a. Understand the prevalence and nature of pain concerns in returning combat veterans.
b. Understand that pain issues are part of a complex group of co-occurring and inter-related issues.
c. Describe a collaborative, bio-psycho-social approach to address pain issues.
d. Understand the stepped-care, collaborative approach in VA.
e. Understand how to implement collaborative pain care on PACT teams - a nuts and bolts approach
This two-part class will begin by highlighting collaborative pain care in Primary Care using real-life scenarios that address the complex issues and needs of returning Veterans and then move on to address how to apply a nuts-and-bolts approach within a Patient Aligned Care Team in the VA.
This document discusses the financial impact of opioid abuse on employers. It identifies the primary causes of increased healthcare costs related to opioid abuse as well as simple steps employers can take to reduce risks and costs. The document explains that prescription drug abuse can impact employers even if they are not currently dealing with issues in their workplace. It provides context on the costs of chronic pain and revenue from opioids. The document examines how cultural factors led to increased opioid prescribing and abuse. It discusses challenges in predicting outcomes for different patients prescribed opioids. Finally, it outlines guiding principles for employers to address opioid abuse, including education, enforcement, oversight, and statutory action if needed.
Principles for more cautious and selective opioid prescribing for chronic non...Group Health Cooperative
Presentation was originally done at Group Health Cooperative’s National Summit on Opioid Safety: http://www.ghinnovates.org/?p=3502
Presentation by: Jane C. Ballantyne, MD FRCA, with the Department of Anesthesiology and Pain Medicine at UW Medicine.
This document discusses pain, its types, effects, assessment, and management. It defines pain and outlines types including acute, chronic, neuropathic, and postoperative pain. It describes physiological and behavioral responses to pain and factors influencing pain. Methods of pain assessment including scales, questionnaires, and initial evaluation are provided. The importance of pain management and various pharmacological and non-pharmacological approaches are summarized.
The document summarizes a national summit on opioid safety convened to develop consensus on safer opioid prescribing practices for chronic non-cancer pain. The summit goals were to: 1) develop consensus principles for more selective, cautious opioid use; 2) share approaches to mitigate risks; 3) share how to change practice and implement guidelines. It provided background on the opioid epidemic and research showing risks increasing with higher doses and limited evidence of long-term benefits. Draft principles for safer opioid prescribing included starting with non-opioid treatments, carefully evaluating risks, limiting dose escalation, and tapering patients off opioids when risks outweigh benefits.
Presentation was originally done at Group Health Cooperative’s National Summit on Opioid Safety: http://www.ghinnovates.org/?p=3502
Presentation by: Roger Chou, MD, Associate Professor of Medicine for Oregon Health & Science University
and Director of Pacific Northwest Evidence-based Practice Center.
This document discusses optimizing pain management in cancer treatment. It provides an overview of concepts like total pain, the WHO analgesic ladder for treating pain with opioids, and the importance of proper pain assessment and documentation. The key points are:
1) Total pain includes physical, psychosocial, emotional, and spiritual suffering experienced by cancer patients.
2) The WHO analgesic ladder recommends treating mild pain with non-opioids like paracetamol, moderate pain with weak opioids like codeine, and severe pain with strong opioids like morphine.
3) Proper pain assessment involves documenting pain scores, characteristics, causes, and impact on function to effectively guide pain treatment decisions.
Pain in the elderly. How to better understand and rate it.Ross Finesmith M.D.
It is often difficult to determine the amount of pain an elderly person is experiencing.This is complicated by dementia and verbal impairment. This presentation describes helpful methods to assess pain in the elderly.
Pain is common in elderly patients, with osteoarthritis, neuropathies, and cancer being leading causes. It is often undertreated in this population due to attitudes that pain is normal with age and concerns about side effects of pain medications. A comprehensive assessment involves evaluating location, intensity, and impact of pain, as well as cognitive and functional status. Treatment should begin with non-pharmacological options and follow the WHO analgesic ladder when drugs are needed. Careful medication management is especially important due to changes in pharmacokinetics and risk of delirium. Effective pain control improves quality of life while communication between providers and education of patients and caregivers are also crucial.
This document discusses the financial impact of opioid abuse on employers. It identifies the primary causes of increased healthcare costs related to opioid abuse as well as simple steps employers can take to reduce risks and costs. The document explains that prescription drug abuse can impact employers even if they are not currently dealing with issues in their workplace. It provides context on the costs of chronic pain and revenue from opioids. The document examines how cultural factors led to increased opioid prescribing and abuse. It discusses challenges in predicting outcomes for different patients prescribed opioids. Finally, it outlines guiding principles for employers to address opioid abuse, including education, enforcement, oversight, and statutory action if needed.
Principles for more cautious and selective opioid prescribing for chronic non...Group Health Cooperative
Presentation was originally done at Group Health Cooperative’s National Summit on Opioid Safety: http://www.ghinnovates.org/?p=3502
Presentation by: Jane C. Ballantyne, MD FRCA, with the Department of Anesthesiology and Pain Medicine at UW Medicine.
This document discusses pain, its types, effects, assessment, and management. It defines pain and outlines types including acute, chronic, neuropathic, and postoperative pain. It describes physiological and behavioral responses to pain and factors influencing pain. Methods of pain assessment including scales, questionnaires, and initial evaluation are provided. The importance of pain management and various pharmacological and non-pharmacological approaches are summarized.
The document summarizes a national summit on opioid safety convened to develop consensus on safer opioid prescribing practices for chronic non-cancer pain. The summit goals were to: 1) develop consensus principles for more selective, cautious opioid use; 2) share approaches to mitigate risks; 3) share how to change practice and implement guidelines. It provided background on the opioid epidemic and research showing risks increasing with higher doses and limited evidence of long-term benefits. Draft principles for safer opioid prescribing included starting with non-opioid treatments, carefully evaluating risks, limiting dose escalation, and tapering patients off opioids when risks outweigh benefits.
Presentation was originally done at Group Health Cooperative’s National Summit on Opioid Safety: http://www.ghinnovates.org/?p=3502
Presentation by: Roger Chou, MD, Associate Professor of Medicine for Oregon Health & Science University
and Director of Pacific Northwest Evidence-based Practice Center.
This document discusses optimizing pain management in cancer treatment. It provides an overview of concepts like total pain, the WHO analgesic ladder for treating pain with opioids, and the importance of proper pain assessment and documentation. The key points are:
1) Total pain includes physical, psychosocial, emotional, and spiritual suffering experienced by cancer patients.
2) The WHO analgesic ladder recommends treating mild pain with non-opioids like paracetamol, moderate pain with weak opioids like codeine, and severe pain with strong opioids like morphine.
3) Proper pain assessment involves documenting pain scores, characteristics, causes, and impact on function to effectively guide pain treatment decisions.
Pain in the elderly. How to better understand and rate it.Ross Finesmith M.D.
It is often difficult to determine the amount of pain an elderly person is experiencing.This is complicated by dementia and verbal impairment. This presentation describes helpful methods to assess pain in the elderly.
Pain is common in elderly patients, with osteoarthritis, neuropathies, and cancer being leading causes. It is often undertreated in this population due to attitudes that pain is normal with age and concerns about side effects of pain medications. A comprehensive assessment involves evaluating location, intensity, and impact of pain, as well as cognitive and functional status. Treatment should begin with non-pharmacological options and follow the WHO analgesic ladder when drugs are needed. Careful medication management is especially important due to changes in pharmacokinetics and risk of delirium. Effective pain control improves quality of life while communication between providers and education of patients and caregivers are also crucial.
This document summarizes barriers to opioid monitoring in primary care as presented by Dr. Erin Krebs. Some key barriers include short appointment times that limit monitoring, an assumption that opioids are effective without formally assessing benefits, overconfidence in risk perceptions, and negative attitudes viewing monitoring as "policing" rather than patient care. Implications discussed are formally assessing opioid benefits, addressing expectations and readiness to change, maintaining focus on medication harms rather than patient trustworthiness, and developing systems to support recommended monitoring practices.
This document discusses PRN pain medication administration and management. It outlines objectives around offering PRN medications consistently based on evidence, using sedation and nonverbal pain scales, and properly documenting PRN medication administration in the Excellian system. Key recommendations include administering pain medications regularly to maintain therapeutic levels and using PRN medications for breakthrough pain. Proper documentation and timely administration of PRN medications can help effectively control pain.
This document provides an overview of pain management strategies presented by Dr. Jeff Higginbotham. It discusses the large number of Americans suffering from chronic non-cancer pain, costing billions in lost work and medical costs. Dr. Higginbotham outlines a multidisciplinary approach to pain management focusing on relieving suffering while preserving function through evidence-based strategies like medications, nerve blocks, rehabilitation, and coping techniques. The document also discusses challenges of treating chronic pain and the need for compassionate care, as well as new research targeting conditions like Complex Regional Pain Syndrome.
This document discusses pain assessment and management for people with advanced dementia. It notes that pain is underreported and undertreated in cognitively impaired older adults due to challenges in assessment. It recommends using behavioral observation scales to assess pain in people with dementia, and provides examples of assessment tools like the Doloplus-2 scale and Abbey Pain Scale. It also provides guidance on managing chronic pain in older adults with dementia, including starting low-dose regular analgesics and considering transdermal patches to provide steady doses.
2015: Post Stroke Fatigue - Why Live With It?-GiapSDGWEP
Post-stroke fatigue is a common problem, affecting 38-73% of stroke survivors. It can persist for months or years after a stroke and significantly impact quality of life. The document discusses factors that may contribute to post-stroke fatigue like depression, sleep disturbances, lack of exercise, and medications. It also reviews tools to assess fatigue severity and differentiates fatigue from excessive daytime sleepiness. While no pharmacological treatments have proven effective, non-drug interventions like exercise, energy conservation, and sleep management may help manage post-stroke fatigue. A randomized controlled trial found that cognitive therapy combined with graded activity training over 12 weeks can reduce persistent post-stroke fatigue.
The Empower Veterans Program provides intensive, integrated self-care coaching through group and individual sessions for veterans suffering from chronic pain. Over 10 weeks, veterans receive training in whole health and well-being, acceptance and commitment therapy, and mindful movement. Preliminary results show improvements in pain, functioning, mental health, and quality of life for veterans, as well as decreased healthcare utilization and costs. The program aims to safely empower veterans with chronic pain through a multidisciplinary approach that promotes self-management over passive treatments.
This document discusses the management of chronic (neurogenic) pain. It provides information on understanding pain, its pathophysiology, assessment, and treatment options. Chronic pain is a complex condition with physical and psychological components. Proper management requires a multidisciplinary approach including pharmacological, rehabilitative, and psychologic interventions to help improve patient function and quality of life.
Cognitive behavioral therapy (CBT) improved quality of life more than standard treatment alone in patients with chronic musculoskeletal pain. A randomized clinical trial assigned 93 patients to either CBT or standard treatment control groups. After 10 weeks, CBT resulted in a 54% reduction in pain levels compared to 28.9% for control. CBT also reduced depressive symptoms and improved physical limitations, general health, and limitations due to emotional problems domains of quality of life more than standard treatment alone. CBT was shown to be an effective addition to standard treatment for improving aspects of chronic pain.
This study examined the relationship between heart rate variability (HRV) and self-reported pain, pain interference, and emotional well-being in adolescents and young adults with neurofibromatosis type 1 (NF1) and plexiform neurofibromas. 24 participants underwent electrocardiograms to measure HRV and completed questionnaires on pain and functioning. Results showed HRV was significantly correlated with pain interference but not pain intensity or disease severity, suggesting those with lower HRV and more chronic pain interpretation may experience greater interference in daily life. Psychological inflexibility was also associated with increased pain interference. Future acceptance-based therapies may help reduce interference and increase HRV by improving psychological flexibility around chronic pain.
Chronic pain: Role of tricyclic antidepressants, dolsulepinSudhir Kumar
Chronic pain is common. Depression often co-exist with chronic pain. This article looks at the pathophysiology, prevalence of chronic pain and depression. The role of TCA, especially dosulepin and amitriptyline has been discussed.
Building on the lecture I gave (and uploaded) "Palliative Care: what every primary care doctor should know" I built this talk. It is geared for 1st year medical students who are learning anatomy, physiology, and perhaps some pharmacology and pathophysiology.
In this talk, I do not explicitly address hospice care - as that was provided in an online chapter for students at UMass. I will later upload another slide set on that topic.
I hope you enjoy it.
FYI- the link to the youtube video: http://www.youtube.com/watch?v=XHtHXGhTIC4
Link to PDF of the slide show: https://files.me.com/s.mak/8fzat6
Geriatric psychosocial assessment of pain induced depressionJames Wilson
This document outlines a proposed study to develop a new assessment tool called the Geriatric Evaluation of Pain-induced Depression (GEAP) scale. The study would involve administering the GEAP scale along with the Geriatric Depression Scale (GDS) and Geriatric Pain Measure (GPM) to older adult participants experiencing chronic pain. Item response theory analysis and exploratory factor analysis would be used to evaluate the psychometric properties and validity of the GEAP compared to the existing GDS and GPM scales. A pilot study with 32 participants would first be conducted to test the proposed data analysis techniques. The goal of developing the GEAP is to address the lack of assessments that specifically measure pain-induced depression among older adults.
The document discusses chronic pain and its treatment. It defines chronic pain as prolonged pain where the pain system is altered and no longer represents injury. Chronic pain is maintained by changes in the nervous system. Treatment of chronic pain focuses on understanding the biopsychosocial model of pain and using multidisciplinary treatments like exercise, CBT, and medication management of conditions like fibromyalgia, low back pain, and migraines. Mood disorders are also discussed as both causing and being caused by chronic pain conditions.
This document discusses emerging pharmacological and non-pharmacological aspects in pain management. It notes that multimodal analgesia using combinations of drugs targeting different pain pathways can provide improved pain relief with reduced side effects compared to single drugs. Newer drugs targeting specific receptor subtypes are emerging. Non-invasive options such as topical agents, exercise, and interventional techniques are increasingly utilized before more invasive options. Interventional pain management techniques discussed include injections, neurolysis, and spinal cord stimulation.
INFLUENCE OF DEMOGRAPHIC FACTORS ON PAIN KILLER USAGE AND ADDICTION SYMPTOMSJing Zang
Pain killers have been a necessity for humans since their skin has been laden with pain receptors to signal them against any invasion or unusual going on in the body.This pain when exceeds the limits of tolerance has to be alleviated to reduce suffering. Since ancient times numerous natural substances like herbs and oils have been used to relieve pain, but in modern era more refined ways to relieve pain have been discovered that exactly target the precise pain. This research identifies the factors that govern painkiller usage and addiction and the people who, in majority fall prey to pleasures of pain killers. The research was carried out through a questionnaire and results were statistically analyzed by fishers exact test. Males, employed people, non medics and graduates are most attracted to pain killers and are susceptible to long term addiction. The reasons for these people falling prey to pain killers are work load, mental stress and physiological responses to the drug. These factors can be managed through proper intervention by health professionals. The role of friends and family too here cannot be ignored.
Interventional Techniques For Cancer Pain Management.guest7342323
The document discusses cancer pain management techniques including conservative management and interventional techniques. It covers assessing pain, diagnosing the type and cause of pain, and treating pain using the WHO analgesic ladder as well as more advanced interventional techniques like intraspinal opioid administration, radiofrequency ablation, vertebroplasty, and neurolytic blocks. The goal is to properly diagnose and treat different types of cancer pain to improve patients' quality of life.
This document discusses pain, including definitions of pain, types of pain, factors influencing pain, effects of pain, individual variations in pain response, and pain assessment tools. It also covers postoperative pain management principles like the WHO pain ladder, pharmacological and non-pharmacological interventions for pain control, preemptive analgesia using local anesthetics or other drugs before a painful stimulus to reduce later pain, and techniques like patient-controlled analgesia and epidural analgesia. The goal of pain management is to prevent pain from interfering with recovery through adequate assessment and treatment.
This randomized controlled trial compared the effectiveness of virtual reality graded exposure therapy (VR-GET) to treatment as usual (TAU) for active duty service members with combat-related post-traumatic stress disorder (PTSD). 19 participants were randomly assigned to either VR-GET (10 participants) or TAU (9 participants). VR-GET consisted of VR exposure combined with skills training, while TAU included various PTSD treatments like prolonged exposure therapy. Results found that 7 of 10 in the VR-GET group improved by at least 30% on the Clinician Administered PTSD Scale, compared to only 1 of 9 in the TAU group, indicating VR-GET was more effective for treating combat-related PTSD.
The document discusses pain assessment and management in elderly patients. It outlines common misconceptions about pain in elderly patients held by patients and nurses. It then covers the pathophysiology of acute and chronic pain and different pain scales used for assessment. Finally, it discusses pharmacological and non-pharmacological pain management strategies including the WHO analgesic ladder and alternative therapies that may help close the "gate" of pain perception.
The document discusses various chronic pain syndromes including low back pain, sciatica, complex regional pain syndrome, trigeminal neuralgia, and cancer pain. It provides details on the definition, causes, symptoms, diagnostic tools and treatment options for low back pain and sciatica, which are the most commonly discussed chronic pain conditions. The treatment sections cover medications, physical therapy, injections including epidural steroid injections, radiofrequency ablation, and other minimally invasive procedures.
This document summarizes barriers to opioid monitoring in primary care as presented by Dr. Erin Krebs. Some key barriers include short appointment times that limit monitoring, an assumption that opioids are effective without formally assessing benefits, overconfidence in risk perceptions, and negative attitudes viewing monitoring as "policing" rather than patient care. Implications discussed are formally assessing opioid benefits, addressing expectations and readiness to change, maintaining focus on medication harms rather than patient trustworthiness, and developing systems to support recommended monitoring practices.
This document discusses PRN pain medication administration and management. It outlines objectives around offering PRN medications consistently based on evidence, using sedation and nonverbal pain scales, and properly documenting PRN medication administration in the Excellian system. Key recommendations include administering pain medications regularly to maintain therapeutic levels and using PRN medications for breakthrough pain. Proper documentation and timely administration of PRN medications can help effectively control pain.
This document provides an overview of pain management strategies presented by Dr. Jeff Higginbotham. It discusses the large number of Americans suffering from chronic non-cancer pain, costing billions in lost work and medical costs. Dr. Higginbotham outlines a multidisciplinary approach to pain management focusing on relieving suffering while preserving function through evidence-based strategies like medications, nerve blocks, rehabilitation, and coping techniques. The document also discusses challenges of treating chronic pain and the need for compassionate care, as well as new research targeting conditions like Complex Regional Pain Syndrome.
This document discusses pain assessment and management for people with advanced dementia. It notes that pain is underreported and undertreated in cognitively impaired older adults due to challenges in assessment. It recommends using behavioral observation scales to assess pain in people with dementia, and provides examples of assessment tools like the Doloplus-2 scale and Abbey Pain Scale. It also provides guidance on managing chronic pain in older adults with dementia, including starting low-dose regular analgesics and considering transdermal patches to provide steady doses.
2015: Post Stroke Fatigue - Why Live With It?-GiapSDGWEP
Post-stroke fatigue is a common problem, affecting 38-73% of stroke survivors. It can persist for months or years after a stroke and significantly impact quality of life. The document discusses factors that may contribute to post-stroke fatigue like depression, sleep disturbances, lack of exercise, and medications. It also reviews tools to assess fatigue severity and differentiates fatigue from excessive daytime sleepiness. While no pharmacological treatments have proven effective, non-drug interventions like exercise, energy conservation, and sleep management may help manage post-stroke fatigue. A randomized controlled trial found that cognitive therapy combined with graded activity training over 12 weeks can reduce persistent post-stroke fatigue.
The Empower Veterans Program provides intensive, integrated self-care coaching through group and individual sessions for veterans suffering from chronic pain. Over 10 weeks, veterans receive training in whole health and well-being, acceptance and commitment therapy, and mindful movement. Preliminary results show improvements in pain, functioning, mental health, and quality of life for veterans, as well as decreased healthcare utilization and costs. The program aims to safely empower veterans with chronic pain through a multidisciplinary approach that promotes self-management over passive treatments.
This document discusses the management of chronic (neurogenic) pain. It provides information on understanding pain, its pathophysiology, assessment, and treatment options. Chronic pain is a complex condition with physical and psychological components. Proper management requires a multidisciplinary approach including pharmacological, rehabilitative, and psychologic interventions to help improve patient function and quality of life.
Cognitive behavioral therapy (CBT) improved quality of life more than standard treatment alone in patients with chronic musculoskeletal pain. A randomized clinical trial assigned 93 patients to either CBT or standard treatment control groups. After 10 weeks, CBT resulted in a 54% reduction in pain levels compared to 28.9% for control. CBT also reduced depressive symptoms and improved physical limitations, general health, and limitations due to emotional problems domains of quality of life more than standard treatment alone. CBT was shown to be an effective addition to standard treatment for improving aspects of chronic pain.
This study examined the relationship between heart rate variability (HRV) and self-reported pain, pain interference, and emotional well-being in adolescents and young adults with neurofibromatosis type 1 (NF1) and plexiform neurofibromas. 24 participants underwent electrocardiograms to measure HRV and completed questionnaires on pain and functioning. Results showed HRV was significantly correlated with pain interference but not pain intensity or disease severity, suggesting those with lower HRV and more chronic pain interpretation may experience greater interference in daily life. Psychological inflexibility was also associated with increased pain interference. Future acceptance-based therapies may help reduce interference and increase HRV by improving psychological flexibility around chronic pain.
Chronic pain: Role of tricyclic antidepressants, dolsulepinSudhir Kumar
Chronic pain is common. Depression often co-exist with chronic pain. This article looks at the pathophysiology, prevalence of chronic pain and depression. The role of TCA, especially dosulepin and amitriptyline has been discussed.
Building on the lecture I gave (and uploaded) "Palliative Care: what every primary care doctor should know" I built this talk. It is geared for 1st year medical students who are learning anatomy, physiology, and perhaps some pharmacology and pathophysiology.
In this talk, I do not explicitly address hospice care - as that was provided in an online chapter for students at UMass. I will later upload another slide set on that topic.
I hope you enjoy it.
FYI- the link to the youtube video: http://www.youtube.com/watch?v=XHtHXGhTIC4
Link to PDF of the slide show: https://files.me.com/s.mak/8fzat6
Geriatric psychosocial assessment of pain induced depressionJames Wilson
This document outlines a proposed study to develop a new assessment tool called the Geriatric Evaluation of Pain-induced Depression (GEAP) scale. The study would involve administering the GEAP scale along with the Geriatric Depression Scale (GDS) and Geriatric Pain Measure (GPM) to older adult participants experiencing chronic pain. Item response theory analysis and exploratory factor analysis would be used to evaluate the psychometric properties and validity of the GEAP compared to the existing GDS and GPM scales. A pilot study with 32 participants would first be conducted to test the proposed data analysis techniques. The goal of developing the GEAP is to address the lack of assessments that specifically measure pain-induced depression among older adults.
The document discusses chronic pain and its treatment. It defines chronic pain as prolonged pain where the pain system is altered and no longer represents injury. Chronic pain is maintained by changes in the nervous system. Treatment of chronic pain focuses on understanding the biopsychosocial model of pain and using multidisciplinary treatments like exercise, CBT, and medication management of conditions like fibromyalgia, low back pain, and migraines. Mood disorders are also discussed as both causing and being caused by chronic pain conditions.
This document discusses emerging pharmacological and non-pharmacological aspects in pain management. It notes that multimodal analgesia using combinations of drugs targeting different pain pathways can provide improved pain relief with reduced side effects compared to single drugs. Newer drugs targeting specific receptor subtypes are emerging. Non-invasive options such as topical agents, exercise, and interventional techniques are increasingly utilized before more invasive options. Interventional pain management techniques discussed include injections, neurolysis, and spinal cord stimulation.
INFLUENCE OF DEMOGRAPHIC FACTORS ON PAIN KILLER USAGE AND ADDICTION SYMPTOMSJing Zang
Pain killers have been a necessity for humans since their skin has been laden with pain receptors to signal them against any invasion or unusual going on in the body.This pain when exceeds the limits of tolerance has to be alleviated to reduce suffering. Since ancient times numerous natural substances like herbs and oils have been used to relieve pain, but in modern era more refined ways to relieve pain have been discovered that exactly target the precise pain. This research identifies the factors that govern painkiller usage and addiction and the people who, in majority fall prey to pleasures of pain killers. The research was carried out through a questionnaire and results were statistically analyzed by fishers exact test. Males, employed people, non medics and graduates are most attracted to pain killers and are susceptible to long term addiction. The reasons for these people falling prey to pain killers are work load, mental stress and physiological responses to the drug. These factors can be managed through proper intervention by health professionals. The role of friends and family too here cannot be ignored.
Interventional Techniques For Cancer Pain Management.guest7342323
The document discusses cancer pain management techniques including conservative management and interventional techniques. It covers assessing pain, diagnosing the type and cause of pain, and treating pain using the WHO analgesic ladder as well as more advanced interventional techniques like intraspinal opioid administration, radiofrequency ablation, vertebroplasty, and neurolytic blocks. The goal is to properly diagnose and treat different types of cancer pain to improve patients' quality of life.
This document discusses pain, including definitions of pain, types of pain, factors influencing pain, effects of pain, individual variations in pain response, and pain assessment tools. It also covers postoperative pain management principles like the WHO pain ladder, pharmacological and non-pharmacological interventions for pain control, preemptive analgesia using local anesthetics or other drugs before a painful stimulus to reduce later pain, and techniques like patient-controlled analgesia and epidural analgesia. The goal of pain management is to prevent pain from interfering with recovery through adequate assessment and treatment.
This randomized controlled trial compared the effectiveness of virtual reality graded exposure therapy (VR-GET) to treatment as usual (TAU) for active duty service members with combat-related post-traumatic stress disorder (PTSD). 19 participants were randomly assigned to either VR-GET (10 participants) or TAU (9 participants). VR-GET consisted of VR exposure combined with skills training, while TAU included various PTSD treatments like prolonged exposure therapy. Results found that 7 of 10 in the VR-GET group improved by at least 30% on the Clinician Administered PTSD Scale, compared to only 1 of 9 in the TAU group, indicating VR-GET was more effective for treating combat-related PTSD.
The document discusses pain assessment and management in elderly patients. It outlines common misconceptions about pain in elderly patients held by patients and nurses. It then covers the pathophysiology of acute and chronic pain and different pain scales used for assessment. Finally, it discusses pharmacological and non-pharmacological pain management strategies including the WHO analgesic ladder and alternative therapies that may help close the "gate" of pain perception.
The document discusses various chronic pain syndromes including low back pain, sciatica, complex regional pain syndrome, trigeminal neuralgia, and cancer pain. It provides details on the definition, causes, symptoms, diagnostic tools and treatment options for low back pain and sciatica, which are the most commonly discussed chronic pain conditions. The treatment sections cover medications, physical therapy, injections including epidural steroid injections, radiofrequency ablation, and other minimally invasive procedures.
This document provides guidance on developing patient education programs for chronic conditions. It discusses principles of patient education including definitions, theories like the Health Belief Model and Social Cognitive Theory, and evidence supporting patient education. The document also covers needs assessment, setting objectives and priorities, educational approaches, and program planning. The overall goal is to empower patients through education tailored to their specific needs and beliefs.
The document discusses pain and the nervous system's response to harmful stimuli. It describes two waves of pain - the initial sharp pain from A-delta fibers and the longer-lasting dull pain from C-nerve fibers. It outlines the ascending pathway where pain signals travel from nociceptors to the dorsal horn and then to the brain. Chronic pain can persist after injury healing or for unknown reasons, and can be caused by various physical and neurological conditions.
This document provides an overview of pain, including definitions, classifications, physiology, assessment, and management. It defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is classified based on location, duration (acute vs chronic), and intensity (mild, moderate, severe). The physiology of pain involves transduction, transmission, modulation, and perception of pain signals in the nervous system. Nurses assess pain using scales and treat it using pharmacological and non-pharmacological methods based on the type and severity of the pain.
1. The document discusses pain, defining it as an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
2. Pain is always subjective and can be somatic, visceral, or neuropathic in nature. It can be acute or chronic, with chronic pain lasting over 3 months and having a large psycho-social component.
3. The gate control theory proposes that psychological factors can affect the experience of pain by opening and closing a "gate" in the spinal cord that modulates pain transmission.
This document discusses palliative pain management in older adults. It defines palliative care and focuses on symptom management using a holistic interprofessional approach. It reviews pain assessment tools, types of pain, pharmacological and non-pharmacological management options, and common pitfalls in treating pain in older adults. Case examples are provided to demonstrate comprehensive pain assessments and developing individualized treatment plans.
The lecture I gave for the Indiana University Health Joint Transplant Education and Research Lecture Series on palliative care. That's right, palliative care in transplant patients NOT at the end-of-life.
Pain management: An Interdisciplinary Approach | VITAS HealthcareVITAS Healthcare
Pain management is first and foremost in a hospice patient’s plan of care. Hospice provides comfort and quality of life near the end of life, and hospice providers are experts at managing pain. The goal of this webinar is to help healthcare professionals understand all aspects of a patient’s pain as a symptom near the end of life, and how to utilize an interdisciplinary approach to provide the most effective pain management.
The document provides an overview of pain management for nurses. It discusses [1] the prevalence and impact of pain, common barriers to treatment, and types of pain experienced by patients. It also [2] outlines principles of effective pain management including thorough assessment, appropriate medication selection and dosing, and multidisciplinary treatment. [3] Barriers to treatment include patients' and clinicians' attitudes as well as institutional factors, and uncontrolled pain negatively impacts multiple aspects of patients' lives.
This document provides an overview of pain management approaches for patients near the end of life. It discusses:
1) The importance of understanding all aspects of a patient's pain, including physical, social, emotional and spiritual components, and utilizing an interdisciplinary team to effectively manage total pain.
2) Common causes of pain in terminally ill cancer and non-cancer patients.
3) Components of a full pain assessment, including tools to evaluate pain in nonverbal and cognitively impaired patients.
4) Factors that influence the pain experience and barriers to effective pain management.
This document discusses the basic principles of palliative care, including definitions, goals, ethical issues and barriers. It provides statistics on palliative care needs in Palestine, including causes of death, cancer rates and lack of services. Recommendations are made to establish national palliative care policies and programs, train healthcare workers, ensure availability of pain medications, and incorporate palliative care into existing healthcare systems to improve end of life care.
Pain Management in the Context of an Opioid Epidemic: Considerations and Tool...VITAS Healthcare
This presentation details how to conduct a comprehensive pain assessment, considerations when prescribing analgesics, and when opioids may be appropriate.
This document discusses optimizing pain management in cancer treatment. It provides an overview of concepts like total pain, the WHO analgesic ladder for treating pain with opioids, and the importance of proper pain assessment and documentation. The key points are:
1) Total pain includes physical, psychosocial, emotional, and spiritual suffering experienced by cancer patients.
2) The WHO analgesic ladder recommends treating mild pain with non-opioids like paracetamol, moderate pain with weak opioids like codeine, and severe pain with strong opioids like morphine.
3) Proper pain assessment involves documenting pain scores, characteristics, causes, and impact on function to effectively guide pain treatment decisions.
2015: Pain Assessment, the Key to Treating Pain in the Inpatient Setting-YiSDGWEP
This document discusses pain assessment in inpatient settings, with a focus on aging and palliative populations. It emphasizes the importance of thorough pain assessment using tools like the numeric pain scale or behavioral assessment tools. It also stresses the need to assess for sedation when treating pain and reassessing patients on a schedule based on medication peaks. The document provides guidance on pain assessment and management for aging patients and those who are dying, noting the need to avoid assumptions and still properly assess and treat pain. It promotes the idea of bolusing pain medication before increasing continuous infusions.
Current opiate prescription treatment has led to increased deaths, patients with marginal improvement in pain with minimal improvement in quality of life and high system utilization.
The integrated high-risk patient pain management clinics have been established to increase quality of pain care, stabilize high-risk patients and reduce impact of on primary care physicians and clinic utilization. These clinics are one aspect of a comprehensive plan to increase high quality pain care and reduce opiate deaths.
Mental Health – In this current period of data collection rates of
depression in all groups were reduced number of patients with mild MDD < 10%, number of patients with moderate < 7%, number of patients with severe depression < 7% and # of patients with all levels of MDD by 23%. The change in sample depression was significant with p =.01. 37% of patients had a score that indicates a likely full diagnosis of PTSD.
Hospice care and palliative care: Is there a difference between the two, and if so, what?
Many people still think that palliative care means hospice care. But today, hospice is only a small part of palliative care.
The goal of palliative care is to prevent or treat the symptoms and side effects of a disease; and it should be part of the picture from the first day a serious illness is diagnosed.
Dr. Jim Meadows, Director of Hospice and Palliative Care at Tennessee Oncology, will discuss this important topic. How does a family and a health care team best work together to guide a patient through a terminal illness? How does everyone continue to support quality, patient-centered, end-of-life care?
I didn't know this option of Palliative care existed prior to my mother's passing earlier this year of colorectal cancer. However, I do now know about it and want to share it with all of you
Rebound Pain - Dalhousie Research Day 2021GarrettBarry3
The study aimed to determine the incidence and risk factors of rebound pain after peripheral nerve blocks for ambulatory surgery. The researchers found that 49.6% of patients experienced rebound pain. Higher risks included being younger, female, having bone surgery, and not receiving IV dexamethasone. IV dexamethasone was underutilized despite being effective at preventing rebound pain. The study concluded more research is needed on modifiable factors like prolonging block duration and optimizing post-op analgesia.
This document summarizes a study on racial and ethnic differences in medication adherence among patients newly prescribed antihypertensive medications. The study found that after controlling for factors like income and health status, black, Asian, and Hispanic patients were more likely than white patients to not fill their initial prescription or refill later prescriptions. However, differences in long-term adherence between white and non-white patients decreased when the model accounted for medication costs and use of mail-order pharmacies. The authors conclude that improving access to medications may help reduce persistent gaps in medication use between racial and ethnic groups.
The document outlines an upcoming conference on responsible opioid prescribing practices that aims to describe how cautious, evidence-based prescribing can lower overdose deaths while maintaining treatment for chronic pain, identify best practice strategies for pain management, and explain evidence-based practices and patient education programs being used across the US.
This document provides an overview of chronic pain for nursing students. It defines chronic pain as pain lasting over 3 months and notes that 7.8 million people in the UK suffer from moderate to severe chronic pain. The document discusses how chronic pain can impact people's lives by causing inactivity, fatigue, sleep issues, mood changes, and difficulties with work and family. It also outlines the nurse's role in assessing pain, educating patients, promoting self-management, and connecting patients to community support services.
Unrelieved pain can have negative physiological effects. It prolongs the stress response and causes harmful changes to the endocrine, cardiovascular, respiratory, immune, and other body systems. Assessing pain in all patients, including those who cannot self-report, is important for effective pain management. A comprehensive pain assessment evaluates location, intensity, quality, onset/duration, relieving/aggravating factors, function, goals, and other details. Non-pharmacological and pharmacological methods are both used to treat pain, and opioids carry side effects like respiratory depression that require monitoring.
This document discusses pain management in cancer patients. It covers the pathophysiology of pain, assessment strategies, drug and non-drug treatment options, managing special populations, patient education, and Joint Commission standards. The key aspects are conducting a comprehensive initial pain assessment, developing an individualized treatment plan using the WHO analgesic ladder as a guide, treating breakthrough pain, managing side effects, and employing multimodal therapies including pharmacological and nonpharmacological options.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
4. 73.36 million High Blood Pressure
17.0 million Diabetes
16.8 million Coronary Heart Disease
11.7 million Cases of Cancer
100+ million Pain Sufferers
8. The bulk of pain care is
provided in the primary care
setting
< 5% of chronic pain patients will be
managed by a pain specialist
40% of all outpatient visits are related to pain
9. Pain in Veterans
• 50% of male Veterans report
chronic pain
• Pain in women Veterans may be as
high as 75%
• Pain is among the most costly
disorders treated in VHA settings
10. How do pain concerns impact our returning
combat Veterans?
11. Karl
• 26 y/o; deployed once to Iraq and once to Afghanistan
• infantryman; convoy security
• exposed to frequent direct and indirect fire,
• saw many casualties, lost several close friends
• multiple IED exposures;
• screens positive for TBI, PTSD and depression.
• chronic back pain; taking hydrocodone.
• initial PACT assessment; desires refill of his hydrocodone
and a refill of his clonazepam (for sleep)
• no mental health treatment in the past year
How can we best help Karl?
12. Poll Question
What percentage OIF/OEF/OND veterans
reported chronic pain after deployment?
A. 14%
B. 33%
C. 47%
D. 96%
13. What are the health concerns
of OEF/OIF/OND veterans seen in the VA?
• Musculoskeletal 56.7%
• Mental disorders 52.8%
• Symptoms/signs 51.9%
• Nervous system (hearing) 44.8%
• GI (dental) 36.0%
• Endocrine/Nutrition 32.4%
• Injury/Poisoning 28.8%
• Respiratory 26.3%
VHA Office of Public Health and Environmental Hazards March 2012
14. Pain is the primary
physical problem
afflicting service
members
16. • 47% OIF/OEF/OND veterans reported chronic pain
after deployment
– 80% have musculoskeletal concerns
– 28% report moderate to severe pain
• Pain is the primary physical problem afflicting
soldiers
– often begins in basic training (25% of male and
50% of female recruits experience at least one
pain-related injury during Basic Combat Training)
– #1 complaint of OEF/OIF/OND Vets
16
17. Factors Contributing to Rise in Pain
Wounding Patterns
IED’s
Poll Results
Body Armor
Time in vehicles
Improvements in Medical Care
18. How do pain concerns impact our returning
combat Veterans?
19. Poll Question
Chronic pain is present in what percentage of
patients with PTSD?
A. 12-29%
B. 21-36%
C. 38-48%
D. 45-87%
22. • Pain and depressive disorder co-occur 30-60% of the
time
• Anxiety disorders occur in 35% of persons with
chronic pain
• 20-34% of persons with chronic pain meet criteria for
PTSD
• Chronic pain occurs in 45-87% of persons with PTSD
• 37-61% of patients seeking substance use treatment
have chronic pain
• Pain undermines treatment for depression, anxiety
disorders, PTSD, and substance use disorders
24. 71% of Primary Care Providers
report chronic pain management
to be challenging
(VHA PC Survey, 2008)
25. Culture of “Cure”
• Urgent and absolute relief:
appropriate in acute and
cancer pain
• Inappropriate in chronic pain
Rehabilitation
Restoring and preserving
function
• Acute strategies are
inappropriate for chronic pain
26. Inadequacies in education and training
Lack of consultant support
Psychosocial complexity
Time pressures
Skepticism
Systems limitations Lincoln et al Survey,
VA Connecticut HCS
27. Monitoring opioid use in primary care
100 76.6
90
80
% of patients
70 48.8
60
50
40
30 8.0
20
10
0
Urine Drug Regular Office <1 Early Refill
Testing Visits
Becker, WC Ann Fam Med 2011
28. So how are we going to help Karl?
What is our mission?
What is our plan?
Who is on our team?
What tools do we have to help us?
How are we going to make it happen?
29. Factors that influence pain experience
• Biological Factors
– Severity of injury/damage
– Presence of source of nociception.
• Psychological Factors
– Mood
– Anxiety (PTSD)
– Stress/Anger
– Cognitions/attention
• Social Factors
– Activity – Occupational status
– Social interactions (+ and 29 –Social role
-)
30. Social Biological
Psychological
We must understand the “whole person with pain”.
32. Collaborative Care requires a new
Communication style
Engage
Find It
Empathize
Educate
Fix It
Enlist
(Keller VF, Carroll JG, Patient Education and Counseling, 1994)
47. The expanded PACT works together to
manage chronic pain
• Collaboration of PCP, Pharm D, RN, PCMHI,
PT/Rehab
• All promoting self-management, goal setting
• Pain school (self-management groups)
• Group Medical Visits, Shared Medical
Appointments(SMA)
• Care management of pain and depression
• Health Coaches/Health Behavior Coordinator
53. Standardization of Opioid Prescribing for
PACT
• Opioid pain agreement/informed
consent/risk discussion
• Chronic Pain on problem list
• Risk evaluation tool
• Random UDS(Urine Drug Screen)
• 4 A’s on every visit
• Opioid Renewal/Refill Clinics
53
55. Stepped Care Approach to
Musculoskeletal Pain
Medications
• NSAIDS, topical analgesics
• TCAs or gabapentin for neuropathic pain
• muscle relaxants for spasm
• Appropriate medications for co-morbid conditions
such as PTSD/depression
56. Stepped Care Approach to
Musculoskeletal Pain
Early utilization of self management and non-
pharmacological modalities
• Pain school
• Health psychology for relaxation training,
biofeedback, cognitive behavioral therapy
• Chiropractor
• Acupuncture
• PT/OT/KT for TENS, massage, exercise
• CAM with MBSR, yoga nidra, yoga with
movement, mindfulness meditation
57. Staff Education/Resources on Pain
• Rural Health Series on PAIN TMS classes…Four
30 min trainings……
• VISN 20 online education
• Wiki
• E-consult pilot
• National Pain Meeting archives
• OEF/OIF/OND National Sharepoint Archives
• VA Pain
site:http://www1.va.gov/painmanagement/
60. Action Plan
1. Goals: Something you WANT to do Begin Exercise
2. Describe
How Walking Where Neighborhood
What 20 min Frequency 3x/week
When After dinner
3. Barriers - Dishes, safety (no sidewalks)
4. Plans to overcome barriers - get kids to clean up, ask
neighbor or husband to join me, wear reflective
vest
5. Conviction and Confidence ratings (0-10) - 9/8
6. Follow-Up: Will keep log and bring to next visit in 1
month
61. Exercise
Taking medications
Physical Therapy
Diet/Weight Loss
Depression
Psychological Strategies
Mindfulness
Massage
(RI Dept of Health Chronic Care Collaborative)
62. Pain School Schedule
• Non-Opioid medications for pain
• How to cope when you can’t cure
• Health and healing through leisure/ living
with pain
• Opioids and pain management
• Physical therapy: improving your pain
and function
• Pain management techniques to break the
cycle of pain
63. But what if our PACT is a small
CBOC and we don’t have a pain
school?
• VTEL it in from your main facility
or how about showing a YouTube!
• Provide the Veteran tools to build
self efficacy
67. Karl and his Team have a Mission: the best pain care
Karl and his Team have a Plan
Karl and his Team are all trained to do their parts
Karl and his Team work together
and by doing so carry out the plan
…and succeed in the mission!
69. References and useful websites
VA Pain site: http://www1.va.gov/painmanagement/
VISN 20 LMS:
http://vhapugweb3/pain/ChronicPain/index.html
www.painedu.org
www.painedu.com
www.globalrph.com
www.jpain.org
www.ampainsoc.org
Dobscha SK et al. Collaborative care for chronic pain in primary care: a
cluster randomized trial. JAMA.2009;301(12):1242-1252
Kroenke K et al. Optimized antidepressant therapy and pain self-
management in primary care patients with depression and musculoskeletal
pain: a randomized controlled trial. JAMA. 2009;301(20):2099-2110
Editor's Notes
IOM reportPain represents a challenge not only for our Veterans but nationally. A cultural transformation is necessary to better prevent, assess, treat, and understand pain of all types. Last summer the IOM issued this report offering a blueprint for action in transforming prevention, care, education, and research recommending that we adopt a population-level prevention and management strategy. Better data are needed and the IOM encourages federal and state agencies and private organizations to accelerate the collection of data on pain incidence, prevalence, and treatments. IOM recommends that providers should increasingly aim at tailoring pain care to each person’s experience, and self-management of pain should be promoted and thateducation programs be better designed to bridge these gaps. Pain is a major driver for visits to physicians, a major reason for taking medications, a major cause of disability, and a key factor in quality of life and productivity. Given the burden of pain in human lives, dollars, and social consequences, relieving pain should be a national priority
20-40% of adults report chronic painIn primary care settings up to 20% of visits generate and opioid prescriptionIn the US overall 4 million adults are prescribed a long acting opioid each yearAs prescriptions have increased so have the consequences such as impairment, diversion, overdose and dependenceThere is little evidence that long term opioid therapy is effective in reducing pain much less in restoring function , the ultimate goal of treatment yet continues to be the backbone of our therapy The few randomized trials that support opioid therapy were of only of a few months duration and not of high qualityWe have an evidence base for non opioid based alternatives such as CBT targeting factors that influence a patients ability to cope with pain symptomsKroenke demonstrated that treating depression in patients with chronic pain who were not previously recognized as depressed led to improvement in pain scores equal the opioids. Recent work using exercise and telephone CBT is promising and represents self management strategies that puts the patient in charge. These skills are available after hours and don’t require monthly refills Cognitive Behavior Therapy, Exercise, or Both for Treating Chronic Widespread PainJohn McBeth, MA, PhD et al ; Arch Intern Med. 2012;172(1):48-57. doi:10.1001/archinternmed.2011.555
The figure above shows rates of opioid pain reliever (OPR) overdose death, OPR treatment admissions, and kilograms of OPR sold in the United States during 1999-2010. During 1999-2008, overdose death rates, sales, and substance abuse treatment admissions related to OPR all increased substantially.Figure from CDCMMWR Vital Signs: Overdoses of Prescription Opioid Pain Relievers --- United States, 1999--2008WeeklyNovember 4, 2011 / 60(43);1487-1492
20-40% of adults report chronic painIn primary care settings up to 20% of visits generate and opioid prescriptionIn the US overall 4 million adults are prescribed a long acting opioid each yearAs prescriptions have increased so have the consequences such as impairment, diversion, overdose and dependenceThere is little evidence that long term opioid therapy is effective in reducing pain much less in restoring function , the ultimate goal of treatment yet continues to be the backbone of our therapy The few randomized trials that support opioid therapy were of only of a few months duration and not of high qualityWe have an evidence base for non opioid based alternatives such as CBT targeting factors that influence a patients ability to cope with pain symptomsKroenke demonstrated that treating depression in patients with chronic pain who were not previously recognized as depressed led to improvement in pain scores equal the opioids. Recent work using exercise and telephone CBT is promising and represents self management strategies that puts the patient in charge. These skills are available after hours and don’t require monthly refills Cognitive Behavior Therapy, Exercise, or Both for Treating Chronic Widespread PainJohn McBeth, MA, PhD et al ; Arch Intern Med. 2012;172(1):48-57. doi:10.1001/archinternmed.2011.555
Lets take a look at what is happening here Karl is one of the soldiers carrying the litter lets hear Karl’s story
Would like to have audio
For women and men Veterans who use VA, the prevalence of painful musculoskeletal conditions including back problems, musculoskeletal problems and joint problems increases every year after deployment…But, it increases more for women than men, so by 7 years after deployment20% of women and 17% of men have back problems12% of women and 10% of men have musculoskeletal conditions19% of women and 17% of men have joint problems
Wounding PatternsSurvivable extremity traumaIED’sBody ArmorIncreased survival ratesRelative increase in extremity traumaLow back painTime in vehiclesImprovements in Medical CareMEDEVAC/CCATT (Critical Care Air Transport Teams)Combat medicine and in-theater hospitalsMason, Eadie, & Holder, 2008; Hicks et al., 2010; Champion et al., 2010; Belmont et al., 2010; Nevin & Means, 2009Slide prepared by: Don McGeary, Ph.D.
Lew, Otis, Tun, Kerns, Clark, & Cifu, 2009 JRR&DSample = 340 OEF/OIF outpatients at Boston VAOverall prevalence in Polytrauma population: -Pain 81.5% -TBI 68.2% -PTSD 66.8% -CLARK- 2009
Pain and PTSD coexist 60-80% of veterans (Lew et al, 2009; Beckham et al, 1997; White et al, 1989)
Recent research suggests that individuals suffering from comorbid chronic pain and traumatic stress may respond poorly to treatment targeting only one diagnosisThe co-occurrence of chronic pain and PTSD is becoming more widely recognizedConcurrent use of opiates and benzodiazepines in the treatment of this population is a concern For people with chronic pain, the pain may actually serve as a reminder of the traumatic event, which will tend to exacerbate the PTSD.Recently a Retrospective cohort study of 141,029 Veterans with non-cancer pain diagnosisComorbid PTSD and Pain Significantly More Likely:Highest quintile for dose; More than one opioid prescribed concurrently; Concurrent sedative hypnotics; Early refillsHave more Opioid related accidents, Overdoses, Alcohol and Non-opioid related accidents and overdoes, Self-inflicted injuries and Violence related injuriesSeal, K.H., Shi, Y., Cohen, G. et al. Veterans with PTSD were more likely to receive higher dose opioids, 2 or more opioids, sedative hypnotics and get early refillsBohnert 2011Pain and depression frequently co-exist (30-50% co-occurrence) and have additive effect on adverse health outcomes and treatment responsiveness of one another *The presence of depressive symptoms is a strong, independent, and highly prevalent risk factor for the occurrence of disabling back pain *** Bair, MJ, Robinson RL, Katon W, Kroenke K. Depression and Pain Co-morbidity: a literature review. Arch Intern Med 2003;163:2433-2455** Reid MC, Depressive symptoms as a risk factor for disabling back pain Am Geriatr Soc. 2000 Dec;51(12):1710-7.
Urgent and complete relief is an expectation of patients and taught in medical schools as the biomedical model Unfortunately opioids became equated with managing pain Pain as 5th VS in 1998 moved us to try to do a better job at fixing pain and opioids at the time seemed to be the answer
Elicit examples of each component from group. Not just the Biomedical model is inadequateBiopsychosocial model best describes the chronic pain experienceComplex interaction among biological, psychological, and social factorsBiomedical ModelDualism: “mind” and “body" are separatePain is a symptom of an underlying physical problemDisease resides in the individualIndependent of psychological and social experienceObjective evidence is valued more than subjective reportpain, or the “chronic pain patient”.
VHA is innovating the way health care is delivered by moving the current system which is reactive “find it, fix it,” disease care to one that is personalized, proactive and patient-driven. This approach is Informed by chronic illness model where we move from a provider centric system to one that is team based and centered around what is important to the Veteran in their livesEmpowering Veterans through reassurance, encouragement and education Conservative safe use of analgesics and adjuvant medicationsPromotion of regular exercise and healthy and active lifestyleDevelopment of adaptive strategies for managing painA system that is centered around the patient will help us better assist with the management of chronic disease and chronic painThis cloud tag emphasizes that Self Management skills are key to managing and improving any chronic pain condition involving a multitude of modalities promoting an active and healthy life style that is personalized proactive This can be can be supported by a Veteran-centered healthcare system that involves patient education, conservative management of acute pain and prevention of chronic pain, overall wellness and healthy living, conservative and safe use of medications, including over the counter medications, and use of adaptive strategies for managing pain
Universal precautions originally to prevent transmission of infection but the principal can be generalized to any practice that applied universally to all as standard protocol improves the safety of patients. As an example in diabetes we have standardized approaches around the use of insulin Periodic Reassessment of Pain Diagnosis and Comorbid Conditions, Including Addictive behaviorsUniversal Precautions in Pain Medicine: A Rational Approach to theTreatment of Chronic PainDouglas L. Gourlay, MD, MSc, FRCPC, FASAM,* Howard A. Heit, MD, FACP, FASAM,† andAbdulazizAlmahrezi, MD, CCFP‡*The Wasser Pain Management Center, Mount Sinai Hospital, Toronto, Ontario, Canada; †Assistant Clinical Professor ofMedicine, Georgetown University School of Medicine, Washington DC; ‡Clinical Fellow, Center for Addiction and MentalHealth, Toronto, Ontario, Canada
Welcome. We are very pleased that you are here. You have come to the right place and we have many resources and services that will be very useful to you. I personally want to acknowledge your service, and the sacrifices that have resulted from that service. We will discuss your pain medications, but I will start by saying that you will be getting the best pain care possible here at the VA. Our approach to pain care has been proven to be the best approach possible. You will have a team and we all will work together to insure that all of your health concerns are addressed in the most effective way possible, including your pain care. Medications may be a part of your pain care, but there will be many other things we will be doing to insure that pain impacts your life as little as possible. Our mission in VA is to support you in having the healthiest and most successful, satisfying life possible. Your team will work with you to make that happen. So let’s get started!”
What do we do in Step 1
Bullet out the key pointsPACT/Medical Home, the non-VA community is looking to VA to lead the way in figuring out how to do these things…and accomplishing true interdisciplinary, collaborative, team function is the key….we have the plan, we have the staff, we have educational materials, we have the sense of mission…we just have to show teams how to “put it all together” and then support them in that process, just as we did with PDICITo do his well we need to emphasize patient education, focus on promoting adaptive self-management and empowerment and improve provider patient communication
Plan Implementation of the directive which emphasizes need to standardize our approaches , follow guidelines Come visit us in our booth and pick up a summary summary of the guidelinesWe have guideline for opioid use but the truth is that we overuse opioids and need to use other evidence based approaches in the management of chronic pain EffectivenessMore than reduction of pain intensity Improved overall function and quality of life Progress toward individual goalsHarmsCommon symptoms (constipation, nausea, somnolence) Long-term harms (sleep disordered breathing, hypogonadism)Psychosocial harms (role interference, dependence concerns) Addiction AdherenceAppropriate medication taking Safe storage and disposalNo sharing, borrowing, or selling Informed ConsentProvide written and verbal educationDiscuss specific goals of treatmentReview opioid agreement (consider signature) Obtain consent for UDT (can be verbal)Visit Frequency Reassess at least every 1-6 monthsEffectiveness Discuss progress toward individualized treatment goalsHarmsEvaluate adverse effects and tolerabilityAdherenceDiscuss how and when patient is taking medicationPerform UDT periodicallyAssess adherence to verall treatment plan
Opioid Risk Mitigation EffectivenessMore than reduction of pain intensity Improved overall function and quality of life Progress toward individual goalsHarmsCommon symptoms (constipation, nausea, somnolence) Long-term harms (sleep disordered breathing, hypogonadism)Psychosocial harms (role interference, dependence concerns) Addiction AdherenceAppropriate medication taking Safe storage and disposalNo sharing, borrowing, or selling Informed ConsentProvide written and verbal educationDiscuss specific goals of treatmentReview opioid agreement (consider signature) Obtain consent for UDT (can be verbal)Visit Frequency Reassess at least every 1-6 monthsEffectiveness Discuss progress toward individualized treatment goalsHarmsEvaluate adverse effects and tolerabilityAdherenceDiscuss how and when patient is taking medicationPerform UDT periodicallyAssess adherence to verall treatment plan
emphasize the interdisciplinary and collaborative nature of pain management at every level, including primary care. At the same time, I think that there is still value in using the term tertiary, interdisciplinary pain centers to further emphasize the concept of a coordinated, integrated “program” that serves as a resource for Veterans with particularly high complexity and risk, and who have been less than optimally responsive to prior interventions. CollaborationConsultationWarm Hand-offs: early on to avoid the “rule-out train”Opioid AgreementAssessment including risk for opioid misuseMonitoring high risk populationHelping to determine when opioid therapy is not appropriateCo-visitsTreatment/functional goalsCoaching for self-management2) Promoting Self-ManagementInformed by chronic illness modelReassurance, encouragement, educationConservative use of analgesics and adjuvant medicationsPromotion of regular exercise and healthy and active lifestyleDevelopment of adaptive strategies for managing pain3) Pain School (Self-Management Groups)Promote self-managementInterdisciplinary: primary care provider, psychologist, clinical pharmacist, rehab medicine (PT/OT), dietitianTopics: biopsychosocial model, mind-body connection, SMART goals, CBT, relaxation training, stress management, assertive communication, pacing, energy conservation, thermal modalities, exercise, CAM, sleep, sexual functioning, medication, nutrition4) Group Medical Visits: CHCC Can discuss the TAMPA model and the Lovell Shared Medical apts)Focus on patient population (high risk or high utilization behavior, i.e. management of chronic pain, diabetes, CHF, hypertension)Goal to increase access while delivering quality of careGroups are co-led by primary care and behavioral health specialistOutcome: Improve provider and patient satisfaction Improve patient outcomesReduce service (utilization of hospital, ER, and nursing facilities)Lower costs 5) Care management of pain and depressionDobschaKroenke6) Working with health coaches/health behavior coordinator7) Shared decision making
Primary Care Providers and PACT TeamsWhat can VA SCAN provide as “added value” to Primary Care Providers and PACT Teams? Specialty Care Practice Guidance Build Competency and Confidence CME, CUE, CE credit Improve patient outcomes Enhance Provider and Patient satisfactionPatients and their familiesWhat can VA SCAN provide as “added value” to patients and family members?1. Continue care with their PCP2. Consult a specialist when needed3. Avoid travel to “distant” medical centers4. Avoid delays in diagnosis and treatment5. Become an “educated consumer” and part of your own healthcare5. Obtain tertiary care if needed
Virtual VisitThe National Telemental Health Center (NTMHC) is designed to provide consultation from panels of designated expert clinicians to Veterans anywhere in the country using telehealth technologies. The NTMHC portfolio includes the National Tele-Behavioral Pain Program, which provides extensive psychosocial evaluation and cognitive behavioral treatment for patients referred with refractory pain management. Expert psychologists deliver care remotely using tele-video conferencing technologies. These evaluations provide recommendations for the patient’s treating clinicians along with enrollment into 6-10 sessions of specialized pain cognitive behavioral therapy (CBT) for pain management. Referrals generally originate from mental health and primary care services or directly from pain programs which benefit from a specialized cognitive-behavioral component. The tele-pain expert provides consultation and adjunctive specialty CBT services. From October 1, 2011 through June 30, 2012, 338 tele-behavioral pain management encounters for 70 individual Veterans were documented. Thirteen sites in six States have thus far been engaged in this program.
E-Consult is an alternative to face-to-face visits, and it is expected to improve access, communication, and coordination of care. E-Consult aims to provide clinical support from provider to provider. Through a formal consult request, processed and documented in the CPRS a provider requests a specialist to address a clinical problem or to answer a clinical question for a specific patient. Utilizing information provided in the consult request and/or review of the patient’s electronic medical record, the consultant provides a documented response that addresses the request without a face-to-face visit. This method of consultation supports Veteran-centric care, reduces the burden of travel to the Veteran, and reduces overall travel and fee basis costs
TAUGHT and reinforced by all team members IN PAIN SCHOOLGroup VISTS SHARED MEDICAL APPOINTMENTSPCP VISITSPCMHI WARM HAND OFFSNURSING VISITS PHARM D VISITSPATIENT EDUCATION MATERIALSMHVAFTERDEPLOYMENTREINFORCED BY ALL
Consider non-pharmacological approaches including: physical therapy (TENS unit), occupational therapy, behavioral modification, cognitive behavioral therapy (with relaxation training), mindfulness-based therapies (Mindfulness-Based Stress Reduction, Acceptance and Commitment Therapy, mindfulness meditation), biofeedback, chiropractic care, acupuncture, yoga nidra and yoga with movement, and massage. Non Pharmacological – Leverage Expanded team(PCMHI, RN Care manager, case manager) May include steps 1, 2, 3Rehab: PT/OT/KT/chiro/Rec therapy, exercise Behavioral: pain psychology/psychiatry/social workCAM yoga MBSR outpatient and inpatient pain rehab, advanced diagnostics and interventionsSubstance abuse treatment
Consider non-pharmacological approaches including: physical therapy (TENS unit), occupational therapy, behavioral modification, cognitive behavioral therapy (with relaxation training), mindfulness-based therapies (Mindfulness-Based Stress Reduction, Acceptance and Commitment Therapy, mindfulness meditation), biofeedback, chiropractic care, acupuncture, yoga nidra and yoga with movement, and massage. Non Pharmacological – Leverage Expanded team(PCMHI, RN Care manager, case manager) May include steps 1, 2, 3Rehab: PT/OT/KT/chiro/Rec therapy, exercise Behavioral: pain psychology/psychiatry/social workCAM yoga MBSR outpatient and inpatient pain rehab, advanced diagnostics and interventionsSubstance abuse treatment
Remember MHVAfterdeploymentSmart phone apps
GOAL SETTING NEED TO BE SMARTAn example of attainable and measureable goals to Anyone on opioids for chronic pain has an Opioid Care AgreementUrine Drug Screens on all starts and q6monthsChronic pain on the problem list All understand and agree on stepped care model usinga biopyschosocial approachInclude Pain Management as a standing agenda item in all team meetings Informed by Chronic Illness Model: 1) Self efficacy 2) Self managementCommunication: Reassurance, Encouragement, Education
T2 collaborated with the VA's National Center for PTSD to develop this app to assist Veterans and Active Duty personnel (and civilians) who are experiencing symptoms of PTSD. It is intended to be used as an adjunct to psychological treatment but can also serve as a stand-alone education tool. Features: Self-assessment of PTSD Symptoms Tracking of changes in symptoms Manage symptoms with coping tools Assistance in finding immediate support Customized support information
How would you work with your team to accomplish that?Be sure to say this is not a real case but the goal of what we are working towardINSTEAD OF HEARING THE AUDIO OF THE IDEAL VISIT I CAN DESCRIBE DEPENDS ON TIME Called the VA, got an appointment ion 2 weeks in a clinic near my homeOne week before my apt a nurse called and asked what I wanted out of the visit asked about my health concerns and how I was doingShe told me about MHV and that it would be good to sign up and told me to check out the VA on MHV and facebookThe Clinic was bright and friendly Welcomed by clerk, thanked for service An assistant checked my BP amd weight and told me that a team would be taking care of me and gave me the card with all their names and contact infoThe doc then came in and pulled up my record, already knew a lot about me but asked me about my military service and seemed really interested . He was very concerned about my PAIN he gave me a head to toe exam and talked to me about how difficult it is to have pain but there are other things that can make pain worse such as depression PTSD and stress He said we would work together to figure out the best care plan for my pain.He then introduced me to the psychologist who talked to me about my experiences and combat stress. She seemed to understand an I was comfortable with her. Before I left I met a social worker on a video screen who could help me with any questions I had about managing my benefits and my life in general. I also got signed up to go to Pain School via VA SCAN Very cool course with Veterans at other sitesI left with a plan – there were instructions on how to take the pain meds and the pills to help me sleep, medication, , when to return to see the psychologist, a follow up visit in one month with my primary care team and something to help me sleep , another visit to meet with the psychologist, a follow visit with my team in 3 months to see how I am doing and all the contact information I needed to reach my primary team and the OEF/OIF program I was impressed, and they are actually going to call me next week to see how I am doing, I got what I needed