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The program is sponsored by IMER. I do not have the sheet that
was supposed to tell me exactly what to say in front of me anymore,
but having said that, it’s all approved. Everything is
above board, and those are the things that you really need to
know.
I’m Patrick Coyne. I am a clinical nurse specialist for
the Thomas Palliative Care Unit at the Virginia Commonwealth University
and my job is managing pain and palliation. That’s where
I come from.
What I was asked to talk about today is how we are going to treat
pain. In an hour, you’re not going to get a lot about pain
and since we are running behind, I’m going to be talking
faster than I would like to. There are things that should challenge
your practice and that’s really what I’d like for you
to walk out of here today and say how can I do a better job in
my practice of pain management. How can I push my peers. How can
I make things be better for those I care for and backup those that
I take care of.
The first thing I think about when I get a consult and I do pain
consults every day of my life is figure out what kind of pain is
it I’m dealing with? Is it an acute pain or is it chronic
pain.
Acute pain, the easiest way to think about it is serves a purpose.
It tells you something is wrong, 90% to 95% of patients who have
acute pain will change vital signs, 5% wont. This is what drives
nurses and doctors crazy. The pain is a 10 and their pulse is
72. They just don’t do what we expect to see. Most patients
will change vital signs with the acute pain. This is something
that’s really important for you to think about because
if you have a cancer patient who is changing vital signs, something
acute is happening and it’s telling something bad is happening.
It’s serving that purpose.
Chronic pain on the other hand, it serves no purpose. Someone who
has rheumatoid arthritis, they hurt every day. Somebody who has
cancer pain, that’s constant, they hurt every day. It serves
no purpose. Vital signs do not change. People who rely on vital
signs are going to be at a loss.
Cancer pain can be acute, it can be chronic and that’s why
cancer pain is different. It drives me crazy when I see people
write they have chronic cancer pain. Cancer pain is a whole separate
entity. It’s acute, it’s chronic, it’s ever changing.
They have the ongoing pain from bone mets and they get a pathological
fracture. They get a zoster infection. It’s going to be ever
changing. Ten percent of cancer patients are going to have 7 or
more sites of pain. You have to keep that in mind as you’re
doing your pain assessment. We will talk about that because when
they are rating their pain a 9, is that an impending cord compression
or new infection or bowel obstruction. Is it related to the treatment?
In our cancer pain clinic 20% of the patients we see every week
are disease-free cancer patients who have pain from their treatment,
from the chemotherapy they got years ago, from the bone marrow
transplant, from the radiation, from their surgery. As cancer becomes
a chronic problem, we are seeing a lot of chronic pain from that
and you have to bear that in mind.
Margo McCaffrey came up with this definition back in 1968. It’s
a definition that’s taught basically in every nursing school
around the country but it has one, what I would say, fatal flaw
to it. What’s wrong with this definition? I’ll give
you a hint. The patient has to be able to tell you they’re
hurting. What about the patient whose language you do not speak,
the patient who is intubated, the patient who is unresponsive,
the two-year-old child, the patients with Alzheimer’s disease.
How are you assessing their pain. Because you have to have a mechanism
in place because these are populations are risk.
We know there is now a lot of research showing a lot of physiological
effects to poor pain management. Wounds wont heal as quickly.
Muscles break down quicker. Higher incidence of DVTs and pulmonary
embolisms, higher incidence of cough suppression, atelectasis,
pneumonia. If they have any renal problems, pain is going to
make it worse because water and sodium retention occurs. Pain
decreases GI function. If you are dealing with a physician who
says I don’t want to give them opioids because I’m
afraid they’ll get an ileus, there is great research now
saying if you don’t manage their pain they are going to
get an ileus. I’d rather be comfortable as I get my ileus
than not be comfortable. Let’s think this one over.
Research in children and in the elderly demonstrated increased
blood pressure, tachycardia, stroke. We are probably going to be
able to demonstrate that in every population.
Psychologically we know when pain is not well managed. Anxiety
increases, 20% to 25% of patients who have pain are clinically
depressed. You are taking care of your population of patients and
they have ongoing pain, you have to think about depression because
1 out of 4 have it. It’s that prominent.
Harvey Churkenoff from British Columbia did a research study
in cancer patients who had pain and he did one question to figure
out if they were depressed and it was 100% effective, which you
could take and put in your practice today and that question was:
are you depressed? A 100% effectiveness in assessing if the patient
was depressed, not hard, real easy to do. You also have to think
about sleep deprivation. Patients in pain get less REM cycle sleep
so they are waking up more fatigued. Do they have a pain regimen
that is waking up at 2:00 in the morning because it doesn’t
last through the night. Those things you have to think about.
Is your patient actually thinking of ending their life because
the pain or the symptoms from pain management are failing. You
get so many symptoms from a lot of our interventions.
Immunologically, new research demonstrates that we have a decreased
natural killer cell count and it infects the patient’s
lymphocytes. This is really interesting research from our point-of-view
in oncology because does this mean that poor pain management
means faster metastatic spread because your immune system is
more compromised because you haven’t treated pain. More
data is to come but it is very interesting.
We have a lot of barriers to getting pain relief done in our country.
The biggest one is our attitudes and beliefs. As healthcare professionals,
we carry baggage. Sometimes we don’t have enough education.
We don’t know what to do. Margo McCaffrey quotes that to
this day, the average physician gets one hour of pain management
in this country. In our medical school we teach 14 hours, that
means 13 others are teaching none if that’s the national
average.
The average patient comes, over 80% comes to see a healthcare
specialist with a chief complaint of pain. Most patients are coming
to use because of pain. We are not even taught well enough on how
to manage it. There are a lot of barriers in terms of new techniques
using adjunct and coanalgesics, interventional strategies for pain
management. Some laws in some states are putting prescription monitoring
there, so physicians are scared to write prescriptions.
Insurance companies, my state will give you 100 pills a month.
What if you need more than 100. That’s all you get. So there
are barriers that your patients may basically inheriting and you
may not know they are there. You also have to look if policies
are stopping their pain management or if they can’t get to
see a pain specialist because their HMO says no. All important
questions.
Patients and family what do they think. Most patients and family
don’t think you can control cancer pain. They have a very
low expectation because most patients have such horrible postoperative
management when they get the big C their expectations of your
ability to manage cancer are really low. They are very fearful
they are going to get addicted and so you have to bring talks
about addiction up front to get those fears out of the way.
I’ve had family members say, “you know I hid those
pills, he was taking them every four hours. I knew he was addicted.” All
very important things. If you’re not talking about that the
first time that prescription is written, there is a problem. You
have to talk about it. It has to be part of patient education.
New research demonstrates if family is taught about pain management,
patients will do better. It just came out yesterday. Teaching families
is important.
Other things to look at are patient and family believes that
it’s going to cause disorientation. It’s going to decrease
their quality of life using opiates so you have to look at that.
How many of you have been with a patient and they are telling you,
no, the pain is a 6, 7 out of 10. A physician walks in, how are
you doing, fine. You kind of sitting there, what just happened.
But patients are really socialized not to complain. They want physicians
to focus on curing disease and that’s really important that
they need to understand they have to advocate. They have to be
part of the team and they have to talk about their pain. They may
not talk about their pain depending on who’s in the room.
They may not want the family to know how much they are hurting.
It may be a form of denial because if they say they have pain it
means disease is progressive, things are failing.
In cancer, depending on the study, between 14% and 100% of cancer
patients do not get good relief. What’s going on in your
facility. What is the biggest barrier to getting your patients
well controlled? I’ll tell you what the research says.
It’s assessment. People don’t ask enough. How are
you asking? All research studies in cancer pain management show
that if someone takes the time and asks about it regularly, patients
do better. Somewhere between 20% and 30% better if someone asks
about it regularly and acts on it.
Postoperatively, most of our patients before the diagnosis have
this issue. They have surgery to get the diagnosis and have of
these patients, 50%, don’t get their postoperative pain
management. This may be what you’re inheriting when you’re
dealing with patients as they get their disease. They get postoperative
pain syndrome. We see it in cancer patients all the time. We
see post thoracotomy pain syndrome. Phantom breast pain, post
mastectomy, head and neck syndromes. What are you doing for those
patients? Are you identifying it?
If they get traumatic neuromas, scar tissue forming after the
surgery, they can have an acute pain that becomes a chronic pain.
What psychological factors are involved? Are they dealing with
depression, change in body image, the role within their family
and community has it changed because of the pain or because of
our treatment of it. Are you treating the symptoms aggressively,
which is really vital because a lot of patients will stop taking
their pain medications because the symptoms are so horrific, the
constipation is so bad. The nausea is not treated aggressively.
The sedation is intolerable.
I always say it’s really easy to get someone comfortable
who is laying flat in bed but if it hurts too much to get out of
bed it’s not much of a pain control regimen or if they are
too sedated to get out of pain, it’s not much of a pain control
regimen. Those are things you have to look at.
In the United States, if you fall into these categories you will
get less pain medications than anyone else. Looking around the
audience, basically almost everyone here is at risk. If you are
a woman, an older adult over 75, a minority, a child, someone
who is poor, someone who is in a nursing home, someone whose
language you do not speak, and someone who comes from a different
socioeconomic, educational, or cultural background than you will
get less pain medication.
The reasons for this are limited verbal communication. Are they
able to communicate their pain. Who is advocating for them? One
study looked at 120 children who had open chest surgery, had to
break the sternum. Postoperatively, 21 got pain medications, 16
got Tylenol. That’s 100 kids who got nothing. You think moms
at the bedside are saying, “give my kid morphine.” Mom
is expecting everyone to do the right thing it just never happened.
Are you doing the right thing? How are you managing your patient’s
pain who cannot communicate to you, who cannot tell you they are
in pain.
We know that one physician, one nurse will do something different
than another. Somebody will give four morphine, the next will give
six. We don’t do things the same. Sometimes we stigmatize
our patients. It’s the famous, “he hits that call bell
every three hours for pain medication.”
That’s probably because it last three hours. If we were smart,
we’d be giving it to them every three hours rather than making
him call for it. There are a lot of problems that can occur in
terms of emotional issues, physiological issues when pain is not
well managed and we don’t have great research in pain medicine.
We really need to do a lot more.
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