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Pain & Symptom Management:

Comprehensive Considerations for the

School Setting Focus on Assessment and Alternative

Intervention and Treatment

What is Pain?

•  Definition: According to the Merriam Webster Online Dictionary, pain is defined as below:

•  1 punishment •  2 a. usu. localized physical suffering associated with bodily disorder

(as a disease or an injury); : a basic bodily sensation induced by a noxious stimulus, received by naked nerve endings, characterized by physical discomfort (as pricking, throbbing, or aching), and typically leading to evasive action

b: acute mental or emotional distress or suffering : grief •  3 plural: the throes of childbirth •  4 plural: trouble, care, or effort taken to accomplish something •  5 :one that irks or annoys or is otherwise troublesome —often used in

such phrases as pain in the neck

types of Pain

•  Physical- illness, injury •  Emotional- feelings hurt, shut-down,

death, divorce, change •  Spiritual- Angry with God or other higher

power, disheartened •  Exacerbation of any of the above in

addition to the effects of pain on aspects of a client’s life, relationships, etc.

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Perpetrators of pain

•  Death •  Change in job/ job loss •  Divorce •  Illness •  Faith challenges •  Injury •  Moving •  Other transitions and changes

Pain Assessment Obtain a comprehensive history- suggestions below are paraphrased

from Scott M. Fishman’s Responsible Opiod Prescribing •  What is the location of the pain? •  “Character” of pain- what does it feel like? Is it worse at certain times of the

day? •  Lowest and highest pain on 0 to 10 scale in a typical day? •  Typical pain on a daily basis on a 0 to 10 scale? •  How and when did the pain first start? •  What exacerbates it and what relieves it? •  How does it effect sleep? •  How does it effect mood? •  How does it effect functioning at work? •  How does it effect quality of life? i.e. relationships, sex, recreation? •  Is the patient involved with an insurance process with regard to a car

accident or disability case? •  What are the client’s hopes/ expectations for therapy and/or other attempts

to relieve their pain?

Pain Rating Scales •  Wong-Baker FACES® Pain Rating Scale- Recommeded for ages

3 and older. The child is asked to point to the picture of the face that describes how much pain they are in. http://www.wongbakerfaces.org/

•  Verbal pain assessment; Recommended for individuals 8 years and older. A patient/ client is asked to rate their pain on a scale from 1 to 10 with 10 being the most pain they have ever experienced/ could imagine. http://www.sjbhealth.org/documents/Pain%20Scale.pdf

•  FLACC stands for face, legs, activity, crying and consolability. It is an observer rated pain scale, performed by a healthcare practitioner such as a doctor or a nurse. The FLACC pain scale was designed for children between the ages of 2 and 7. However, some practitioners in adult settings may use the FLACC pain scale for people who are unable to communicate their pain. FLACC provides a pain assessment scale between 0 and 10.

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Pain Rating Scales Continued

•  Edmonton Symptom Assessment System: (revised version) (ESAS-R) –  (English, Spanish and Arabic versions

available through Alberta Health Services and Cancer Care Ontario)

•  N-PASS NEONATAL PAIN, AGITATION

AND SEDATION SCALE for infants less than 1 year

A few Ethical considerations for pain assessment…

•  Age

•  Language

•  Developmental level

•  Different ages require different assessment tools/ styles

•  Use of tools in native language, interpreters

•  May require consideration of a different tool based on cognitive ability

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Please mark on these pictures where it is that you hurt:

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Quick Quiz! • Get out your

electronic device- smart phone, tablet,

lap top, whatever you have handy!!!!

Pain and Symptom Management Options

•  Home Remedies •  Over-the-Counter Medication •  Prescription Medication •  Essential Oils •  Physical, Mental & Spiritual Exercises and

therapies •  Illegal drugs

Home Remedies •  Stomach-ache

–  Drink warm vernors •  Toothache

–  Put whiskey on it •  Sore throat

–  Drinking tea with honey and lemon •  Headaches

–  steaming hot towel over the forehead and face, ice pack/ frozen vegetables on the top of the head

–  sitting in a chair leaning over it with hands in a pot of hot water

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Over-the-counter Medication

•  Ibuprofen (Advil, Motrin), Acetominophen (Tylenol), Aspirin (Bayer)

•  Pepto Bismol, Tums •  Throat Lozenges, cold/ cough medicine,

Vicks Vapor Rub •  Icy Hot, Bengay •  Neosporin, Bacitracin •  Alcohol, Cigarettes

Prescription Medications

•  Omeprazole •  Klonopin •  Ativan •  Xanax •  Zithromax •  Albuterol

Overview on Major Drug Groups Used in Pain Medicine and Psychiatry from Scott M. Fishman’s

Responsible Opiod Prescribing Pain •  Na + blockers •  Nsaids •  Opiods •  Alpha Blocker Pain and Psychiatry Overlap •  Alpha 2 agonists •  Lithium •  Beta blockers •  Antidepressants •  Antipsychotics •  Anticonvulsants •  Stimulants •  BNZs

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Medications Organized by Trade Name http://www.nimh.nih.gov/health/publications/mental-health-medications/complete-index.shtml

Trade Name Generic Name FDA Approved Age

Combination Antipsychotic and Antidepressant Medication

Symbyax (Prozac & Zyprexa)

fluoxetine & olanzapine 18 and older

Antipsychotic Medications

Abilify aripiprazole

10 and older for bipolar disorder, manic or mixed episodes; 13 to 17 for schizophrenia and bipolar;

Clozaril clozapine 18 and older

Fanapt iloperidone 18 and older

fluphenazine (generic only) fluphenazine 18 and older

Geodon ziprasidone 18 and older

Haldol haloperidol 3 and older

Invega paliperidone 18 and older

Loxitane loxapine 18 and older

Moban molindone 18 and older

Navane thiothixene 18 and older

Orap (for Tourette's syndrome) pimozide 12 and older

perphenazine (generic only) perphenazine 18 and older

Risperdal risperidone 13 and older for schizophrenia; 10 and older for bipolar mania and mixed episodes; 5 to 16 for irritability associated with autism

Seroquel quetiapine

13 and older for schizophrenia; 18 and older for bipolar disorder; 10-17 for treatment of manic and mixed episodes of bipolar disorder.

Stelazine trifluoperazine 18 and older

thioridazine (generic only) thioridazine 2 and older

Thorazine chlorpromazine 18 and older

Zyprexia olanzapine 18 and older; ages 13-17 as second line treatment for manic or mixed episodes of bipolar disorder and schizophrenia.

Trade Name Generic Name FDA Approved Age

Antidepressant Medications (also used for anxiety disorders)

Anafranil (tricyclic) clomipramine 10 and older (for OCD only)

Asendin amoxapine 18 and older

Aventyl (tricyclic) nortriptyline 18 and older

Celexa (SSRI) citalopram 18 and older

Cymbalta (SNRI) duloxetine 18 and older

Desyrel trazodone 18 and older

Effexor (SNRI) venlafaxine 18 and older

Elavil (tricyclic) amitriptyline 18 and older

Emsam selegiline 18 and older

Lexapro (SSRI) escitalopram 18 and older; 12 - 17 (for major depressive disorder)

Ludiomil (tricyclic) maprotiline 18 and older

Luvox (SSRI) fluvoxamine 8 and older (for OCD only)

Marplan (MAOI) isocarboxazid 18 and older

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Nardil (MAOI) phenelzine 18 and older

Norpramin (tricyclic) desipramine 18 and older

Pamelor (tricyclic) nortriptyline 18 and older

Parnate (MAOI) tranylcypromine 18 and older

Paxil (SSRI) paroxetine 18 and older

Pexeva (SSRI) paroxetine-mesylate 18 and older

Pristiq desvenlafaxine (SNRI) 18 and older

Prozac (SSRI) fluoxetine 8 and older

Remeron mirtazapine 18 and older

Sarafem (SSRI) fluoxetine 18 and older for premenstrual dysphoric disorder (PMDD)

Sinequan (tricyclic) doxepin 12 and older

Surmontil (tricyclic) trimipramine 18 and older

Tofranil (tricyclic) imipramine 6 and older (for bedwetting)

Tofranil-PM (tricyclic) imipramine pamoate 18 and older

Vivactil (tricyclic) protriptyline 18 and older

Wellbutrin bupropion 18 and older

Zoloft (SSRI) sertraline 6 and older (for OCD only)

Trade Name Generic Name FDA Approved Age

Mood Stabilizing and Anticonvulsant Medications

Depakote divalproex sodium (valproic acid) 2 and older (for seizures)

Eskalith lithium carbonate 12 and older

Lamictal lamotrigine 18 and older

lithium citrate (generic only) lithium citrate 12 and older

Lithobid lithium carbonate 12 and older

Neurontin gabapentin 18 and older

Tegretol carbamazepine any age (for seizures)

Topamax topiramate 18 and older

Trileptal oxcarbazepine 4 and older

Trade Name Generic Name FDA Approved Age

Anti-anxiety Medications (All of these anti-anxiety medications are benzodiazepines, except BuSpar)

Ativan lorazepam 18 and older

BuSpar buspirone 18 and older

Klonopin clonazepam 18 and older

Librium chlordiazepoxide 18 and older

oxazepam (generic only) oxazepam 18 and older

Tranxene clorazepate 18 and older

Valium diazepam 18 and older

Xanax alprazolam 18 and older

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Trade Name Generic Name FDA Approved Age

ADHD Medications (All of these ADHD medications are stimulants, except Intuniv and Straterra.)

Adderall amphetamine 3 and older

Adderall XR amphetamine (extended release) 6 and older

Concerta methylphenidate (long acting) 6 and older

Daytrana methylphenidate patch 6 and older

Desoxyn methamphetamine 6 and older

Dexedrine dextroamphetamine 3 and older

Dextrostat dextroamphetamine 3 and older

Focalin dexmethylphenidate 6 and older

Focalin XR dexmethylphenidate (extended release) 6 and older

Intuniv guanfacine 6 and older

Metadate ER methylphenidate (extended release) 6 and older

Metadate CD methylphenidate (extended release) 6 and older

Methylin methylphenidate (oral solution and chewable tablets) 6 and older

Ritalin methylphenidate 6 and older

Ritalin SR methylphenidate (extended release) 6 and older

Ritalin LA methylphenidate (long-acting) 6 and older

Strattera atomoxetine 6 and older

Vyvanse lisdexamfetamine dimesylate 6 and older

Essential Oils •  Single Oils: Lavender, Peppermint, Frankincense

•  Oil Blends: Breathe, Deep Blue, In Tune Focus Blend

•  “Cocktails”- mix of various single oils for a specific purpose

*Found from a variety of vendors including DoTerra, Young

Living, and many others.*

Physical or Mental Exercises and other alternative options

•  Therapy, Counseling •  Yoga •  Meditation •  Reiki •  Stretching •  Physical, Occupational, Recreational and other

therapy and Exercises •  Reflexology •  Music, art and other therapies

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https://www.youtube.com/watch?v=6JGRhypSknA

https://www.youtube.com/user/Lusterlearning/videos

Illegal Drugs

•  Marijuana- legal/ not legal… •  Heroin •  Cocaine •  Medications not prescribed to you •  Use of items available for purchase

and used in a different way than intended i.e. bath salts, potpourri

Some Pain Responses…

•  May vary based on numerous factors… •  Pain responses may be similar to grief/

loss response: Denial, Anger, Bargaining, Depression, Acceptance

•  Withdrawal/ isolation •  Short-fuse •  Increased self-medication i.e. substance

use/ abuse

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Some to pain relief

•  Not believing the individual’s report of pain •  Fear of verbalizing pain due to stigma for those who

report having a difficult time- “cry baby”, “suck it up”

•  Preconceived notions •  Family/ friends’ discomfort can result in isolation •  Access: knowledge of available resources,

insurance, transportation •  Providers having a difficult time with a specific client

and/or their family due to beliefs, thoughts or perceptions

•  A client that has a different native language than a provider/ providers that are working with them

Cultural considerations: some perceptions

•  Language barriers •  Not socially acceptable for men to cry or express

being in pain •  Religious beliefs about acceptable behavior and

medications •  Customs/ traditions •  Stigma attached to specific illnesses, sexual

orientation •  Women are expected to cry and show emotion-

considered heartless if they don’t

Gender considerations •  Single parent households- having to be the “man of the

house” and “be strong for the family” •  Expectations: strong males shouldn’t cry or need pain,

anxiety or depression medication; females would share if they are in pain- if they don’t say anything, they must be fine

•  Shift in familial roles: many households are now headed by females (or always have been within some cultures)

•  Gender identity including preferred name and sexual orientation

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Considerations regarding Socioeconomic status

•  Preconceived ideas about “the type of people that use pain medications” or “drunks” or “druggies”

•  Access – Knowledge – Funds – Transportation – Other

Age and Developmentally Appropriate Considerations

What does pain look like to: • Toddlers • Children in Pre-school • Children in Elementary School • Adolescents in Middle School • Young adults in High School • Adults • Elderly • Developmentally delayed individuals How would you change the way you assess the pain of different ages/ abilities?

Suicide •  Feeling overwhelmed, like the pain will never end •  Feeling helpless, hopeless •  This is the only way to get rid of the pain

Contracting for Safety •  Benefits •  Concerns- legal issues

Petitioning for Psychiatric Treatment •  Process- 18 and above •  School process for students under 18 •  Appropriate forms •  After-math

Adam’s Song- Blink 182 Perfect- Pink

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Ethical considerations- be sure to discuss with your client ahead of time… •  Referring personal contacts to another

professional •  Inform clients up front that you are obligated by

law to take appropriate steps to keep them safe. •  Certain information is required by law to be

divulged i.e. suicidal thoughts/ ideations •  Duty to warn others about potential harm or

intent to harm. •  Reporting the abuse/ neglect of an adult or child

as mandatory reporters

A sign of the times… •  Economics: challenges of a struggling economy

–  Unemployment –  Crime –  Alcohol/ drug use and abuse –  Suicide attempts

Internet frenzy •  Technological implications

–  Face book, Instagram, Twitter, Kik, Snapchat: messages are available for all to see (can’t take it back)

–  Wikipedia: the new way to learn everything you ever wanted to know?

–  You tube: videos available on self- mutilation and other self-destructive coping mechanisms

Some thoughts on the Social Work role in pain/ symptom management

•  Congratulate them on trying to find a healthy and constructive way to work through their pain- it is often difficult to seek help

•  Empathize- but don’t tell them, “I know how you feel”. Try, “I can’t imagine what that must be like.”

•  Validate and normalize feelings- “there are other people going through similar challenges”. Suggest a support group, crisis line

•  Provide atmosphere of acceptance- do not judge “you couldn’t possibly be in that much pain”

•  Explore fears •  Explore livable solutions •  Prioritize based on the client’s concerns

–  Ask, “What is the biggest thing on your mind right now?” •  Educate other professionals and advocate for your client

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Social Justice • How do different factors affect

equality for our clients? • What can we do to bridge the “inequality gap”

• Where do we go from here?

Personal implications •  Self Assessment: Who am I? What are my strengths? Weaknesses? What pain

management strategies am I uncomfortable with or am I skeptical about? •  How does pain affect us in our own lives? Imagine the worst pain you have ever

felt- –  What was going through your mind? –  What did you do to relieve it? –  Who did you talk to? –  What were your fears?

•  When might we refer a client to another provider? i.e.- a social worker does not believe in the use of narcotics for pain control. Working with a client with a history of physical pain and use of narcotics for pain control may not be appropriate.

•  Remember that pain is what a client says it is! There are many other factors that we may not be familiar with or understand such as low pain tolerance from someone who has abused a substance or someone with chronic pain that has been prescribed multiple medications over time and has built up a tolerance.

Practical Implications and Strategies in the School Setting

Once identified, determine the least restrictive, most appropriate course of action in school:

•  General Education Consent –  Offer social work services through individual and/or group

•  Medical Plan –  Utilization of Power School or other program in your district to identify to all appropriate staff any medical

implications that may be appropriate for a student

•  504 Plan (Consideration if a Medical Plan is not sufficient enough to meet student’s needs) –  Through the American’s with Disabilities Act (ADA)

•  IEP (Consideration if a 504 Plan is not sufficient enough to meet student’s needs) –  Through the Individuals with Disabilities Educational Act (IDEA)

•  Homebound Services –  The signature of an MD verifying that a student is not able to participate in the traditional school setting due

to medical diagnosis, symptom management or other factors –  This may be able to be certified by a therapist or PhD under specific circumstances such as if a student is in

a psychiatric hospital,etc. ***Remembering to be cognoscente that the former criteria for qualifying for special education of negatively

impacting educational progress is not the only criteria. One also is required to consider the negative effects on one’s home/ social life as well***

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When is a medical plan sufficient?

•  When a student is self sufficient but may require additional exceptions to school rules/ regulations.

•  Examples: –  They may need diabetic supplies in the office –  They may require the capability to eat a piece of

candy or drink juice in the middle of a class period –  They may need to be able to get up and stand –  They may require school staff to be trained *Many districts are utilizing a 504 plan instead of a

medical plan to be sure all needs are fully met.

When is a 504 plan appropriate?

•  When the student requires additional accommodations and/or support that require staff members to make changes to their instruction or structure in a classroom

When is an IEP appropriate?

•  When a student’s mental and/or physical disability requires additional accommodations and/ or support to allow for success in the educational environment with consideration also to the impact at home/ social life

•  Examples: –  Arthrogryposis, Cerebral Palsy

•  Student may require additional time to make up work due to excessive physician appointments, setting due to physical pain sitting in a desk

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Accommodation and Intervention Examples for school:

•  Alternate setting within the school when identified/ requested by student and/or staff

•  Capability to get up and walk around the classroom when utilizing an agreed upon signal with an appropriate staff member

•  Capability to utilize headphones at times direct instruction is not taking place

•  Break cards •  Scheduled breaks •  Support groups

Break-out sessions

•  Answer the following questions for the case vignette your group is reviewing:

•  Who is experiencing pain? •  What type of pain can you identify? What tools

might you use and/or suggest for assessment? •  What type of assistance/ support is currently in

place? •  What could you suggest/ introduce for a plan at

school to support the student?

Supportive Resources There is hope- there are options!

•  Hotlines •  Support Groups (physical and online)- local and national

crisis lines and support groups, yahoo support groups •  Counseling/ therapy •  Referral to a physician or psychologist to explore

medication options •  Alternative therapy: Accupuncture, massage therapy,

aromatherapy, music therapy, art therapy, yoga, meditation, Reiki, others

* Remember- it is not the role of the social worker to determine

what is best for a client. It is the role of the social worker to help build/ identify the “tool kit” and encourage the client to try the different options to help them practice and determine what works best for them*

Island In the Sun- Weezer

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Bibliography •  Allen-Meares, P., Fraser, M.W. (2004). Intervention with Children and

Adolescents: An Interdisciplinary Perspective. Boston, MA: Pearson Education Inc. •  AromaTools. Modern Essentials.2015.6th edition. Orem, UT. www.aromatools.com •  CARE, www.careofmacomb.com. •  Child Protective Proceedings Benchbook. http://courts.michigan.gov/mji/resources/

cppbook/CPP_2009-2010-August.pdf •  Egan, M. (2010). Evidence-Based Interventions for Social Work in Health Care.

New York, NY: Routledge. •  Fishman, S. M. (2013). Responsible Opiod Prescribing: A Guide for Michigan

Physicians. Washington D.C.: Waterford Life Sciences. •  Gliatto, M.F., Rai, A.K. Evaluation and Treatment of Patients with Suicidal

Ideation, American Family Physician 1999:59(6): http://www.aafp.org/afp/990315ap/1500.html.

•  Handzo, G. July 2011. A Dictionary of Patients’ Spiritual & Cultural Values for Health Care Professionals. Journal of Hospice and Palliative Nursing. 2010;12(6):337-342. © 2010 Lippincott Williams & Wilkins

•  Luster, J., Luster, J.Calm Classroom: High School Edition. Luster Learning Institute. www.lusterlearning.org. Highland Park, IL.

•  Montgomery, K.L., Kim, J.S., Franklin, C. Acceptance and Commitment Therapy for Psychological and Physiological Illnesses: A Systematic Review for Social Workers, Health and Social Work. 2011; 36(3):169-181.

•  National Institute of Mental Health Science Writing, Press & Dissemination Branch 6001 Executive Boulevard Room 8184, MSC 9663 20892-9663 Web site: http://www.nimh.nih.gov

•  Bethesda, MD Sermersheim, M.A. Levels of Loss, The Path. Hopeline Newsletter. •  White S. You Should Be Over “It” Thoughts by Sharon White, Cedar Rapids,

Iowa, Bereavement Magazine 2003 July/August.