aspectsOther factors influencing pain e.g. Other factors influencing pain e.g. past pain experience, loss of control, past pain experience, loss of control, difficulties with the health systemdifficulties with the health system

Managing chronic painManaging chronic pain

Diagnose and treat causeDiagnose and treat causeAvoid unnecessary Avoid unnecessary investigationsinvestigationsTreat exacerbating co-Treat exacerbating co-morbidities, e.g. depressionmorbidities, e.g. depressionSet realistic goalsSet realistic goalsPrevention- seating, Prevention- seating, clothing, positioningclothing, positioning

Methods used in chronic painMethods used in chronic pain

Analgesics Analgesics AcupunctureAcupunctureTens MachineTens MachineAromatherapyAromatherapyPhysiotherapyPhysiotherapyHypnotherapyHypnotherapySpinal blocks Spinal blocks CounsellingCounsellingEducation programmes Education programmes

Barriers of effective pain Barriers of effective pain management in the community management in the community

Lack of knowledgeable carersLack of knowledgeable carersAssessment inadequateAssessment inadequatePoor quality of life - disability, Poor quality of life - disability, depressiondepressionLack of collaborationLack of collaborationBurden on the caregiverBurden on the caregiverNon-complianceNon-compliance

Over coming pain management Over coming pain management barriers in the community barriers in the community

Be aware of age-related bias in Be aware of age-related bias in health care workershealth care workersUse standard assessment Use standard assessment protocols protocols Individualise plan of care - Individualise plan of care - simplify treatments - minimise simplify treatments - minimise night-time monitoring night-time monitoring Educational support - address Educational support - address misbeliefs, e.g. fears of misbeliefs, e.g. fears of addiction- counsel patient and addiction- counsel patient and caregiver about medication use caregiver about medication use and how to deal with side and how to deal with side effectseffects

Cont…Cont…Use calendars and pill organisersUse calendars and pill organisersUse home-care nursing agencies Use home-care nursing agencies Recommend pain logs/diariesRecommend pain logs/diariesConsider inpatient Consider inpatient hospitalisation/respite carehospitalisation/respite careListen to family caregiverListen to family caregiverReinforce pain management Reinforce pain management principles principles Communicate regularly with nurse Communicate regularly with nurse and family and family caregivercaregiver

Acute Pain Acute Pain vv

Chronic Pain Chronic Pain