Cme Questionschapter

When is interventional pain management an option to consider a. Only after a patient has shown a positive response to conservative treatment with NSAIDs. b. When a patient is very near recovery from a painful disease. c. Interventional pain management is always the best option. d. After the pathophysiology of a patient's pain is understood. 2. The following drugs are approved by the FDA for intrathecal administration for pain a. fentanyl, morphine, and asprin b. morphine, fentanyl, and asprin...

Conclusion

Anticipatory planning and prevention care plans must be part of the overall pain management strategy. To be successful in preventing pain, a thorough history that incorporates nutraceutical use, an in-depth social history, an evaluation of resource access, and determination of patient expectations must be part of the process. Preemptive measures may include nonpharmacological therapies as well as nonopioid and opioid medications. When drug-seeking behavior is...

Contribute Wisely

Most people in politics start out with great intentions and are quite personable. In general, they will be genuinely grateful to anyone who has demonstrated any interest and support along the way. Even small contributions at that level are often remembered. Of course, years later a comment like, I can remember contributing to your campaign for will go a long way to jogging that memory. Contributions do not have to be monetary. Helping during a campaign, especially in smaller contested ones, can...

Michael Gloth III md facp

Greatness is not in where we stand, but in what direction we are moving. We must sail sometimes with the wind, and sometimes against it but sail we must, and not drift, nor lie at anchor. Everyone should have access to affordable, convenient, and effective assessment and pain management. The concepts for improving pain management in our society encompass three broad areas education, policy, and communication. This is not to ignore reimbursement. However, because of the federal and state...

Pain Management in Long Term Care

Ferrell, md The healthcare system has an obligation to provide comfort and pain American Geriatrics Society guidelines, The Management of Persistent Pain in Older Persons The importance of pain control in the geriatric patient population is now well recognized and has received increasing attention since the 1980s. Growing interest and commitment by the medical community has led to an advancing body of research and literature in this area. Nursing home patients...

All Politics Are Local

In reality, most of the politics associated with pain management occurs far removed from state or national capitols. Such pain politics flourish in hospitals, with insurance providers, and among colleagues and family members. Beyond good skills in communication and spending time addressing concerns, it is helpful to understand the political dynamics of various settings. Sadly, it is not always as simple as defining what is in the best interest of patients. Although many of the principals are...

Contents

Preventive Analgesia Evaluation and 4. Spirituality As an Adjunct to Pain Management 63 Aparna Ranjan, Hana Ayele, Kalu Uma, and Thomas Mulligan 5. The Role of Rehabilitation in Managing Pain in Seniors 73 6. Pharmacotherapy of Pain in Older Adults 7. Pharmacotherapy of Pain in Older Adults Opioids 8. Interventional Strategies for Pain Maneesh C. Sharma, Peter S. Staats, and Frederick W. Luthardt 9. Pain Management in Long-Term Susan L. Charette and Bruce A. Ferrell 10....

Do The Groundwork

As is true with any legislative body, when policy changes are desirable, it is crucial to get as much support as possible before any presentation to the staff at large. Policies should be acceptable to official leadership as well as unofficial, but commonly acknowledged, leaders in the group. Although it should be understood, all too often basics, like notifying the key players in a policy change before it presenting to anyone else, are overlooked. A policy that requires a great deal of nurse...

Education

Every US health care professional school, especially medical, nursing, and pharmacy schools, needs to add further, more standardized instruction on pain management and end-of-life (or hospice) care to the curriculum (1). Certainly, we can do better than the current dismal performance of medical schools with such programs (2). Because every medical practitioner, with only a few exceptions (e.g., pathologists), will regularly confront patients with pain, this would only make sense, even at the...

Drug Allergies

Often a patient reports expected side effects of analgesics as allergies. Opioid analgesic drug allergies are often less accurate than those of other medications. Patients also frequently report nausea and vomiting as drug allergies instead of expected untoward analgesic effects. There is very little evidence in the literature that true anaphylactic-type reactions occur with opioids. Most of the reported adverse events are because of symptoms (e.g., hypotension, itching, hives, and rash)...

Independent Nonprescription And Alternative Therapies

Pain patients will seek pain relief from many sources. Sometimes, this is done without informing the primary care physician or whoever is orchestrating the pain relief efforts. This can be a formula for trouble. Some typical experiences have to do with over-the-counter NSAIDs. A new class of NSAIDs, cyclooxygenase-2 selective inhibitors (COX-2 inhibitors or coxibs), has been recommended for seniors because of their increased safety (22). This recommendation was supported in 2002 when, for the...

Drug Dependency Assessment

Drug dependency assessment should include information not only on illicit drug use, but also on personal habits and prescription medication use. A patient who takes two tablets of hydrocodone and acetaminophen three times daily will be quite different from a patient who takes six tablets of hydrocodone and acetaminophen once daily. The patient who daily takes everything at once will have a much higher opioid tolerance than a patient who takes the six tablets in divided doses. Alcohol use is...

Interventional Strategies for Pain Management

Staats, md, and Frederick W. Luthardt, ma Do not rashly use every new product of which the peripatetic siren The general paradigm is to begin with conservative therapies in treating pain, but conservative therapies do not always relieve it. Furthermore, conservative therapies sometimes relieve pain only by substituting equally intolerable side effects. These side effects, which can be triggered by pharmaceuticals or even by a seemingly innocuous therapy like bed...

Fear Of Opioids

There are many reasons for noncompliance with recommendations from a physician or other health care provider. One of the most common reasons given is fear of opioids (3,4). Drugs like morphine, oxycodone (OxyContin is a long-acting oxycodone), and hydromorphone (Dilaudid is one brand name) are excellent medications in the armamentarium for fighting pain. Fear of such opioids encompasses misconceptions about a street drug for addicts that once started cannot be stopped about aller- gies about...

Emr To Improve Pain Relief

The heart is not evaluated in the same way as Sir William Osler did in the 1800s, but curiously, most physicians still keep their medical records the same way. Although the medical profession has embraced the advances in technology for most aspects of medicine, including three-dimensional echocardiography, magnetic resonance imaging, and poly-merase chain reactions, there has been a tremendous reluctance to embrace a computerized version of the electronic medical record. The reasons are...

Helping The Media Help

Regardless of the setting, part of pain politics must involve the media. Marketing a good idea is as important as the idea itself. Some would argue that it is even more important if the policy or idea comes into general use. Few would disagree that Beta was better than VHS, or that Macintosh had a better operating system than Microsoft . With this in mind, communication is absolutely important. In the local setting, it will be necessary to become involved with local hospital marketing and...

Establishing Representation

In 1998, after becoming so frustrated with how health care was being adversely affected by government and the lack of good leadership and From Aging Medicine Handbook of Pain Relief in Older Adults An Evidence-Based Approach Edited by F. M. Gloth, III Humana Press Inc., Totowa, NJ representation in Washington, DC, a young physician in Maryland initiated a campaign for US Senate that targeted a well-entrenched (and well-funded) incumbent (1). The odds of actually winning such an election were...

Humana Press Totowa New Jersey

2004 Humana Press Inc. 999 Riverview Drive, Suite 208 Totowa, New Jersey 07512 All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise without written permission from the Publisher. All papers, comments, opinions, conclusions, or recommendations are those of the author(s), and do not necessarily reflect the views of the publisher. Due...

Factors To Consider

Pharmacotherapy for older adults is complicated by a narrower therapeutic index (dosage range between therapeutic efficacy and toxicity) for most medications compared to the index for younger individuals. Epi-demiological studies of adverse drug reactions attempted to determine if age alone increases the risk for adverse drug outcomes. Although controversial, it seems that advancing age does increase the risk of experiencing an adverse drug effect (9). Beyth and Shorr proposed, however, that...

Join Your Professional Society

Participation in one's professional organization may also be helpful. Simply belonging to the organization will provide opportunities to raise issues that might be embraced by the organization and further developed for ultimate presentation by the organization to legislators or other bodies or individuals with an influence on policy. If time constraints prevent active committee participation, do not fret. Issues can be selected and participation increased as matters related to those key issues...

Management

Aparna Ranjan, md, Hana Ayele, md, Kalu Uma, md, Nothing in life is more wonderful than Faith the one great moving force which we can neither weigh in the balance nor test in the crucible. Pain typically comprises sensory and emotional features, with four described components physical (e.g., the sensation associated with hitting your finger with a hammer) emotional (the anxiety, depression, or psychological distress associated with finding out that back pain is the result of a metastatic...

Patients Description Of Pain And Meaning

Accurate assessment of pain starts with deciphering the patient's pain report. Although the issues surrounding assessment are covered in depth in Chapter 2, they are worth some additional discussion here. The location, temporal nature, description by the patient (e.g., whether it is sharp, dull, aching, stabbing, pulsating, buzzing, numb, burning, tingling, cramping), and activities that might be the cause of the pain can provide valuable clues that might eventually lead to the correct...

Pharmacotherapy of Pain in Older Adults

Mary Lynn McPherson, PharmD, bcps, cde Remember how much you do not know. Do not pour strange medicines Opioids are naturally occurring, semisynthetic, and synthetic drugs with effects that are mediated through opioid receptors they alter the perception and emotional response to painful stimuli (1,2). There are three major classes of opioid receptors p, k, and 5, with subtypes in each receptor class (3). Opioid receptors are found in the periaqueductal gray matter and throughout the spinal...

Risk Assessment

Risk assessment may involve identification of existing patient physiological risk factors, such as sleep apnea, obesity, and cardiopulmonary compromise such as emphysema or chronic obstructive pulmonary disease. Patients with these risk factors are at much higher risk for developing opioid-induced respiratory depression (128-135). If opioid analgesics will be used, then these patients will require much closer monitoring than comparable patients without these preexisting risks. For all high-risk...

Physical Modalities

The physical modalities involved in the management of pain include several management approaches performed by physicians, physical therapists, occupational therapists, and other health professionals. The efficacy of these individualized therapies is enhanced by an interdisciplinary team approach and direct patient education. The debate over heat and cold is as old as the modalities. The advantage of cryotherapy appears to be in its rapid analgesic effect, reduction of acute inflammation, and...

Analgesics in Older Adults

Mary Lynn McPherson, PharmD, bcps, cde From Aging Medicine Handbook of Pain Relief in Older Adults An Evidence-Based Approach Edited by F. M. Gloth, III Humana Press Inc., Totowa, NJ Starting oral dose Maximum daily oral dose Special considerations Nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) Carboxylic acid derivatives (salicylic acid derivatives) *Reduce maximum dose 50-75 in patients with hepatic insufficiency or history of alcohol abuse *Reduce dosage in renal insufficiency...

Mark J Gloth do

Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it. Since Plato first spoke those words, physical medicine and rehabilitation have played an increasingly important and well-substantiated role in the management of pain in the elderly. The basic principles of rehabilitation in the geriatric population are to prevent disability, treat specific impairments, prevent secondary disability, restore functional...

Assessment Of Pain In The Nursing Home

The assessment of pain in the nursing home should begin with the initial intake on admission. The nursing staff often performs a detailed evaluation of every patient who enters a nursing home. In addition, a complete history and physical examination by the patient's physician provide an opportunity to identify pertinent diagnoses and concerns, current and past treatments, and problems to be addressed. Subsequent assessments should be performed when there is a change in the level of care, after...

Nutraceuticals

Nutraceuticals, which are used as nutritional and health supplements, are naturally occurring products from plants or animals. These supple ments do not require the same study as drugs under federal Food and Drug Administration regulations. However, claims for the treatment of any disease states with these products cannot be made. The manufacturers are allowed to describe physiological actions of the products and market them on that basis. In a US survey, one in four adults took at least one...

Reasons For Poor Pain Control In Seniors

Despite such high prevalence of pain and painful syndromes in older adults, there have been relatively few studies in older populations with pain (29). Studies have indicated that less than 1 of the thousands of papers published on pain focus on the aging society (30). This lack of research may explain part of the failure to provide adequate pain relief to seniors. A variety of other factors also seems to contribute to the dismal performance of the health care profession in providing...

Compliance Issues

Lack of compliance can be another impediment to attaining pain relief. Failure to take medication or to take it differently than prescribed can create havoc when trying to establish the best treatment regimen. Not only is it confusing to those trying to render therapy, but also there is an associated increase in risk for adverse events. For example, a patient who is taking more medication than prescribed may run out of medication before the prescription plan will fill a new prescription of a...

Social History And Habits

Social history and habits can also play an important role in pain management therapy. Smoking and alcohol use can complicate acute pain management. Patients who use alcohol on a regular basis can experience various degrees of withdrawal symptoms if it is discontinued abruptly. This is especially important in postsurgical patients. Alcohol withdrawal symptoms can occur 24 to 48 hours after abrupt discontinuation. Alcohol withdrawal can cause anxiety and agitation, which can make the patient far...

Clinical Response Assessment

Clinical response assessment should start before initiating drug therapy because each patient is different in ability to tolerate pain and in interpretation of pain. In planning clinical response assessment, the patient might be asked prior to initiating drug therapy about his or her current level of pain and what level he or she would like to achieve. The answers may be surprising because patients might prefer not to have total pain elimination, but rather have the pain reduced to a tolerable...

Peter J S Koo PharmD

Believe nothing that you see in the newspapers they have done more to create dissatisfaction than all other agencies. If you see anything in them that you know is true, begin to doubt it at once. As noted in Chapter 2, successful pain management must initially include careful review of the patient's experience with pain management and medications. This is especially important for patients suffering chronic pain. Such patients often feel that no one believes them, and they are fearful of being...

Selecting Pain Scales For Seniors

Few scales have been developed specifically with older individuals in mind. Almost none have been evaluated for responsiveness or sensitivity to changes in pain. Given the importance that hospitals and nursing homes are now mandated to place on pain assessment (and subsequent treatment and evaluation of that treatment), it is disturbing that most instruments to assess pain have not had such testing. Many scales are variations of an identical concept that is, the scale has one end that indicates...

Electrical Stimulation Of The Spinal Cord And Peripheral Nerves

Centuries before the nature of electricity was understood, observant people discovered that electrical stimulation (caused by the proximity of electrical eels) relieved pain. When electricity was controlled, healers replaced the eels with hand-cranked generators and continued to practice electrical therapy without understanding how it relieved pain (12). Eventually, in the mid-20th century, Melzack and Wall crafted a gate-control theory of pain that permitted the incorporation of electrical...

Nerve Destruction

Nerve Blocks For Pvd Pain

Neurodestruction has a prolonged effect and is generally reserved to treat cancer pain. Several techniques are used to destroy nerves. Cryoablation can be accomplished by touching a nerve with a -60 C cryoprobe. This degenerates the nerve axons without damaging surrounding tissue. Nerves can also be destroyed by applying heat, phenol, or alcohol, or they can be cut with a surgical implement. With few excep- Fig. 4. (A) Anterior posterior view of lumbar sympathetic block. (B) Lumbar sympathetic...

References

Barry KL, Fleming MF, Greenley J, Widlak P, Kropp S, McKee D. Assessment of alcohol and other drug disorders in the seriously mentally ill. Schizophr Bull 1995 21 313-321. 2. Hancock D, Kennington JM, Beckner RR, Quick G. Emergency department medication and drug interaction evaluation. Hosp Pharm 1992 27 129-132. 3. Klungel OH, de Boer A, Paes AH, Herings RM, Seidell JC, Bakker A. Influence of question structure on the recall of self-reported drug use. J Clin Epidemiol 2000 53 273-277. 4. Lu...

Botulinum Toxins

Nucleoplasty

Botulinum toxins block or reduce muscle contractions and spasms by interfering with the release of acetylcholine, which transmits the contraction signal from the brain to muscle. Botulinum toxins may also block parasympathetic nervous system action. Intermuscular injections of botulinum toxin performed on an outpatient basis three or four times per year are used to treat many conditions that involve abnormal muscle contraction. Hsiung et al. reported that, during a 10-year period, they found...

Intradiscal Electrothermal Annuloplasty And Nucleoplasty

Radiofrequenz Nucleoplasty

The interior nucleus pulposus of a disc can bulge out of its tough outer annulus fibrosis, creating what is commonly known as a herniation and Fig. 10. Anterior posterior view of intradiscal electrothermal annuloplasty treated disk. Fig. 10. Anterior posterior view of intradiscal electrothermal annuloplasty treated disk. more properly called a disc protrusion. When this protrusion compresses a nerve root, it can cause serious problems. Two new minimally invasive techniques, intradiscal...