Pain: Current Understanding of Assessment, Management, and Treatments

[Pages:101]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 related 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 distributed. 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 addition, 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 Assistant Professor College of Nursing University of Utah Salt Lake City, UT

C. Richard Chapman, PhD Professor and Director Pain Research Center Department of Anesthesiology University of Utah School of Medicine Salt Lake City, UT

Edward C. Covington, MD Director, Chronic Pain Rehabilitation Program Cleveland Clinic Foundation Cleveland, OH

June L. Dahl, PhD Professor of Pharmacology University of Wisconsin Medical School Madison, WI

Jeffrey A. Katz, MD Associate Professor of Anesthesiology Director Pain Clinic VAHCS, Lakeside Division Northwestern University Medical School Chicago, IL

Christine Miaskowski, RN, PhD, FAAN Professor and Chair Department of Physiological Nursing University of California San Francisco, CA

Michael J. McLean, MD, PhD Associate Professor of Neurology and Pharmacology Department of Neurology Vanderbilt University Medical Center Nashville, TN

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

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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 Guidelines Apply to Pain Management? ................................. 75 2. Are Clinicians Adopting and Using Clinical Practice Guidelines?................... 76 B. Standards and Outcome Measures........................................................................... 77 1. JCAHO Standards ............................................................................................... 77 2. Institutional Commitment to Pain Management ............................................... 78

Glossary of Abbreviations and Acronyms ...................................................................... 79

References .................................................................................................................... 82 Section I: Background and Significance ...................................................................... 82 Section II: Assessment of Pain ..................................................................................... 84 Section III: Types of Treatments .................................................................................. 85 Section IV: Management Of Acute Pain And Chronic Noncancer Pain .................. 89 Section V: Strategies to Improve Pain Management................................................... 91

National Pharmaceutical Council

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Section I:

Background and Significance

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