understanding pain management practice in patient...
TRANSCRIPT
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UnderstandingPainManagementPracticeinPatientExperience
Presenter:SusanE.Mazer,PhD
SusanE.Mazer,Ph.D.
UnderstandingPainManagementPracticeinThePatientExperience
BerylInstitutePXConference2018
1. Whatispaintothepatient?2. Historyofpain:themanymyths3. Painrelief:fromopiumtoopioids4. PainTheory:relevancetoday5. Handingthepowerofreliefbacktothepatient
WhatI’llCoverToday
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WhatEveryoneKnowsAboutPain
ThisisPain
MostCommonResponse
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ResponsetothePainofOthers
WhatisPaintothePatient?
2018:WhatisPain?
Whatever thepatientsaysitis!
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2018:WhatisPain?
Noticeable
2018:WhatisPain?
“…canbeoverwhelming,demandsimmediateattention,anddisruptsongoingbehaviorandthought…”
Melzac,R.1968
Painis#1motivator…• “TodoorNottodo,”thatisthedilemma• “TotellornottoTell”• “Totakemoreortakeless(ortakenothing)”• “Totry,tonottry,andtotrystillmore”
Pain:TheBig“P”
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Painreliefdemotivatesalltheabove.
PainRelief:TheLittle“p”
OpioidEpidemic:HowDidWeGetHere?
Opioids:• Prescribedasneeded• Ondemand• TosecureHCAHPSrating• Easiest/mosteffective*?
Hint:*Thedefinitionofanaddiction.
• Homer:“ArrowshotfromGod”
• Aristotle:“Painisapassionofthesoul”
• Plato:“Painisanemotion,notasensation”
TheMythologyofPain?
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Thestimulationgoesstraighttothebrain(“PainCenter”).Isfullyofthebody,notthemind.
Breakthrough:ReneDescartes
TheCartesianDivide:“Ithink,thereforeIam.”
• Acutevschronic• Knownvsunknown• Expectedvsunexpected• Mildvsdebilitating• Other?
NotAllPainsAreAlike
Thecausemaybeobjective,buttheexperienceisalwayssubjective.
NotAllPainsAreAlike
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HistoryofPainRelief
Mandragora:• Hallucinogenic,hypnotic,
poisonous,etc• Analgesicforrheumaticpain• 2ndcenturyBCto7thAD:
Mainlyusedwithopium.
Andinthebeginning…
Dodoens,Rembert,1583.Stirpium historiae pemptades sexsivelibri XXX.Antverpiæ,exofficina Christophori Plantini.(scannedfromReprint1979,Uitgeverij deForel,Nieuwendijk(Netherlands).,PublicDomain,https://commons.wikimedia.org/w/index.php?curid=21709570
• Opium• NitrousOxide• Laudenum• Ether• Cannabis• Morphine• Codeine• Opioids
FromOpiumtoOpioids
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FirstuseoffullanesthesiainBoston*,1846
PainRelief:Anesthesia
*CrawfordW.Long,Columbus, GA
• Bayer!!• AcetylsalicylicAcid,
1899
PainRelief:Potions
Tylenol,1955• Children’s• Adult
PainRelief:Acetaminophen
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PainManagementTheories
• Patientcanmodulatepain• Pathwayfromcentralnervoussystemtothebrain• Non-painfulstimulicaninhibitpainfulstimuli• Mayindicatetissuedamage,butmaynot
Melzack/Wall:GateControlTheory(1965)
Melzack/Casey:ExperienceofPain(1968)
• Somatic, orsensationofpain• Perception ofpleasantnessorunpleasantness(whichcanleadtothefightorflightresponse)
• Evaluation or“appraisal,culturalvalues,context,andcognitivestate”
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Melzack/Casey:MechanismforSelf-Management(1968)• Meaningmaking• DirectedAttention• ActiveDistraction
“Thereignofpainliesmostlyinthebrain.”
Melzack/Casey:MechanismforSelf-Management(1968)
--Cathryn Jakobson Ramin
Whatinfluencestheexperienceofpainandwhetheritisrelieved?
• PainExpectancy:Isitavoidableornot• PainAcceptance:Ifunavoidable,preparationforit• PainApprehension:Anticipatorysuffering• PainAnxiety: Thegreaterthefear,thegreaterthe
pain
MarkZborowski (1908– 1990)MedicalAnthropology
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Involvestheimmediacyoftheexperienceanditsexpressionconstrainedbysocialcontextandenvironmentalsetting.
Craig,K.D.:SocialCommunicationModelofPain(2015)
• Distinguishesintrapersonalandinterpersonalsourcesofinfluenceonbothsufferingpersonsandobservers
• Emphasizes(Intrapersonal)whattheindividualbringstothepainfulexperience
SocialCommunicationModelofPain
SocialCommunicationModelofPain
KennethD.Craig,2015
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Timeline:ChronologyofPain
AntecedentPain
ExperiencePain
Expression
Timeline:ChronologyofPain
Decoding/Response
Action-DeliveryofCare
Antecedent
PainDenial:BeingMetWithDisbelief
• Illness/Pain:deviantbehavior• Judgement:abarriertorelief• Cultural/socialnorms:informself-report/
medicationuse• Under-reporting:under-treatment
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Autonomousresponsebasedon:• Beliefs
• Anticipation
• Expectancy
ThePlacebo-NoceboResponse
“… themeaningresponse[isthe]physiologicorpsychologicaleffectsofmeaningintheoriginsortreatmentofillness;meaningresponseselicitedaftertheuseofinertorshamtreatmentcanbecalledthe“placeboeffect”whentheyaredesirableandthe“noceboeffect”whentheyareundesirable.”
MeaningResponse
Moerman,D.D.,Jonas,W.B.(2002)
Pain’sImpactonthePatientExperience
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Thesumofapatient’spriorexperienceswithpain,shapedbyapatient'sbeliefs,expectations,andtheirsocial/culturalcontextthatinformthepatient’sresponsetopainanditsmeaning.
ThePatientExperienceofPain
Painbeliefsfullyinfluencepatients’painthreshold,participationintheircare,andinformtheirsuccessinself-regulation.
• Agitation• Anxiety• Stress• Suffering
HowPainisthePatientExperience
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• Environmentalstressors
• Expectancy• Placebo/nocebo effects• Social/culturalvalues
HowPainBecomesthePatientExperience
• Minimizeenvironmentalstressors• Provideaccesstobeauty,nature,including
mediatednature• Minimizeclutter• Assessandadjusttheenvironmentwithevery
patientinteraction
CreateaHealingEnvironment
• Asenseofpleasantness• Makestimemovefaster• Musicpacestime,providesanemotionalcontext
Whatdoestalktelevisionprovide?
PositiveValence
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APositiveDistraction“…anenvironmentalfeaturethatelicitspositivefeelingsandholdsattentionwithouttaxingorstressingtheindividual,therebyblockingworrisomethoughts.”
Isthisscary?Isthistheendorthebeginning?Isithotorcold?Isthisgoodorbad?Whatdoesthismeannow?Arewesafe?AmIsafe?Howlongwillthislast?
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• Notoneelementworksforeveryone• Notoneelementworks24/7foranyone• Habituation• Variety• Stimulating
PositiveDistraction
• Nature(variousforms)• Music(bothpatientpreferenceandnew)• Conversation(hopeful,personal)• Media
PositiveDistraction
VirtualReality• Cedars-Sinai:24%drop
inpainscores• Universityof
Washington:76-22%dropinamountoftimethinkingaboutpain
VirtualReality/ImmersiveInterventions
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• 29%reductioninpainmeds
• Fewersideeffects• 1.5dayaverage
reducedlengthofstay
Non-PharmaceuticalInterventions
Theidentificationandmanagementofpainisanimportantcomponentof[patient]-centeredcare.[Patients]canexpectthattheirhealthcareproviderswillinvolvethemintheirassessmentandmanagementofpain.Bothpharmacologicandnonpharmacologic strategieshavearoleinthemanagementofpain.
• Engagesmindandbodytoreduceanxiety,increasecopingskills
• Providespositivedistraction• Providesrespitefrommental/emotionalfatigue• Providestooltousebeyondthehospital
GuidedImagery
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NightsareDifficult
• Elusiverest
• Unfamiliarenvironment(includingnoises)
• Limitedresources• Isolation
• Loneliness• Ruminations
PainIsWorseatNight
• Isolating• Influencedbythemeaningattributedtoit• Ismitigatedbypositivedistractions,evenatnight
NightsDoNotHavetoBeasDifficult
• Planinadvancew/patient-family• Optionsforpatient• Restfulnessshouldbeofferedthroughtheday• Patientandfamilyshouldcoordinate• Whatworksforthispatient?
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• Acupuncture• Chiropractictherapy• Osteopathicmanipulativetreatment• Massagetherapy• Physicaltherapy• Relaxationtherapy• Immersiveexperiences• Cognitivebehavioraltherapy
Non-pharmacologicInterventions
HandingthePowerofHealingBacktothePatient
• Attheleast,Unpleasant• Notalwaysavoidable,notalwaysbad• Influencedbyphysicalandnon-physicalfactors• Informedbymood,attitude,beliefs,values,
social/familialcontext,andthemeaningattributedtothepainbythepatient.
PainIs…
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Patientsneedmorethantheblurofactivity.
Painbeliefsinformpatients’painthreshold,participationintheircare,andinformtheirsuccessinself-regulation.
• Aninformedcaregiver/bedsidestaff
• Involvementofthebedsideteamwiththepatient
• Anenvironmentthatminimizesstressors
• Positivedistractions,includingaccesstonature,variety
• Supportofthefamily/closesocialcircle
WhatdoesManagingPainRequire?
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• Equanimitybetweenpatient/caregiver
• Alignmentbetweensocialvaluesandtreatment
• Acknowledgementandsupportbetweenpatient/caregiver
• Altruisticpracticesembeddedinclinicalexcellence
WhatdoesManagingPainRequire?
Summary
• Communicatesupportandempathy• Createahealingenvironment• Providepositivedistractions• Offerguidedimagery• Offerimmersivetechnologies• Beawareofpositive/negativemedia• Planfornights
• Gate-ControlTheory:Positivedistractionisprimarytoself-managementandincreasingpaintolerance
• SocialCommunicationTheory:Painmanagementusesthesymbiosisbetweenpatient/others
• Painreliefissubjectiveandobjective• Painisephemeral:livesandchangesovertime• Combinationofbiomedicalandpsychosocial
strategiesisrequisiteCaution:Addictionisalwaysariskwhenthegoalisself-medication/management
Summary
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Howfaryougoinlifedependsonyourbeingtenderwiththeyoung,compassionatewiththeaged,sympatheticwiththestrivingandtolerantoftheweakandstrong.Becausesomedayinlifeyouwillhavebeenallofthese.
GeorgeWashingtonCarver
Theonlydifferencebetweenthepatientandthecaregiverisacuity.
PatLinton
SusanE.Mazer,Ph.D.President&CEO,HealingHealthCareSystems
Email: [email protected]:www.healinghealth.com/susan-mazer-blogLinkedIn:www.linkedin.com/in/susanmazer
QuestionsandThankYOU!
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PainManagementandthePatientExperience2018References
SusanE.Mazer,[email protected]
Keywords:Pain,Painmanagement,paintheory,historyofpain,Gate-ControlTheory,SocialCommunicationsModelofPain,Placebo,Meaning-response,psychologyofpain,ReneDescartes
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