Cancer PainCancer PainChapter 13Chapter 13

Last Class:Last Class:

• Discuss the goals of chemotherapy.Discuss the goals of chemotherapy.• Describe the agents used in Describe the agents used in

chemotherapy, including classification, chemotherapy, including classification, methods of administration and side methods of administration and side effects.effects.

• Describe the nursing management of side Describe the nursing management of side effects of chemotherapyeffects of chemotherapy

Today’s Objectives:Today’s Objectives:

• Describe radiation as a modality for cancer Describe radiation as a modality for cancer treatment, and the uses of radiotherapytreatment, and the uses of radiotherapy

• Identify factors affecting cell response to Identify factors affecting cell response to radiotherapy.radiotherapy.

• Discuss the principles of radiation protectionDiscuss the principles of radiation protection• Describe the types of radiation therapy and Describe the types of radiation therapy and

related nursing care.related nursing care.• Discuss side-effects of radiation therapy and Discuss side-effects of radiation therapy and

nursing care.nursing care.

Today’s Class:Today’s Class:

Define painDefine painOutline the pathophysiology of painOutline the pathophysiology of painDiscuss the concept of “total pain”Discuss the concept of “total pain”Compare and contrast acute and chronic pain Compare and contrast acute and chronic pain Discuss the different classifications of pain and Discuss the different classifications of pain and common descriptors.common descriptors. Describe the WHO analgesic ladderDescribe the WHO analgesic ladderDescribe common assessments and Describe common assessments and interventions for paininterventions for painRead Chapter 13 TextRead Chapter 13 Text

Pain DefinitionPain DefinitionDifficult to describe b/c it is such a multi-Difficult to describe b/c it is such a multi-dimensional phenomenon. According to dimensional phenomenon. According to International Association for the Study of International Association for the Study of Pain:Pain:

““An unpleasant sensory and emotional experience An unpleasant sensory and emotional experience associated with actual or potential tissue associated with actual or potential tissue

damage, or described in terms of such damagedamage, or described in terms of such damage””

Pain DefinitionPain Definition

McCaffrey’s McCaffrey’s definition addresses definition addresses the subjectivity of the subjectivity of pain ….pain ….

““whatever the whatever the experiencing person experiencing person

says it is and says it is and existing whenever existing whenever the person says it the person says it

is”is”

Facts About Pain:Facts About Pain:

Pain is always subjective.Pain is always subjective.The severity of pain is not in linear relation The severity of pain is not in linear relation to the amount of tissue damageto the amount of tissue damageMany factors influence a person’s Many factors influence a person’s perception of pain, including:perception of pain, including:

FatigueDepressionAngerFear & anxiety (including past experience with pain)Feelings of helplessness and hopelessness.Pain tolerance

Total PainTotal Pain

Seven “P’s”:Seven “P’s”:

Physical PainPhysical Pain

Intellectual PainIntellectual Pain

Emotional painEmotional pain

Interpersonal painInterpersonal pain

Spiritual PainSpiritual Pain

Financial PainFinancial Pain

Bureaucratic PainBureaucratic Pain

Pathophysiology of PainPathophysiology of Pain

TransductionTransduction – initial pain stimulus – initial pain stimulus triggers action potentialtriggers action potential

TransmissionTransmission – action potential travels – action potential travels from the site of damage to spinal cord and from the site of damage to spinal cord and brainbrain

PerceptionPerception – the conscious perception of – the conscious perception of painpain

ModulationModulation – – inhibition of pain impulse inhibition of pain impulse

Pathophysiology of PainPathophysiology of Pain

http://www.bayareapainmedical.com/http://www.bayareapainmedical.com/nervanim.htmlnervanim.html

Types of PainTypes of Pain

May be Acute or Chronic

Acute Pain– Short duration (<6 mths)– Immediate, identifiable onset

(surgery)– Limited & often predictable duration– Often described as “sharp”,

stabbing”, “shooting” SharpStabbingShooting

Chronic Pain

Three types: Three types:

chronic non-malignantchronic non-malignant (low back pain),(low back pain), chronic chronic intermittentintermittent (migraine headaches),(migraine headaches), chronic chronic malignantmalignant (cancer-related pain)(cancer-related pain)

Characteristics of Characteristics of chronic pain:chronic pain:– Lasts long periods of time(months to years)Lasts long periods of time(months to years)– Is not readily treatableIs not readily treatable– Pain that is constant, continuous, & moderate Pain that is constant, continuous, & moderate

is described as is described as “difficult to bear””– Often associated with withdrawal & Often associated with withdrawal &

depressiondepression

Cancer-Related PainMalignant pain has characteristics of both acute & Malignant pain has characteristics of both acute & chronic pain.chronic pain.Moderate to severe pain occurs in 30% of clients Moderate to severe pain occurs in 30% of clients receiving treatment and in receiving treatment and in 60-90% in clients with 60-90% in clients with advanced diseaseadvanced diseaseSources of pain in persons with cancer:Sources of pain in persons with cancer:– The cancer itself 46-92%The cancer itself 46-92%– Related to cancer or debility (i.e. muscle spasms, Related to cancer or debility (i.e. muscle spasms,

constipation) 12-29%constipation) 12-29%– Related to treatment (i.e. mucositis, incisional Related to treatment (i.e. mucositis, incisional

pain) 5-20%pain) 5-20%– Concurrent disorder (i.e. arthritis) 8-22% Concurrent disorder (i.e. arthritis) 8-22%

Remember that…..Remember that…..

A A receptorreceptor is any functional macromolecule in a is any functional macromolecule in a cell to which a drug binds to produce an effectcell to which a drug binds to produce an effect

The term The term affinityaffinity to a receptor means the to a receptor means the strength of attraction between receptor and drugstrength of attraction between receptor and drug

Pain:Pain:

Pain Pain - is a perceptual interpretation of nerve - is a perceptual interpretation of nerve activity that reaches consciousness.activity that reaches consciousness.

Pain can be classified according to Pain can be classified according to pathophysiologic mechanism:pathophysiologic mechanism:

Nociceptive pain:Nociceptive pain: pain that pain that arises directly from chemical, arises directly from chemical, thermal or physical stimulation thermal or physical stimulation of normal nerve endings.of normal nerve endings.http://www.youtube.com/http://www.youtube.com/watch?v=PMZdkac4YLkwatch?v=PMZdkac4YLkNeuropathic pain:Neuropathic pain: results from results from injury to a nerve or from injury to a nerve or from abnormal nerve function at abnormal nerve function at any point along the line of any point along the line of neuronal transmission from neuronal transmission from the most peripheral tissues to the most peripheral tissues to the CNS.the CNS.

Nociceptive PainNociceptive Pain

Types: – Somatic (superficial)– Visceral (deep)

Somatic pain originates in skin, bone, joints, muscles, or connective tissue.

Visceral (deep) originates in the organs (lungs, GI, GU tract)

Somatic PainSomatic Pain

Originates in bones, joints, muscles, skin or Originates in bones, joints, muscles, skin or connective tissueconnective tissue

Usually localized & non-radiatingUsually localized & non-radiatingOften described as sharp, deep, dull, aching, throbbingOften described as sharp, deep, dull, aching, throbbingConstant or intermittentConstant or intermittentOften worse with movementOften worse with movementPalpation of area usually elicits painPalpation of area usually elicits painNSAIDs should be considered in any patient with bone NSAIDs should be considered in any patient with bone pain. Often combined with opioidspain. Often combined with opioidsExamples bee sting, sunburnExamples bee sting, sunburn

Visceral painVisceral pain

Originates in cardiac, lung, GI or GU tract Originates in cardiac, lung, GI or GU tract tissuestissues

Is more diffuse over the viscera involvedCramping, gnawing or colicky pain associated with

obstruction of hollow viscusOften referred to cutaneous sitesOther visceral tissues, pain described as aching,

stabbing, or throbbing, spasm, cramping, pressure.Ex. Acute appendicitis, cholecystitis, bowel

obstruction

Neuropathic PainNeuropathic Pain

Results from abnormal sensory processing which occurs Results from abnormal sensory processing which occurs after damage to a nerve, the spinal cord or brainafter damage to a nerve, the spinal cord or brain

Burning, deeply aching that may be accompanied by sudden, sharp, lancinating painOften distributed along a dermatome or peripheral nerveNumbness or tingling over the skinHyperesthesia over an area of the skinSevere pain from the slightest pressure or touchEx. Phantom limb pain

http://www.youtube.com/watch?v=qq5VsVf3CzA

Pain relief can be accomplished by:Pain relief can be accomplished by:

1.1. Preventing activation of Preventing activation of nociceptive receptors in nociceptive receptors in the peripherythe periphery

2.2. Preventing transmission Preventing transmission of electrical signal along of electrical signal along a pathwaya pathway

3.3. Preventing transfer of Preventing transfer of the signal from one the signal from one neuron to anotherneuron to another

Methods for Pain ControlMethods for Pain ControlNonopioid analgesicsNonopioid analgesicsOpioid analgesicsOpioid analgesicsAdjuvant drug therpyAdjuvant drug therpyRadiation therapyRadiation therapyChemotherapyChemotherapyHormonal therapyHormonal therapyAnesthetic proceduresAnesthetic proceduresNeurosurgical proceduresNeurosurgical proceduresPsychosocial interventionsPsychosocial interventions

RadiationRadiation

Good to excellent relief in:Good to excellent relief in:– Painful bone metastasesPainful bone metastases– Acute spinal cord Acute spinal cord

compressioncompression– Chest pain 2ndary to Chest pain 2ndary to

bronchial carcinomabronchial carcinoma– Dysphagia due to Dysphagia due to

esophageal canceresophageal cancer

ChemotherapyChemotherapy

May provide excellent pain relief in May provide excellent pain relief in responsive tumorsresponsive tumors

Usually administered in oral formulations Usually administered in oral formulations when possiblewhen possible

Single agents with lowest toxicity are usedSingle agents with lowest toxicity are used

Administered in short coursesAdministered in short courses

Hormonal therapyHormonal therapy

Is used primarily for cancers arising in cells that have an endocrine function (breast, endometrium, prostate)Hormonal therapy to relieve pain is most likely to be effective in carcinoma of the prostrate. Bilateral orchidectomy brings relief of bone pain in 60-80% of clients within hours of surgery & may last up to 2 years

Palliative surgeryPalliative surgery

Indicated for:Indicated for:

Stabilization of long bone Stabilization of long bone with mets to prevent a with mets to prevent a pathological fracturepathological fracture

Decompression of the Decompression of the spinal canal to prevent spinal canal to prevent impending paralysisimpending paralysis

Relief of bowel obstruction Relief of bowel obstruction in selected patientsin selected patients

Anesthetic & Neurosurgical Anesthetic & Neurosurgical ProceduresProcedures

Anesthetic procedures are most helpful Anesthetic procedures are most helpful in treating well-localized somatic or in treating well-localized somatic or visceral pain.visceral pain.

Procedures include injections, inhalation Procedures include injections, inhalation of nitrous oxide, epidural infusion with of nitrous oxide, epidural infusion with opioids or local anesthetics. opioids or local anesthetics.

Neuroablation involves interruption of Neuroablation involves interruption of specific nerve tractsspecific nerve tracts

Physical/non-pharmaceutical Physical/non-pharmaceutical MethodsMethods

Local heatLocal heat

Local cold Local cold applicationsapplications

MassageMassage

TENSTENS

Vibration therapyVibration therapy

AcupunctureAcupuncture

ExerciseExercise

Psychosocial InterventionsPsychosocial Interventions

The goal of most psychosocial The goal of most psychosocial interventions is to help the client regain a interventions is to help the client regain a sense of control that has been under-sense of control that has been under-mined by illness and pain. These mined by illness and pain. These include:include:

– Education and accurate information Education and accurate information about pain, pain control, & common about pain, pain control, & common misconceptions about the use of misconceptions about the use of opioids (fear of addiction, side opioids (fear of addiction, side effects..)effects..)

Psychosocial Interventions Con’tPsychosocial Interventions Con’t

Relaxation Relaxation techniques (focused techniques (focused breathing, meditation)breathing, meditation)

Guided imageryGuided imagery

HypnosisHypnosis

MusicMusic

HumorHumor

Therapeutic touchTherapeutic touch

ABCDE’s of PainABCDE’s of Pain AA- - AskAsk about the pain regularly. Assess pain about the pain regularly. Assess pain

systematicallysystematically

BB- - BelieveBelieve the patient and family in their reports of the patient and family in their reports of pain and what relieves it.pain and what relieves it.

CC- - ChooseChoose pain control options appropriate for the pain control options appropriate for the patient and family, and setting.patient and family, and setting.

DD- - Deliver Deliver interventions in a timely, logical , and interventions in a timely, logical , and coordinated fashioncoordinated fashion

EE- - EmpowerEmpower patients and their families. Enable patients and their families. Enable them to control their course as much as possiblethem to control their course as much as possible

Pay Attention to Detail:Pay Attention to Detail:

Take nothing for grantedTake nothing for grantedBe precise in history takingBe precise in history takingExplore the client’s “total pain”Explore the client’s “total pain”Determine what the person knows about Determine what the person knows about the situation, what s/he believes and fears the situation, what s/he believes and fears about pain and the things that can relieve about pain and the things that can relieve ititMake sure instructions are precise and Make sure instructions are precise and written downwritten down

Pain AssessmentPain Assessment

““Tell me about your pain”Tell me about your pain”Why is it important to pay attention to the Why is it important to pay attention to the

words the patient uses to describe the words the patient uses to describe the painpain

Pain AssessmentPain Assessment

How intense is your pain? How intense is your pain?

Use a pain scaleUse a pain scale

Where is your pain?Where is your pain?

How long does it last?How long does it last?

What makes it better or worse?What makes it better or worse?

How does the pain affect your sleep, How does the pain affect your sleep, appetite, energy, mood, relationships, appetite, energy, mood, relationships, daily activities?daily activities?

Pain AssessmentPain Assessment

Are you having any other symptoms?Are you having any other symptoms?What do you think is causing the pain?What do you think is causing the pain?What medications are you taking for the What medications are you taking for the pain?pain?Do have any concerns about medications?Do have any concerns about medications?What are you doing to try to relieve the What are you doing to try to relieve the pain?pain?Do you have support from family and Do you have support from family and friends?friends?

Pain AssessmentPain Assessment

What investigations have been done?What investigations have been done?

X-raysX-rays

CT scanCT scan

Bone scanBone scan

Blood workBlood work

Pain Assessment ToolsPain Assessment Tools

Subjective tools such as the Subjective tools such as the Visual Analog Scale (VAS) Visual Analog Scale (VAS) and the Faces Scale are and the Faces Scale are used to assess pain.used to assess pain. The VAS is a straight The VAS is a straight horizontal 100 mm line horizontal 100 mm line anchored with "no pain" on anchored with "no pain" on the left end and "worst the left end and "worst possible pain" or "pain as possible pain" or "pain as bad as it could possibly be" bad as it could possibly be" on the right. Clients are on the right. Clients are asked to choose a position asked to choose a position on the line that represents on the line that represents their pain.their pain.The Faces Scale depicts The Faces Scale depicts facial expression on a scale facial expression on a scale of 0-6, with 0=smile, and of 0-6, with 0=smile, and 6=crying grimace. Clients 6=crying grimace. Clients should choose a face that should choose a face that represents how the pain represents how the pain makes them feel. makes them feel.

The African-American The African-American version of the Oucher version of the Oucher was developed and was developed and copyrighted by Mary J. copyrighted by Mary J. Denyes, PhD, RN, Denyes, PhD, RN, Wayne State Wayne State University School of University School of Nursing, and Antonia Nursing, and Antonia M. Villarruel, PhD, RN, M. Villarruel, PhD, RN, currently of the currently of the University of University of Pennsylvania. Pennsylvania.

Behavioral CuesBehavioral Cues

Non-verbal cues include:Non-verbal cues include:– Decreased activity or restlessnessDecreased activity or restlessness– Furrowed browFurrowed brow– GrimacingGrimacing– Crying, moaningCrying, moaning– Withdrawal from interacting with each otherWithdrawal from interacting with each other– Guarded or stiffened postureGuarded or stiffened posture– irritabilityirritability

Physical Physical signs include increased BP, rapid signs include increased BP, rapid pulsepulse

WHO General Principles of Pain WHO General Principles of Pain ManagementManagement

By mouthBy mouth

By clockBy clock

By the ladderBy the ladder

For the individualFor the individual

Use of adjuvantsUse of adjuvants

Attention to Attention to detailsdetails

WHO 3-step Analgesic LadderWHO 3-step Analgesic LadderThe WHO has developed a three-step The WHO has developed a three-step analgesic ladder to guide the use of analgesic ladder to guide the use of drugs in treating cancer paindrugs in treating cancer pain

First stepFirst step: non-opioid drug with/without : non-opioid drug with/without adjuvant drug as requiredadjuvant drug as required

Second stepSecond step:: add a weak opioid for add a weak opioid for mild to moderate pain, with adjuvant mild to moderate pain, with adjuvant drugs as requireddrugs as required

Third stepThird step:: a strong opioid should be a strong opioid should be substituted for the weak. substituted for the weak.

WHO Ladder:WHO Ladder: outlines pain management principles.outlines pain management principles.

A Stepped ApproachA Stepped Approach

Step OneMild pain(1-2 / 10)Acetaminophen, NSAIDs ±adjuvants

Step TwoModerate pain(3-5 / 10)Acetaminophen with codeine, acetaminophen or ASA with oxycodone ± adjuvants ± nonopioid analgesics

Step ThreeSevere pain(6-10 / 10)Morphine, hydromorphone, methadone, fentanyl, oxycodone ± adjuvants ± nonopioid analgesics

Nonopioid Analgesics –Nonopioid Analgesics – AcetaminophenAcetaminophen

Effective for mild painEffective for mild pain

No anti-inflammatory effectNo anti-inflammatory effect

Usual adult dose 325-1000 mg po q4h Usual adult dose 325-1000 mg po q4h (maximum 4000 mg daily)(maximum 4000 mg daily)

Often combined with opioidsOften combined with opioids

Nonopioid Analgesics – NSAIDsNonopioid Analgesics – NSAIDs

Act by inhibiting prostaglandinsAct by inhibiting prostaglandinsAnalgesia and anti-inflammatory actionAnalgesia and anti-inflammatory actionAppropriate for mild to moderate painAppropriate for mild to moderate painEffective adjuvants for bone painEffective adjuvants for bone painSide effect profiles vary between agents within the Side effect profiles vary between agents within the classclassGastroprotectants may be necessaryGastroprotectants may be necessaryUse cautiously in patients with renal insufficiency Use cautiously in patients with renal insufficiency Due to ↓ platelet aggregation, NSAIDs should be Due to ↓ platelet aggregation, NSAIDs should be avoided in patients at risk of thrombocytopeniaavoided in patients at risk of thrombocytopenia

Opoid Opoid AnalgesicsAnalgesicsAct primarily by stimulation of receptors in the Act primarily by stimulation of receptors in the brainbrainAre the mainstay of cancer pain management of Are the mainstay of cancer pain management of moderate to severe intensitymoderate to severe intensityUse the oral route whenever possibleUse the oral route whenever possible

Use the SC or IV route for rapid pain relief or if Use the SC or IV route for rapid pain relief or if the patient is not able to take medications orallythe patient is not able to take medications orally

All parenteral opioids can be given SCAll parenteral opioids can be given SC

IM injections not recommended IM injections not recommended

Opioid Analgesics – Opioid Analgesics – Choice of Choice of AgentAgent

Start with morphine (unless contraindicated) as Start with morphine (unless contraindicated) as most patients will achieve pain control and it is most patients will achieve pain control and it is easily available in multiple doses and dosage easily available in multiple doses and dosage routes routes

Hydromorphone and fentanyl may be preferred Hydromorphone and fentanyl may be preferred in the elderlyin the elderly

Oxycodone, fentanyl and methadone may be Oxycodone, fentanyl and methadone may be safer in patients with renal failuresafer in patients with renal failure

Avoid meperidine/DemerolAvoid meperidine/Demerol

Useful for short term acute care.Useful for short term acute care.Has a long half-life Has a long half-life The metabolite of meperidine is associated with The metabolite of meperidine is associated with many adverse effects and may reach toxic levels, many adverse effects and may reach toxic levels, leading to CNS excitation or even seizures.leading to CNS excitation or even seizures.

Sphincter of Oddi is sensitive to all Sphincter of Oddi is sensitive to all narcotics.narcotics.

The sphincter of Oddi is a muscular valve that controls the flow of digestive juices (bile and pancreatic juice) through the ampulla of Vater into the first part of the small intestine (duodenum).

Narcotics cause spasms of the spinchter of oddi. The spasms cause a back-up of these digestive juices the result being episodes of severe abdominal pain.

Sphincter of Oddi: Sphincter of Oddi: is sensitive to narcoticsis sensitive to narcotics

Equianalgesic Doses and Half-Lives of Equianalgesic Doses and Half-Lives of Selected Morphine-Like Agonists Selected Morphine-Like Agonists

Equianalgesic Conversion TableEquianalgesic Conversion Table

For the IndividualFor the Individual

Requirements vary deeplyRequirements vary deeplyTThe average person will require 60 to

120mg of oral morphine per day

Some will require less opioid

A small % may require very high doses (>2000mg/day)

The dose of analgesic must be titrated against the particular patient pain

Use of AdjuvantsUse of Adjuvants

Enhances the analgesic effect (steriods, Enhances the analgesic effect (steriods, anticonvulsants)anticonvulsants)

Controls the adverse effects of opiods Controls the adverse effects of opiods (e.g. antiemetics, laxatives)(e.g. antiemetics, laxatives)

To manage symptoms that are To manage symptoms that are contributing to the client’s pain (anxiety, contributing to the client’s pain (anxiety, depression, insomnia)depression, insomnia)

1.1. Aim for graded reliefAim for graded relief

2.2. Start with a specific drug for a Start with a specific drug for a specific painspecific pain

3.3. Choose an appropriate route of Choose an appropriate route of administrationadministration

4.4. Titrate the dosage of opioidsTitrate the dosage of opioids

5.5. Provide for rescue dosesProvide for rescue doses

6.6. Anticipate and treat side effectsAnticipate and treat side effects

Attention to DetailAttention to Detail

Take nothing for grantedTake nothing for grantedBe precise in history takingBe precise in history takingExplore the client’s “total pain”Explore the client’s “total pain”Determine what the person knows about Determine what the person knows about the situation, what s/he believes and fears the situation, what s/he believes and fears about pain and the things that can relieve about pain and the things that can relieve ititMake sure instructions are precise and Make sure instructions are precise and written downwritten down

Initiating An OpioidInitiating An Opioid

Assess the level of painAssess the level of pain

Start with an immediate-release preparation, q4h Start with an immediate-release preparation, q4h around the clockaround the clock

Follow a titration schedule to establish pain Follow a titration schedule to establish pain controlcontrol

Breakthrough doses of the same opioid Breakthrough doses of the same opioid (immediate-release only) should be provided(immediate-release only) should be provided

When pain is controlled, convert to a sustained-When pain is controlled, convert to a sustained-release product release product

Side Effects of OpioidsSide Effects of Opioids

CommonCommon Less FrequentLess Frequent RareRare

ConstipationConstipation

NauseaNausea

GI UpsetGI Upset

SedationSedation

Dry MouthDry Mouth

Urinary retentionUrinary retention

PruritusPruritus

Severe myoclonusSevere myoclonus

ConfusionConfusion

Hallucinations, Hallucinations, nightmaresnightmares

Postural hypotensionPostural hypotension

VertigoVertigo

Respiratory depressionRespiratory depression

AllergyAllergy

Use of AdjuvantsUse of Adjuvants

Enhances the analgesic effect (steriods, Enhances the analgesic effect (steriods, anticonvulsants)anticonvulsants)

Controls the adverse effects of opiods Controls the adverse effects of opiods (e.g. antiemetics, laxatives)(e.g. antiemetics, laxatives)

To manage symptoms that are To manage symptoms that are contributing to the client’s pain (anxiety, contributing to the client’s pain (anxiety, depression, insomnia)depression, insomnia)

Ongoing AssessmentOngoing Assessment

Pain is a dynamic process and may Pain is a dynamic process and may change from hour to hour!change from hour to hour!

New pains, disease progression, a New pains, disease progression, a treatable acute problem may arise.Pain treatable acute problem may arise.Pain assessment must be documentedassessment must be documented

Assess for tolerance:the need to increase Assess for tolerance:the need to increase dosage of a drug over time to maintain a dosage of a drug over time to maintain a given level of analgesia. (rare)given level of analgesia. (rare)

Factors Affecting PainFactors Affecting Pain

Situational factorsSituational factorsSociocultural factorsSociocultural factorsAgeAgeGenderGenderMeaning of painMeaning of painAnxietyAnxietyPast experience with painPast experience with painExpectations & placebo effectExpectations & placebo effect

Barriers to Effective Pain Barriers to Effective Pain ManagementManagement

Who is at risk for inadequate pain Who is at risk for inadequate pain management?management?

Rural clients (access)Rural clients (access)

Elderly (natural part of aging? Difficulty Elderly (natural part of aging? Difficulty describing pain?describing pain?

Cultural differencesCultural differences

Ethnic minorities, lower income bracketsEthnic minorities, lower income brackets

Gender - womenGender - women

Religious beliefs (positive & negative Religious beliefs (positive & negative impact)impact)

Barriers to Pain ManagementBarriers to Pain Management HCPs & FamiliesHCPs & Families

Lack of education about pain management from Lack of education about pain management from health professionals.health professionals.Poor communication (subjectivity)Poor communication (subjectivity)

Personal BarriersPersonal BarriersStigma associated with use of narcoticsStigma associated with use of narcoticsFear of addictionFear of addictionSide effectsSide effectsNeed to be “good patient”Need to be “good patient”Fear it will impede progressFear it will impede progressFear of injectionsFear of injections

Barriers to Pain ManagementBarriers to Pain Management

Health Care System FactorsHealth Care System Factors

Pain not recognized as a major Pain not recognized as a major management priority in pastmanagement priority in past

Lack of prescription drug coverage for Lack of prescription drug coverage for many peoplemany people

Restrictions on prescriptions for narcoticsRestrictions on prescriptions for narcotics

Health Care ProfessionalsHealth Care Professionals

Lack of educationLack of education

Fear of regulatory scrutinyFear of regulatory scrutiny

Concerns about addiction and respiratory Concerns about addiction and respiratory depression from opioidsdepression from opioids

Poor pain assessment skillsPoor pain assessment skills

Concerns about people seeking drugs for Concerns about people seeking drugs for illicit useillicit use

Patients and FamilyPatients and Family

Fears about the meaning of the painFears about the meaning of the pain

Strong views on the use of opioidsStrong views on the use of opioids

The belief that pain is a “normal” part of the The belief that pain is a “normal” part of the illnessillness

Past experiences with painPast experiences with pain

Cultural, or religious beliefsCultural, or religious beliefs

Denial of disease or disease progressionDenial of disease or disease progression

Fears about constipation, addiction, sedation, Fears about constipation, addiction, sedation, cognitive changescognitive changes

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