Pain Evaluation Triage and Treatment : An Innovative Option for the Integration of Pain Management i

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Pain Evaluation Triage and Treatment An
Innovative Option for the Integration of Pain
Management in the Primary Care Setting

• Robin L. Mack, CANP, CPM
• Pain Evaluation Triage and Treatment Clinic
• G.V. (Sonny) Montgomery VA Medical Center
• Jackson, Mississippi

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Objectives

• Recall VHA Pain Management Strategy.
• Review Pain Management Directive 2003-021 and
  National VA Pain Management resources for pain
  management in the OEF/OIF Population
• Integration of tradition and nontraditional
  evaluations and interventions for pain
  management.
• Compare and contrast OEF/OIF veterans with
  chronic pain to the typical older veteran
  population in Pain Evaluation Triage and
  Treatment.

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KEY ELEMENTS OF VHA NATIONAL PAIN MANAGEMENT
STRATEGY

• Pain Assessment and Treatment Procedures for
  early recognition of pain and prompt effective
  treatment shall be implemented by all VA medical
  treatment facilities.
• VHA will implement "pain as the 5th vital sign"
  in all clinical settings to assure consistent
  assessment of pain.
• Pain management protocols will also be
  established and implemented in all clinical
  settings.
• Evaluation of Outcomes and Quality of Pain
  Management.
• Clinician Competence and Expertise in Pain
  Management. Establishing target goals, mechanisms
  for accountability and a timeline for
  implementation for a comprehensive, integrated
  VHA Pain Management Strategy.

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VHA PAIN MANAGEMENT STRATEGY

• BACKGROUND
• Pain is a significant health care problem in the
  United States.
• 30-40 of the population annually suffers from
  acute pain and/or chronic pain syndromes with
  incidence and severity increasing with age.
• 75 of advanced cancer patients experienced
  moderate to severe pain.
• VHA challenged to develop a systematic approach
  to pain management that assures that pain is
  recognized and treated promptly and effectively.
• VHA PAIN MANAGEMENT DIRECTIVE 2003-021

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VHA Pain Management Strategy-1998-2008

• PURPOSE to develop a system-wide approach to
  pain management that will reduce pain and
  suffering for veterans experiencing acute and
  chronic pain associated with a wide range of
  illnesses, including terminal illness.

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Pain Evaluation Triage and Treatment Clinic

• Challenge to make pain a priority, and assure
  that pain addressed promptly and appropriately.
• Shortage/limited access to secondary pain
  providers for comprehensive pain screenings,
  assessment, management and reassessment.
• Collaboration/management of behavioral health,
  primary care and pain management.
• Promotion of facility wide interdisciplinary
  approach to pain management.

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PAIN EVALUATION TRIAGE AND TREATMENT
CLINIC(PETT) Pain Management in the Primary care
Setting

• Comprehensive Pain evaluations, triage and
  treatment in a timely manner. Interdisciplinary
  approach to pain management.
• Appropriate referral to specialty clinics (e.g.
  PMRS, Anesthesiology, Rheumatology, Neurology,
  neurosurgery, Orthopedics, Psychology, CDTP,
  Chaplain, Oncology).
• Integration of pain management plan from the
  specialty to primary care. Increase
  responsibility of PCP with pain care in primary
  care setting.

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PAIN MANAGEMENT DIRECTIVE 2003-021PAIN STRATEGY

• Provide a system-wide VHA standard of care for
  pain management that will reduce suffering from
  preventable pain.       
• Assure that pain assessment is performed in a
  consistent manner.       
• Assure that pain treatment is prompt and
  appropriate.       
• Include patients and families as active
  participants in pain management.       
• Provide for continual monitoring and improvement
  in outcomes of pain treatment.       
• Provide for an interdisciplinary, multi-modal
  approach to pain management.       
• Assure that clinicians practicing in the VA
  healthcare system are adequately prepared to
  assess and manage pain effectively.

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VA NATIONAL PAIN MANAGEMENTPOST DEPLOYMENT PAIN

• Recent data suggest that a significant percentage
  of veterans of Operations Enduring Freedom and
  Iraqi Freedom will experience pain conditions
  that interfere with daily functioning and
  adversely affect quality of life.
• The following resources are provided to assist VA
  providers, researchers, and administrators with
  the implementation of effective strategic
  planning, resource allocation, and personnel
  training to ensure the early identification and
  treatment of chronic pain among veterans of
  Operations Enduring Freedom and Iraqi Freedom

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Prevalence of Chronic Pain

• Rates 30-50 million Americans annually (Chronic
  Acute )
• 38 Americans Back Pain/Musculoskeletal
• 16 Migraines/Other Headaches
• 15 Neuropathies
• 4 Facial/Jaw
• 5 Abdominal/GI
• Cost
• 100 Billion Dollar Problem (annually)

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What is Chronic Pain?

• Chronic Pain
• 3 months
• Typically ill defined via source/cause
• Commonly associated with biological,
  psychological, and social/cultural consequences
• Two Types
• Intermittent/Acute Recurrent occurs when pain
  condition is chronic but episodic.
• Intractable/constant pain is non-episodic and is
  constant, may have flare-ups that are worse but
  typically have moderate to high level of daily
  pain.

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Most common diagnosis OEF/OIF Musculoskeletal
Pain

• Chronic back/lower extremity pain-Osteoarthritis-d
  egenerative changes-mechanical- axial.
• Chronic neck/upper extremity pain.
• Chronic hip, knee, shoulder pain.

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PETT Clinic Other common diagnosis in OEF/OIF

• Myofascial pain
• Peripheral neuropathies, chronic neuropathic pain
• Depression, anxiety
• Fatigue
• Insomnia
• Headaches

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Biopsychosocial Model of Pain
Nociception Physiological Unit
Pain Sensation CNS sensory interpretation
Pain Distress Psych. Reaction Past/Future
Pain Behavior
Socio-Cultural
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Pain Evaluation Triage and TriageAn
Interdisciplinary Pain Care Team integrated in
the Primary Care Setting

• Disciplines-team model
• Physical Medicine Rehabilitation
• Psychiatry/CDTP Neurology
• Surgery (Ortho/NSGY) -PT/OT
• Anesthesiology -Patient Care Service
• Primary Care -Chiropractic Clinic
• Clinical Pharmacy -Psychology

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PETT EVALUATION FOCUS

• Pain
• Standardized method of assessment.
• Identifying source of pain.
• Education related to chronicity of painful
  condition.
• Films reviews, explaining physical findings
• Mood
• Stigmatism of depression
• Function
• Developing realistic expectations and goals for
  veteran and provider.
• Follow-up-telephone/clinic.

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PAIN ASSESSMENT

• Fifth vital sign
• Solve the mystery
• Primary source of pain
• History
• Onset and temporal patterns
• Location
• Intensity(VAS) description
• Chronology/pattern
• Precipitating factors
• Alleviating/Aggravating factors (Previous
  treatments-effectiveness)
• Associated symptoms- effects on physical and
  social function

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Measuring Pain What Works

• General Principles
• Always get Pain today, average pain, best and
  worst pain, dont lead on worst pain.
• Use same scale(s) for Pain Interference
• More Sensitive Measure of Functioning
• Use behavior to assess validity of pain level
• This can change with little change in subjective
  pain
• Common Scales
• Analogue Scale 1-10
• Visual Analogue Rating Scale
• Wrong Baker Faces Scale

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Psychological Treatments for Chronic Pain
Pain-Distress Cycle
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PAIN PSYCHOSOCIAL ASSESSMENT

• Understanding and the effects of diagnosis.
• Meaning of Pain to the veteran.
• Significant past experiences of pain and their
  effect on the veteran and his/her life/family.
• Knowledge and expectation of pain control and
  direction of pain management.
• Concerns about controlled substances.
• Economic effect of the pain and its treatments.
• Changes in mood that have occurred as a result of
  pain (e.g., depression, anxiety)

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FACTORS THAT INFLUENCE PAIN PSYCHOLOGIC FACTORS

• Fear and Anxiety
• Complex and difficult to manage
• Fear worsens pain, pain worsens feelings of fear
  (limbic system)
• Serious injuries heighten levels of pain and
  anxiety due to helplessness and lack of control.
• Coping-personalities
• Internally controlled, self-sufficient, and
  independent-denial
• Insufficient, externally controlled, and
  dependent of others

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TIPS FEARS FRUSTRATION-DEALING WITH CHRONIC
PAIN AND LIMITATIONS

• Validate feelings.
• Describe concrete actions to take.
• Build confidence.
• Dont arouse fear.
• Downplay negative consequences.
• Empathy.

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PAIN ASSESSMENT BEHAVORIAL OBSERVATIONS

• Behavioral observations
• Verbal-integrate and clarify
• Nonverbal
• Facial expressions
• Vocalizations
• Body movement
• Social interaction

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FACTORS THAT INFUENCE PAINPHYSIOLOGIC FACTORS

• Fatigue
• Genetic Makeup
• Memory
• Stress Response
• Neurologic Function

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PAIN PREVALENCE- OEF/OIF

• Chronic pain syndromes- OEF/OIF
• 97 Chronic severe pain
• 54.5 Back
• 18.5 lower extremities
• 18.5 Neck
• 3.5 Headache
• 4.0 Neuropathic/neuralgias
• 65 PTSD/depression
• 75 Insomnia/fatigue

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PAIN ASSESSMENTPHYSICAL EXAMINATION

• Neurological Examination- Red flags
• Muscle weakness and strength, sensory, reflexes,
  atrophy, gait, bladder and bowel function.
• Discussing goals (veteran and provider),
  expectations, and understanding of the reality of
  chronic pain.
• Respect, Privacy, and Confidentiality.

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DIAGNOSING DIFFUSE ACHES AND PAINS

• Diagnostics
• Plain films w/flexion extension view-
  subluxation-slippage-spondylolithesis-reviweing
  these films with veteran.
• CT/MRI/EMG/NCS
• Normal EMG does not exclude neuropathic
  pain-small fiber not assessed. Discuss results,
  and verify understanding of condition.
• Blood studies-
• Erthrocyte sedimentation rate (ESR)
• Inflammatory polyathritis (e.g. rheumatoid
  arthritis, anklosing spondylitis, psoriatic
  arthritis)
• Serum alkaline phosphatase (SAP) BUN, Creatinine,
  SGOT/SGPT
• B12- Folate
• DAU

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DIAGNOSING TREATING THE PAIN

• PHYSICAL EXAMINATION- close examination of
  painful area.
• Exact nature of the pain
• More specific the diagnosis the more effective
  the intervention, and less complications.
• Synthesizing information from a variety of
  sources (family, significant others,surveys)
• Treatment goals include balance.
• Respect for the validity of veterans experience
  of pain

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TREATMENT OPTIONS

• Rational polypharmacy is often necessary.
• Planning and managing-goal setting.
• Treatment goals include
• Balancing efficacy, safety, and tolerability.
• Reducing baseline pain scores and pain
  exacerbations.
• Improving function and quality of life.

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COMPLIMENTARY ALTERNATIVE MEDICINE

• Complimentary nontraditional healing theories
  and practice to supplement traditional science
  based theories and and practices
• Alternative options means the sole use of
  nontraditional practices interventions

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COMPLIMENTARY ALTERNATIVE PRACTICES

• Biologic (herbal, diets, vitamins, melatonin)
• Energy Fields (acupuncture, therapeutic touch,
  CES, TENS)
• Manipulative and body based (Chiropractic,
  lymphatic drainage, reflexology)
• Mind-Body (biofeedback, hypnosis, art therapy,
  prayer

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MEDICATION SELECTION IN CHRONIC PAIN

• Nociceptive Pain- Short-Term NSAIDS, Cox2,
  Opioids
• Neuropathic Tricyclics, Trazadone, Gabapentin
• Pain Conditions Major Depression-
• Tricyclics, Tizandine, SSRI, Venlafaxine,
  Duloxetine, Opioids

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TRADITIONAL INTERVENTIONSPHARMACOLOGIC
NONOPIOID

• Non-opioid Analgesics (Mild -Moderate Pain)
• act on peripheral nerve endings at the injury
  site, whereas opioids work at the level of the
  CNS, decreasing the perception of pain. (Tylenol
  3)
• NSAIDs- Acetylsalicylic acid (aspirin) and
  Ibuprofen, Naprosyn, Piroxicam, Salsalate,
  Etodolac (Lodine), Toradol, Cox- 2 inhibitors
  (Celebrex), Indomethacin, Acetaminophen (Tylenol)

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COMMON NONOPIOID ANALGESICS
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OPIOID ADVERSE EFFECTS AND PREVENTABLE MEASURES
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Medical Management of other diagnosis

• Depression, anxiety, PTSD-Mental Health
• Insomnia- Trazadone
• Fibromyalgia- NSAIDS-new medications (Lyrica,
  Cymbalta)
• Chronic fatigue
• Check folate, and levels-
• injections B6 supplements 50-100mg daily- f/u
  levels
• Vitamin D

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Typical Pain Management Plan

• Discuss condition, make sure veteran informed.
  Set functional/pain score goals together,
  consider whole person.
• Consult PMRS- for TENS unit- for acupuncture
• Consult PMRS-Pain Management for interventional
  options, adjustments for acute flairs.
• Consulting Ortho, Neurology, Neurosurgery,
  Rheumatology, and inform PCP.
• Schedule f/u phone and clinic visits.
• Consider Psychological contacts- education-
  behavioral.

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VA NATIONAL PAIN MANEGMENT WEBSITE

• Facilitates effective pain management by
  providing convenient, centralized access to
  resources for the provision of pain services
  within the VA healthcare system.
• Users of this site are VA administrators,
  clinicians, and researchers who have an interest
  in any aspect of pain management.
•  
• Designed to provide these groups of individuals
  with quick access to a range of relevant
  resources from both internal and external sources

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PAIN PREVALENCE DATA

• Post Deployment Resources Deployment Health
  Clinical Center Web Site
• American Pain Foundation Survey of Veterans and
  Pain   The results of an online survey of a total
  of 753 veterans or members of the military.
• Gironda, Clark, Massengale, Walker, 2006
  abstract   Published in  Pain Medicine , this
  article provides an estimate of the prevalence
  and severity of pain among veterans of Operations
  Enduring Freedom and Iraqi Freedom (N 970). 
•  

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Clinical Resources

• Pain Management in Severely Impaired Polytrauma
  Patients Entering Rehabilitation   The satellite
  broadcast presented by the Department of Veterans
  Affairs Employee Education System and the Office
  of Patient Care Services Pain Management on
  December 12.
• VA/DoD Clinical Practice Guideline for Management
  of Medically Unexplained Symptoms (MUS) Chronic
  Pain and Fatigue    This CPG was designed to
  assist clinicians in primary care settings in all
  aspects of patient care related to medically
  unexplained symptoms involving chronic pain and
  fatigue.
• VA Seamless Transition Web Site   The VA web site
  for returning Active Duty, National Guard and
  Reserve service members of Operations Enduring
  Freedom and Iraqi Freedom. The web site provide
  benefits information and assistance to eligible
  veterans who honorably fought and served in our
  Nation's armed forces.

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Additional Clinical Resources

• VA Pain List Serve
• PBM resources
• Monthly National Pain Management Conferences.

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VA NATIONAL PAIN MANAGEMENT WEBSITE

• Educational Resources for Providers
• Chronic Pain Primer   A brief introductory text
  that provides basic information regarding chronic
  pain and multidisciplinary treatment.
• EES Web Course  Clinical Use of Placebo An
  Ethics Analysis  A course designed to educate VHA
  practitioners about the ethical issues around the
  clinical use of placebo  (1.0 ACCME, ANCC, or EES
  credit).
• EES Web Course  Opioids in the Management of
  Acute and Chronic Pain- Independent Study   This
  course will assist staff in learning how to  use
  opioids appropriately in the management of acute
  and chronic pain (3.0 ACCME, ACPE, ANCC, or APACE
  credit).

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CLINICAL TOOLS RESOURCES

• Assessing Pain in the Patient with Impaired
  Communication    The consensus statement from the
  VHA National Pain Management Strategy
  Coordinating Committee.
• The International Classification of Headache
  Disorders   The 2nd edition of the hierarchical
  nosology designed for both clinical practice and
  research.
• Pain as the 5th Vital Sign Toolkit   The Pain as
  the 5th Vital Sign Toolkit revised, 2000 is
  designed to help VA staff initiate the pain
  screening and assessment. The toolkit contains a
  wealth of information including VA medical center
  pain management policies, patient and staff
  education resources, and references.
• VHA Pain Outcomes Toolkit   The VHA Pain Outcomes
  Toolkit, revised February 2003 is designed to
  assist healthcare providers and facilities to
  devise methods and implement processes to measure
  pain treatment outcomes

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Resources To Own

• General Resources
• 1. Clinical Essentials of Pain Management, by
  Robert Gatchel ISBN 1-59147- 153-2
• 2. Psychological Approaches to Pain Management,
  edited by Turk and Gatchel ISBN 1-57230-642-4
• 3. Managing Pain Before it Manages You,
  Margret Caudill, ISBN 1-57230-718-8
• 4. Managing Chronic Pain A cognitive-behavioral
  approach John Otis, Treatments that Work
  Series. www.opu.com
• Patient Resources
• 1. Managing Pain Before it Manages You, Margret
  Caudill, ISBN 1-57230-718-8
• 2. Managing Chronic Pain A
  cognitive-behavioral approach (Work Book) John
  Otis, www.opu.com
• 3. The Pain Survival Guide, Dennis C. Turk, and
  Frits Winter, ISBN 1-59147-049-8
• 4. The Headache Neck Pain Workbook An
  integrated mind and body program. Douglas E.
  DeGood, ISBN 1-57224-086-5

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VA National Pain Management TeleconferenceNovembe
r 4, 2008

• THANK YOU FOR YOUR TIME AND COMMITMENT TO
  SERVING OUR VETERANS.
• THEY NEED IT, AND DESERVE IT!