Pain Management Coping With Pain

Pain Management

COPING WITH PAIN IN A NEW WAY

Sid's most immediate pain needs are chronic osteoarthritis, limited flexibility due to increased pain on movement, current but ineffective pain relief and cessation of treatment. He ranked his pain level at 8 in a scale of 10. His secondary needs relate to the care of his wife with dementia and sagging hope for the future.

Assessment Tools of Chronic Pain

Many of these proven reliable and valid tools include the Brief Pain Inventory, the McGill Pain Questionnaire and the Short-form McGill Pain Questionnaire, the Massachusetts General Hospital Pain Center's Pain Assessment Form, and Neuropathic

Screening Tools (Brevik et al., 2008 p 22). The Brief Pain Inventory evolved from the Wisconsin Brief Pain Questionnaire. It may be self-administered, administered during an interview or even on the telephone in as short as two minutes. It charts and evaluates the varying levels of pain and its locations. It also measures pain interference in general activity, walking, normal work, relationships, mood, sleep and enjoyment of life. It likewise asks the patient to rank the relief he receives from current pain therapy (Brevik et al.).

The McGill Pain Questionnaire and the Short-form McGill Pain Questionnaire

These assess sensory, affective-emotional, evaluative and temporal aspects of pain condition (Brevik et al., 2008 p 22). They consist of 11 sensory and four affective verbal descriptors. The patient rates the intensity from 0-3. Then the scores are calculated to frame the sensory, the affective and the total pain index (Brevik et al., 2008).

The Massachusetts General Hospital Pain Center's Pain Assessment Form and Neuropathic Screening Tools

This is a brief self-report form, consisting of important issues relating to pain needs

(Brevik et al., 2008 p 22). Neuropathic Pain Screening Tools, on the other hand, list and evaluate neuropathic symptoms and signs. Its pain quality assessment scale or PQAS differentiates between more nociceptive and more neuropathic pain conditions. The rationale for these tools is that complex chronic pain conditions may include nociceptive, inflammatory, and neuropathic pain mechanisms. Thus, treatments may produce different effects of diverse pain mechanisms (Brevik et al. p 23).

Pain History

Chronic pain strongly affects physical, emotional and mental functions, social and family life, capability to work and produce an income (Brevik et al., 2008 p 20). Measuring chronic pain requires more than measuring acute pain both in clinical practice and testing approaches to long-lasting pain. It requires documenting pain history, physical examination, and specific diagnostic tests. Pain history includes a general medical history, which often reveals certain conditions that may explain or contribute to the patient's complex chronic pain. Specific pain history includes the location, intensity, descriptors, temporal aspects and possible pathophysiological and etiological concerns. Questions that may be asked are where the pain is, how intense it is, the description, how it started, how long it is felt, what relieves it, what aggravates it, its effects on sleep, physical functions, ability to work, economic conditions, mood, family life, social life, sex life, and treatments and their effects, positive or adverse. The patient may also be asked if he is depressed, worried about his true pain condition and overall health and if he is involved in any litigation or compensation process (Brevik et al. p 21).

Information on Opioids

These are synthetic compounds, which produce similar physiological or pharmacological effects as natural opium or opiate narcotic, but which are not derived from opium (Medical Dictionary.com 2010). One central issue in their use is addiction or continued use of the drug despite harm to the user, such as legal problems, relationship conflicts and loss of job (Benedict, 2008). Other issues are tolerance and physical dependence, which often produce withdrawal symptoms. Tolerance is the body's adapting to continual ingestion of an opiate drug, which gradually increases the dose for the same level of pain relief. Physical dependence is the body's compensatory adapting to the opiate substance, which creates symptoms when withdrawn abruptly. The 10 universal precautions that guide pain medicine are appropriate diagnosis; psychological assessment; informed consent; treatment agreement; pre and post-intervention assessment of pain level and function; proper trial of opioid therapy with or without other medications; re-evaluation of pain rate and function level; regular evaluation of analgesia, activity, adverse effects, and aberrant behaviors; periodic review of pain diagnosis and other conditions, especially addiction; and documentation (Benedict).

The Share the Risk model helps reduce the addiction risk to both the clinician and the patient (Benedict, 2008). It involves a psychologist-expert in pain management to handle the depression aspect of pain, which raises the risk of suicide. An addiction specialist may also be consulted to look into possible overuse of opiates, pseudo-addiction or un-authorized dose increase. The model provides patient advocacy and educational support needed for the family to co-sign an opiate therapy agreement. Chronic pain is a serious and divisive issue within the family. It requires documentation in the form of a signed narcotic contract for the long-term use of opiates with strict provisions. It takes precautions by screening for potential substance abuse. And it includes a clear management of risks through cautions and by documenting these cautions (Benedict).

Non-Pharmacological Therapies

These are physiotherapy or physical therapy, hydrotherapy, verbal and written information about the illness, Chronic Behavior Therapy or CBT, alternative medicine, homeopathic remedies, Transcutaneous Electrial Nerve Stimulation or TENS, and self-management (Mitchell & Hurley, 2008). A patient's lack of knowledge or information about chronic joint pain can strongly influence his preference for, acceptance and maintenance of the treatment. He needs to know the causes, effects, prognosis and effective treatment for it to elicit his cooperation in treatment. CBT includes biofeedback and relaxation, which are important to pain control. Examples of alternative pain treatments are acupuncture, acupressure, reflexology and magnetic healing. Homeopathic remedies include herbs. Self-management includes simple pain control, exercise, wearing the right footwear, and weight control (Mitchell & Hurley). Psychological interventions are aimed at cognitive processing and behavioral change, using relapse prevention techniques (Kroner-Herwig, 2009). The techniques have been shown to produce long-term improvement. Psychological interventions, on the whole, have not proved to be effective in primary care (Kroner-Herwig).

The Multi-disciplinary Chronic Pain Team

The main goals of this team are to improve or restore the patient's total function, alleviate his pain condition where possible, and introduce communication and coping skills and adaptive behaviors (Peng, 2008). The aim of treatment is, therefore, to address not only the clinical symptoms and the patient's pain experience, but also the dysfunction, distress and disability associated with the pain experience. Physicians in this team are usually a general practitioner, an anesthesiologist, and a physiatrist. The anesthesiologist's chief rule is in the early development and determination of the chronic pain medicine. His expertise in neural blockade for the treatment of acute and chronic pain syndromes is his contribution to the team. He also plays an important role in the pharmacological aspect of pain relief, improvement of sleep, mood and exercise tolerance (Peng).

Non-physician members of this team include physiotherapists or physical therapists, occupational therapists, psychologists or psychiatrists, nurses, addiction specialists, patient advocates (Peng, 2008) and caregivers. A patient suffering from chronic pain avoids physical activity for fear of repeating or aggravating his pain. The physiotherapist, physical therapist or occupational therapist provides the solution or treatment to many complex chronic pain conditions. He also conducts functional assessments, structured exercise programs, and counseling for the patient. The nurse provides coordinating care and helps the patient go through the health care system for the needed services. She evaluates and assesses the patient's pain condition, supervises his medication titration, educates him, and conducts non-pharmacological therapy and research. Non-pharmacological therapy includes biofeedback and relaxation techniques (Peng).

The improvement of the patient's psychosocial well-being is a significant part of the success of the multidisciplinary healthcare team (Peng, 2008). It introduces techniques, which aim at helping the patient change his perceptions and feelings about pain, such as CBT techniques. CBT program of therapy is often administered by different members of the chronic pain team, but most often by the psychologist member. The program fosters coping skills, reinforces non-pain behavior, reframes cognition, and teacher education and self-management strategies. The purpose of psychological therapies, as well as the function of the psychologist member of the team, is to restore the patient's life as close as possible to normal levels. He does this by helping the patient learn strategies to regain control of his pain. He also provides psychotherapy to address the patient's anxiety and depression (Peng). He is often or preferably an expert in pain management in this special function, as the risk of suicide is high among chronic pain and depressed patients (Benedit, 2008). The addiction specialist member of the team monitors a possible overuse of opiates, pseudo-addiction or un-authorized increase of opiate dose, as earlier mentioned. The patient advocate and educator member of the team assists the patient's family in undertaking and formalizing an opiate therapy agreement (Benedict).

New Intervention Plan

A group of 415 patients with chronic knee pain was recently surveyed on their previous pain management strategies and their preferred treatments as well as their reasons for the preferences (Mitchell & Hurley, 2008). Findings showed that medication was the most common treatment, followed by physiotherapy and no treatment. The majority preferred physiotherapy and no surgery was the third most popular choice. Their preferences and choices evolved from previous experience. They did not perceive their pain as severe enough to require surgery. (Mitchell & Hurley).

A revised regimen for Sid consists of 10 parts. These are a record of his general medical history for a total and comprehensive picture; the use of the four assessment tools mentioned earlier in this paper; his complete and updated pain history; instruction on chronic pain, opioids and opiate therapy; information about non-pharmacological treatment options for chronic pain; continuation of interrupted physiotherapy treatment sessions; conduct of training on self-management and pain control; warning about the risks of smoking; counseling on depression; matching preferences with evidence-based guidelines recommended for chronic pain; and hiring caregivers for himself and his wife.

General Medical History

This may reveal prior conditions, which may have led to chronic pain and thus underlies or contributes to it. It also provides a total picture on which to base a comprehensive approach to treatment.