Podcast
Questions and Answers
What key factor differentiates the treatment approach for acute pain from chronic pain?
What key factor differentiates the treatment approach for acute pain from chronic pain?
Which of the following is NOT a component of a mutually agreed upon pain treatment plan?
Which of the following is NOT a component of a mutually agreed upon pain treatment plan?
In the biopsychosocial model of pain for older adults, which component is primarily focused on the psychological aspect of pain?
In the biopsychosocial model of pain for older adults, which component is primarily focused on the psychological aspect of pain?
What is a major limitation of using standard pain scales for patients with cognitive decline?
What is a major limitation of using standard pain scales for patients with cognitive decline?
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Which class of medications is typically avoided in the treatment of chronic pain due to high potential for abuse?
Which class of medications is typically avoided in the treatment of chronic pain due to high potential for abuse?
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What is the first step in a thoughtful step-wise approach to pain treatment?
What is the first step in a thoughtful step-wise approach to pain treatment?
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Which of the following alternatives to pharmacology could be considered for pain treatment?
Which of the following alternatives to pharmacology could be considered for pain treatment?
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What key benefit do pain assessment tools provide in clinical settings?
What key benefit do pain assessment tools provide in clinical settings?
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What type of contract is essential in managing treatment plans for chronic pain patients?
What type of contract is essential in managing treatment plans for chronic pain patients?
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Why is it essential to establish treatment goals with pain management?
Why is it essential to establish treatment goals with pain management?
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Pain is always easy to diagnose in older adults.
Pain is always easy to diagnose in older adults.
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Study Notes
Geriatrics Module 6: Pain
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Instructional Objectives:
- Differentiate acute vs. chronic pain presentations. Module 3
- Identify various pain scales used in clinical settings. Module 3
- Describe pain treatment plan components, review narcotics contract, and strategies for substance abuse. Module 3
- Detail common non-pharmacological pain treatments. Module 3
- Differentiate acute vs. chronic pain medication classes. Module 3
- Detail narcotic contracts and their importance in chronic pain treatment. Module 3
Roadmap
- Origins and diagnosis of pain
- Cases on diagnosis of pain
- Pain medication, uses, and forms
- Treatment cases
- Narcotic contract
Biopsychosocial Model of Pain (for Older Adults)
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Factors influencing pain:
- Demographics (age, sex, race/ethnicity)
- Health factors (comorbidities, fatigue, sleep)
- Psychosocial factors (depression, anxiety, stress)
- Lifestyle (diet, activity, drug/alcohol use)
- Social factors (support, isolation)
- Ageism, elder abuse
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This model emphasizes the interconnectedness of biological, psychological, and social factors in pain experience.
Determining Pain Type
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Nociceptive:
- Physiologically induced by potentially damaging stimuli.
- Includes visceral and somatic (superficial, deep) pain.
- Characterized by a natural, protective function (transient withdrawal reflex).
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Neuropathic:
- Caused by lesions or dysfunction in the peripheral or central nervous system.
- Characterized by abnormal processing of sensory input.
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Inflammatory:
- Associated with tissue damage and inflammation.
- Often aims to promote healing by preventing contact and movement.
Pain Types (Nociceptive vs. Neuropathic)
| Feature | Nociceptive | Neuropathic |
|---|---|---|
| Definition | Pain caused by physiological activation of pain receptors | Pain initiated by lesions/dysfunction in the peripheral or central nervous system |
| Mechanism | Natural physiological transduction | Ectopic impulse generation, central sensitization |
| Location | Local or referred pain | Confined to innervation territory of the lesioned nervous structure |
| Quality | Ordinary painful sensation | New, strange sensations |
| Treatment | Good response to conventional analgesics | Poor response to conventional analgesics |
Dermatomes
- Useful in differentiating between different types of pain.
- Shows the specific body area affected by each nerve root.
Neuropathic Pain Causes
- Herpes zoster rash: A strong indicator of neuropathic pain. (95% chance).
- Other causes (e.g., broken ankle, dislocated hip, osteoarthritis, vertebral compression) are much less likely to be associated with neuropathic pain.
Pain Scales
- UniVTR (Pain assessment tool)
- Wong-Baker FACIAL GRIMACE SCALE
- Activity Tolerance Scale
- Improved Pain Scale
- Ranges from "It might be an itch" to "Bedrest Required" (1-10)
Assessment with Cognitive Decline
- Assessment of pain in patients with cognitive decline or dementia
- Requires interdisciplinary involvement of all care providers
Mild Acute Pain in Cognitively Impaired Seniors
- Behavioral changes, rather than new onset vomiting, weight loss, slow cognitive deterioration, or constipation, are more typical indicators of pain.
Pain Treatment Considerations
- Non-Pharmacological therapies may be beneficial, but insurance coverage is not always consistent.
- Assess the specific type and severity of pain to determine the most appropriate treatment strategy.
- Individualize pharmacological strategies based on need (mild vs. severe)
Opioid Treatment and Management
- Before starting/periodically during opioid therapy: Discuss realistic benefits and management strategies
- If starting opioids:
- Use immediate-release formulations.
- Start at the lowest effective dose.
- Assess acute pain (<3 days) differently than chronic pain
- Re-evaluate within 1-4 weeks to adjust treatment.
- Monitor risks for reducing risk (Review PMP and UDM).
- Avoid concurrent benzodiazepines.
- Consider alternatives if opioid use disorder exists.
Narcotic Tolerance
- Opioids can exhibit diminished effectiveness over time due to tolerance.
Alternative Therapies
- Often effective, but insurance coverage can vary. Examples may include massage, heat therapy, acupuncture, etc.
Pain Medication Forms
- Severe pain: Long-acting opioids (e.g., transdermal fentanyl, morphine SR, oxycodone SR).
- Moderate pain: Short-acting opioids (e.g., codeine, hydrocodone, oxycodone).
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Mild pain: Non-opioid medications (e.g., acetaminophen, NSAIDs, tramadol, COX-2 inhibitors, salicylates).
- Adjunctive medications often helpful for various types of pain.
Adjuvants for Neuropathic Pain
- Antidepressants are more likely to be helpful in treating neuropathic pain syndromes.
Time-to-Effect of Pain Medication Routes
- Different administration routes affect pain relief times differently.
Pharmacokinetic Considerations (Aging)
- Aging affects drug absorption, distribution, metabolism, and elimination.
- Understanding these pharmacokinetic changes is important for appropriate dosages.
Case Study 1 - Judith (Osteoarthritis)
- Patient presents with osteoarthritis, mild morning hands and knees pain (4/10)
- Possible treatments include: non-pharmacological strategies and non-opioid medication.
Case Study 2 - Sheila (Hip Fracture)
- Patient presenting with constant, deep, achy hip pain (8/10) following a hip fracture.
- Treatment considerations include strong pain management options (potentially including opioids), physical therapy.
Case Study 3 - George (Diabetes and Burning Pain)
- Patient with diabetes experiencing burning pain in feet (6/10), affecting sleep.
- Treatment depends on further diagnosis and assessment.
Case Study 4 - Carol (Overweight, Sedentary, Depressed)
- Patient with generalized body pain (6/10) with a sedentary lifestyle and depression.
- Treatments may include non-pharmacological choices and non-opioid options.
Narcotic Contracts
- Required for long-term narcotic prescriptions
- Review and chart updates every three months to monitor treatment and patient needs.
- Includes review of pain diagnosis, alternative treatments attempted, potential for substance abuse, co-existing medical conditions, pain treatment plan (including PT, injections, topicals, etc.)
- Importance of discussing the risks and benefits of narcotics
Opioid Verification
- UDM documentation is required every six months for patients receiving narcotics..
Patients Exempted from Contracts
- Patients who fill less than 90 opioid tablets per 90 days
- Patients using stimulants/benzodiazepines/hypnotics (still require UDM).
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Description
This quiz covers essential concepts in pain management specific to geriatrics. It focuses on differentiating acute and chronic pain, various pain scales, and treatment plans. Additionally, it explores non-pharmacological treatments and the significance of narcotic contracts in managing chronic pain.
