Lecture 13 Flashcards
Pain Management
1
Q
Are patients with pain usually under or overtreated?
A
Undertreated
2
Q
Are the pathophysiologic mechanisms for pain well understood?
A
No, they are complex and usually do not translate into necessary skills for managing pain in most patients.
3
Q
Marks & Sachar
A
Evidence of Undertreatment
- 1973
- 38 inpatients treated for pain
- 37% continued to experience severe distress and 41% experienced moderate distress despite analgesics
- Chart reviews showed records of significant undertreatment compared to doses ordered and knowledge deficits among physicians
4
Q
Brescia et al
A
Evidence of Undertreatment
- 1992
- 1103 patients hospitalized with advanced cancer
- 73% had pain upon admission
- Only 36% received regular, around-the-clock dosing
- Actual pain amount not assessed
5
Q
Anand et al
A
Evidence of Undertreatment
- 1992
- Neonates undergoing cardiac surgery were either given deeper anesthesia with higher doses of opioids post-surgery or lower doses of each
- Those who had deeper anesthesia and higher doses of opioids had decreased stress responses and lower incidents of sepsis, acidosis, clotting, and death
6
Q
Cleveland et al
A
Evidence of Undertreatment
- 1994
- Examined pain control in outpatients with cancer treatment
- 42% of 597 patients had inadequate analgesic therapy
- Patients at centers serving predominantly minorities were 3x more likely to be undertreated
- Discrepancy between patient and physician judgement of pain severity
7
Q
Reasons for Undertreatment (5)
A
- Lack of routine assessment
- Lack of Advocacy
- Lack of prescriber and patient education
- Lack of multidisciplinary team-based care
- Lack of availability
8
Q
Lack of Assessment
A
- Pain isn’t visible if it isn’t assessed and documented
- Examples of assessment scales - 0-10, smiley scales
- Patients are best judge of their pain severity
9
Q
Lack of Advocacy
A
- Patients may not advocate for their own analgesia out of concerns that they’ll be viewed as malingering or drug seeking
- Health professionals may need to be the patient’s advocate
- May need to change the system in order to provide routine pain assessments or hire anesthesiologists or intensivists to provide aggressive analgesic support (use propofol/fentanyl) for children’s pain
10
Q
Lack of Multidisciplinary Teams
A
-Critical for patients with more complex chronic pain syndromes
11
Q
Lack of Availability
A
- Opioids may be unavailable for patients with severe pain in inner city neighborhoods (esp. in minority neighborhoods)
- Studies showing this may not be accurate based on calling pharmacists and pharmacists not providing truthful information
- NM study by the COP showed the opposite of this and that availability wasn’t a concern and that pharmacists were willing to order opioids for those with severe pain
- Perceived lack of availability may be related to underprescribing of opioids to minority patients
12
Q
Bastian et al, Psychological Science
A
- Study using experimental pain and its connection with guilt
- Revealed that those who had identified as feeling guilty from a recent event felt less pain when exposed to the ice water bath
- Guilt ratings then drop after the exposure, suggesting a cathartic effect
13
Q
Regulatory Concerns (2)
A
- Growing fear of prosecution among providers
2. Concerns of addiction, tolerance, and toxicity
14
Q
Fear of Prosecution
A
- Connected to marked increase of opioid overdoses in recent years
- Most overdoses are connected to misuse or lack of education between prescribers, patients, and relatives
- Can also be connected to pill mills or healthcare system problems like fee for service
- Mismanagement, lack of team-based care, and lack of adequate patient education/follow-ups all lead to overdoses
- The push back of under-prescribing patients with legitimate pain will likely be significant due to this
15
Q
Concerns of Addiction/Tolerance/Toxicity
A
- Includes physical dependence, tolerance, and physiological dependence (cravings)
- Patients with no addiction history have not been shown to develop it from appropriate analgesic therapy
- Addiction usually developed at a young age and is connected to genetic predisposition and socialization in early life, not by using opioids
- One opioid isn’t less addictive than another
