Pain Assessment Lecture PDF

Part 1: Assessment of Pain 1 Ivy Poon, PharmD, MS, BCPS Professor, Pharmacy Practice ([email protected]) Phar 504 Pharmacotherapy in Neurologic & Psychiatric Disorders Fall 2023 2 Learning Objectives Recognize the differences between unidimensional and multidimensional pain assessment Know the...

Part 1: Assessment of Pain 1 Ivy Poon, PharmD, MS, BCPS Professor, Pharmacy Practice ([email protected]) Phar 504 Pharmacotherapy in Neurologic & Psychiatric Disorders Fall 2023 2 Learning Objectives Recognize the differences between unidimensional and multidimensional pain assessment Know the eight elements of pain symptom analysis Conduct a multidimensional pain symptom analysis 3 Pain is defined as … An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in such terms as damage. - International Association of the Study of Pain (IASP 2010) 4 Case Study 1 Mr. M is a 84 years old male presented to clinic for routine follow up. His Past Medical History (PMH) include Type 2 Diabetes X 20 years, Hypertension X 30 years, and shoulder pain onand-off X 2 years. He used to be a mechanic and reported injured his shoulder while fixing his car. 5 Unidimensional Pain Assessment Measure the subjective/patient-reported SEVERITY of pain  Numeric Rating Scale (NRS)  Verbal Descriptor/Rating Scale (VDS)  Baker Wong Faces scale  Visual Analog Scale (VAS) VRS= verbal rating scale 6 Multidimensional Pain Assessment Measures the subjective/patient-reported pain severity, location, sensation, affect, functional status (impact on activities of daily livings) McGill Pain Questionnaire Brief Pain Inventory VHA Pain Management Multidimensional Pain Symptom Analysis 7 P • precipitating/previous therapy Q • Quality R • Region/ radiating S • Severity T • Temporal U • You- associated symptoms 8 P (Precipitating factors) Precipitating •What helps to relieve pain? •What makes it worse? Previous therapy •Medications •Herbal and natural products •Coping strategies 9 Q (Quality) What does the pain feel like? Aching, deep, dull, throbbing, sharp, well localized (somatic nociceptive pain) Diffuse, gnawing, cramping, squeezing, pressure, distant sites (visceral nociceptive pain) Burning, numb, radiating, shooting, stabbing, tingling (neuropathic pain) 10 R (Radiation) Region = location/ Radiating Where does it hurt? Does it spread or radiate to other areas? S (Severity) 11  S=severity  Use a pain scale  How much does it hurt  Now?  At its worst?  At its best?  On average?  Before and after medication?  After exercise? 12  Temporal  Onset  Duration  Frequency  Patterns  Acute, current, or chronic? T (Temporal) 13 You- Associated symptoms  How does the pain affect you?  Work  Activities of daily livings  Mood  Relationships  Sleep  Appetite 14 Pain Assessment can be a challenge, but we have the tools for it! Pediatrics • CRIES, NIPS, FLACC • Read this reference: https://www.mypcnow.org/fastfact/pediatric-pain-assessment-scales/ Geriatrics • PAINAD https://www.mdcalc.com/calc/3701/painassessment-advanced-dementia-scale-painad Non-English speaking • British Pain Society Pain Scale in multiple languages • https://www.britishpainsociety.org/british-painsociety-publications/pain-scales-in-multiplelanguages/ PAT (Spence K, Gillies D, Harrison D, Johnston L, Nagy S. A reliable pain assessment tool for clinical assessment in the neonatal intensive care unit. J Obstet Gynecol Neonatal Nurs. 2005;34(1):80-86. COVERS (O'Sullivan AT, Rowley S, Ellis S, Faasse K, Petrie KJ. The Validity and Clinical Utility of the COVERS Scale and Pain Assessment Tool for Assessing Pain in Neonates Admitted to an Intensive Care Unit. Clin J Pain. 2016;32(1):51-57) 15 Setting a Treatment Goal can have Multiple Dimensions!  Treatment goals should be patient-centered considering what matters the most in their lives  The goal in pain management does not need to be “no pain”, and in many cases, it is not realistic, almost misleading to set a goal of “no pain” for all patients  Individualized pain goal (“I want to reduce my pain to a 4 when driving to Dallas to visit my grandkids.”)  Functional goal (“I want to be able to do gardening.”)  Reduce dependency/tolerance of medications (“I want to stay away from opioid because it makes me sleepy and I can’t focus on writing my journal.”)  Monitor medication-related aberrant behavior  Improve quality of life (“I want to feel well enough to organize my family album for my kids after I die.”) 16 Case Study 1 (Con’t) • Mr. M reports his shoulder pain has been around 2-3 at rest and 6-7 when he moves his shoulder. He uses Tylenol and it reduces his pain to a 4. He also use Diclofenac gel (topical) and not sure how much it is helping. • He loves to fish, but due to the pain, he has not been able to drive to his favorite fishing spot. • He has a referral to see Orthopedics in two weeks. • What are some goals in pain management you can think of? 17 Case Study 2  Mr. A is a 76 years old male calling the clinic for an urgent care visit. He reports his pain from his bad knee is 12 out of 10 and needs to be seen now! When he presents to the clinic, you notice that he is laughing, joking, walking at ease (no sign of limping) without any walking device (cane, rollator, wheelchair). He said, “You better give me some morphine for this pain. It is over the roof.”  What would you suspect? And how would you handle this case? 18 Classifications of Pain Acute Pain Chronic Pain  < 1 month  ≥ 1 month  Commonly has identifiable causes (e.g. trauma, injury, acute illness, labor, surgery, cancer)  Higher risk for dependence and tolerance to drugs  Psychological component (insomnia, depression) Types of Pain 19 Cause Somatic Pain Visceral Pain Tissue damage to skin, Pain in the visceral organs soft tissue, muscle or bone such as gallbladder, intestine, liver (may be accompanied by Neuropathic Pain Injury or inflammation of nerves. Often coexists with somatic or visceral pain. nausea, vomiting or sweating) Descriptors - Aching - Gnawing - Deep - Dull - Sharp, stabbing - Cramping, squeezing Pressure Full, bloated All-Over Gassy Distribution Well localized – patients can often point with one finger to the location of their pain e.g. Bone metastases, decubitus ulcer Referred: - Kidney stone – back pain - Liver capsule – shoulder - Colicky - severe abdominal pain that comes and goes, may come in waves - Bowel obstruction - Gallstone - Burning Electric Numb Radiating, lancing Shooting, stabbing Tingling Hypersensitive skin Radicular: single or multiple nerve roots • Herpes zoster • Sciatica Stocking-glove: • Fingers and toes Diabetic or chemotherapyinduced neuropathy 20 How Analgesics are Used? Based on your multidimensional pain assessment and a review of the patient’s past medical histories, the first step is to identified the type of pain that a patient is experiencing (somatic, visceral, neuropathic). A patient can present with more than one type of pain in different locations. Your treatment plan should address all the pain experienced. Acetaminophen NSAIDS Opioids • Mild to moderate pain • Somatic and visceral • As a single agent or combined with an opioid • Treats fever, headache, muscle, and general pain • Mild to moderate • Somatic and visceral pain • As a single agent or combined with opioid • Treats inflammatory states in musculoskeletal system • Moderate to severe pain as a single agent or combined with APAP or NSAIDS • Effective for somatic, visceral, and neuropathic pain Antiepileptic • Moderate to severe neuropathic pain • Examples: Gabapentin, Pregabalin Antidepressants Others • Moderate to severe pain as a single agent of combined with other synergistic drugs • Treats neuropathic pain and mood disorders • Tricyclic antidepressants and SNRIs • Corticosteroids: for moderate to severe somatic and visceral pain • Example: dexamethasone 21 Case Study Mr. B is a 56 years old male who has been diagnosed with stage 4 lung cancer with bone metastasis. How many TYPES of pain did you find? What class(es) of agents will you expect to prescribe for his pain? My back hurts all the time. It is dull and about 3 at rest, 7 when I get up. The pain has been so much. I can’t sleep, I can’t walk. Honestly, I am getting very depressed. I don’t’ know how long I can live like this or kill myself. My ribs hurt every time I move my arm. It is deep, dull, and achy. About 5 out of 10. In several occasions, I have a shooting pain that go from my leg to toe. It is so painful at night. It is burning, feeling like I have an electric shock. It is 9 out of 10 when this happens.