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Pain: Current Understanding of Assessment, Management, and Treatments NATIONAL PHARMACEUTICAL COUNCIL, INC This monograph was developed by NPC as part of a collaborative project with JCAHO. December 2001 DISCLAIMER: This monograph was developed by the National Pharmaceutical Council (NPC) for which it is solely responsible. Another monograph relat- ed to measuring and improving performance in pain management was developed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for which it is solely responsible. The two monographs were produced under a collaborative project between NPC and JCAHO and are jointly dis- tributed. The goal of the collaborative project is to improve the quality of pain management in health care organizations. This monograph is designed for informational purposes only and is not intended as a substitute for medical or professional advice. Readers are urged to consult a qualified health care professional before making decisions on any specific matter, particularly if it involves clinical practice. The inclusion of any reference in this monograph should not be construed as an endorsement of any of the treatments, programs or other information discussed therein. NPC has worked to ensure that this monograph contains useful information, but this monograph is not intended as a comprehensive source of all relevant information. In addi- tion, because the information contain herein is derived from many sources, NPC cannot guarantee that the information is completely accurate or error free. NPC is not responsible for any claims or losses arising from the use of, or from any errors or omissions in, this monograph. Editorial Advisory Board Patricia H. Berry, PhD, APRN, BC, CHPN Assistant Professor College of Nursing University of Utah Salt Lake City, UT C. Richard Chapman, PhD Professor and Director Pain Research Center Department of Anesthesiology University of Utah School of Medicine Salt Lake City, UT Edward C. Covington, MD Director, Chronic Pain Rehabilitation Program Cleveland Clinic Foundation Cleveland, OH June L. Dahl, PhD Professor of Pharmacology University of Wisconsin Medical School Madison, WI Jeffrey A. Katz, MD Associate Professor of Anesthesiology Director Pain Clinic VAHCS, Lakeside Division Northwestern University Medical School Chicago, IL Christine Miaskowski, RN, PhD, FAAN Professor and Chair Department of Physiological Nursing University of California San Francisco, CA Michael J. McLean, MD, PhD Associate Professor of Neurology and Pharmacology Department of Neurology Vanderbilt University Medical Center Nashville, TN Section I: Background and Significance 1 A. Introduction 3 B. Definitions and Mechanisms of Pain 4 1. What Is Pain? 4 2. How Does Injury Lead to Pain? 4 3. What Happens During Transduction? 5 4. What Is Transmission? 6 5. What Is Perception? 7 6. What Is Modulation? 7 7. What Is Peripheral Sensitization? 8 8. What Is Central Sensitization? 8 9. What Is Nociceptive Pain? 9 10. What Is Neuropathic Pain? 9 C. Classification of Pain 10 1. Acute Pain 11 2. Chronic Pain 11 3. Cancer Pain 12 4. Chronic Noncancer Pain 12 D. Prevalence, Consequences, and Costs of Pain 13 1. What Is the Size and Scope of Pain As A Health Care Problem? 13 2. What Evidence Suggests That Pain Is Undertreated? 13 3. What Are the Consequences and Costs of Undertreatment of Pain? 14 E. Barriers to the Appropriate Assessment and Management of Pain 15 1. Barriers Within the Health Care System 15 2. Health Care Professional Barriers 16 3. Patient and Family Barriers 16 4. Legal and Societal Barriers 16 5. Tolerance, Physical Dependence, and Addiction 16 Section II: Assessment of Pain 19 A. Initial Assessment of Pain 21 1. Overcoming Barriers to Assessment 21 2. Goals and Elements of the Initial Assessment 21 B. Measurement of Pain: Common Assessment Tools 25 1. Unidimensional Scales 25 2. Multidimensional Tools 26 3. Neuropathic Pain Scale 29 C. Reassessment of Pain 29 1. Frequency 29 2. Scope and Methods 29 ii Pain: Current Understanding of Assessment, Management, and Treatments Table of Contents Section III: Types of Treatments 31 A. Pharmacologic Treatment 33 1. Drug Classifications and Terminology 33 2. Common Analgesic Agents 33 3. General Principles of Analgesic Therapy 47 B. Nonpharmacologic Treatments for Pain 53 1. Psychological Approaches 54 2. Physical Rehabilitative Approaches 54 3. Surgical Approaches 54 Section IV: Management Of Acute Pain And Chronic Noncancer Pain 59 A. Acute Pain 61 1. Treatment Goals 61 2. Therapeutic Strategies 61 3. Elements of Treatment 62 4. Management of Some Common Types of Acute Pain 62 B. Chronic Noncancer Pain 63 1. Treatment Goals 63 2. Therapeutic Strategies 66 3. Elements of Treatment 66 4. Management of Some Common Types of Chronic Noncancer Pain 67 Section V: Strategies to Improve Pain Management 73 A. Clinical Practice Guidelines 75 1. Which Practice Guidelines Apply to Pain Management? 75 2. Are Clinicians Adopting and Using Clinical Practice Guidelines? 76 B. Standards and Outcome Measures 77 1. JCAHO Standards 77 2. Institutional Commitment to Pain Management 78 Glossary of Abbreviations and Acronyms 79 References 82 Section I: Background and Significance 82 Section II: Assessment of Pain 84 Section III: Types of Treatments 85 Section IV: Management Of Acute Pain And Chronic Noncancer Pain 89 Section V: Strategies to Improve Pain Management 91 National Pharmaceutical Council iii Table of Contents [...]... potential misuse and misunderstanding of the nature and risk of addiction limit their appropriate use.152 Disparate definitions of tolerance, physical dependence, and addiction contribute to this problem Therefore, the American Society of Addiction Medicine (ASAM), the American Academy of Pain Pain: Current Understanding of Assessment, Management, and Treatments Section I: Background and Significance... retention) Electrolyte disturbances Sources: References 13 and 23 aMechanical, dynamic, or adynamic obstruction of bowel often manifests as colicky pain, distension, vomiting, and absence of the passage of stool ACTH: adrenocorticotrophic hormone 14 Pain: Current Understanding of Assessment, Management, and Treatments Section I: Background and Significance ence health care.15 Left unchecked, these... goals Expectations and goals for pain management in regard to pain intensity, daily activities, and quality of life What are your goals for treatment? Have you had any problems with pain in the past? If so, how did you manage the pain? Sources: References 5 and 7-8 22 Pain: Current Understanding of Assessment, Management, and Treatments Section II: Assessment of Pain influence the pain and/ or its management... quality of life instruments (e.g., Medical Outcome Study Short-Form 36 Health Survey Instrument) assess pain Pain: Current Understanding of Assessment, Management, and Treatments Section II: Assessment of Pain Table 15 Physical Examination of a Patient With Pain Region General Site of pain Other regions Neurological system Musculoskeletal system Rationale, Methods, and Potential findings Observe and/ or... examples of diagnostic studies used in patients with pain Pain: Current Understanding of Assessment, Management, and Treatments Section II: Assessment of Pain Table 12 Preoperative Assessment and Patient Education Recommendations • • • • • • • • Establish a positive relationship with patients and/ or families Obtain a pain history Educate the patient about pain assessment (e.g., methods, frequency) and pharmacologic... syndrome types I and II; CRPS II: complex regional pain syndrome type II; HIV: human immunodeficiency virus 10 Pain: Current Understanding of Assessment, Management, and Treatments Section I: Background and Significance based on pain duration (i.e., acute vs chronic pain) and underlying pathophysiology (i.e., nociceptive vs neuropathic pain) are used most often (see I.B.9-10) This section of the monograph... sclerosis; PUD: peptic ulcer Pain: Current Understanding of Assessment, Management, and Treatments Section I: Background and Significance interdisciplinary approach that addresses the complex interaction of physical, psychological, and social factors that contribute to the ongoing pain D P R E VA L E N C E , CONSEQUENCES, C O S T S O F PA I N AND Pain is common, and inadequately managed pain is associated... phosphorylate ion channels and NMDA receptors Potential consequences of these changes include altered synaptic transfer and gene expression (e.g., c-fos).27,60,73-74 Collectively, these changes may promote long-lasting increases in DH neuron excitability (i.e., central sensitization) Pain: Current Understanding of Assessment, Management, and Treatments Section I: Background and Significance difficult... motor and sympathetic efferents Other activity produces signals that ascend to various areas in the brain This simple sketch shows only the anterolateral funiculus, which ascends to the brain stem and thalamus Inhibitory influences include certain spinal interneurons and descending pathways from periadqueductal gray and other areas (dashed line) Pain: Current Understanding of Assessment, Management, and. .. standards and guidelines and commitment to some core principles of pain assessment and management (Table 7) 2 Goals and Elements of the Initial Assessment Important goals of the initial assessment of pain include establishing rapport with the patient and providing an overview of the assessment process.8 These processes help to engage the patient, foster appropriate treatment expectations, and promote . Reassessment of Pain 29 1. Frequency 29 2. Scope and Methods 29 ii Pain: Current Understanding of Assessment, Management, and Treatments Table of Contents Section. inhibit nociception in the 6 Pain: Current Understanding of Assessment, Management, and Treatments Section I: Background and Significance Figure 3. Source: