Pain School for Caregivers

Course 2- Acute Pain

Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 2 - Approximate time required: 120 min. 

Educational Goal:

To provide Adult Foster Care providers with information that will help them understand and manage acute pain.

Educational Objectives:

1. Instruct about Acute Pain and how to treat it.
2. Discuss non drug pain therapies.
3. Know the different pain drug classes
4.  Expound about the issues of drug abuse.     

Procedure:           

1. Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records. 

Disclaimer       

   The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

 

Pain School for Caregivers

Course 2- Acute Pain

 

 

     All pain starts off as acute pain. These are the aches that resolve quickly, or at least that is what everyone hopes for.  At this point pain is just a symptom of a larger issue. So how do care providers manage acute pain correctly? It’s time to apply some of your new found knowledge from pain school-course 1.

     It is human nature to try to resolve the pain as quickly as possible.  But as a care giver you have to see things from a broader point of view. If you remember, pain is a warning signal that something is wrong. So the first step in effective care giving would be to understand what is going wrong? What is the patient’s body trying to tell you? Is that head ache, toe pain, or whatever, the tip of a much bigger iceberg of trouble?  As you take care of your client’s complaints are you looking for unusual signs and symptoms when the resident is in pain? Or are you just mindlessly signing your initials on the pain med prn medication log? I hope you are getting the point of how to use this knowledge for more effective care giving and not just clicking off another CE hour for re-licensure.
 

     Back to the original question, so how does modern medicine manage acute pain? You find out what’s going wrong and fix it, of course. Then the warning light will turn off by itself, (the pain will resolve itself). That is why the doctor sometimes won’t prescribe pain medication. They are fairly sure that they can take care of the underlining problem and the pain will go away without the use of medication. 

     Realistically though most often the patient is going to need something extra to help manage the pain. And by managing pain what we’re really talking about is interrupting the pain signal pathway to the brain somewhere. Either you use chemicals (pain meds) or use some other means to mask, replace or stop the nerve pain signal from getting thru to the brain.  You’ll be glad to know that I am not going to go into a lot of detail on how each pain remedy affects the pain pathway. That is way too much information and frankly sometimes we don’t even know exactly why a medication or treatment works. But I think some broad category understanding would be useful to you.

 

How to shut off the pain signal

 

 

     There are a lot of different pain killing options to choose from. The choice depends on a lot of different factors. What’s causing the pain? What pain signal pathway is being activated? What are the side effects? What is the doctor’s knowledge of a particular treatment? What is the expectation of the patient? What is the skill level of the care giver? How trustworthy is the patient?   

 

Prevention strategies

     The best pain killer is to not have pain in the first place. What can you do as a care provider to prevent pain from happing in the first place?  Provide a safe living environment, ensure a healthy lifestyle, maintain a proper diet, get enough exercise (my first suggestion is regular walks), pay attention to the small complaints so they don’t become big ones, maintain proper blood flow and always, see the doctor regularly, always, always fight against a sedentary lifestyle. Having the patient just sit and watch TV may be easy care giving but your just asking for bigger problems down the road.  Ever had to deal with a bedsore? It’s worth the effort to; establish a schedule of activities, regularly reposition the patient, massage the legs and back, encourage outings. Good care giving techniques will really pay off in the end. Healthier patients are easier, more “pain free” patients.  

 

NON-DRUG therapies

     There are some techniques that can either turn off or interrupt the pain signal without the use of drugs.  Some of these are among the oldest known pain therapies and are considered just good care giving practice, which brings up a good question.

     When do good care giving techniques turn into therapies and thus need to be approved by a doctor? The rule of thumb is when you have to make a medical decision.  For example- you can massage a client’s legs when you apply skin lotion without the doctor’s permission. But if you want to apply a numbing lotion to cure pain then you have made a medical decision and you would have to get prior approval from a doctor.  The bottom line is you do have some latitude as caregivers but  the more involved therapies should be initiated and approved by the doctor.  When in doubt, ask. It will keep you out of trouble.  

   Massage is more than just rubbing an area of the body it is the purposeful manipulation of superficial and deeper layers of the muscles, joints and skin using various techniques. You might be surprised to know that there are over 40 different kinds of massages.

How does it work?

     Massage is probably the oldest pain relieving therapy that has ever existed. Numerous studies have proven its therapeutic benefits over and over again and yet modern medical science still haven't figured out exactly why it works. Current thinking is massages are beneficial for several different reasons.

• Pumps more oxygen and nutrients into tissues and vital organs while helping to remove metabolic waste.
• Helps the body enter a relaxing rest-and-recovery mode that enhances the healing processes. (reduces inflammatory responses and increases healing and pain killing hormones)
• Reduces stress and tension, factors that slows the healing process.
• Increases the general since of well-being which helps fight depression, depression is another factor that slows healing and makes you feel pain more.
• Better attitudes also help bear pain easier which enables you adhere to other healing therapies better.

Hot and Cold packs-

     Reducing pain by applying Hot or Cold packs or compresses has been around for hundreds of years. 

How does it work?

 Hot packs are beneficial in the management of pain by increasing blood flow to the area. This brings more nutrients and oxygen to the damaged area and removes metabolic waste. It also relaxes tense muscles and stiff joints, increasing the range of motion in an area which is an important quality of life issue.

Cold packs on the other hand reduce blood flow, reducing inflammation and swelling. Reduced swelling also has a positive effect on range of motion. Additionally cold packs create area numbness, reducing the body’s ability to feel pain.

Alternating hot and cold packs is thought to be of greater benefit than either alone because it relieves a greater combination of factors.  In addition constantly changing the areas temperature tends to compete with the pain signal for the brain attention, effectively "drowning out” some of the pain. Something similar happens when we relieve a painfully bumped elbow by rubbing it. Alternating packs is generally reserved for more chronic pain issues.

 

Other therapies

     There are other non-drug therapies that are more complex. They are usually reserved for chronic pain issues so we will cover them in class number three.  

     Special note- There are those who would include herbs and homeopathic medicines in the non-drug section. Make no mistake, herbs and homeopathic remedies are a chemical therapy thus by definition a drug. The only exception is those herbs eaten for the purpose of food. Caregivers who give their residents an herb as a medical treatment have crossed the line into medical practice and need a doctor’s permission to do so. Even if it’s part of the menu.

Drug Therapies

 

     Over the years medical science has learn how to chemically alter and interrupt points all along the pain pathway. Caregivers should know how the drug works so that they can know what is going on and monitor the drug for effect. I will explain all the different pain meds as a group or category, based on their chemical structure and mechanism of action.

 

Pain Drug Categories

 Topicals

     Topical counterirritants are creams, ointment and oils that stimulate (irritate) the skin. They provide pain relief by diverting some of the mind’s attention away from the original pain signal. The chemicals themselves and the required massaging application techniques also have the added benefit of stimulating blood flow to the area. This increases the body’s own healing and pain resolution ability. An exception to this group is capsaicin (a pepper plant derivative). It has the added benefit of depleting a nerve transmission chemical called substance P. Without enough substance P around the nerves can’t transmit nerve pain signals very well.

APAP

     Acetaminophen (Tylenol) is an analgesic that that blocks the pain signal and disrupts some of the chemical pathways in the central nervous system. It is considered a first-line therapy because its use is relatively safe, though it is possible to take too much and cause liver damage. It is not recommended to take more than 4 grams per day or 1.5 grams per day in continuous use from all sources. Many other medications contain acetaminophen and must be included in the daily limits. Unfortunately, acetaminophen does not reduce inflammation.  

NSAID

     Non-Steroidal Anti-Inflammatory Agents (NSAID) are drugs that reduce pain by modulating the inflammatory process that triggers the pain signal. They also help reduce the redness and swelling associated with such events. There are many side effects associated with this class of medication, which can include upset stomach, ulcers, tinnitus (ringing in the ears), heart and kidney problems, and blood thinning. Celecoxib (Celebrex) is a newer NSAID that has fewer side effect problems. Diclofenac (Voltarin) is available as a gel that is applied to the skin, which helps bypasses many of the NSAIDs troublesome side effects.

Other Agents

     Other common anti-Inflammatory agents include Aspirin, and Magnesium Salicylate (Doans pills). They have a similar side effect and efficacy profiles as the NSAIDs.

Opiates

     Opiate, narcotic and synthetic narcotics are pain killers that directly block the central nervous system pain receptors. As such they are very powerful pain killers. They are designed to mimic the body’s own pain killing endorphins. Unfortunately, this also leads to euphoria which means opiates can be diverted (stolen) and abused. Addictions are also possible but not always, more about this subject later. They are usually reserved for when other therapies produce difficulties or fail to relieve pain.

Steroid Injections

     Intra-Articular Glucorticoids (Steroid Joint Injections) are a synthetic version of our bodies’ own anti-inflammatory chemicals. They are very powerful drugs, but are limited in their use due to their side effects and difficult route of administration.      

OTC

     Herbal Remedies and OTC supplements have been used for pain relief for a long time. Unfortunately, not much scientific research has been done on these cures and they are not officially FDA approved.  They are medicines and must be reviewed by the patient’s doctor before they are used. Commonly used remedies for arthritis pain are Glucosamine, Chondrotin, S-adenosylmethionine (SAMe) and Methylsulfonylmethane (MSM).  These medicines take a long time to be effective. It has been recommended that the patient take the supplements for at least a month before determining their continued use. They have limited use in Rheumatoid Arthritis. Willow bark extract contains aspirin. Clove oil and Tea tree oil can have numbing effect on the skin.

Numbing Anesthetics

     One way to eliminate pain is to reduce or completely block all feeling in the nerves which is called anesthesia. There are two classes of drugs; general anesthesia that cause a loss of consciousness (used in surgery) and local anesthesia used for a limited area of the body. The medications are topical (on the surface) or injections. The anesthetic agents most seen and used by care givers are mild numbing cream and ointments that help with skin irritations, cold sores and teeth numbing agents. 

Nerve pain

     Nerve pain originates from the nerve fibers themselves. These types of pain are generally harder to manage. The damage to the nerve fibers make the nerve fire easier. This results in random and uncontrolled nerve signals to the brain. Traditional pain killers just don’t work very well in controlling this type of pain.  Fortunately it was discovered that anti-seizure medications that was used to slow down or block the nerve function itself could be utilized to relieve some nerve pain.

Add ons

     There are many drugs that are used as add on therapy that you would not normally be considered pain killers. They help relieve pain by helping to control contributing factors that make us feel pain more intensely.  Anxiety, depression and stress are symptoms that are major contributors to how we feel pain. Usually reserved for chronic pain conditions, nevertheless care givers should not be surprised if they see drugs like antidepressants, muscle relaxers, and sedatives used in conjunction with pain meds. The care provider can help the patient understand why they are being used if they have questions. For example it can confuse and worry a client if the doctor all of a sudden prescribes an anti-depressant medication to a patient who feels they are not depressed. 

 

Care givers and medications

     It is not by accident that another name for practicing health care is practicing medicine. Medication use involves a major portion of how we treat patients. We have done some amazing things through the use of drugs. Unfortunately these chemicals can interfere with other portions of our bodies as well. Professional care giving requires that you understand what the medicine is for (what is the purpose of taking the chemical). What are the goals of therapy (what is the doctor trying to do). What effects do you have to monitor the patient for (is it having the desired effect). Are there significant side effects (unintended drug effects that are interfering with the patient’s welfare)?

     You may think (like most patients) that you don’t have to worry about all the details because doctor and pharmacist will take care of them. You as a professional care giver are part of the medical team, in my opinion the most important part. You live with the patient. You have more opportunity to monitor the patient than all other members of the health care team combined. With your full involvement patients can reach therapeutic goals faster and problems can be resolved much quicker. All it requires is you read the drug information that comes with the medication, know what the doctor is trying to treat (diagnosis) and communicate effectively with the doctor.

Here is a general overview of pain medication that will help monitor for effect. For more details contact your pharmacist.

Drug Class	On set of action	How they work	Major side effects
Topical counterirritants	Very quick	Creates hot and cold sensations that competes with pain signal for the brain attention	Skin irritation
APAP	½ - 1 hour	Acts on the central nervous system.	High dose liver toxicity
NSAID	¼ - 1 hour	Interrupts the chemical cascade that leads to inflammation	Some sedation, Stomach problems with long term use, interacts with blood thinners, nausea
Opiates	¼-1/2 hour	Binds to opioid receptors in the central nervous system that produces pain relief and euphoria	Euphoria, sedation, breathing problems, dizziness , dependency hallucinations, nausea, allergies
Steroids	Very slow, days	Interrupts the chemical cascade that leads to inflammation	Nausea, injection site reaction
Numbing agents	Very quickly	Stops nerves from feeling	Skin reactions, allergies
Nerve pain agents	Slow- hours to days	Changes the way nerves send signals to the brain	sedation
Antidepressants	Very slow- days to weeks	Alters the chemical balance in nerves and brain	Sedation, alters mood, nausea hallucinations, dizziness
Muscle Relaxers	½-1 hour	Alters nervous system	Dependency, euphoria, sedation, dizziness
Anti-anxiety	Slow- hours to days	Alters the chemical balance in the nerves and brain	Dependency, sedation, dizziness

 

Pain and the PRN medication orders

 

     Most pain prescriptions end with PRN or take as needed.  Sometimes I think that the doctor should give better instruction than that.  PRN forces the caregiver to make a decision, “when does the patient need it? So to help the care provider make good decisions about “take as needed” med orders, consider the following.

1. Pain is felt subjectively. We as medical practitioners can never really tell how much pain our patients are in. Some care providers try to figure out when a patient is “faking it” or is just being a “sissy”. The care provider doles out the medication when they think the pain is needed, not the patient, which is the wrong way to do it. All pain specialists agree – the care provider should believe what the patient says about their pain. If the patient is asking for a lot of medication then more likely the pain medication is not strong enough in the first place, or other issues need to be addressed.  Work with the doctor about these concerns. Let the doctor worry about the drugs, you worry about your client.
2. Pain begets Pain. Some patients (and some care providers) wait until the pain is a five alarm fire before pain medication is used. What people don’t understand is that intense pain actually causes you to feel pain more. It causes stress which also adds to the feeling of pain. Also over time intense pain potentiates pain. We start to feel it faster than before. In other words when the mind senses a lot of damage signals it tries to compensate by making the alarm (pain) quicker and louder.

I always tell people that they will use less medication if they keep the pain under control. Don’t wait until you have a five alarm fire pain before getting help.  It takes more water (drugs) to put it out.

3. Frequency is important info. I know how tedious the prn pain med log can be. But a properly filled out log can tell the doctor a lot of information. You can tell if a condition is getting better or worse just by the prn pain med log. It can also become an early warning system about other conditions that can crop up. If pain is an important symptom of the client’s disease state or if the frequency of taking meds changes significantly, I would make a copy of the log and send it to the doctor. A wise caregiver saying is “The more info doctors have the better decisions they make”

 

 

A Major issue with pain meds- Abuse

     Pain killer drug abuse is a serious problem in health care today. It is an unavoidable problem that needs to be address in every health care setting where they are used.  Home owners and care givers must understand the problem, monitoring drug use vigilantly, and aggressively solve issues before they become problems. 

 

Understanding

     Drug abuse and addiction have become part of our pop culture. There are so many myths surrounding it that it’s hard to understand what really is happening. We are constantly being bombarded with information that makes a good story line but is just plain wrong. You need to take some time to become familiar with some proper definitions to key terms concerning drug abuse.

Addiction

     Our understanding of term addiction has become clearer after much research. It is a complex reaction with physical, emotional and genetic factors. Simply put, addiction is a brain disease process that is characterized by compulsive drug cravings, where the individual has impaired self-control. Impairment is so advanced that drug use will persist despite potentially devastating consequences.   Due to multiple factors the drug use has grown beyond voluntary control.  Some of those factors are genetics, social pressures, mental health, and impairment of brain development. It is important to remember that addiction is both a psychological and biological occurrence. True addiction is occurring when the patient cannot physically and emotionally resist the urge to take the medication. 

Dependency

     Drug dependence means that a person needs a drug to function normally. It usually takes a prolong period of use for dependency to develop. Abruptly stopping the drug leads to withdrawal. Dependency itself is not always a bad thing. It all depends on why the medication is being used and what the consequences are for continued use verses stopping the drug. Example- an advanced arthritic patient with no joint cartilage will be dependent on pain killers to function normally.  Being dependent on a drug is not the same thing as being addicted.

Withdrawal

     Withdrawals are the symptoms an individual experiences after reducing or stopping a drug that is beyond what was caused by the original condition for which the medication was taken. The symptoms are frequently the opposite of what the meds are taken for. For example pain med withdrawal creates more sensitivity to pain, anti-anxiety withdrawal creates more anxiety.  For drugs that create euphoria, withdrawal often generates depression, anxiety and craving. When the cravings become so strong that it overcomes the user’s voluntary control, addictive behaviors start to occur.

Abuse

     Abuse is any use of a drug beyond what is prescribed by the doctor or manufacturer instructions.  It may seem like an overly harsh definition but that is really what abuse is. You do not have to be addicted to abuse a drug, and most people who abuse drugs don’t become addicted. Yes, you can abuse OTC medication.

Diversion

     Diversion is the use of a medication by any person other than whom it was originally intended. It is theft and a felony. Caregivers who “borrow” medication are putting themselves at a very high risk, even if they are giving it to a family member or another resident.  They would also be guilty of practicing medicine without a license and patient abuse.

Tolerance

     Often a patient’s body will become use to a medication and more drugs will be required to achieve the same results. Tolerance almost always develops with opiate pain killers though at different rates with different people.  Tolerance for a drug creates a real need for higher doses and is often confused with addiction. The main outward difference is what the patient is willing to do in order to get the desired drug effect.  Developing tolerance is not the same as becoming addicted.

Pseudo addiction

     Addiction is a very complex drug outcome.  There is always a risk of becoming addicted to any pain medication that creates euphoria but the risk may not be as high as people might think. Some experts think that real addiction occurrence can be as low as 3-20% with long term use.

     No one wants themselves or a patient to become addicted to a drug.  Such thinking often creates fear, which leads patients and practitioners to misinterpret pain symptoms. The natural effects of tolerance and dependence are often mistakenly labeled as addictive behaviors.

     In addition sometimes the fear of addiction and lack of knowledge about pain will lead prescribers and caregivers to under treat a painful condition.  Not enough drugs are given to eliminate the pain and the patient suffers terribly.  Understandably after suffering for so long the patient becomes more aggressive about obtaining pain relief. Such aggressiveness mistakenly leads the practitioners to believe the patient is becoming addicted and they limit the pain killers even more.  Tragically this leads to more suffering and more aggressive addictive behaviors. This maladaptive behavior is known as pseudo-addiction and is actually caused by the medical prescriber and or caregiver. The main way to tell addiction and pseudo-addiction apart is in pseudo-addiction aggressive drug seeking behaviors will subside once pain is adequately controlled.

Monitoring Vigilance

     There are many ways that pain medication therapy can get sidetracked.  Too much drugs given, too little drugs given, side effects problem, abuse and diversion are all pitfalls of managing pain medication.   The main way that care givers can avoid the pitfalls of pain therapy is to diligently paying attention to the medication administration record (MARS) and follows the doctor’s orders.  The following are some of my thoughts on how to be diligent.

• Pay attention to the accuracy of the MARS. Are they being filled out sloppily or incompletely? Do the pills remaining agree with the MARS? 
• Those who are in charge should perform regular controlled substance audits.  Audits could be as simple as the owner counting the pills and letting the employees know that the owner is counting them.
• Are PRN meds being taken on a regular basis? Does that mean that the patient is having problems with controlling pain, or is it drug diversion or is has it just become a habit with no visible need or benefit?
• Regularly interview your patients about their pain levels. Are they still in pain? Is the pain still there because they aren’t getting their pain meds at all? Are they in pain because they are not getting enough pain meds? Are they experiencing side effects? Are they aggressively seeking drugs when there is no pain?
• Are family members or employees having moods swings? Do they go from being agitated to being too laid back?
•  Is “borrowing” medications occurring?

Aggressive intervention

     Because drug abusers hide their activities, irregularities such as the ones listed above are red flags that must be followed up on. You are not doing anyone any favors by ignoring the problem. The main characteristic of addiction is that abusers have lost the ability to control themselves and need outside help. The first step to getting that help is by blowing the whistle on them. The cycle of abuse most often has to be broken from someone else.  By not doing anything you’re actually saying, “Go ahead and ruin your life. I don’t care about you or the others around you that are being harmed.” For care home owners not catching and getting rid of drug abuse is a business killer. Your reputation and thus your income is on the line.

 

Conclusion

End of Course 2

     Acute pain is managed as a symptom of larger issues. Treatment emphasizes taking care of the underlining problem and the temporary relief of pain through various therapies. Caregivers must remember that pain is a warning signal of the body that something is going wrong. More effective caregiving entails a more investigative approach to the management of acute pain. Find out what is going wrong first then treat the pain.

      Caregivers must also remember that acute pain management goes beyond the simplistic “a pill for every ill” approach. Non pill therapy can be just as effective as oral pain killers.  If a medication is chosen for acute pain relief, skill and understanding must be practiced by caregivers and their supervisors. These efforts are necessary for safe, effective therapy and to avoid the pitfalls of abuse.

It’s time to test your knowledge again with another exam-Good Luck. 

After you take the exam- class is dismissed.

 

References:

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http://www.spine-health.com/treatment/pain-management/invasive-pain-management-techniques

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http://pain-topics.org/glossary/

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17. NINDS Chronic Pain Information Page. National Institute of Neurological Disorders and Strokes. 5/22/13

http://www.ninds.nih.gov/disorders/chronic_pain/chronic_pain.htm

18. Sleep Hygiene: Helpful Hints To Help You Sleep. Sleep Disorder Center. University of Maryland Medical Center  8/3/2010

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20. Exercise to Help Manage Chronic Pain And/Or Fatigue. War Related Illness and Injury Center, Office of Public Health, Department of Veterans Affairs.

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22. Chiropractic. Wikipedia The free Encyclopedia

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Pain School for Caregivers

Course 2- Acute Pain

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