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Pain – An Introduction & Opportunity for Social Work Intervention Terry Altilio LCSW Department of Pain Medicine & Palliative Care Beth Israel Medical Center CONVERGING CONTEXTS Industry Insurers Pt/Family Advocates Litigators Legislators Clinicians Media Regulators Supreme Futurology NY Times 8/2005 William Stuntz, Harvard professor is 47 & suffers from chronic back pain. “My generation will include lots of very old people who have more chronic pain than middle-aged people and also get cancer at higher rates, and both of these trends will massively change the way the baby boom generation thinks about drug policy.” Impact The annual cost of chronic pain in the United States, including healthcare expenses, lost income, and lost productivity, is estimated to be $100 billion. More than half of all hospitalized patients experienced pain in the last days of their lives and although therapies are present to alleviate most pain for those dying of cancer, research shows that 50-75% of patients die in moderate to severe pain. An estimated 20% of American adults (42 million people) report that pain or physical discomfort disrupts their sleep a few nights a week or more. American Pain Foundation website for references Incidence An estimated 76.5 million Americans - report that they have had a problem with pain of any sort that persisted for more than 24 hours in duration. (excluding acute pain). More women (27.1%) than men (24.4%) reported that they were in pain. Non-Hispanic white adults reported pain more often than adults of other races and ethnicities (27.8% vs. 22.1% Black only or 15.3% Mexican). Adults living in families with income less than twice the poverty level reported pain more often than higher income adult American Pain Foundation website for references Mandates Ethical principles – Justice, beneficence, nonmaleficence Scientific standards & guidelines JCAHO standards Litigation Emphasis on end of life care Groups at Risk for Under-treatment Babies, children, women, & frail elderly Racial & ethnic minorities Language & culture different from HCPs Patients with –Dementia –Communication problems –Emotional disturbance –Cognitive impairment –Substance abuse issues When Patients Cannot Report Pain Assess with others – Changes in behavior Quiet when normally talkative Restless Sudden anger Loss of appetite – Watch for pain behaviors Agitation / crying out Rubbing Confusion Excessive sleep Clinical / Systems Barriers to Managing Pain Lack of pain assessment skills Lack of interdisciplinary collaboration Absence of accountability Absence of practical tools Overstressed & desensitized staff Mistrust – mutual Barriers - Patient & Family Fears – – – – – – – Distracting HCP from survival efforts Med side effects - confusion, sedation, hastening death Painful interventions - injections Addiction / tolerance Upsetting family Handling medication / “killing” the patient Financial burden Barriers - Patient & Family Beliefs & Values – – – – – – Pain is inevitable Pain is necessary / builds character Requires stoic response Represents sacrifice Good patients do not complain Intent of clinicians & medical system is suspect Barriers - Patient & Family Emotional Factors – Distress, denial & / or depression impact – Ability to assess & report pain – Acknowledging pain means disease is worse – Acceptance of need for treatment Knowledge Factors – No expectation for good treatment – Do not know how to report pain Pain & Substance Abuse Some Considerations Some Definitions To enhance critical thinking & inform plan of care – Addiction – Physical dependence – Chemical coping – Tolerance – Pseudoaddicton Substance Abuse Use of any drug outside accepted norms. Labels any use of illicit drugs and misuse of prescribed drugs as abuse. ASAM, APS, AAPM (2003) Addiction A primary, chronic, neurobiological disease with genetic, psychosocial & environmental factors influencing its development & manifestation; characterized by one or more of the following – Impaired control over drug use – Compulsive use – Use despite harm – Craving ASAM, APS, AAPM (2003) Tolerance A state of adaptation in which exposure to the drug induces changes that result in diminution of one or more of the drug’s effect over time ASAM, APS, AAPM (2003) Physical Dependence A state of adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug &/or administration of an antagonist ASAM, APS, AAPM (2003) Pseudoaddiction Term used to delineate the distress and drugseeking behaviors, similar to those of people with the disease of addiction, that can occur in the context of unrelieved pain Weissman & Haddox (1989) Chemical Coping Most adults fall somewhere between the two extremes of abstinence & addiction & therefore, one needs to establish the degree of chemical coping & the role of alcohol or drugs in the coping strategy of the vast majority of cancer patients (self medicating?) Bruera (1998) The Complexity Aberrant drug related behaviors – Exist on a continuum – Inadequate management of symptoms may be the motivation for problem drug-taking behaviors – May reflect pseudoaddiction, psychiatric disorders, family distress, criminal intent Barriers & “Non-adherence” The history & tradition of social work rests in the embracing & overcoming of obstacles. It is where we begin while for others, it is where they end…….. Culture & Pain Lasch, IASP (2002) Culture of Pain –Way in which society shapes meaning & treatment of pain Culture in Pain –Way in which culture molds perceptions, expression, coping responses, behaviors, expectations & ascribed meanings Rural / prisons……. Some Things to Ponder 1993- NIH mandates inclusion of women in research 1998- FDA requires drug companies to include sex specific information on safety & efficacy when applying for new drug approval Some Things to Ponder WEB MD (2002) 2001- IOM & DHHS recommend that sex & gender differences be taken into account when designing & analyzing studies 7/97 – 2/01- 8 of 10 prescription drugs taken off the market caused more negative effects in women then men. Some Thoughts on Gender Biological differences – Reproductive hormones – Stress induced analgesia responses – Brain & central nervous system Some Thoughts on Gender Is more than physiology at work? – Cognitive appraisal & meaning-making Women more often experience pain as normal biological process….sort normal from pathological Hurt not equal to harm – Communication Women give contextual description - relationships Men objectively report symptoms / limitations – Which reporting style most consistent with medical model???? Some Thoughts on Gender Behavioral coping Culture, gender & pain The complex interplay between behaviors & values systems impacts patients and clinicians Gender of researcher has been shown to influence male pain response Some Thoughts on Gender Are there differences in health care provider’s perceptions? – Sensitivity to pain – Tolerance for pain – Validity of self reports – Objective, biological facts more credible Pain “An unpleasant sensory & emotional experience associated with actual or potential tissue damage or described in terms of such damage…” “Pain is always subjective…” “A sensation in a part or parts of the body, but it is always unpleasant & therefore an emotional experience.” IASP Definition (1979) Multidimensional Aspects of Pain Multidimensional exploration of pain is not a denial of physical pain but rather an expression of interest, caring & concern for the total person. Medical management needs to be accompanied by efforts to understand beliefs, thoughts, behaviors & feelings that may contribute to pain, suffering & distress. Pain: a Multidimensional Phenomenon Integrates – Knowledge of symptoms & treatments – Individualized illness experience - patient & family Impacts – Mood – Function – Quality of life – Grief & bereavement . Suffering Distress brought about by the actual or perceived impending threat to the integrity or continued existence of the whole person. Suffering can include physical pain but is by no means limited to it - failure to understand the nature of suffering can result in a medical intervention that not only fails to relieve suffering but becomes a source of suffering itself. Cassell (1982) Impact of Unrelieved Suffering Pain tolerance is diminished. Medications might mask existential angst, but they don’t resolve it. Assess family suffering; respond to discrepancies. Explore possibility that pain behaviors have become metaphors for unrelieved suffering Multidimensional Assessment Complements medical & pharmacologic Engages & partializes pain experience Includes clinical interview/tools & scales Validates importance of patient perception & information May include input from family & health care professionals Traditional Biomedical Pain Assessment Diagnose underlying medical condition If “organic” – physical Analgesics, medical intervention If “supratentorial” Analgesics, medical intervention discouraged Pain Experience Pain (Sensory) Suffering Biopsychosocial Spiritual Approach to Pain (Revised) Pain Physical Sensory Nociception (Tissue damage) Social/Environmental Family, Culture, Work, Finances, Litigation Psychological Affective Cognitive Behavioral Spiritual Meaning, Purpose Biopsychosocial Spiritual Pain Assessment Diagnose underlying medical condition Assess – Psychological status – Pain behaviors – Social environmental factors – Spiritual aspects – Cultural variables Biopsychosocial Spiritual Pain Assessment Assess – Mental status – Cognitive response to pain condition – Adjustment & coping – Psychiatric history – Substance use/abuse & dependence Pain Behaviors Verbal – – Pain complaints Analgesic requests Non Verbal – – – Activity level and pattern Complaints – grimacing, groans Body posture Social & Environmental Assessment Work status Economic status Disability compensation? Litigation? Family & social support Behavioral Interventions Cognitive-Behavioral Therapy Biofeedback Relaxation Training/ Stress Management Hypnosis Imagery Distraction Techniques Psychotherapy Bereavement / Loss Altered self-identity Anger management Develop new sources of meaning, Family/relationship issues Behavior Therapy Active coping responses to increase selfefficacy Graded tasks & goal setting Problem-solving skills Contingency management Modeling Behavioral rehearsal Cognitive Therapy Cognitive restructuring, reinterpretation Correct distortions, exaggerations Distraction techniques Education Relaxation-Based Modalities Muscle relaxation (passive & active) Hypnosis Autogenics Imagery Meditation Integrative Techniques Acupuncture Exercise Journaling Massage ………. Comprehensive Pain Management Potential outcomes related to goals of care Manage pain Reduce anxiety & distress Treat depression, mood disorders Impact activity & participation in meaningful activity Increased feelings of self efficacy & competence to manage symptoms Response to Witnessed Distress “Being alerted to reported or witnessed distress begs an appropriate response by the caregiver.” Frager (1997)