Managing and Controlling Clinical Pain PDF

CHAPTER 12 MANAGING AND CONTROLLING CLINICAL PAIN CHAPTER OUTLINE I. Clinical Pain A. Section introduction 1. Definition of clinical pain - any pain that requires or receives professional attention 2. Why treat clinical pain...

CHAPTER 12 MANAGING AND CONTROLLING CLINICAL PAIN CHAPTER OUTLINE I. Clinical Pain A. Section introduction 1. Definition of clinical pain - any pain that requires or receives professional attention 2. Why treat clinical pain a. deserves treatment in and of itself, not just because it may be a symptom of some progressive disease b. humanitarian reasons c. treatment produces medical and psychosocial benefits for patient B. Acute clinical pain 1. Most acute pain has little survival value. 2. Many surgical patients experience higher-than-necessary pain. a. American Pain Society recommends assessing pain intensity and satisfaction with pain relief after surgery - a 1/3 change in pain ratings probably meaningful pain relief for patients b. unnecessary post-surgical pain may lead to adverse physiological changes which can lead to death C. Chronic clinical pain 1. The realization that pain is chronic frequently leads to helplessness. a. neurotic triad dominates personalities and parallels changes in lifestyles, employment status, and family lives b. half of chronic pain patients reportedly consider suicide c. long-term psychosocial problems and impaired interrelationships can emerge 2. Characteristics of chronic pain syndrome a. symptoms i. tissue damage or irritation ii. persistent pain complaints and pain behaviors iii. disrupted daily activity patterns iv. disrupted social, marital, employment, and recreational activities v. excessive use of drugs or repeated surgery vi. disturbed sleep patterns vii. increased anxiety or depression b. usually first two symptoms plus one of remaining symptoms are demonstrated c. more symptoms patient has, greater impact pain has and greater maladjustment it produces 3. Accurate distinction between acute and chronic pain needs to be made to insure that appropriate pain relief techniques are used. II. Medical Treatments for Pain A. Section introduction 1. Early treatments for pain relief included piercings with a “vigorous” twig, alcohol and medicines laced with opium B. Surgical methods for treating pain 1. Surgery represents a radical approach to treating chronic pain. a. early surgical procedures involved removing or disconnecting parts of the peripheral nervous system or spinal cord to prevent pain i. pain relief didn't last ii. this procedure rarely used today due to possibility of paralysis b. current surgical procedures i. types of procedures - synovectomy - removal of inflamed membranes in arthritic joints - spinal fusion - joins two or more vertebrae to treat severe back pain ii. little evidence these procedures are more effective in long term than non-surgical methods iii. such procedures most appropriate when person is severely disabled and nonsurgical treatments have failed C. Chemical methods for treating pain 1. Section introduction 2. Types of pain-relieving chemicals a. peripherally acting analgesics i. act by inhibiting synthesis of neurochemicals that sensitize nociceptors to algogenic substance at site of damage. ii. examples - aspirin, acetaminophen, ibuprofen. b. centrally acting analgesics i. narcotics that bind to opiate receptors in CNS and inhibit nociceptor transmission or alter perception of pain stimuli. ii. examples - morphine, codeine, Percodan, Demerol. iii. medical concerns about tolerance and addiction over long term use. c. local anesthetics i. block nerve cells in region from generating impulses. ii. examples - novocaine, lidocaine, bupivacaine. iii. long term use not recommended due to side effects.  d. indirectly acting drugs i. drugs that affect nonpain conditions that produce or contribute to pain. ii. examples - sedatives, tranquilizers, antidepressants 3. Using chemicals for acute pain a. factors that influence administration of medications i. intensity, location, and cause of pain ii. physicians administer drugs based on characteristics of drug, patient and sociocultural factors b. half of all patients are undermedicated i. children and minorities frequently undermedicated ii. reasons - - physician beliefs about child's pain perception - physician concerns about addiction - patient not asking for meds c. conventional methods for administering pain medications i. pills or injections - administered on a prescribed schedule or as needed (PRN) ii. epidural block - injection near the spinal cord iii. patient-controlled analgesia - although physicians have been concerned about abuse potential, patients actually decrease medication when given control - caution should be used with young, high anxiety, low social support patients 4. Using chemicals for chronic pain a. narcotics are used for severe pain in terminal illness. i. patients still tend to be inadequately medicated ii. patients may fear addiction and want to be "good" patient iii. narcotics in low doses can provide effective pain relief without progressively larger doses b. increasing use of narcotics approached with caution. i. findings on low dose relationship with addiction need to be confirmed with various types of patients and pain conditions ii. some people are still at high risk for addiction iii. studies are needed to see how daily doses of narcotics affects patients' lives iv. research needs to discover why tolerance and addiction are less likely when taken for pain relief c. chemical methods alone are not enough for controlling pain i. three psychosocial findings that suggest need for other approaches  - chronic headache patients use maladaptive coping strategies to deal with stressors - arthritis patients with feelings of helplessness before drug treatment report poor treatment results - patients who receive placebo drugs report pain relief 5. Collaborating with other professionals a. team approach may involve physicians, psychologists, and other health professionals. i. patient may be reluctant to accept psychologist's role because interpret it as sign of that physician believes pain isn’t real - physician needs to reassure patient regarding roles of other team members b. role of pain groups i. team members also likely to experience similar problems, provide support for talking about them, can say things to patients that others may not be able to, and can confront patient’s “pain games” c. goals of treatment i. goals include: - reducing frequency and intensity of pain - improving patient’s emotional adjustment - increasing social and physical activity - reducing use of analgesic drugs III. Behavioral and Cognitive Methods for Treating Pain A. Section introduction 1. Impact of gate-control theory on concept of pain and treatment a. theory argued biochemical, motivational, and cognitive processes affect the pain experience i. health care workers have begun to change how they conceptualize and treat pain b. psychological techniques help patients to: i. cope more effectively with pain ii. reduce their reliance on drugs B. The operant approach 1. Initial chapter example involved extinction for pain behaviors and reinforcement for appropriate behavior 2. Operant approach can be used with people from all age groups, in a variety of settings, and both before and after pain has produced difficulty for person. 3. Main goals in operant approaches a. reduce need for medication i. medications are put on fixed administration schedule that receiving meds independent of requests for meds b. reduce disability that accompanies pain conditions i. train people in social environment to monitor and record pain behaviors and reward physical activity 4. Effectiveness of operant techniques  a. has been shown to increase activity and decrease use of drugs b. limitations i. when rewards are discontinued, patients have a tendency to revert to old pain behaviors ii. not all chronic pain patients benefit from operant techniques iii. effectiveness is low if patient or others in social environment unwilling to cooperate or if receiving disability benefits C. Fear reduction, relaxation, and biofeedback 1. Fear and stress are identified as triggers for pain a. if fear and stress can be controlled, should be able to reduce pain 2. Fear reduction a. fear leads to avoidance of certain activities, resulting in negative reinforcement b. negative reinforcement makes fear persist c. systematic desensitization helps reduce fears 3. Relaxation and biofeedback a. stress has been thought to trigger migraine and tension-type headaches by dilating arteries/contracting muscles - recent research has found that nervous system dysfunction is involved in these types of headache 4. Progressive muscle relaxation involves focusing attention to specific muscle groups while tensing and relaxing muscles. 5. Biofeedback involves EMG feedback of muscle tension or temperature feedback. 6. Both procedures appear effective in relieving pain. a. clarification to this conclusion i. majority of studies have been done on headache pain ii. although both methods about equally effective with headache pain, EMG biofeedback somewhat more effective - great deal of variability in range of improvements (17-94%). iii. other psychological factors play a role in pain reduction - placebo conditions more effective than simply monitoring headache pain - massage therapy over time can reduce pain - explanation: patient’s thoughts, beliefs, and spontaneous cognitive strategies probably contribute to success of relaxation and biofeedback 7. Durability of effects of relaxation and biofeedback techniques for pain a. Blanchard and colleagues found significant reduction in headache pain in a 5 year longitudinal study. i. these methods don’t provide all pain relief most patients need D. Cognitive methods 1. Section introduction a. thoughts during acute pain i. in one study, 80% of subjects focus on negative emotions and pain - focusing on negative aspects of experience is linked to increased pain b. thoughts during chronic pain i. some people use active coping such as ignoring pain or engaging in interesting activity ii. other people use passive coping, which leads to vicious cycle of learned helplessness and more passivity c. family and friends influence and reinforce coping behaviors d. beliefs about pain influence coping behaviors i. active coping occurs more in those who understand the nature of their pain and believe their condition will improve ii. practitioners need to know and address patients' beliefs 2. Distraction involves focusing on non-painful stimuli in the environment to divert attention. a. technique is most effective with mild or moderate pain b. aspects of task that affects its effectiveness i. amount of attention the task requires ii. if the task is interesting or engrossing iii. the task is viewed as a credible activity to relieve pain 3. Nonpain (guided) imagery involves imagining a mental scene unrelated to or incompatible with the pain for as long as possible a. therapist guides patient to include aspects of different senses in image i. most common images are pleasant b. difference between imagery and distraction i. imagery is based on imagination whereas distraction is focus on real objects in environment c. factors that influence effectiveness i. best when it attracts significant attention and is involving ii. most useful for mild to moderate pain iii. some individuals not adept at imaging scenes 4. Redefinition involves substituting constructive or realistic thoughts for those that arouse feelings of threat or harm. b. varieties of redefinition i. coping statements that emphasize ability to tolerate discomfort ii. reinterpretive statements that negate unpleasant aspects of discomfort iii. information about sensations to expect iv. deconstructing illogical beliefs 5. Value of cognitive strategies in controlling pain a. effectiveness with acute pain. i. distraction and imagery are effective with mild/moderate  pain ii. redefinition is effective with strong pain b. effectiveness with chronic pain i. effectiveness depends on severity of pain, type of illness, cognitive methods used - redefinition found to be more effective in relieving chronic pain than distraction in studies on arthritis, amputation, and spinal cord injury ii. programs combining behavioral and cognitive methods as effective as chemical methods in reducing pain IV. Hypnosis and Interpersonal Therapy A. Hypnosis as a treatment for pain 1. Section introduction a. section introduction i. in 1800s, dramatic stories about surgery using only hypnosis as analgesia captured attention 2. Can hypnosis eliminate acute pain? a. surgical patients claim not to feel pain under hypnosis i. presence of pain behaviors suggested that pain was being suppressed - intensity of acute pain was probably reduced ii. hypnosis not effective for all people - people vary in susceptibility to being hypnotized 3. Possible mechanisms responsible for pain reduction effect of hypnosis a. physiological changes in brain and spinal cord b. deep relaxation c. cognitive factors that produce increased attention to internal images 4. In laboratory research, Barber (1982) found a. suggestible people receive the greatest pain relief b. regardless of whether hypnotized or not, subjects who were told to try not to feel pain used distraction and redefinition c. pain reduction from hypnosis equal to that obtained with cognitive strategies 5. Can hypnosis relieve chronic pain? a. hypnosis reduces chronic pain i. studies on recurrent headache, low back pain, cancer pain find hypnosis as effective as relaxation ii. pain relief greatest in those people high is suggestibility - what is it about high suggestibility that helps people apply psychological methods to control pain? B. Interpersonal therapy for pain 1. Description: a therapy approach that uses psychoanalytic and cognitive-behavioral perspectives to help people deal with emotional difficulties by changing the way they interact with and perceive their social environment. a. purpose of insight therapy  i. discover underlying motivations for problems - awareness of motivations may lead to controlling behaviors and emotions. - showing how pain behaviors are part of "pain games" that maintain identity as "suffering person". 2. Patients and families can come to understand problems in the family system. a. areas explored may be changes in roles, communication, sexual relationship b. benefits include new perspective and increased cooperation c. useful in treating depression that is common in pain patients V. Physical and Stimulation Therapies for Pain A. Section introduction 1. Counter-irritation a. involves concept of reducing one pain by creating another b. historical example i. cupping - placing heated glass cup on skin to produce bruise c. practice forms basis for present-day stimulation techniques B. Stimulation therapies 1. Why counter-irritation works a. distraction from stronger pain to milder pain b. gate-control theory suggests mildly irritating stimuli closes pain gate i. led to the development of transcutaneous electrical nerve stimulation (TENS) in which an electrode is placed on the skin near pain area and a mild electrical current is supplied - success of treatment has been largely anecdotal - generally viewed as not effective for acute or chronic pain and, in those cases where it is successful, effects are short-lived 3. Acupuncture – ancient Chinese technique in which needles inserted into special locations and twirled or electrically charged a. effectiveness is limited i. rarely effective for surgical patients in Western cultures ii. produces only mild analgesia in most people iii. degree of analgesia depends not on location of needle but intensity of stimulation iv. patients who can be easily and deeply hypnotized receive most benefit. v. evidence that procedure may be useful for headache or low back pain. c. Why acupuncture works i. since procedure produces analgesia in some animals, must rule out suggestion or distraction as cause ii. plausible explanations include closing of pain gates or release of opioids  C. Physical therapy 1. Treatment involves a variety of techniques to enhance muscular strength and tissue flexibility. a. exercise is common feature of program. 2. Programs, tailored to patient’s needs, are planned between physical therapist and patient. a. paced to increase sense of accomplishment without overexertion, reinjury or failure b. widely used for arthritis and low back pain 3. Research findings comparing physical therapy and cognitive - behavioral approach i. both approaches result in pain reduction and improvements specific to program used - physical therapy is linked to improved physical functioning and cognitive-behavioral to improved psychosocial functioning. ii. chronic pain patients might benefit from receiving both treatments in combination VI. Pain Clinics A. Section introduction 1. Pain clinics, or pain centers, provide effective pain control treatments. a. program organization and treatment options vary across centers B. Multidisciplinary programs 1. Intervention methods include medical, psychosocial, physical therapy, occupational therapy and vocational elements in both assessment and treatment. 2. Typical program goals a. reducing pain b. improving functioning c. decreasing drug usage d. enhancing social factors e. reducing use of medical services 3. Services are integrated to achieve specific goals. C. Evaluating the success of pain clinics 1. Procedures and results of treatment programs at two pain centers. a. common procedures for programs i. program conducted by hospital-affiliated pain clinic ii. treatment provided on inpatient basis for 4 weeks with weekends off iii. group treatment with variety of treatment techniques iv. staff provided medical, psychological, physical, and occupational therapy v. program included medication reduction procedure, physical therapy, relaxation and biofeedback training, cognitive-behavioral group therapy, family involvement and therapy plus other methods  b. results from first program i. assessment at beginning and end of program as well as a 6- and 12-month follow-up ii. at end of program, activity levels had increased and pain experiences and behaviors as well as drug use had decreased iii. at follow-up, activity levels remained high, 1/2 were employed, and pain had continued to decrease c. results from second program i. study design included experimental and control groups ii. at follow-up, treatment group reported less pain, depression, and interference of pain in lives; less use of medications; higher rate of employment 2. Meta-analyses of studies on multidisciplinary treatment for chronic pain a. less pain and more likely to have returned to work b. treatment costs only a fraction of medical and disability payments c. reduction in helplessness and catastrophizing during treatment program led to decreases in pain severity and anxiety d. not all patients benefit from this kind of treatment but most do