Avoid Opioids for Most Long-Term Pain
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Opioid-Induced Hyperalgesia in Humans Molecular Mechanisms and Clinical Considerations
SPECIAL TOPIC SERIES Opioid-induced Hyperalgesia in Humans Molecular Mechanisms and Clinical Considerations Larry F. Chu, MD, MS (BCHM), MS (Epidemiology),* Martin S. Angst, MD,* and David Clark, MD, PhD*w treatment of acute and cancer-related pain. However, Abstract: Opioid-induced hyperalgesia (OIH) is most broadly recent evidence suggests that opioid medications may also defined as a state of nociceptive sensitization caused by exposure be useful for the treatment of chronic noncancer pain, at to opioids. The state is characterized by a paradoxical response least in the short term.3–14 whereby a patient receiving opioids for the treatment of pain Perhaps because of this new evidence, opioid may actually become more sensitive to certain painful stimuli. medications have been increasingly prescribed by primary The type of pain experienced may or may not be different from care physicians and other patient care providers for the original underlying painful condition. Although the precise chronic painful conditions.15,16 Indeed, opioids are molecular mechanism is not yet understood, it is generally among the most common medications prescribed by thought to result from neuroplastic changes in the peripheral physicians in the United States17 and accounted for 235 and central nervous systems that lead to sensitization of million prescriptions in the year 2004.18 pronociceptive pathways. OIH seems to be a distinct, definable, One of the principal factors that differentiate the use and characteristic phenomenon that may explain loss of opioid of opioids for the treatment of pain concerns the duration efficacy in some cases. Clinicians should suspect expression of of intended use. -
Guidline for the Evidence-Informed Primary Care Management of Low Back Pain
Guideline for the Evidence-Informed Primary Care Management of Low Back Pain 2nd Edition These recommendations are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. They should be used as an adjunct to sound clinical decision making. Guideline Disease/Condition(s) Targeted Specifications Acute and sub-acute low back pain Chronic low back pain Acute and sub-acute sciatica/radiculopathy Chronic sciatica/radiculopathy Category Prevention Diagnosis Evaluation Management Treatment Intended Users Primary health care providers, for example: family physicians, osteopathic physicians, chiro- practors, physical therapists, occupational therapists, nurses, pharmacists, psychologists. Purpose To help Alberta clinicians make evidence-informed decisions about care of patients with non- specific low back pain. Objectives • To increase the use of evidence-informed conservative approaches to the prevention, assessment, diagnosis, and treatment in primary care patients with low back pain • To promote appropriate specialist referrals and use of diagnostic tests in patients with low back pain • To encourage patients to engage in appropriate self-care activities Target Population Adult patients 18 years or older in primary care settings. Exclusions: pregnant women; patients under the age of 18 years; diagnosis or treatment of specific causes of low back pain such as: inpatient treatments (surgical treatments); referred pain (from abdomen, kidney, ovary, pelvis, -
Headache and Chronic Pain in Primary Care
FAMILY PRACTICE GRAND ROUNDS Headache and Chronic Pain in Primary Care Thomas Greer, MD, MPH, Wayne Katon, MD, Noel Chrisman, PhD, Stephen Butler, MD, Dee Caplan-Tuke, MSW Seattle, W a s h in g t o n R. THOMAS GREER (Assistant Professor, Depart automobile accident while vacationing in another state Dment of Family Medicine): The management of pa and suffered multiple contusions and rib fractures. Oral tients with chronic headaches is difficult and often a source methadone had been prescribed at her second clinic visit of discord between the patient and his or her physician. when other oral narcotics failed to control her pain. She The patient with chronic headaches presented in this con also had a long history of visits for headaches, treated with ference illustrates most of the common problems encoun injections of a narcotic, usually meperidine, and oral co tered in the diagnosis, treatment, and management of pa deine. tients with other kinds of chronic pain as well. As her acute injuries healed and she was tapered off the methadone, her chronic headaches emerged as a signifi cant problem. Within a few months the patient was reg EPIDEMIOLOGY ularly requesting oral codeine for the management of her severe, intractable headaches. More than 40 million Americans consult physicians each In early September she was brought to our emergency year for complaints of headache.1 The National Ambu department by ambulance following an apparent seizure. latory Medical Care Survey, which gathered information Witnesses reported that the patient had “jerking move on approximately 90,000 patient visits to a nationally ments.” There was no incontinence; and the ambulance representative sample of physicians, determined that personnel found the patient to be irritable and disoriented headache was the second most common chronic pain but with stable vital signs. -
Damages for Pain and Suffering
DAMAGES FOR PAIN AND SUFFERING MARCUS L. PLANT* THE SHAPE OF THE LAw GENERALLY It does not require any lengthy exposition to set forth the basic principles relating to the recovery of damages for pain and suffering in personal injury actions in tort. Such damages are a recognized element of the successful plaintiff's award.1 The pain and suffering for which recovery may be had includes that incidental to the injury itself and also 2 such as may be attributable to subsequent surgical or medical treatment. It is not essential that plaintiff specifically allege that he endured pain and suffering as a result of the injuries specified in the pleading, if his injuries stated are of such nature that pain and suffering would normally be a consequence of them.' It would be a rare case, however, in which plaintiff's counsel failed to allege pain and suffering and claim damages therefor. Difficult pleading problems do not seem to be involved. The recovery for pain and suffering is a peculiarly personal element of plaintiff's damages. For this reason it was held in the older cases, in which the husband recovered much of the damages for injury to his wife, that the injured married woman could recover for her own pain and suffering.4 Similarly a minor is permitted to recover for his pain 5 and suffering. No particular amount of pain and suffering or term of duration is required as a basis for recovery. It is only necessary that the sufferer be conscious.6 Accordingly, recovery for pain and suffering is not usually permitted in cases involving instantaneous death." Aside from this, how- ever,. -
Common Myths About the Joint Commission Pain Standards
T H S Y M Common myths about The Joint Commission pain standards Myth No. 1: The Joint Commission endorses pain as a vital sign. The Joint Commission never endorsed pain as a vital sign. Joint Commission standards never stated that pain needs to be treated like a vital sign. The roots of this misconception go back to 1990 (more than a decade before Joint Commission pain standards were released), when pain experts called for pain to be “made visible.” Some organizations tried to achieve this by making pain a vital sign. The only time the standards referenced the fifth vital sign was when examples were provided of how some organizations were assessing patient pain. In 2002, The Joint Commission addressed the problems of the fifth vital sign concept by describing the unintended consequences of this approach to pain management, and described how organizations subsequently modified their processes. Myth No. 2: The Joint Commission requires pain assessment for all patients. The original pain standards, which were applicable to all accreditation programs, stated “Pain is assessed in all patients.” This requirement was eliminated in 2009 from all programs except Behavioral Health Care. It was The Joint Commission thought that these patients were less able to bring up the fact that they were in pain and, therefore, required a more pain standards aggressive approach. The current Behavioral Health Care standard states, “The organization screens all patients • The hospital educates for physical pain.” The current standard for the hospital and other programs states, “The organization assesses and all licensed independent practitioners on assessing manages the patient’s pain.” This allows organizations to set their own policies regarding which patients should and managing pain. -
AAFP Chronic Pain Toolkit
AAFP Chronic Pain Toolkit PAIN ASSESSMENT | Section 1 OVERVIEW Assessment of chronic pain should be multidimensional. Consideration should be given to several domains, including the physiological features of pain and its contributing factors, with physicians and other clinicians assessing patients for function, quality of life, mental health, and emotional health. In addition to a complete medical and medication history typically obtained at an office visit, documentation should be obtained about pain intensity, location, duration, and factors that aggravate or alleviate pain. A physical exam should include musculoskeletal and neurological components, as appropriate. Diagnostic testing and imaging may also be considered for some types of chronic pain. Many organizations, including the AAFP, recommend against imaging for low back pain within the first six weeks of treatment unless there are reasons for the imaging. These reasons may include concerns of underlying conditions, such as severe or progressive neurological deficits, or if osteomyelitis is suspected.1 Periodic reassessments of chronic pain and treatment should focus on evaluating improvements in physical health; mental and emotional health; progress towards functional treatment goals; and effectiveness and tolerability of medications for chronic pain treatment. Currently, there are no universally adopted guidelines or recommendations for assessment of chronic pain. The use of appropriate assessment tools can assist in diagnostic assessment, management, reassessment, and monitoring of treatment effects. Multiple tools are available, with many embedded in electronic health record (EHR) systems. Pain Assessment Tools The table on the next page includes selected tools for pain assessment included in this toolkit, along with links and reference to additional tools. Assessments about other relevant domains are covered in Functional and Other Assessments (Section 2). -
Pain Management in People Who Have OUD; Acute Vs. Chronic Pain
Pain Management in People Who Have OUD; Acute vs. Chronic Pain Developer: Stephen A. Wyatt, DO Medical Director, Addiction Medicine Carolinas HealthCare System Reviewer/Editor: Miriam Komaromy, MD, The ECHO Institute™ This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under contract number HHSH250201600015C. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government. Disclosures Stephen Wyatt has nothing to disclose Objectives • Understand the complexities of treating acute and chronic pain in patients with opioid use disorder (OUD). • Understand the various approaches to treating the OUD patient on an agonist medication for acute or chronic pain. • Understand how acute and chronic pain can be treated when the OUD patient is on an antagonist medication. Speaker Notes: The general Outline of the module is to first address the difficulties surrounding treating pain in the opioid dependent patient. Then to address the ways that patients with pain can be approached on either an agonist of antagonist opioid use disorder treatment. Pain and Substance Use Disorder • Potential for mutual mistrust: – Provider • drug seeking • dependency/intolerance • fear – Patient • lack of empathy • avoidance • fear Speaker Notes: It is the provider that needs to be well educated and skillful in working with this population. Through a better understanding of opioid use disorders as a disease, the prejudice surrounding the encounter with the patient may be reduced. -
Pain Management Assessment and Reassessment
North Shore-LIJ Health System is now Northwell Health System Patient Care Services POLICY TITLE: CLINICAL POLICY AND PROCEDURE Pain Management: Assessment and MANUAL Reassessment POLICY #: PCS.1603 CATEGORY SECTION: System Approval Date: 10/20/16 Effective Date: NEW Site Implementation Date: 12/2/16 Last Reviewed/Revised: NEW Prepared by: Notations: System Nursing Policy and Procedure This policy was created by incorporating the Committee Northwell Health’s Geriatric Guidelines for Pain Management into the Northwell Health’s Pain Management : Assessment and Reassessment Policy dated 11/10 that can be found on the Intranet. GENERAL STATEMENT of PURPOSE To establish a standard for routine assessment, reassessment and documentation of pain as appropriate to the patient’s condition and treatment regimen. POLICY 1. Patients are screened and assessed for pain based upon clinical presentation, services sought, and in accordance with the care, treatment, and services provided. Facility personnel use methods to assess pain that are consistent with the patient’s age, condition, and ability to understand. 2. If the patient reports pain to a health care worker other than a licensed health care provider, the health care worker will escalate the report of pain to a licensed health care provider for assessment. 3. Pain assessment performed by health care providers will address individual, cultural, spiritual, and language differences. Pain measurement scales are available in various languages and, if necessary, access to a medical interpreter will be provided to assist in the evaluation of the patient’s pain. 4. The patient’s self-report of pain is considered the “gold standard.” For those patients who are unable to communicate the health care provider will assess pain by using the appropriate pain Measurement Scale. -
Assessment of Pain
ASSESSMENT OF PAIN Pediatric Pain Resource Nurse Curriculum © 2017 Renee CB Manworren, PhD, APRN, FAAN and Ann & Robert H. Lurie Children’s Hospital of Chicago. All rights reserved. Objectives • Critically evaluate pain assessment tools for reliability, validity, feasibility and utility Table of Contents for communicating pediatric patients’ pain experiences • Formulate processes and policies to ensure the organization’s pain assessment and care planning for pediatric patients is sensitive to children’s pain by acknowledging the sensory, cognitive and affective experience of pain and behavioral responses as influenced by social, cultural, spiritual and regulatory context. • Engage in pain assessment demonstrating evidence-based processes, modeling assessment principles, and using valid and reliable tools that are appropriate for the developmental level, cognitive ability, language, and care needs of pediatric patients cared for in your clinical area. page page page page page 3 8 15 17 30 Why Assess Pain in Principles of Pain Pain Assessment Process Initial Assessment Choosing Pain Children? Assessment Assessment Tools page page page page page 35 48 56 63 66 Pain Assessment Tools Assessment of Those Special Populations In Summary References for Self-report Unable to Self-report | 2 Why Assess Pain in Children? Why do you think it is Type your answer here. important to screen for and assess pain in children? | 4 Because… Assessment and treatment of pain is a fundamental human right. Declaration of Montreal , The International Association for the Study of Pain., 2011 Pain in children occurs across a spectrum of conditions including everyday pains, acute injuries and medical events, recurrent or chronic pain, and pain related to chronic or life-limiting conditions. -
Perioperative Pain Management for the Chronic Pain Patient with Long-Term Opioid Use
1.5 ANCC Contact Hours Perioperative Pain Management for the Chronic Pain Patient With Long-Term Opioid Use Carina Jackman In the United States nearly one in four patients present- patterns of preoperative opioid use. Approximately one ing for surgery reports current opioid use. Many of these in four patients undergoing surgery in the study re- patients suffer from chronic pain disorders and opioid ported preoperative opioid use (23.1% of the 34,186-pa- tolerance or dependence. Opioid tolerance and preexisting tient study population). Opioid use was most common chronic pain disorders present unique challenges in regard in patients undergoing orthopaedic spinal surgery to postoperative pain management. These patients benefi t (65%). This was followed by neurosurgical spinal sur- geries (55.1%). Hydrocodone bitartrate was the most from providers who are not only familiar with multimodal prevalent medication. Tramadol and oxycodone hydro- pain management and skilled in the assessment of acute pain, chloride were also common ( Hilliard et al., 2018 ). but also empathetic to their specifi c struggles. Chronic pain Given this signifi cant population of surgical patients patients often face stigmas surrounding their opioid use, with established opioid use, it is imperative for both and this may lead to underestimation and undertreatment nurses and all other providers to gain an understanding of their pain. This article aims to review the challenges of the complex challenges chronic pain patients intro- presented by these complex patients and provide strate- duce to the postoperative setting. gies for treating acute postoperative pain in opioid-tolerant patients. Defi nitions Common pain terminology as defined by the Chronic Pain and Long-Term International Association for the Study of Pain, a joint Opioid Use consensus statement by the American Society of Addiction Medicine, the American Academy of Pain The burden of chronic pain in the United States is stag- Medicine and the American Pain Society (2001 ), and the gering. -
Mechanical Low Back Pain Joshua Scott Will, DO; David C
Mechanical Low Back Pain Joshua Scott Will, DO; David C. Bury, DO; and John A. Miller, DPT Martin Army Community Hospital, Fort Benning, Georgia Low back pain is usually nonspecific or mechanical. Mechanical low back pain arises intrinsically from the spine, interverte- bral disks, or surrounding soft tissues. Clinical clues, or red flags, may help identify cases of nonmechanical low back pain and prompt further evaluation or imaging. Red flags include progressive motor or sensory loss, new urinary retention or overflow incontinence, history of cancer, recent invasive spinal procedure, and significant trauma relative to age. Imaging on initial presentation should be reserved for when there is suspicion for cauda equina syndrome, malignancy, fracture, or infection. Plain radiography of the lumbar spine is appropriate to assess for fracture and bony abnormality, whereas magnetic resonance imaging is better for identifying the source of neurologic or soft tissue abnormalities. There are multiple treatment modalities for mechanical low back pain, but strong evidence of benefit is often lacking. Moderate evidence supports the use of nonsteroidal anti-inflammatory drugs, opioids, and topiramate in the short-term treatment of mechanical low back pain. There is little or no evidence of benefit for acetamin- ophen, antidepressants (except duloxetine), skeletal muscle relaxants, lidocaine patches, and transcutaneous electrical nerve stimulation in the treatment of chronic low back pain. There is strong evidence for short-term effectiveness and moderate-quality evidence for long-term effectiveness of yoga in the treatment of chronic low back pain. Various spinal manipulative techniques (osteopathic manipulative treatment, spinal manipulative therapy) have shown mixed benefits in the acute and chronic setting. -
Psychosexual Characteristics of Vestibulodynia Couples: Partner Solicitousness and Hostility Are Associated with Pain
418 ORIGINAL RESEARCH—PAIN Psychosexual Characteristics of Vestibulodynia Couples: Partner Solicitousness and Hostility are Associated with Pain Mylène Desrosiers, MA,* Sophie Bergeron, PhD,* Marta Meana, PhD,† Bianca Leclerc, B.Sc.,* Yitzchak M. Binik, PhD,‡ and Samir Khalifé, MD§ *Department of Sexology, Université du Québec à Montréal, Montreal, Quebec, Canada; †Department of Psychology, University of Nevada Las Vegas, Las Vegas, NV, USA; ‡Department of Psychology, McGill University, Montreal, Quebec, Canada; §Jewish General Hospital—Department of Obstetrics and Gynecology, Montreal, Quebec, Canada DOI: 10.1111/j.1743-6109.2007.00705.x ABSTRACT Introduction. Provoked vestibulodynia is a prevalent yet misunderstood women’s sexual health issue. In particular, data concerning relationship characteristics and psychosexual functioning of partners of these women are scarce. Moreover, no research to date has examined the role of the partner in vestibulodynia. Aims. This study aimed to characterize and compare the psychosexual profiles of women with vestibulodynia and their partners, in addition to exploring whether partner-related variables correlated with women’s pain and associ- ated psychosexual functioning. Methods. Forty-three couples in which the woman suffered from vestibulodynia completed self-report question- naires focusing on their sexual functioning, dyadic adjustment, and psychological adjustment. Women were diagnosed using the cotton-swab test during a standardized gynecological examination. They also took part in a structured interview during which they were asked about their pain during intercourse and frequency of intercourse. They also completed a questionnaire about their perceptions of their partners’ responses to the pain. Main Outcome Measures. Dependent measures for both members of the couple included the Sexual History Form, the Locke-Wallace Marital Adjustment Scale and the Brief Symptom Inventory.