Pain Assessment and Management

Module 1: Pain in residents in RACFs

• Pain is a personal experience, occurring when and where the resident says it does

• Pain management in RACFs is not addressed well. The incidence of pain is higher in residents who have impaired cognition or a communicative disability.

• There are multiple barriers to effective pain management which are related to false beliefs and attitudes of residents, families and health professionals

Barriers to effective Pain Management

• For health professional:– lack of pain assessment skills– lack of knowledge of current therapeutic approaches– uncertainty about the role of opioid treatment– insufficient knowledge of opioid treatment– overestimation of the risks of addiction– concern about the management of adverse effects– concern about regulation of controlled prescription

drugs

Barriers to effective Pain Management

• For residents/families:– fear of addiction– fear of adverse effects– an inability to comply with complicated programs– communication difficulties (language differences

cultural issues, intellectual disability)– fear that pain may suggest worsening disease– pain is an expected part of ageing.

Factors affecting a residents experience of pain

• The perception of pain can be influenced by the resident’s mood, past pain experiences, social and physical situation.

Module 2: Types of Pain

• Pain can be classified as:– Acute– Chronic– Nociceptive– Neuropathic– Incident pain– Breakthrough

Module 3: Pain Assessment• Pain assessment tools provide a framework for staff to

obtain an accurate pain assessment and assists in determining response and on-going treatment for the pain.

• Important elements to be included in a tool include; the site of the pain, quality of pain, severity, exacerbating and relieving factors, its exact onset, interference with activities of daily living, impact on the patient’s psychological state, response to previous and current analgesic therapies.

Estimating pain in the absence of direct communication

• Changes in behaviour• Vocalizations• Facial expressions • Observations of caregivers/relatives• Changes in physiological responses

1.Increase in pulse rate2.Increase or decrease in BP

• Response to a trial dose of analgesia

Abbey Pain Scale For measurement of pain in people with dementia who cannot verbalise

Abbey, J 'Ageing, Dementia and Palliative Care' in O'Connor, M and Aranda, S (Eds) 2003 Palliative Care Nursing . A guide to practice , Ausmed Publications, Melbourne, pp. 313-339 ( the pain scale is on page 323).

Jennifer Abbey, Neil Piller, AnitaDe Bellis, Adrian Esterman, Deborah Parker, Lynne; Giles and Belinda Lowcay (2004) The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia , International Journal of Palliative Nursing, Vol 10, No 1pp 6-13.

0-2No pain

3-7Mild

7-13Moderate

14+Severe

Chronic Acute Acute on chronic

Total pain scoreTick the box that matches the total pain score

Tick the box that matches the type of pain

Q1. Vocalisation (eg whimpering, groaning, crying)Absent 0 Mild 1 Moderate 2 Severe 3

Q2. Facial expression (eg looking tense, frowning, grimacing, looking frightened)Absent 0 Mild 1 Moderate 2 Severe 3

Q3. Change in body language (eg fidgeting, rocking, guarding part of body, withdrawal)Absent 0 Mild 1 Moderate 2 Severe 3

Q4. Behavioural change (eg confusion, refusing to eat, alteration in usual pattern)Absent 0 Mild 1 Moderate 2 Severe 3

Q5. Physiological changes (eg temp, pulse/BP outside normal limits, perspiring, flushing, pallor)

Absent 0 Mild 1 Moderate 2 Severe 3

Q6. Physical changes (eg skin tears, pressure areas, arthritis, contractures)Absent 0 Mild 1 Moderate 2 Severe 3

Module 4: Pain Management

General WHO principles of pain management– By the mouth– By the clock– By the ladder– Individual treatment– Supervision

WHO Pain Ladder

STEP 1: Non-opioid + adjuvant

STEP 2:Opioid for mild to moderate pain +non-opioid + adjuvant

STEP 3: Opioid for strong pain +non-opioid + adjuvant

Pain persisting

↑

Pain persisting

↑

FREEDOM FROM PAIN

Adjuvant Analgesics

• Defined as drugs with other indications that may be analgesic in specific circumstances

• Numerous drugs in diverse classes

Pharmacology of Analgesics in the Elderly

• Decline in the ratio of lean body mass to total body weight

• Decreased hepatic metabolism

• Decline in renal drug clearance

• Poor compliance

• Drug-disease interactions– E.g. CCF causes diminished hepatic blood flow

Precautions with Drugs in the Elderly

• Start with the lowest anticipated effective dose

• Monitor frequently, on the basis of expected absorption and known pharmacokinetics

• Titrate the dose on the basis of likely steady state blood levels

Likelihood of side effects

Sensitivity to central acting analgesics

Schedule 8 Drugs (Step 3 WHO Ladder)

SLOW RELEASE ORAL• MS Contin• MS Contin Suspension• OxyContin• Kapanol• MS Mono• Palladone XL

INJECTABLES• Morphine • Hydromorphone• Fentanyl

TRANSDERMAL• Fentanyl

IMMEDIATE

RELEASE- ORAL• Ordine• Oxycodone• OxyNorm• OxyNorm Syrup• Hydromorphone• Methadone• Palfium• Morphine

Sulphate• Fentanyl Lollipops• Sevredol

Breakthrough Medication

• 50 – 100% of the 4-hourly dose OR

1/12 to 1/6 of total daily dose

i.e. MS Contin 30mg BD

B/T = 5mg

Opioid Conversion• Panadeine (codeine 8mg) = oral Morphine 1mg

• Panadeine Forte (codeine 30mg) = oral Morphine 3.75mg

• Codeine Phos 30mg = oral Morphine 3.75mg

• Tramadol 50mg = oral Morphine 6.25mg

• Endone 5 mg = oral Morphine 7.5mg

• Fentanyl 12.5mcg = oral Morphine 30mg

(Tramadol 8 × 50mg (400mg) = 50mg morphine)

Morphine Myths• There is a limit to the dose of morphine I can use

• If I use it now, it will be ineffective when I really need it

• I will become addicted

• Morphine is only used when death is imminent

• The parental dose is more effective

• Morphine causes respiratory depression

Morphine common side effects

• 95% constipated

• 100% dry mouth

• < 20% nausea & vomiting

• > 60% mild sedation resolves within 24 – 48 hrs

• <2% confusion – need to reduce dose

Non-pharmacological methods of pain relief

• Massage – muscle tension, headaches, anxious patient

• Heat & cold applications – muscle spasm

• Distraction – periodic or procedural pain

• Transcutaneous Electrical Nerve Stimulation (TENs) – musculosketal problems

• Complimentary and alternative therapies

• Aromatherapy