Managing Pain in Long Term Care

Transcription

1 Troubleshooting Managing Pain in Long Term Care presented by Melanie Simpson, PhD, RN-BC, OCN, CHPN Click to View Webinar All handouts for this webinar are included in this document. You may access the webinar at any time.* 1. Make sure your speakers are turned on. 2. Make sure you have downloaded Flow Player on your computer. 3. Contact LeadingAge Kansas at or s.org Important Information This webinar is pre-recorded. It was purchased by your organization. You have the right to share with any individual who is employed by your organization. Sharing this information with individuals working in other organizations or companies is strictly prohibited. They should purchase their own copy at Continuing Education Units will not be provided for purchased webinars. *LeadingAge Kansas reserves the right to disable this webinar for any reason at any time. In order to view the Webinar, you must have the following software downloaded on your computer: Flow Player you can download it at LeadingAge Kansas 217 SE 8 th Avenue Topeka, KS

2 MANAGING PAIN IN LONG- TERM CARE Melanie Simpson, PhD, RN-BC, OCN, CHPN The University of Kansas Hospital

3 The Pain Pathway Nociception - Term used to describe how pain becomes conscious 4 processes involved Transduction Transmission Perception of pain Modulation

4 Pain Pathway 4 processes involved: 1. Transduction 2. Transmission 3. Perception of pain 4. Modulation 4. Descending modulation 3. Brain 1. Peripheral tissues 2. Spinal cord

5 Ascending pathway Descending pathway TCAs, SNRIs Anticonvulsants Opioids NSAIDS COX-2s Nerve Blocks Anticonvulsants Mechanism of Action of Selected Analgesics

6 Types of Pain: Nociceptive Somatic Well-localized Tender, sharp, achy in quality Usually musculoskeletal in origin Usually responsive to opioids May also respond to NSAIDs, steroids, muscle relaxants, some antidepressants Examples: Post-operative pain, Sprains, Broken bones, Bone metastasis, Arthritis, Muscle strains,

7 Types of Pain: Nociceptive Visceral Involves solid organs Poorly localized Dull, crampy, tight, pressure in nature May refer to other areas Usually responds to opioids May respond to NSAIDs, steroids, antispasmodics Examples: Pancreatitis, Constipation-related, Bowel obstruction, Cancer in the liver or brain

8 Types of Pain: Neuropathic May be peripheral, central, sympatheticallymaintained Numbness, shooting, stabbing, burning in nature Poorly responsive to opioids May respond to TCAs, anticonvulsants, topical local anesthetics Examples: Post-herpetic neuralgia (shingles), Sciatica, Pain from strokes, Trigeminal neuralgia, Phantom limb pain, Peripheral neuropathy from diabetes or chemotherapy

9 Comprehensive Assessment of Pain Detailed histories Pain/pain treatment Medical Psychosocial Physical examination Diagnostic tests Observable physiologic signs The most important tool: Patients Self Report

10 Assessment of Pain WILDA Words (ex. aching, burning, stabbing ) Intensity (0-10) Location (all sites) Duration (constant, episodic) Aggravating and alleviating factors (what makes the pain better or worse)

11 How does the pain affect? Sleep Appetite Energy Activity Relationships Mood

12 Pain Assessment in the Elderly Poor memory, depression and sensory impairment may make getting pain information from the patient difficult Use of standard tools Pain assessment by proxy

13 Assessing the Demented Patient Recognizing pain behaviors facial grimacing guarding any areas change in breathing patterns restless impatient motion isolation, increasing time in bed/alone negative vocalizations

14 Lane, P. Assessing pain in patients with advanced dementia. Nursing. 2004;8:17.

15 Recommended Persistent Pain Therapy in Demented Patients Treat behavioral symptoms with pain medications first Fewer side effects with correct analgesics than with psychotropics Psychotropics may sedate and obscure pain indicators, without pain relief If pain treatment is unsuccessful, can proceed to psychiatric management AGS, 1998; AMDA, 1999

16 Reassessment of Chronic Pain After pharmacologic intervention 60 min after PO 24h after Transdermal Weekly, monthly Level of function Mood More anxiety and anger in acute pain More depression in chronic pain Documentation

17 Treatment of Pain Pharmacologic Nonpharmacologic Should not be one or the other

18 Pharmacologic Approaches to Pain Management Balanced Analgesia Non-opioids Adjuvants/Coanalgesics Opioids Advanced Techniques Patient-controlled analgesia Regional analgesia Invasive methods Provides better pain relief Fewer side effects Opioid-sparing

19 Non-opioids Acetaminophen Aspirin NSAIDs/Cox-2 First-line for mild to moderate pain Unless contraindicated, any analgesic regimen should include a nonopioid drug, even if pain is severe enough to require the addition of an opioid Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 5th ed., American Pain Society, 2003.

20 Acetaminophen Well-tolerated 4,000 mg limit in 24 hours in healthy adults 3,000 mg in elderly, 2,000 mg in elderly with hepatic or renal insufficiency Non-opioid of choice for patients with renal disease Can cause excessive anticoagulation for patients on warfarin

21 NSAIDs Extremely useful in nociceptive pain Numerous trials to investigate differences in clinical efficacy, none evident Adverse effect profile, GI, renal and CV Drowsiness and confusion common in elderly Should be limited to 7-10 days in the elderly Should use a PPI to reduce the risk of GI bleed

22 NSAIDs-COX-2 Indications: somatic pain, arthritis, bone metastasis, post-operative pain Examples: Nonselectives: Ibuprofen, Alleve, Trilisate, Relafen, Diclofenac, Disalcid, Voltaren, DayPro, Toradol COX-2: Celebrex Other: Flector Patch (Diclofenac), Volteran Gel (Diclofenac)

23 May 6, 2009, 1:15 pm Experts Warn Against Long-Term Use of Common Pain Pills By RONI CARYN RABIN Aspirin and ibuprofen are staples in just about every medicine chest and first aid kit. They re sold over the counter, and they re not expensive. Most people don t think twice about taking them. But they should especially if they re elderly. Last week, an expert panel of American Geriatrics Society pretty much bumped all non-steroidal anti-inflammatory drugs, or NSAIDs, off the list of medicines recommended for adults ages 75 and older with chronic, persistent pain. Getty Images Long-term use of drugs like ibuprofen, naproxen and high-dose aspirin is so dangerous, the panelists said, that elderly people who can t get relief from alternatives like acetaminophen may be better off taking opiates, like codeine or even morphine. All this despite the fact that NSAIDs are known to be effective for chronic pain conditions that often plague older adults and despite the fact that opiates can be addictive.

24 Adjuvant Medications Do not directly provide analgesia Used more extensively in persistent/chronic pain than acute pain Help with suffering Use great caution when adding sedating meds

25 Selected Adjuvant Medications Antidepressants - Ex: TCA (Elavil, Pamelor, Sinequan), SSRI (Paxil, Zoloft, Celexa, Lexapro), *SSNRI (Cymbalta, Effexor, Savella) Anticonvulsants - Ex: Neurontin, Tegretol, Depakote, Klonopin, Dilantin, Gabatril, Topamax, Lamictal, Trileptal, Zonegran, Lyrica

26 Selected Adjuvant Medications Benzodiazepines Ex: Valium, Ativan, Xanax, Halcion, Restoril, Klonopin, Versed Muscle relaxants Ex: Valium, Robaxin, Flexeril, Soma, Norflex, *Zanaflex, *Baclofen Misc. Agents Ex: Lidoderm 5% patch, Capsaicin, Emu oil

27 Combination (Weak) Opioids Used for mild to moderate pain Doses are limited due to non-opioid component (acetaminophen, ASA) Limited use in chronic pain Codeine (Tylenol #3, Fioricet) Hydrocodone (Lortab, Vicodin) Oxycodone (Percocet, Percodan) Tramadol (Ultram, Ultracet)

28 Hydrocodone The number one overused and abused opioid in US Schedule III Refillable Not available as single agent Equal in analgesic effect to morphine

29 Single-Agent Opioids Used for moderate to severe pain No maximum dose Can be given by many different routes Long-acting forms available for chronic pain Morphine Hydromorphone Methadone Oxycodone Fentanyl Oxymorphone Tapentadol

30 Long-Acting Opioids for Chronic Pain Morphine (MS Contin, Oramorph, Kadian, Avinza) Oxycodone (OxyContin) Methadone (Dolophine) Fentanyl (Duragesic) Oxymorphone (Opana ER) Hydromorphone (Exalgo) Tapentadol (Nucynta)

31 Benefits of Long-Acting Opioids in Chronic/Persistent Pain Avoids peaks and valleys Improves functionality Patients use less medication Patient satisfaction/compliance Easier medication surveillance

32 Side Effects of Opioids Constipation Nausea and Vomiting Sedation Dry Mouth Pruritis Myoclonus Respiratory Depression

33 Nonpharmacologic Therapies Empowers patients Takes focus away from medications Provides relaxation and relief from pain Diminishes emotional component of pain Decreases anxiety Decreases fatigue Improves quality of life

34 Considerations in Selecting and Using Nonpharmacologic Methods Relationship between nonpharmacologic methods and use of analgesics Patient s previous experience and present attitude Patient preferences and coping styles Patient s physical and mental abilities Involvement of family and friends Support materials and patient education

35 Selected Complementary Methods of Pain Management Exercises/positioning/PT, OT Heat and Cold TENS Ultrasound Massage Diet/Nutrition/Herbals Acupuncture/Acupressure Music Therapy Therapeutic Touch Reflexology Aromatherapy Psychological methods Psychotherapy Imagery Relaxation/meditation Hypnosis Biofeedback Distraction Humor

36 Discussion

37 Bibliography Abraham, J. L. (2000, May). Advances in pain management for older adult patients. Clinical Geriatric Medicine, 16(2): AGS Panel on Persistent Pain in Older Persons, (2002). The management of persistent pain in older persons. JAGS, 50:S205-S224. American Medical Directors Association (2009). Pain Management Clinical Practice Guideline. Columbia, MD AMDA. American Pain Society. (2003)Principles of Analgesic Use in the Treatment of Acute Pain and Chronic Cancer Pain, 5 th ed., American Pain Society, Skokie, IL. American Pain Society. (2008) Principles of Analgesic Use in the Treatment of Acute Pain and Chronic Cancer Pain, 6 th ed., American Pain Society, Skokie, IL. Harden, N. Chronic Opioid Therapy: Another Reappraisal. Bulletin. January/February 2002, Vol. 12(1):1, Herr K, et al. Pain assessment in the nonverbal patient: position statement with clinical practice recommendations. Pain Management Nursing, June 2006, 7(2): Jones KR et al. Translation research in long-term care: Improving pain management in nursing homes. Worldviews Evidenced Based Nursing, 2004 Supplement 1 S13-20

38 Bibliography Kaasalainen S. et al. Optimizing the role of the nurse practitioner to improve pain management in long-term care. Canadian Journal of Nursing Research, June 2007, 39(2): Kaasalainen S. et al. Pain management decision making among long-term care physicians and nurses. Western Journal of Nursing Research,August 2007, 29(5): Kanner, R., Pain Management Secrets, Mosby, St. Louis, MO McCaffery, M. and Pasero, C., Pain Clinical Manual, Mosby, St. Louis, McQuay H. Opioids in pain management. Lancet, June 1999, 353(9171): Smith, R., Curci, M. and Silverman, A. Pain Management: The global connection. Nursing Management, June 2002, Tarzian A. & Hoffman D. Barriers to managing pain in the nursing home: findings from a statewide survey. Journal of the American Medical Directors Association,May-June 2005, S13-9. Winn P. & Dentino, A. Effective pain management in the long-term care setting. Journal of the American Medical Directors Association, September-October 2004, 5(5):

39 Helpful Web Sites rts-warn-against-long-term-use-of-common-pain-pills/