Improving Pain Outcomes

Transcription

1 Improving Pain Outcomes Professor Laserina O Connor PhD, RANP, RNP Joint Chair of Clinical Nursing University College Dublin Mater Misericordiae University Hospital St Vincent s Health Care Group 1

2 Aim O Create an awareness of the challenges ahead! Specific Measurable Achievable Relevant Timed Laserina O Connor UCD, MMUH, SVHCG

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4 Impeccable Management of Cancer Pain O Appropriate Assessment 1. Documentation of Pain Characteristics 2. Determination of Pain Mechanisms 3. Identification of Modulating Factors 4. Clarification of a Personalised Goal 5. Regular Reassessments Laserina O Connor UCD, MMUH, SVHCG

5 1. Pain Characteristics O Medical Treatments O Allergies O Intensity O Location O Number of Episodes O Onset O Position O Quality O Radiation O Severity O Triggers 5

6 2. Pain Mechanisms O Identify likely source O Aetiology O Cancer-related O Therapy-related O Unrelated to cancer or its treatments Laserina O Connor UCD, MMUH, SVHCG

7 Cancer 3. Pain Expression Cancer Treatments Tissue Damage Nerve Injury Cytokine Release Noncancer Depression Spiritual Distress Chemical Coping Cognitive Impairment Pain Generation Pain Perception Pain Expression 7 Hui D. Breura E. (2014) A personalised approach to assessing and managing cancer pain. Journal of Clinical Oncology, 32,

8 4. Personalised Pain Goal Laserina O Connor UCD, MMUH, SVHCG

9 5. Reassessment of Pain O Longitudinal Follow-up O Dose Titration O Proactive Management of Adverse Effects Individualised on the basis of: O Level of Pain Expression O Pain Modulators O Any Associated Symptoms O Comorbidities Laserina O Connor UCD, MMUH, SVHCG

10 Case 1 Discussion Cancer Pain Laserina O Connor UCD, MMUH, SVHCG

11 Approach to Chronic Pain Assessment and Treatment: Older Person-5 C s Condition or Diagnosis Context of Pain that the patient is experiencing in their daily lives Compliance Comorbid Conditions Cognition Level Laserina O Connor UCD, MMUH, SVHCG

12 Principles of Pain Management for People with Dementia Observe and Document Build a Hypotheses Examine Consider Agree a Goal of Care Trial Treatment and Check Laserina O Connor UCD, MMUH, SVHCG

13 Assessment of Chronic Pain: Predictors of Outcome Flag Methodology Red Flags Yellow Flags Orange Flags Blue Flags Black Flags Laserina O Connor UCD, MMUH, SVHCG

14 Monitoring Outcomes During Long-term Opioid Therapy Chronic Non Cancer Pain 5 A s Analgesia Activities of Daily Living Affect Adverse Effects Aberrant Behaviours 14 Passik S. et al. (2005) Monitoring outcomes during long-term opioid therapy for non-cancer Pain: results with the Pain Assessment and Documentation Tool. Journal of Opioid Management,

15 Assessment with Patients Prescribed Opioid Therapy for Chronic Pain Current Opioid Misuse Measure (COMM) O Patient self-report assessment of pastmonth aberrant medication-related behaviours Laserina O Connor UCD, MMUH, SVHCG 2015 COMM O Developed to track patient status over time, [30 day period], can be used repeatedly and provide an estimate of the patients current status 15

16 Long-term Opioid Therapy Outcomes Chronic Noncancer Pain Clear Improvements Pain Function Quality of Life 16 Laserina O Connor UCD, MMUH, SVHCG 2015

17 Chronic Opioid Therapy Adverse Outcomes Respiratory Depression Falls and Fractures Gastrointestinal Effects Hormonal Effects Cognitive and Neurophysiologic Effects Psychosocial Effects Addiction Other Effects 17

18 Long-Acting Versus Short-Acting Opioids? O Study of patients receiving long-term opioid therapy for chronic non-cancer pain; time-scheduled opioid dosing was associated with higher levels of patient opioid control concerns than pain-contingent dosing (1). O Fordyce (2) sought to break the link between pain behaviour and medication rewards by replacing paincontingent medication regimens with timecontingent medication regimens. 1. Von Korff M. et al. (2011) Time-scheduled versus pain-contingent opioid dosing in chronic Opioid therapy. Pain 152, Fordyce s Behavioural Methods for Chronic Pain. (2015) IASP Laserina O Connor UCD, MMUH, SVHCG 2015

19 CASE 2 74 year old-male 19 Laserina O Connor UCD, MMUH, SVHCG 2015

20 MEDICINES RECONCILIATION Check Collect Communicate Process to Facilitate Patient Safety Laserina O Connor UCD, MMUH, SVHCG

21 Nociceptive versus Neuropathic Pain Nociceptive Pain Caused by activity in neural pathways in response to potentially tissuedamaging stimuli 1 Mixed Type Caused by a combination of both primary injury and secondary effects 1 Neuropathic Pain Initiated or caused by primary lesion or dysfunction in the nervous system 1 Postoperative pain Mechanical low back pain Pain from injuries Sickle cell crisis Arthritis Pancreatitis Postherpetic neuralgia Neuropathic low back pain Distal polyneuropathy (eg, diabetic, HIV) CRPS Trigeminal neuralgia Central post-stroke pain Portenoy RK, Kanner RM. Definition and Assessment of Pain. In: Portenoy RK, Kanner RM, eds. Pain Management: Theory and Practice. Philadelphia, Pa: FA Davis Company; 1996:4.

22 Multimodal Therapy: Clinical Advantages O O Peripheral Local anesthetics Anticonvulsants TCAs Opioids Anti-inflammatory agents Multimodal therapy provides a way to achieve balanced, safer pain therapy 1 O Improved quality of analgesia 2,3 O Fewer side effects 2,3 O Better functional status 4 Distinct from polypharmacy Central Anticonvulsants Opioids Tricyclic/SNRI antidepressants 2 -agonist (clonidine) Local anesthetics NMDA Antagonists Descending Anticonvulsants Opioids Tricyclic/SNRI antidepressants 2 -agonist (clonidine) 1. Gottschalk A, Smith DS. Am Fam Physician. 2001;63: , Tiippana EM, et al. Anesth Analg. 2007;104: Reuben SS, Buvanendran A. J Bone Joint Surg Am. 2007;89: Basse L, et al. Brit J Surg. 2002;89:

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26 Laserina O Connor UCD, MMUH, SVHCG 2015 Tapentadol 26

27 Case 3 36 year old female 27

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32 Case 4 Female -79-[thin but wiry] Laserina O Connor UCD, MMUH, SVHCG

33 Case Analgesic MEDS Laserina O Connor UCD, MMUH, SVHCG

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35 Maintain Competence O Professional / ethical practice O Holistic approaches to care and the integration of knowledge O Interpersonal relationships O Organization and management of care O Personal and professional development Laserina O Connor UCD, MMUH, SVHCG

36 Continuing Professional Development Mentor Clinical Pharmacist Journal Clubs Audit Attend Conferences/ Credits Laserina O Connor UCD, MMUH, SVHCG 2015 Prescriber Network Supervisor/ Rounds Guidelines /Standards / APP/eBNF Scope of Practice 36

37 Research Care-related Outcomes Patient-related Outcomes Performance related Outcomes 37 Laserina O Connor UCD, MMUH, SVHCG 2015

38 Final Thoughts O Lack of data may ultimately put the speciality of pain medicine at risk. We need to redouble our efforts to demonstrate that what we do, in fact matters and that the care we provide improves the lives of those we serve as well as society as a whole (1) Laserina O Connor UCD, MMUH, SVHCG Ashburn M. Witkin L. (2012) Commentary: integrating outcome data collection into the care of the patient with pain. Pain 153,

39 Future O Personalised Analgesic Prescribing Protocols O Genetics O Biomarkers O Other patient-related Factors O Practice-based Evidence Protocols O Thereby facilitating Metric-Based Pain Care Laserina O Connor UCD, MMUH, SVHCG

40 Thought Apprehension sharpens it Hopelessness intensifies it Loneliness protracts it Laserina O Connor UCD, MMUH, SVHCG

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