strategies and approaches for education in chronic pain rev
TRANSCRIPT
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Strategies and Approaches for Education in Chronic PainBeth Brianna Hogans, M.S., M.D., Ph.D.
Associate Professor of Neurology
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Dr. Hogans has no financial interests to disclose.
I have published a book on back pain for patients.
Reference may be made to off-label uses of medications in this presentation.
No pharma funding since 1998, although I like to prescribe medications, especially when safe and effective!
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Learning objectivesAt the conclusion of this session, the participant will be able:
1. Discuss factors that contribute to effective education about pain
2. Describe strategies for educating patients about pain
3. Express perspectives on what they would like to incorporate in their own practice of educating patients about pain
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Simple model
Target population
Content DesirableOutcomes
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ProcessSetting
Educator Learner
Content
Extras
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Real-life meets ProcessSetting
Educator Learner
Content
+ Extras
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Tips• Try sketching – people enjoy seeing ideas ‘come to life’
• Engage your audience in putting the ideas together
• Add structure, show that you can work the framework
• Check for prior knowledge and understanding
• Start by asking questions
• Ask-tell-ask
• Avoid and eliminate extraneous material
• Use handouts to dig in to the details
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Acute vs. Chronic painWhat are some of the differences between acute and chronic pain?
ACUTE PAIN CHRONIC PAIN
Short duration: hours or days Long duration: e.g. longer than expected for healing; 3 months
Cause is usually clear cut Cause may or may not be clear
Effects on behavior are usually obvious and easy to recognize
Effects on behavior can be subtle and hard to understand
Treatments are highly effective, depending on access
‘Meds’ only partially effective, multiple approaches needed
Side effects of treatment, although problematic, can be tolerated for short periods
Side effects of treatment become harder to tolerate over time and interfere with normal function
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Three types of pain
NOCICEPTIVE: ‘normal’ pain sensing in response to threats in the environment; sharp
INFLAMMATORY: increased pain sensing that raises sensitivity to normal levels of pressure and activity; aching
NEUROPATHIC: abnormal pain in response to things that normally ‘do’ and ‘don’t’ hurt; burning, zinging, tingling.
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PAIN
Poor sleep
Socialwithdrawal
Reduced activity
Low function
How chronic pain spirals out of control
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Types of pain treatments
PAIN
Sleep ‘tune-up’
Physical therapy
Ergonomic adaptation
Conditioning
SleepProductivity
OPIOIDS
Psychological support Acupuncture,
MassageNatural defenses
Skillful living
‘Neuro-active’ medications
Pain Resistance
Injections, proceduresFocal treatment
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How we evaluate pain treatments
Risks Benefits
Costs + Barriers Side effects
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Types of pain medicationsNSAIDS and STEROIDS
NEURO-ACTIVE: ANTI-DEPRESS.
NEURO-ACTIVE: ANTI-CONVUL.
OPIOIDS NEURO-ACTIVE: LOCAL ANESTH. AND OTHERS
Ibuprofen, Naproxen, Etodolac, Ketorolac, etc.
Nortriptyline, amitriptyline; venlafaxine, duloxetine, etc.
Gabapentin, pregabalin, carbemazepine, topiramate, etc.
Morphine, oxycodone, codeine,Fentanyl, etc.
Lidocaine, AcetaminophenTramadol, Musc. relaxants
Work especially well for inflammatory pain but also good for mild-moderate nociceptive pain
Take time to start working but quite effective and generally safe for long-term use
Work especially well for neuropathic (nerve) pain, work well together with other agents
Work well for short periods, but effect wears off quickly and potency declines with use
Work through various pathways, often used alone or in combination with other medications
NSAIDs: GI bleeding, renalSteroids: not for long term use
Some may increase suicide risk, need to monitor use
May increase dizziness, impair thinking
Very dangerous: many deaths each year
Side effects vary but should be reported if suspected
As needed and limited courses
Must take daily for drug to work
Recommended for daily dosing
Not ideal for daily use
Dosing varies with drug
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Why do drugs in the morphine family stop relieving pain over time?
Morphine
Receptor for morphine
Once the receptor for morphine binds to the drug, it is targeted for destruction. The drug then has nowhere to ‘bind’ and stops working.
‘Pain Cell’
Disposal
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Potentially harmful Passive
Ineffective
Safe Self-directed
Effective
Bridge therapies
Pain killersInjections
Cycle of dependence
MassageAcupuncture
Manual therapy
MovementBreathing
PacingErgonomics
Independence
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Biopsychosocial model of painadapted from Loeser
Perception(pain awareness)
Suffering
Behavior
Nociception(pain generator)
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Biopsychosocial model of pain - modifiedModified to show normative function of the pain system
Perception
Nociception(pain generator)
Suffering
Event, e.g., Trauma, surgery, procedure, dressing change
Perception, in basal state, mirrors nociception
Suffering is proportional to perception
Behavior
Behavior reflects nociception and facilitates social communication of threat
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T
Biopsychosocial model of painHow psychosocial factors can make pain amplified, chronic, and
difficult to diagnose and manage
Perception is heightened
Suffering
Nociception(pain generator)
Suffering is magnified Behavior is
exaggerated and difficult to manage
minor trauma
state variables, e.g., fear, hyper-vigilance
Cognitive/affective factors, e.g. depressed mood
Social factors, e.g., poor social support
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InflammatoryPain Nociceptive
Pain
Neuropathic Pain
1. Diagnosis with reasonable differential
Peripheralneuropathy
Abscess Osteoarthritis
RadiculopathySpinal stenosis
Surgical pain
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NSAIDs/Acetaminophen
Opioids
How do we design a pharmacological regimen?
Neuromodulating: gabapentinoidsNeuromodulating:
anti-depressants
Inflammatory Nociceptive
Neuropathic
Local anesthetics
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Conclusions1. What factors do you think contribute to effective education about pain?
2. What strategies are you most likely to adopt in educating patients about pain?
3. After the conference today, what new elements would you like to incorporate into your own practice of educating patients about pain?
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Thank you
Thanks to: Judy Watt-Watson, Pat Thomas, John Griffin, VA colleagues, the Johns Hopkins Pain Curriculum Development Team, and my patients!
https://www.youtube.com/watch?v=L_pY7cTDygs
Take Back Your Back