What do people know about pain isapm 2015 - dr. Mary S

Do People Know

About Pain and Its

Management?

Dr Mary Suma Cardosa

Selayang Hospital,

Selangor, Malaysia

Outline

• What do people need to know about pain?

– Pain relief as a human right

– Effects of unrelieved pain

– Differences between acute and chronic pain

• What do people really know about pain?

– Healthcare providers

– Patients

• How do we address the gaps?

Outline







– Patients

• How do we address the gaps in

knowledge and attitude?

2004

―We all must die. But that I can save

him days of torture, that is what I feel

is my great and ever new privilege.

Pain is a more terrible lord of

mankind than even death itself.‖

Albert Schweitzer

2010

Outline







– Patients



Adverse effects of

severe acute pain

CVS

Increased sympathetic

activity

Myocardial O2 demand

MI

RS

Splinting shallow

breathing

Atelactasis hypoxaemia hypercarbia

Pneumonia

GI

Impairs GI motility

Constipation

Delays recovery

General & MSK

Increased catabolic demands

Poor wound healing and

muscle weakness

Weakness &impaired

rehabilitation

Psychologi-cal

Anxiety and fear

Sleepless ness &

helplessness

Psychologi-cal stress

Neuro-plasticity

Peripheral sensitization

Central sensitization

P5VS: Doctors’ training module Chronic pain

Worldwide Impact Of Chronic

Pain

Gujere O, et al. 1998

Depression Poor health Work

impaired

Activity

limited

Chronic pain

No pain

0

20

30

50

10

Primary care attendees (%)

40

WHO Collaborative Study of Psychological Problems in General Health

Pain Interference with Daily Activities

18.6

39.4

25.3

9.6

7.2

0 10 20 30 40 50

Not at all

A little

Moderate

Quite a lot

Extreme

3rd National Health and Morbidity Survey, Malaysia, 2006

Impact of chronic pain on daily activities

Breivik H, et al. Eur J Pain 2006;10:287–333.

Outline







– Patients



NOT ALL PAIN IS THE SAME!

Cancer pain

Pain

Chronic pain Acute pain

Nociceptive pain

Neuropathic pain

Widespread pain

Non-Cancer pain

Acute Vs Chronic Pain

ACUTE PAIN

• Physiological

– Normal nociceptor

response

• Protective

• Pain = damage

• Diminishes when

healing takes place

CHRONIC PAIN

• Pathological

– Changes at periph, sp

cord and brain

• Not protective

• Pain damage

• Healing period over

but pain persists

Chronic pain as a Disease

Chronic pain

SYMPTOM

DISEASE

Pain What the patient says hurts.

What must be treated.

Injury

Other illnesses

Coping strategies

Social factors e.g. family, work

Biopsychosocial model

Nociception is not the same as pain!

Modified from Analgesic Expert Group. Therapeutic Guidelines 2007

Beliefs/concerns about pain

Psychol. factors anxiety/anger/depression

Cultural issues Language, expectations

WHAT HAPPENS WHEN PAIN

BECOMES CHRONIC?

Sensitization

- Periphery

- central

WHAT HAPPENS

WHEN PAIN

SIGNALS GO ON

FOR A LONG

TIME?

Pain

PAIN IS NO LONGER A

SIGNAL OF DAMAGE

Chronic pain

TISSUE

DAMAGE

―WRONG

SIGNAL‖

HOW DO WE MANAGE THE

DIFFERENT TYPES OF PAIN?

TRADITIONAL /

COMPLEMENTARY

MEDICINE

MULTIDISCIPLINARY MANAGEMENT OF PAIN

PAIN

MEDICATIONS

PSYCHOLOGICAL

METHODS

SURGERY

ASSESSMENT PHYSIOTHERAPY

Occupational

therapy

Functional improvement

Quality of Life

INTERVENTIONS

(INJECTIONS) PAIN

PERSON

WITH

PAIN

ACUTE

PAIN


PSYCHOLOGY


(passive)

Occupational

therapy

Functional improvement

INTERVENTIONS

(INJECTIONS)

Traditional

medicine SURGERY

PAIN

MEDICATIONS

MULTIDISCIPLINARY MANAGEMENT

PAIN

MEDICATIONS

PSYCHOLOGICAL

THERAPY

SURGERY


Occupational

therapy

IMPROVEMENT IN

QUALITY OF LIFE

TRADITIONAL /

COMPLEENTARY

MEDICINE

INTERVENTIONS

(INJECTIONS)

CANCER

PAIN


PAIN

MEDICATIONS

SURGERY


(active)

Occupational

therapy

LONG TERM improvement

-Function and Quality of Life

INTERVENTIONS

CHRONIC

PAIN TRADITIONAL /

COMPLEENTARY

MEDICINE

PSYCHOLOGICAL

METHODS

Treatment:

Acute Vs Chronic Pain

ACUTE PAIN

• Analgesics, rest

appropriate

– Short term: not required

when healing complete

– Main goal is pain relief

– Function usually

restored back to normal

after healing

• Responsibility more on

healthcare provider

(patient has a more

passive role)

CHRONIC PAIN

• Analgesics, rest not appropriate – Pain will persist

– Problems of long term drug use / disability

– Goal of treatment is to IMPROVE FUNCTION, not just to provide pain relief

• Responsibility is more on the patient (active role)

Outline







– Patients



• Survey of attitude and knowledge of

healthcare providers on Pain as the 5th

Vital Sign in Malaysian Ministry of Health

Hospitals, 2012

Access to Pain Treatment as a Human Right

“Please, do not make us suffer

anymore…….”

http://www.hrw.org/en/reports/2 In this 47-page report Human Rights Watch said

that countries could significantly improve access to pain medications by

addressing the causes of their poor availability. These often include the failure to

put in place functioning supply and distribution systems; absence of government

policies to ensure their availability; insufficient instruction for healthcare workers;

excessively strict drug-control regulations; and fear of legal sanctions among

healthcare workers. 009/03/02/please-do-not-make-us-suffer-any-more

http://www.hrw.org/en/reports/2

http://www.hrw.org/sites/default/files/reports/health1009webwcover.pdf

Prevalence and correlates of pain in the Canadian National Palliative

Care Survey

Wilson, et al., Pain Res. Manag. 2009;14:365-70

• 70% had pain of any intensity

• 33.9% reported moderate to severe pain

Cancer-related pain: A pan-European Survey of

prevalence, treatment and patient attitudes Breivik H, et al. Ann Oncol. 2009;8:1420-33

5084 patients studied

--56% suffered moderate to severe pain

573 patients studied – 77% receiving prescription-only analgesics

– 40% taking strong opioids alone or with other combinations

– 63% experienced breakthrough pain

– 69% reported pain-related difficulties with everyday activities

Undertreatment of Cancer Pain

in United States

2011 : Medical oncology outpatient

survey:

67% reported pain, 33% received

inadequate prescribing

2011: Medical Oncologists survey:

Response to two vignettes: 60% and

80% responded inadequately

Fibromyalgia: SE Asia FACTS study

Fibromyalgia is a debilitating chronic pain

condition and has a negative impact on patients'

quality of life

Patients with fibromyalgia report serious financial

consequences from the condition, including an

inability to work

It often takes a long time and many physicians for

patients to receive an accurate diagnosis of

fibromyalgia

There is a potential need for more training of

physicians for them to recognize and effectively

treat fibromyalgia

More understanding and awareness of

fibromyalgia is needed for early detection and

treatment

Marker Research Survey of 506 physicians & 941 pts, in 5 SEA countries (2009)

Findings Courtesy of Pfizer

Hospital Selayang

Phenomenological study of chronic pain

patients

• Impact of chronic pain on self

– Loss of health

• Pain interference with usual activities

• Feeling of being worn out and sickly

– Loss of independence & control

– Isolation

– Depression

– Loss of self worth

Anna Wong SM, Masters Thesis 2014

Hospital Selayang


patients

• Impact of chronic pain on others

– Family

• Pain binds families together –help from family members

• Pain causes worries in caregivers (and guilt in patient)

• Lack of understanding

• Dependence

• Change in roles


• Lack of effective communication by some, good

communication by others

• Doctors’ disbelief; Inaccurate diagnosis

• Kind doctors / nurses

• Self-management skills


Hospital Selayang


patients

What helps them to cope?

•Social support, acceptance and understanding

– Family, friends, co-workers, employers, HCP

•Understanding and accepting their pain

– Clear explanation by HCP

•Physical therapy

•Psychological techniques

– ―positive thinking‖

•Spirituality


COMPETING MINDSETS IN COPING WITH CHRONIC PAIN

AMONG FILIPINO OLDER PERSONS A PHENOMENOLOGICAL INQUIRY

Calimag MMP1,2,3, Calimag AP3, Ang JM3, De Mesa M3, Mandapat J3, Ong A3 1Research Cluster for Culture, Education, and Social Issues, 2Research Center for the Health Sciences,

3UST Faculty of Medicine and Surgery; University of Santo Tomas, Philippines

Background: The older person belongs to a very vulnerable population, deprived of voice…not

just the physical voice but most importantly, the metaphorical voice as well. There are various forms

of suffering that come with age. Advancing age is associated with a higher prevalence of pain, and

although people older than 60 years old are more likely to experience chronic pain symptoms than

younger adults are, they are less likely to obtain pain relief in response to therapy (Rouff 2002). It is

not only the physical aches and pains but the fear, the loss of control, the sense of helplessness,

mental anguish and the dread of impending death. The culture of the health practitioner is often one

that denies the reality of sickness and death. Medicine glorifies youth and health, often shoving the

older persons and their sufferings to the sidelines…a patient’s identity reduced to a particular

physical ailment.

Purpose: This phenomenological inquiry explores the personal meaning

of chronic pain in the older person relative to the central question: What

competing mindsets do Filipino elderly patients portray in collectively

characterizing their lived experience of chronic pain.

Method: The chronic illness experiences of a purposive sample of

six older pain patients were evoked through semi-structured

interviews to identify how they respond and cope with their

chronic pain.

Results: Using Colaizzi's (1978) descriptive

phenomenologic methodology, the competing

mindsets evolved were clustered into three central

themes: HAND to seclude or to secure whereby

patients either choose to suffer their pain alone or

seek the help of physicians and significant others;

HEAD to suffer or to supplicate whereby patients

either choose to physically endure or to lift up their

condition through prayers; and HEART to succumb

or to surmount whereby patients either choose to

exhibit hopelessness or to overcome the pain

experience.

Conclusion: In this study the ambiguous nature of the boundaries of

authority and responsibility in medicine is explored by discussing two

competing mindsets as older patients respond to long-term ramifications

of chronic pain. Rather than interpret the illness process as a dichotomy

between medical control and patient autonomy, this study presents some

assumptions about the boundaries of medical authority that are held by

patients and practitioners alike. Dilemmas that patients face following a

chronic pain experience are responses to medicine's limits and scope as

well as reflections of medicine's goals and values. As Kauffman (2009)

avers, phenomenological studies of existential responses to illness are

necessary in order to understand cultural sources of unmet expectations

resulting from chronic conditions.

HAND

TO SECLUDE OR TO SECURE “Never mind, I just keep the pain and hurt to myself ”

versus

“I trust my doctor to tell me the truth about my pain”

HEAD TO SUFFER OR TO SUPPLICATE

“I do not know if I can endure this much longer”

versus

“…I just pray, I want to do penance for my sins, I know

that the Lord will give me strength”

HEART

TO SUCCUMB OR TO SURMOUNT “I would rather die than suffer this pain”

versus

“I will be strong and overcome my feelings of depression”














physical ailment.








chronic pain.












experience.













HAND


versus




versus



HEART


versus















physical ailment.








chronic pain.












experience.













HAND


versus




versus



HEART


versus















physical ailment.








chronic pain.












experience.













HAND


versus




versus



HEART


versus















physical ailment.








chronic pain.












experience.













HAND


versus




versus



HEART


versus


(71.6) 239 276

174

186

193 216

157 169 153

168

213 235

170 191

17 17

81

109

60 78

97 121 102

126

40 58

81 102

40%

50%

60%

70%

80%

90%

100%

P5VS ✔ P5VS ✖ P5VS ✔ P5VS ✖ P5VS ✔ P5VS ✖ P5VS ✔ P5VS ✖ P5VS ✔ P5VS ✖ P5VS ✔ P5VS ✖ P5VS ✔ P5VS ✖

Pain assessmentshould be doneon admission

We should notgive patients too

much painmedicine

because there isa high risk of

addiction

Pain assessmentshould only bedone when the

patientscomplains of pain

If pain relief isgiven to the

patient regularlyit may mask the

signs ofcomplications or

worseningdisease

Analgesicsshould only be

given to patientswhen they

complain of pain

A patient whokeeps asking foranalgesia mustbe addicted to

the painmedication

Patient shouldonly be startedon morphinewhen painbecomes

unbearable

Correct

Wrong

Slide courtesy of Dr Richard Lim

1. We try really hard to look good.

Tea Lynn Moore

http://www.thepainrelieffoundation.com/patient-perspectives/want-you-to-know/

At times we hurt so much

and are tired from trying

to play healthy that we

feel like laying down right

then and there

16 Things People in Chronic

Pain Want You to Know 1. We try really hard to look good.

2. It’s not all in our heads.

Tea Lynn Moore





3. We are not making a mountain out a of

molehill.

Tea Lynn Moore






molehill.

4. No matter how long we’ve been suffering for, it

still hurts.

Tea Lynn Moore






molehill.


still hurts.

5. Sometimes we just don’t have the spoons. ―Spoon theory‖

when you have a chronic condition you wake up each day with a

certain number of spoons. Every time you exert effort — by getting

out of bed, cleaning, getting dressed — you lose a spoon. When

you run out of spoons, that’s it, the day’s activities are done

Tea Lynn Moore






molehill.


still hurts.

5. Sometimes we just don’t have the spoons.

6. We’re not lazy - In fact, we often have to work

twice as hard to accomplish the tasks that most

people do easily.

Tea Lynn Moore



Pain Want You to Know 7. If we don’t have a job it’s for a reason

8. It’s really hard to get out of bed in the morning…

and always!

Tea Lynn Moore





and always!

9.Every minute feels like an eternity when waiting.

10.We are not ignoring you.

- Pain can be very distracting and mentally draining. We try

our best to stay sharp and attentive but if we seem not to

fully be there please don’t take it personally.

Tea Lynn Moore





and always!

9.Every minute feels like an eternity when waiting

10.We are not ignoring you

11. We get REALLY excited when we have a good

day

12.And get really bummed when we have a bad

day and can’t do the things we love

Tea Lynn Moore



Pain Want You to Know 13.It can be hard to find a good doctor

14.We are not drug seekers - We are pain

relief seekers.

15. You don’t need to give us suggestions or

medical advice

16. All we really need is your love and

support.

Tea Lynn Moore


Outline







– Patients

• How do we address the gaps?

Education

Research and

Implementation

Medicine

Availability

WHO Public Health Model

Policy C

o

n

t

e

x

t

O

u

t

c

o

m

e

s

US Efforts to Improve Cancer Pain

• 2011 IOM Report: Relieving Pain in America

• 2013 Development of a National Pain Strategy

• Funding to the NIH Pain Consortium

• 2014 IOM Report Dying in America

US Efforts to Improve Cancer

Pain

PAINS Alliance of Pain groups to

improve pain care for all

ACS Quality of Life Initiative

Achieving Balance in State Pain Policy

Report Cards PPSG University of

Wisconsin

Pain Treatment and Right to Health

• Opioids are essential medicines and countries

need to provide them as a core obligation under

the right to health

• States must put in place an effective

procurement and distribution system

• Create a legal and regulatory framework

• Allow health care professionals to prescribe and

dispense

• Drugs do not have to be free but affordable

UN and WHO Resolutions

2010 WHA Resolution on Cancer included

palliative care

2012 UN Resolution on Universal Health Care

2012 WHA Resolution on Non-Communicable

Diseases (NCD”s) includes palliative care

2014 WHA Resolution on Palliative Care

61

World Health Organization

Resolution 2014

Patient in South India presenting at a palliative care clinic

Patient after a dose of morphine sitting up and enjoying tea

Chronic

pain

Reduced

activity

Unhelpful

thoughts &

beliefs

Repeated

treatment

failures

Long term

analgesics /

sedatives

Loss of job,

financial &

family stress

Excessive

suffering

Feelings of

depression,

helplessness,

irritability

S/E of drugs

e.g. constipation,

lethargy, gastric

ulcers

Physical deterioration

e.g. ms wasting, joint

stiffness

OVERVIEW OF PROBLEMS CAUSED BY CHRONIC PAIN

Chronic

pain

Reduced

activity

Unhelpful

thoughts &

beliefs

Repeated

treatment

failures

Long term

analgesics /

sedatives

Loss of job,

financial &

family stress

Excessive

suffering

Feelings of

depression,

helplessness,

irritability

S/E of drugs

e.g. constipation,

lethargy, gastric

ulcers

Physical deterioration

e.g. ms wasting, joint

stiffness

OVERVIEW OF PROBLEMS CAUSED BY CHRONIC PAIN

X

X

X

X

X

X X

X

X

PAIN SELF MANAGEMENT

• Education – Understanding difference between acute and chronic pain

• Relaxation

• Exercise

• Pain Management Skills

JA, F, 38 years, chronic back pain

after a fall in 2000

“After the fall, I had severe pain in my back, I could not breathe, I could not hear or talk. I went to the hospital and they told me I had compression fracture of the spine. I was given pain killers but the pain never went away.

“Because of the pain, I used to have so much problem - I could not walk very far, I could not sit or stand for very long, I could not do much for myself.

“After I attended the Pain Management Program, I realised that I have to learn to manage the pain myself. I started doing regular exercise, stretching, walking and relaxation (breathing).. Now I have no problems sitting and standing for a long time, and I can walk as fast as I could before the accident. I don’t take any more pain killers.”

ML, M, 46 y, chronic back pain

• Unemployed for many years, and

taking a lot of medication because

of his pain. Had back surgery with

no relief.

ML, M, 46 y, chronic back pain

“I feel that the pain is hell, a kind of torture, and I feel it myself

only - no one else knows. Not even my loved ones understand

me. We are in different worlds - I am in pain all the time, they

are not; there is no common ground between us.

“I used to take more than the prescribed dose of pain killers, and

lie in bed the whole day. I was angry with the whole world.

“Luckily I learnt about pain management and now, although I still

have pain, I don’t take medication any more. When the pain is

bad, I do my stretches and relaxation, and it’s like a miracle

happens. The pain is under control and I can go on.”

Although few

people die of Pain,

Many die in Pain

And even more live

in Pain

EFIC declaration,

Global Day Against

Pain, 2004