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Pain and its Management


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Title: Pain and its Management

Pain and its Management
What are we going to talk about today?
  • Pain
  • Definition, assessment, pain management
  • Adherence to medical advice
  • Prevalence of nonadherence
  • Costs of nonadherence
  • Causes of nonadherence
  • Solutions

  • The pain usually starts with nausea and a vague
    headache. The real attack follows after somewhere
    between one and six hours. It is as if a burning
    nail is being pushed inside my head, not once,
    but all the time, day and night. The only thing I
    can do is lie on my bed with a wet cloth on my
    forehead and a bole next to me. I do not want
    anyone near to me, no one can help me anyway. And
    that is the worst thing of migraine the
    loneliness. Pain is such a lonely feeling.
  • Ria Weteling (56)
  • In Libelle (2001, 44)

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Examples of pain
  • Headache
  • Musculoskeletal problems
  • Rheumatoid arthritis
  • Neuropathic pain
  • Herpes zoster (shingles)
  • Abdominal pain
  • Postoperative pain
  • Pain caused by cancer

Consequences of pain
  • Work
  • Household
  • Leisure time activities
  • Social activities
  • Sleeping problems
  • Family / marital problems
  • Emotional problems (depression, anxiety)

Physiological significance of pain
  • Pain hurts and so it disrupts our lives
  • Pain is critical for survival
  • Minor pains provide low-level feedback
  • Shift posture, uncross legs
  • Roll over when asleep
  • Medical consequences
  • Pain is the symptom most likely to lead an
    individual to seek treatment

Psychological significance of pain
  • Depression and anxiety worsen the experience of
  • Patients fear pain when undergoing treatments
  • Inadequate relief from pain is the most common
    reason for euthanasia requests

The elusive nature of pain
  • Pain is a psychological experience

Loesers Onion-model
Definition of pain(1994)
  • An unpleasant sensory and emotional experience
    associated with actual or potential tissue
    damage, or described in terms of such damage.
  • Note pain is only associated with actual or
    potential tissue damage, or described in terms of
    such damage

The elusive nature of pain
  • Interpretation of the pain influences
  • The degree to which it is felt
  • How incapacitating it is
  • Beechers study of WWII injuries
  • To soldiers, pain means, Im alive
  • To civilians it interrupts activities
  • Pain is influenced by
  • Context, culture, and gender

  • Acute Pain Annually 15-20 of approximately 31
    million Canadians have acute pain warranting
    clinical care the cardinal symptom of disease!
  • Chronic pain (CP) pain that is persistent in
    either continuous or intermittent forms
  • CP associated with terminal illness (cancer,
    HIV/AIDS, etc.) estimated that as many as 80
    of us will die in pain (Salter, 2002)
  • CP nonmalignant
  • 25-30 have chronic pain
  • Pain a lifelong experience

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Measuring Pain - Verbal Reports
  • Large informal vocabulary
  • Throbbing pain? Shooting pain? Dull ache?
  • Questionnaires
  • Nature of pain (throbbing, shooting, dull)
  • Intensity of pain
  • Psychosocial components
  • Fear
  • Degree to which it has been catastrophized

The McGill Pain Questionnaire
Pain is what the person says it is and exists
whenever he or she says it does (McCaffery, 1968)
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Parent Ratings of Pain
Pain expression did not differ across 2, 4, 6,
and 12 months
Self-report measures of pain
  • Serious limitations
  • speech only partially reflects complexities of
  • cognitive and communication competence crucial
  • inevitably selective reflects perceived best
    interests, context driven, audience effects

Facial activity during pain
  • Highly visible
  • Faces are very plastic remarkable array
  • Stereotypic display
  • Acute pain (injury, exacerbation of disease)
  • Sensitive, relatively specific
  • Vigour reflects intensity of distress
  • Moderately correlated with self-report

Pain in children with autism
  • reduced pain sensitivity, not feeling pain as
    intensely as others, indifference to pain, a
    high threshold for pain, etc. (DSM-IV TR, 2000
    Wing, 1996 Bettelheim, 1967 Peeters, 1999,
  • anecdotal and clinical impressions
  • Nader, R., Oberlander, T.F., Chambers, C.T.,
    Craig, K.D. (2004). Expression of pain in
    children with autism. The Clinical Journal of
    Pain, 20, 88-97

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Revised definition of pain
  • Revised definition of pain
  • Definition of pain(1994) An unpleasant sensory
    and emotional experience associated with actual
    or potential tissue damage, or described in terms
    of such damage.
  • Added note (2002) The inability to communicate
    verbally in no way negates the possibility that
    an individual is experiencing pain and is in need
    of appropriate pain relieving treatment

Physiology of Pain
  • Pain is protective
  • Brings into consciousness the awareness of tissue
  • Pain doesnt feel protective
  • It is accompanied by motivational and behavioural
  • Crying
  • Fear
  • Withdrawal

Physiology of Pain
  • Pain perception is called Nociception
  • Three kinds of pain perception
  • Mechanical nociception
  • Mechanical damage to body tissue
  • Thermal nociception
  • Damage due to temperature exposure
  • Polymodal nociception
  • General category
  • Pain triggers chemical reactions from tissue

Physiology of pain
  • http//

Acute Pain
  • Typically results from a specific injury
  • Wound or broken limb
  • Disappears when damaged tissue is repaired
  • By definition, acute pain goes on for six months
    or less
  • During acute pain, there is an urgent search for

Chronic Pain
  • Chronic Pain
  • Typically begins with an acute episode
  • Pain does not decrease with treatment
  • Pain does not decrease as time passes
  • Three types of chronic pain
  • Chronic benign pain
  • Recurrent acute pain
  • Chronic progressive pain

Chronic Pain
  • Chronic benign pain
  • Persists more than 6 months
  • Varies in severity
  • Example Chronic low back pain
  • Recurrent acute pain
  • Intermittent episodes of acute pain
  • Chronic because the condition lasts more than 6
  • Example Migraine headaches
  • Chronic progressive pain
  • Increases in severity over time
  • Persists longer than 6 months
  • Typically associated with malignancies or with
    degenerative disorders
  • Example Rheumatoid arthritis

Chronic pain must be thought of not as a
particular pain that simply goes on for a long
period of time, but as an unfolding
physiological, psychological, and behavioural
experience that evolves over time (Flor,
Birbaumer Turk, 1990)
Acute vs. Chronic Pain
  • Acute and chronic pain present different
    psychological profiles
  • Chronic pain often produces depression
  • Pain present in 2/3 of patients seeking care from
    physicians with primary symptoms of depression
    (Bair et al)
  • Pain control techniques work well with acute pain
    but less successfully with chronic pain
  • Chronic pain involves more secondary gain role
    of the social environment is key

Who Becomes a Chronic Pain Patient?
  • All chronic pain patients were once acute pain
  • Patients for whom pain interferes with life
    activities make the transition to chronic pain
  • Chronic pain may result from a predisposition to
    respond to a bodily insult with a specified
    bodily response
  • Chronic jaw pain by tensing jaw can be aggravated
    by stress and poor coping

The effects of chronic pain
  • Lifestyle of chronic pain
  • Can entirely disrupt a persons life
  • Little social or recreational life
  • Difficulty performing simple tasks
  • Goals are set aside self esteem suffers
  • Toll on relationships
  • Communication is inadequate
  • Sexual relationships deteriorate
  • Chronic pain behaviours emerge

Pain and Personality
  • Pain-Prone Personality
  • Constellation of personality traits predisposing
    a person to experience chronic pain (neuroticism,
    introversion, passive coping)
  • This hypothesis is simplistic because
  • Pain alters personality
  • Individual experiences of pain are too complex to
    be explained by a single personality profile

Psychological risk factors of chronic pain
  • Excessive emotional reactions
  • Stress
  • Debilitating fear of pain or depression
  • Destructive thinking
  • Catastrophizing Magnification, rumination,
  • Behavioural maladjustment
  • Excessive avoidant behaviour and inactivity
  • Deteriorating social relationships
  • Stress and strain in relationships
  • Reinforcement for pain/illness behaviour
  • Social isolation

Protective psychological factors of chronic pain
  • Self-efficacy
  • Confidence in ones ability to follow a course of
    action that will accomplish desired outcomes
    (e.g., control pain)
  • Pain coping strategies
  • Relaxation, distraction, commitment, redefinition
  • Readiness to change
  • Willingness to take an active role
  • Acceptance
  • Patients lives often consumed by unsuccessful
    effort to eliminate pain

Pain control techniques
  • Pain control can mean a person
  • No longer feels anything in an area that once
  • Feels sensation but not pain
  • Feels pain but is no longer concerned about it
  • Is hurting but is able to stand it

Pain management
  • Biomedical
  • Pharmacological anti-inflammatories (e.g.,
    acetaminophen), opioids, etc.
  • Other somatic physiotherapy, massage, exercise,
    transcutaneous electrical nerve stimulation,
    acupuncture, surgery, etc.
  • Psychosocial
  • Environmental/operant interventions
  • Cognitive/behavioural relaxation, exercise,
    coping strategies, operant control, placebos,
  • Family and marital therapy

Pharmacological control of pain
  • Most common method of controlling pain through
  • Morphine has been the most popular painkiller for
  • Any drug that influences neural transmission is a
    candidate for pain relief
  • Main concern with using drugs Potential for
  • This threat is lower than once thought

Surgical control of pain
  • Cutting pain fibers at various points so pain
    sensations cant be conducted
  • Effects are often short-lived
  • Regenerative powers of the nervous system mean
    that blocked pain impulses reach the brain
    through different neural pathways
  • Can worsen the problem due to damage of the
    nervous system

Sensory control of pain
  • Counterirritation
  • Inhibiting pain in one part of the body by
    stimulating or mildly irritating another area
  • Example Scratching a part of the body near the
    part that hurts
  • Dorsal Column Stimulation
  • Electrodes near the nerve fibers from the painful
    area deliver a mild electrical stimulus, thus
    inhibiting pain

Biofeedback an operant learning process
  • A method whereby an individual is provided with
  • Ongoing specific information about a particular
    physiological process by a machine
  • So that s/he can learn how to modify that process
  • Once patients can control this process, they can
    usually make the changes on their own without the
  • http//

  • Relaxation techniques
  • Enable patients to cope with stress and anxiety,
    reducing pain
  • What is relaxing?
  • A person shifts his/her body into a low state of
  • Progressively relaxing different parts of the
  • Controlled breathing using long, deep breaths
  • Meditation focusing attention fully on a very
    simply, unchanging stimulus

  • An old and misunderstood technique
  • How does it work?
  • Hypnosis involves relaxation, reinterpretation,
    distraction, and drugs
  • Hypnotherapy has successfully controlled
  • Irritable bowel syndrome
  • Acute pain due to surgery, childbirth, dental
    procedures, burns, headaches
  • Pain due to laboratory procedures
  • Chronic pain, such as pain due to cancer

  • Technique of healing developed in China over
    2,000 years ago
  • Long, thin needles are inserted into designated
    areas of the body to reduce discomfort in a
    target area of the body
  • How acupuncture controls pain is unknown
  • Sensory method?
  • Expectations? Relaxation?
  • Endorphins released?

  • Attention is redirected in order to reduce pain
  • May involve focusing on some stimulus irrelevant
    to the painExample Singing O Canada backwards
    while the dentist drills
  • May involve reinterpreting the pain
    experienceExample Im a secret agent and the
    dentist is trying to get me to reveal secrets!
  • Effective for acute pain and low-level pain

Coping techniques
  • Coping skills training is used to help chronic
    pain patients manage pain
  • Is any particular coping technique more effective
    for managing pain?
  • It depends on how long the patient has had the
  • Recent Onset Avoidant styles work
  • Chronic Pain Attending directly to the pain is

Guided imagery
  • Person conjures up a picture and holds it in mind
    during painful experiences
  • Used to induce relaxation
  • Controls slow-rising pains
  • May be used as aggressive imagery
  • Chemotherapy treatment was a cannon blasting the
    cancer dragon apart
  • What does guided imagery do?
  • Relaxing or aggressive imagery both induce
    positive mood states (relaxation or excitement)

Other cognitive techniques
  • Reconceptualize the problem from overwhelming to
  • Enhance expectations that this training will be
  • Clients role is to be active, resourceful, and
    competent (not passive)
  • Clients monitor maladaptive cognitions and stop
    negative self-talk

Psychological interventions with chronic pain
  • No longer treatment as a last resort (after
    biologically-based treatment failed)
  • Should be considered soon after injury or onset
    of pain for those vulnerable to chronicity
  • Systematic reviews show they work for low back
    pain, arthritis pain, cancer pain, tension
    headache and migraine headache, mixed chronic
    pain syndromes
  • Variety of contexts multidisciplinary,
    independent practice, outpatient or inpatient,
    individually or in groups, with or without family

Biological substrates Personal History
Sensitivity Knowledge, Attitudes (biases)
Motor programs
Pain Expression
Assessment or attribution of pain
Action dispositions
Pain Experience
Tissue Trauma (real or Perceived)
(self-report, nonverbal display, physiological rea
(pharmacological, cognitive/ behavioural,
(thoughts, feelings, sensations)
Social display rules
Context, social and physical
The World of a Person in Pain A
Sociocommunications Model
  • What is pain?
  • Assessment of pain
  • Acute vs. chronic pain
  • Pain management

What are we going to talk about today?
  • Pain
  • Definition, assessment, pain management
  • Adherence to medical advice
  • Prevalence of nonadherence
  • Costs of nonadherence
  • Causes of nonadherence
  • Solutions

The extent to which a patient follows medical
The extent to which a persons behaviour taking
medication, following a diet, and/or executing
lifestyle changes corresponds with agreed
recommendations from a health care provider
Sources Haynes RB. Determinants of compliance
the disease and the mechanics of treatment.
Baltimore Johns Hopkins University Press
1979. Adherence to Long-Term Therapies Evidence
for action. World Health Organization 2003.
Adherence is a worldwide issue that will grow as
populations age and chronic diseases increase
In developed countries, adherence among patients
suffering chronic diseases averages only 50
World Health Organization 2003Adherence to
Long-Term Therapies Evidence for Action
Adherence to Treatment for Hypertension
United States 51 China 43 Gambia 27
Dual burden of disease in developing countries
infectious and chronic
Sources Adherence to Long-Term Therapies
Evidence for action. World Health Organization
2003. Available at http//
ditions/adherencereport/en/. American Medical
Association. The Patients Role in Improving
Adherence. Available at http//
ma/pub/article/12202-8427.html. Magee M.
Attacking Chronic Diseases in Developing
Countries. . Available at http//www.healthpoliti
Types of nonadherence Prescription drug use
  • Not having prescription filled
  • Taking too much or too little medication
  • Erratic dosing
  • Stopping medication too soon
  • Using medications without a prescription
  • Combining a prescription with
  • Incorrect over the counter medication
  • Alcohol, illicit drugs

Types of nonadherence Lifestyle changes
  • Not following
  • Dietary recommendations
  • Exercise recommendations
  • Activity Limitations
  • Following surgery
  • During pregnancy
  • Following diagnosis (e.g., osteoporosis)
  • Rates of nonadherence are highest with lifestyle
    changes, particularly over time

Patients arent the only ones who are noncompliant
  • 5 of hospital patient deaths are estimated to
    be due to failure of health care providers to
    wash their hands properly.
  • Reasons cited for noncompliance
  • Soaps are skin irritants
  • Repeated need becomes tedious
  • Centres for Disease Control do not track these

Typical Published Nonadherence Rates for
  • Medication Type Ley Food Barofsky (1976)
    Drug (1980) (1979)
  • Antibiotics 49 48 52
  • Psychiatric 39 42 42
  • Hypertensive --- 43 61
  • Tuberculosis 38 42 43
  • Other Medications 48 54 46
  • SourceLey (1982)

New patients remaining on cholesterol-lowering
medications since first prescription (n11,000)
Bottom line
  • Only 5 of patients requiring cholesterol-lowering
    therapy in Canada are actually receiving it.

Is investing in adherence worth it?
U.S. Annual Costs of Poor Adherence
  • 75 billion 100 billion
  • 125,000 deaths
  • 10 25 of hospital and nursing home admissions

Better adherence will not threaten health care
budgets. On the contrary, adherence will result
in a significant decrease in the overall health
budget. This is due to the reduction in the need
for more costly interventions, unnecessary use of
emergency room services and highly expensive
intensive care services.
Eduardo SabatéMedical Officer, WHO
Source Adherence to Long-Term Therapies
Evidence for action. World Health Organization
Rising health care costs
SourceCIHI (1999)
Total Health Expenditure as a Percentage of GDP,
Canada 1960 - 1997
SourceCIHI (1999)
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Health Care Expenditures in Canada (total 95B)
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Medications 15 of Canadian health care costs
(and growing)
  • There is a need to control costs without
    degrading health care quality
  • Few methods available to do this
  • Improving medication use is one way
  • Treatment unit costs are lower with medication
    than most other treatments
  • Medication is constantly improving

Problems with randomized clinical trials for
assessing effectiveness of treatment
  • Medical research is based on the double-blind,
    randomized clinical trial (RCT)
  • Patients are randomly assigned to
  • treatment or
  • placebo group
  • Double blind
  • Neither Pt or Dr knows what group it is

Randomized clinical trials
  • RCTs attract highly motivated Pts, noncompliant
    ones tend to be dropped from analysis
  • RCTs are essential science tools, but we must be
    cautious in conclusions drawn.

Problems with RCTs
  • RCTs measure the efficacy of the molecule
  • How well it works in the body under optimal
  • Effectiveness is different
  • How well the medication works in the real world,
    by the average patient
  • Many medications are not being used to their full
  • Key problem is noncompliance

Measuring adherence is problematic, but
technology and partnerships may help
There is no gold standard for measuring
adherence behavior measurement of adherence
remains only an estimate of a patients actual
World Health Organization 2003Adherence to
Long-Term Therapies Evidence for Action
  • Technology Smart delivery systems to release
    medicine in the body
  • Cross-sector partnerships deliberately attacking
    behavioral change and chronic diseases

Sources Adherence to Long-Term Therapies
Evidence for action. World Health Organization
2003. Available at http//
ditions/adherencereport/en/. American Medical
Association. Facilitating Adherence with
Technology. Available at http//
ama/pub/article/12202-8430.html. Pfizer Clear
Health Communication Initiative 2003-2004.
In addition to the financial benefits of
adherence, the medical benefits are real
Medical Benefits of Patient Adherence
  • Fewer medical complications
  • Better quality of life
  • Decreases in drug resistance
  • Wiser use of health resources
  • Decreases in pain and intervention
  • Increases in work productivity

When we are sick, working is hard and learning
is harder still. Illness blunts our creativity,
cuts out opportunities.
Kofi AnnanSecretary-General, United Nations
Sources Adherence to Long-Term Therapies
Evidence for action. World Health Organization
2003. Family Medicine NetGuide. Patient
Adherence Explained. Available at
Canada Cost of nonadherence
  • In Canada, patient nonadherence and physician
    inappropriate prescribing combined have been
    estimated to cause
  • 20,000 deaths per year
  • one million hospitalizations per year
  • (McLean et al., 1998)

Why is there such poor adherence?
  • Video on nonadherence
  • http//

Ex of Hypertension Most people have had their
blood pressure checked
  • Blood pressure is a vital sign (heart rate,
    respiration, temperature, blood pressure)
  • Hypertension (high blood pressure) is strongly
    linked to mortality and morbidity
  • 4.1 million hypertensive individuals in Canada,
    many die each year
  • 98 had had their blood pressure tested at least
  • 73 had had their BP tested in the last year

The Problem of HypertensionWhy dont patients
get treated?
  • Of those with high Blood Pressure (BP) who
    were18-34 of age
  • 64 of males 19 of females did not know that
    they had high blood pressure
  • Only 16
  • Were in treatment for their condition, and
  • Had brought their BP to acceptable levels
  • Most people with high BP who die do not have
    their condition under control

The Problem of hypertension
  • How can it happen that checking blood pressure is
    a standard part of medical care,
  • YET, so many people with high BP are unaware of
    the problem?

The ecology of the medical consult
  • Approx. 25,000 active General Practitioners
    (GPs) and Family Practitioners (FPS) in Canada
  • Each responsible for approximately 1200 patients
    (30 million Canadians /25,000 GP/FPs)
  • Average visit lasts approximately 12 min
  • Check-ups are longer
  • Physician sees 30-35 patients/day

Preconditions for the medical consult
  • Pt identifies health problem Breast lump?
  • Self-assessment of medical problem occurs
  • Health care professional is chosen visited
  • Power relationship is established
  • Who is the agent of change, patient or Dr?
  • How will power be shared?
  • When is cure achieved?

The consult timeline
  • Dr asks for patient to report problem
  • Patient presents 1 or more problem(s)
  • Dr tries to focus on most important
  • Diagnosis made (or not)
  • Treatment prescribed, instructions given
  • Case notes made (or not)
  • Consult ends
  • Patient makes notes (or not)
  • Treatment plan followed (or not)

Problems in the consult 1
  • Patient often has not done enough to prevent the
    condition (e.g., smoking, previous noncompliance)
  • Ignorance
  • Incorrect personal risk assessment
  • Perceived personal immunity
  • Patient is passive about treatment
  • Patient wants too much in one visit
  • Physician does not centre on patient needs
  • Inadequate diagnosis

Problems in the consult 2
  • Patient does not attend properly to physician
    instructions, notes seldom taken
  • Approximately 50 of information is forgotten
    shortly after the consult
  • Patient often does not
  • Fill Rx, take Rx, or continue Rx
  • Adhere to other treatment recommendations
  • Report treatment problems and concerns to doctor

Medical communication problems
  • Patients are not being informed adequately
  • Patients are forgetful
  • Patients are noncompliant with lifestyle
  • Patients are noncompliant with medications
  • Patients do not feel sufficiently empowered to
    take care of their own health

  • Adherence is lower when
  • Recommendations do not seem medical
  • Lifestyle modification is needed
  • Complex self-care regimens are required
  • Patients have private and conflicting theories
    about the nature of their illness or treatment.
  • Adherence is increased when
  • Patients have decided to adhere
  • They feel the provider cares about them
  • They understand what to do
  • Good communication is used
  • They have received clear, written instructions.

Factors affecting adherence
  • Demographic Factors
  • Gender, ethnicity and age
  • Treatment regimen complexity, duration,
    disruptive effects, cost
  • Side effects
  • Avoidant Coping Strategies
  • People with avoidant coping strategies are less
    likely to adhere?
  • Presence of Life Stressors
  • Other problems affect adherence
  • Lack of time
  • No money
  • Problems at home

Some determinants of adherence to treatment
regimens and care
The Modern Patient-Physician Relationship Is
Becoming Horizontal
Evolving Patient-Physician Relationship
  • Paternalism
  • One-on-one strategies
  • Knowledge gap
  • Doctors orders
  • Intervention

Partnership Team approaches Educational
empowerment Mutual decision-making Prevention
Sources Magee M, DAntonio M. The Best Medicine.
New York Spencer Books 2001. Magee M.
Relationship Based Health Care in the United
States, United Kingdom, Canada, Germany, South
Africa, and Japan. Presented at the World Medical
Association Annual Meeting. Helsinki, September
11, 2003.
How do we improve adherence?
  • Teach providers how to communicate
  • Spend some time in conversation about non-medical
  • Train providers Patient-centred communication
  • Listen to the patient and ask them to repeat what
    has to be done
  • Gear the frequency of visits to adherence needs
  • Involve the patients spouse/partner
  • Avoid medical jargon Give clear instructions on
    exact treatment and why it is so

Improving adherence contd
  • Postcard reminders or telephone calls reminding
    them to come back in
  • Reduce time spent in waiting room
  • Repeated presentation of treatment regimen
  • Providers personal authority can be used to
    instill compliance
  • Provider must probe for potential adherence
    barriers or obstacles What are the patients
  • Adopt a friendly, less business like attitude

Reasons for poor adherence are understood
Solutions are taking shape
Questions to Generate Information
Adherence Requires
  • How much medication is needed?
  • How often? Same time every day?
  • Empty the bottle? Refills? Side effects?
    Addiction? Interactions?
  • Information? Phone number?
  • 1) Understanding the plan
  • 2) Agreement on course of action
  • 3) Commitment to execution

  • No single strategy known to be effective
  • Interventions must be tailored to the individual
  • Peer, family and community support helps
    (especially peer support, according to the WHO)

Sources Adherence to Long-Term Therapies
Evidence for action. World Health Organization
2003. Available at http//
ditions/adherencereport/en/. Family Medicine
NetGuide. Patient Adherence Explained. Available
at http//
What did we talk about today?
  • Pain
  • Definition, assessment, pain management
  • Adherence to medication
  • Prevalence of nonadherence
  • Costs of nonadherence
  • Causes of nonadherence
  • Solutions