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Pain Management 1 PAIN MANAGEMENT A COMPREHENSIVE REVIEW PART I Jassin M. Jouria, MD Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology. Abstract There are a number of approaches in the management of pain, each with respective advantages and disadvantages. Ultimately, there should be proper pain management measures in place in order to reduce the root cause of pain, the length of pain, and the effectiveness of pain management. This course aims to offer a comprehensive review of pain management that is currently available, as well as offer some new insight into the modern and innovative measures of pain management. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2 Continuing Nursing Education Course Director & Planners William A. Cook, PhD, Director, Douglas Lawrence, MS, Webmaster, Susan DePasquale, CGRN, MSN, FPMHNP-BC, Lead Nurse Planner Accreditation Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. Credit Designation This educational activity is credited for 4 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Course Author & Planner Disclosure Policy Statements It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. All authors and course planners participating in the planning or implementation of a CNE activity are expected to disclose to course participants any relevant conflict of interest that may arise. Statement of Need Individuals experience pain in unique ways. Health professionals need to be informed of the various pain theories and tools to help identify individual perceptions of pain and methods of treatment. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3 Course Purpose To provide nursing professionals with knowledge of types of pain, methods to identify pain and options for treatment. Learning Objectives 1. Define pain 2. Describe the magnitude of pain 3. Enumerate the characteristics of pain 4. Explain the types of pain 5. Describe the negative consequences of pain 6. Describe the pathophysiology of pain 7. Elaborate the theories of pain 8. Identify the factors affecting the pain Target Audience Advanced Practice Registered Nurses, Registered Nurses and Licensed Practical Nurses, and Associates Course Author & Director Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MS, Susan DePasquale, CGRN, MSN, FPMHNP-BC – all have no disclosures Acknowledgement of Commercial Support: There is no commercial support for this course. Activity Review Information: Reviewed by Susan DePasquale, CGRN, MSN, FPMHNP-BC Release Date: 1/1/2015 Termination Date: 7/8/2016 Please take time to complete the self-assessment Knowledge Questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4 1. At least 3 types of somatic discernable pain include: a. surface pain b. sub-surface pain c. deep pain d. all of the above 2. True or False. The visual analog scale is ideal for use with individuals who possess a strong ability to define their pain. a. True b. False 3. Chronic pain is pain that: a. persists for 1 to 3 months b. can be affected by physical impairments and lack of energy c. can be associated with depression, anxiety, anger and fear d. answers b and c above 4. Melzack and Casey offered a theory of pain focused on: a. cognitive-evaluative, sensory-discriminative, affective- motivational dimensions b. cultural and superstitious beliefs c. age-specific factors d. none of the above 5. Education for patient and caregivers include a variety of tools, such as: a. pain-specific brochures b. videos/audio material and web-based sites c. pain notebooks d. all of the above nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5 Introduction Pain can be defined as a complex, multi-dimensional provocation. It is one of the major reasons that people seek health care. Pain is a response to noxious stimuli and can function as a protective mechanism of the body to prevent further injury. The sensation of pain as the warning of potential tissue damage may be absent in people with certain disorders, such as diabetic neuropathy, multiple sclerosis, and nerve or spinal cord injury. According to a recent medical report titled ‘Relieving the pain in America' published by A Blueprint for Transforming Prevention, Care, Education, and Research, pain is a significant public health problem that costs Americans at least $560-$635 billion annually, an amount equal to about $2,000.00 per person living in the U.S. Consequently, the total incremental cost of health care for controlling pain ranges between $261 and $300 billion, and $297-$336 billion is attributable to a loss in manpower productivity. Pain is considered a “universal disorder”1 that comes in many forms. Regardless of the form it is seen in, everyone experiences pain, with the perception of pain occurring differently in each individual. In the most benign form, pain serves to warn the individual that something is not quite right. Pain can, however, disrupt productivity, well- being, and indeed, the entire life of the individual experiencing the pain. At its core, pain is complex and differs greatly among individuals, including those who seem to have identical injuries or illnesses. Pain has a long history. Ancient civilizations recorded accounts of pain and the various treatments and cures used on stone tablets. Early humans also related pain to magic, demons, and evil. In early times, the responsibility of pain relief fell on shamans, priests, and sorcerers, who utilized herbs, rites and ceremonies to treat pain. The Romans and Greeks were the first peoples to advance the idea that the brain and nervous system is key in producing pain sensations. However, evidence was not nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6 available to support this theory until well into the Renaissance in the 1400 and 1500s. It was not until the 19th century that real advancements in science led to advancements in pain treatment. Physicians discovered that such drugs as morphine, codeine, cocaine, and opium could be used to treat pain. These drugs then led to the development of aspirin as a pain treatment; even today this is the most commonly utilized pain reliever. Finally, anaesthesia advanced and became the standard for surgery. As we have moved into the 21st century, scientists and physicians are gaining an even greater understanding of pain and pain treatment.1 Pain: definition The International Association for the Study of Pain defines pain as: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”.5 Pain is an unpleasant sensation that ranges from mild, localized discomfort to extreme agony. There are physical as well as emotional components to pain. The physical component is the result of nerve stimulation.6 Emotions have the ability to affect the way a person perceives pain. While all human beings have the same anatomical structures that convey nociception to the central nervous system, there are quite a few factors that alter the intensity of the pain perception.7 It is important that practitioners consider both physical and emotional factors when treating patients, as these both influence a patient’s recovery.8 The word pain is derived from the Latin word poena, which means a fine, or penalty. Some people indicate that they tolerate pain well, whereas other individuals indicate that they are highly sensitive to pain. Pain is clinically as the 5th vital sign,9 an important landmark implementing the standard assessment of pain using a pain analogue as part of the routine patient assessment. The assessment of pain as the 5th vital sign has evolved, as a standard process to avoid undertreating pain, to become more integrally part of a comprehensive biopsychosocial evaluation where nursece4less.com nursece4less.com nursece4less.com nursece4less.com 7 the patient’s belief system and culture are expected to be considered. Beyond the use of a pain analogue to quantify pain, the evaluation of pain must include “recognition of the intersubjective, a place where numbers and stories converge… patients should be encouraged to be active participants in their pain-related care”.9 Magnitude of pain Magnitude of pain is a difficult thing to measure, primarily because different people experience pain in different ways.10 However, there are some instruments designed to measure pain that apply universal standards to pain sensation and can be used across the board for all individuals. One such instrument is the visual analog scale.
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