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Pain: Current Understanding of Assessment, Management, and Treatments NATIONAL PHARMACEUTICAL COUNCIL, INC This monograph was developed by NPC as part of a collaborative project with JCAHO. December 2001 DISCLAIMER: This monograph was developed by the National Pharmaceutical Council (NPC) for which it is solely responsible. Another monograph relat- ed to measuring and improving performance in pain management was developed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for which it is solely responsible. The two monographs were produced under a collaborative project between NPC and JCAHO and are jointly dis- tributed. The goal of the collaborative project is to improve the quality of pain management in health care organizations. This monograph is designed for informational purposes only and is not intended as a substitute for medical or professional advice. Readers are urged to consult a qualified health care professional before making decisions on any specific matter, particularly if it involves clinical practice. The inclusion of any reference in this monograph should not be construed as an endorsement of any of the treatments, programs or other information discussed therein. NPC has worked to ensure that this monograph contains useful information, but this monograph is not intended as a comprehensive source of all relevant information. In addi- tion, because the information contain herein is derived from many sources, NPC cannot guarantee that the information is completely accurate or error free. NPC is not responsible for any claims or losses arising from the use of, or from any errors or omissions in, this monograph. Editorial Advisory Board Patricia H. Berry, PhD, APRN, BC, CHPN Jeffrey A. Katz, MD Assistant Professor Associate Professor of Anesthesiology College of Nursing Director Pain Clinic VAHCS, Lakeside Division University of Utah Northwestern University Medical School Salt Lake City, UT Chicago, IL Christine Miaskowski, RN, PhD, FAAN C. Richard Chapman, PhD Professor and Chair Professor and Director Department of Physiological Nursing Pain Research Center University of California Department of Anesthesiology San Francisco, CA University of Utah School of Medicine Salt Lake City, UT Michael J. McLean, MD, PhD Associate Professor of Neurology and Edward C. Covington, MD Pharmacology Director, Chronic Pain Rehabilitation Program Department of Neurology Cleveland Clinic Foundation Vanderbilt University Medical Center Cleveland, OH Nashville, TN June L. Dahl, PhD Professor of Pharmacology University of Wisconsin Medical School Madison, WI Table of Contents Section I: Background and Significance ................................................................................. 1 A. Introduction............................................................................................................. 3 B. Definitions and Mechanisms of Pain....................................................................... 4 1. What Is Pain?....................................................................................................... 4 2. How Does Injury Lead to Pain?........................................................................... 4 3. What Happens During Transduction?................................................................. 5 4. What Is Transmission?......................................................................................... 6 5. What Is Perception?............................................................................................. 7 6. What Is Modulation?........................................................................................... 7 7. What Is Peripheral Sensitization? ...................................................................... 8 8. What Is Central Sensitization?............................................................................ 8 9. What Is Nociceptive Pain?.................................................................................. 9 10. What Is Neuropathic Pain? ............................................................................... 9 C. Classification of Pain............................................................................................... 10 1. Acute Pain ........................................................................................................... 11 2. Chronic Pain........................................................................................................ 11 3. Cancer Pain ......................................................................................................... 12 4. Chronic Noncancer Pain ................................................................................... 12 D. Prevalence, Consequences, and Costs of Pain........................................................ 13 1. What Is the Size and Scope of Pain As A Health Care Problem?..................... 13 2. What Evidence Suggests That Pain Is Undertreated? ....................................... 13 3. What Are the Consequences and Costs of Undertreatment of Pain?................ 14 E. Barriers to the Appropriate Assessment and Management of Pain ........................ 15 1. Barriers Within the Health Care System............................................................ 15 2. Health Care Professional Barriers ....................................................................... 16 3. Patient and Family Barriers ................................................................................. 16 4. Legal and Societal Barriers .................................................................................. 16 5. Tolerance, Physical Dependence, and Addiction............................................... 16 Section II: Assessment of Pain ...................................................................................... 19 A. Initial Assessment of Pain....................................................................................... 21 1. Overcoming Barriers to Assessment.................................................................... 21 2. Goals and Elements of the Initial Assessment.................................................... 21 B. Measurement of Pain: Common Assessment Tools ............................................... 25 1. Unidimensional Scales ........................................................................................ 25 2. Multidimensional Tools....................................................................................... 26 3. Neuropathic Pain Scale....................................................................................... 29 C. Reassessment of Pain ............................................................................................... 29 1. Frequency............................................................................................................. 29 2. Scope and Methods ............................................................................................. 29 ii Pain: Current Understanding of Assessment, Management, and Treatments Table of Contents Section III: Types of Treatments ................................................................................... 31 A. Pharmacologic Treatment ....................................................................................... 33 1. Drug Classifications and Terminology................................................................. 33 2. Common Analgesic Agents................................................................................. 33 3. General Principles of Analgesic Therapy ........................................................... 47 B. Nonpharmacologic Treatments for Pain.................................................................. 53 1. Psychological Approaches ................................................................................... 54 2. Physical Rehabilitative Approaches.................................................................... 54 3. Surgical Approaches ............................................................................................ 54 Section IV: Management Of Acute Pain And Chronic Noncancer Pain ......................... 59 A. Acute Pain............................................................................................................... 61 1. Treatment Goals .................................................................................................. 61 2. Therapeutic Strategies......................................................................................... 61 3. Elements of Treatment......................................................................................... 62 4. Management of Some Common Types of Acute Pain ....................................... 62 B. Chronic Noncancer Pain ........................................................................................ 63 1. Treatment Goals .................................................................................................. 63 2. Therapeutic Strategies......................................................................................... 66 3. Elements of Treatment......................................................................................... 66 4. Management of Some Common Types of Chronic Noncancer Pain................. 67 Section V: Strategies to Improve Pain Management ....................................................... 73 A. Clinical Practice Guidelines ................................................................................... 75 1. Which Practice
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