Crucial Conversations About Pain; Bridging the Gap Between Providers and Patients

Transcription

1 Crucial Conversations About Pain; Bridging the Gap Between Providers and Patients David Nagel, MD According to a report from the Institute of Medicine published in 2011, there are 100 million people in the United States who suffer from chronic pain. Some are calling this a public health crisis, which it is. However, that is not the biggest problem that intractable pain poses. The real problem is that most of us are unaware the problem exists at all. If we are aware, too often we trivialize it. Even those burdened with pain are often unaware. Too many are convinced they are the only ones, and so they suffer in isolation. That is the problem.

2 My Goal: It is my hope to make you look at pain from a different perspective

3 Barriers Chronic pain remains somewhat mysterious A lot we don t know Too often we don t agree on what we do know Too often, rather than recognizing our impotence, we blame the patient for their problem

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5 There is no cure! The world is not capable of making man happy. It is not capable of saving him from every evil in all of its types and forms illness epidemics, cataclysms, catastrophes and the like. This world, with its riches and its wants, needs to be saved, to be redeemed. The world is not free to make man free from suffering Pope John Paul II

6 Objectives 1: Develop a basic understanding of the social impact of refractory pain on the individual and society 2: Develop an understanding of the difference between nociception and suffering with implications for the development of pain, its maintenance, and its effect on provider-patient communication 3: Develop an understanding of what pain management really is 4: Develop strategies for improving communication between patient and provider about pain. 5: Develop an understanding of both practitioner s and patient s rights and responsibilities in the prescription of opioids/cannabinoids including the bilateral agreement.

7 How did I get here?

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10 Pain is not always obvious Listen to the patient The importance of family support The importance of continuity of care

11 How did I get here???

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13 Mr. Smith comes to Dr. Nagel

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15 How do we manage pain?

16 Step 1: Understand the social implications of chronic pain The biggest disease today is not leprosy or tuberculosis (or pain), but rather the feeling of being unwanted, uncared for, and deserted by everybody. The greatest evil is the lack of love and charity, the terrible indifference toward one s neighbor. Mother Teresa

17 100 Million Americans suffer from chronic pain at a cost of $560 -$635 billion annually (IOM, June, 2011)

18 Mayday report, 2009: Chronic pain is a tragically overlooked public health problem. The burden of chronic pain is greater than that of diabetes, heart disease, and cancer combined

19 Chronic Pain Kills Chronic pain patients have a suicide risk of 2-3 times that of the normal population. Risk of depression is 3x that of the normal population. In 2003, the American Psychiatric Association recognized chronic pain as an independent risk factor for suicide 75% of chronic pain patients who voice suicide ideation state that medication overdose is their method of choice The incidence of chronic pain is 55x greater than that of prescription opiate abuse in the United States.

20 Despite the extent of the problem, we make little attempt to learn about it. Only 4000 trained pain physicians in the United States Pain education for North American medical schools is limited, variable, and often fragmentary A large number of US medical schools do not teach pain at all, and an equally large number devote fewer than 5 hours over 4 years (Mezei et al, Jl of Pain, 2011) Veterinary students receive more education about pain than medical students

21 PAINS: Pain Action Alliance to Implement a National Strategy Goal: Destigmatize the stigmatized Objective: Transform the way pain is perceived, judged, and treated by establishing chronic pain as a public health priority through professional education and training, public policy advocacy, public education and communication, health service delivery and reimbursement, and prevention. Interdisciplinary

22 STEP 2: UNDERSTAND WHAT PAIN MANAGEMENT IS The greater the ignorance, the greater the dogmatism. Sir William Osler, MD

23 What it isn t A Cure.

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25 Goals Minimize pain, palliate Minimize suffering Improve function, both avocational and vocational Minimize side effects of treatment Minimize secondary LOSS!

26 Patients do need to suffer.just not as much as we make them. Pain management involves every element of society, not just health care No matter who we are or what we do, we are all involved.

27 Even though there is no cure, there is still plenty we can do

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29 Step 3: Take a deep breath Analyze your feelings Be aware of your pre-conceived notions, perception IS reality Take a chance to believe Don t apologize!!!! Don t be afraid to say I don t know Don t be afraid to ask for help Don t be afraid to fly by the seat of your pants. Evidence Based Medicine is not all it is cracked up to be

30 There are four types of questions in the medical literature: Those which have been answered beyond a reasonable doubt. Assessment of the Cochrane data suggests these are rare. Those which have been addressed, but require further study, and for which there are no firm guidelines. Those which have never been studied for whatever reason and lacking guidelines. Those, because of their complexity, that will never be studied satisfactorily.

31 You do not understand what the patient is feeling

32 Step 4: Understand pain

33 Pain is a signal Requires activation of a complicated pain system Neural/Plastic changes occur at the peripheral, spinal, subcortical and cortical levels Response adapts/changes over time it s a moving target!!! How this system responds depends on a multitude of factors unique to each individual

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35 Pain Suffering Every Patient is Unique!!!

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37 There is no objective test for pain

38 Does he hurt or doesn t he?