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Title: Disparities in Care: Managing Pain in Special Populations


1
Disparities in Care Managing Pain in Special
Populations
2
Activity Agenda
  • How to improve pain management in
  • Children
  • Older adults
  • Women
  • Racial and ethnic minorities

3
Pain Management in Children
  • Module 1

4
Module 1 Educational Objectives
  • Discuss general issues of pain in children,
    including
  • Pathophysiology of pain
  • Differences in perception and expression of pain
  • Differences in response to and acceptance of pain
    treatment
  • Physician attitudes and beliefs
  • Barriers to pain management
  • Strategies to improve management
  • Assessment tools

5
Chronic Pain in Children
From Marcus DA. Chronic Pain A Primary Care
Guide to Practical Management. 2nd Edition.
Totowa, N.J. Humana Press, 2008.
6
Prevalence of Recurring Pain in Children and
Adolescents
From Marcus DA. Chronic Pain A Primary Care
Guide to Practical Management. 2nd Edition.
Totowa, N.J. Humana Press, 2008.
7
Pathophysiology of Pain
  • Once assumed that neonates
    and infants didnt experience pain
  • Continued exposure to painful
    stimuli may increase sensitization
  • Undertreatment of chronic pain
    has a significant consequence

Taddio A. Paediatric Drugs. 20057245-57.
8
Perception and Expression
of Pain
  • Expression influenced by level of cognitive
    development
  • Pain may be expressed by
  • Crying and facial expressions conveying pain
  • Increases in vital signs (e.g., pulse,
    respirations)
  • Sleeplessness or irritability

Howard R. JAMA. 20032902464-9.
9
Response to and Acceptance of Pain
Therapy
  • Children may be reluctant to report pain
  • Consider actions of medications
  • Doses are different for children compared with
    adults
  • Ensure that analgesic levels are achieved

Texas Cancer Council. 1999. Currie J. Arch Div
Child Ed Pract. 200691ep111-4.
10
Physician Attitudes and Beliefs
  • Infants / children experience pain the same way
    adults do
  • Reliance on adult reports of pain rather than
    childs
  • Pain experienced by very young children isnt
    remembered
  • Pain cant be adequately assessed in children

11
Barriers to Managing Pain
  • Misconceptions about pain in children (e.g.,
    assuming that verbal children will state when
    they are experiencing pain)
  • Barriers for children requiring palliative care
    (e.g., uncertain prognosis, family perception
    that palliative care means giving up)
  • Lack of evidence-based guidelines

Davies B, et al. Pediatrics. 2008121282-8.
12
Strategies to Improve Pain Management
Provider
Patient
Child
School
Family
Currie J. Arch Div Child Ed Pract.
200691ep111-4.
13
Strategies to Improve
Pain Management
  • Be alert to the possibility of pain
  • Engage families
  • Engage with schools in school-aged children
  • Target the intervention to the patient to the
    extent possible
  • When possible, give the child some control over
    the treatment

Currie J. Arch Div Child Ed Pract.
200691ep111-4.
14
Evidence-based Recommendations
  • Recommendations
  • Distraction and hypnosis are effective
    interventions for procedures in children and
    adolescents (age 2-19)
  • Listening to music may have a small effect, but
    is not recommended because of its limited benefit
  • Source Cochrane
  • Web Site http//www.cochrane.org
  • Strength of Evidence Meta-analysis

Eccleston C, et al. Psychological therapies for
the management of chronic and
recurrent pain in children and adolescents.
Cochrane Database of
Systematic Reviews 2003, Issue 1. Art. No.
CD003968. Cepeda MS, et al. Music for pain
relief. Cochrane Database of
Systematic Reviews
2006, Issue 2. Art. No. CD004843.
15
Management Starts with Recognition
  • Assessment should include thorough history and
    physical
  • Establish presence of pain and determine, if
    possible, source of pain
  • Use targeted strategies
  • Observation of painful behaviors is important
  • Remember, there may be inconsistencies between
    behavior and pain intensity
  • Determine if there is another source of distress
  • Reports from parents, family members, and others

Chambliss CR, et al. Pediatric Drugs.
20024737-46. Herr K, et al. Pain Manag Nurs.
2006744-52.
16
Pain Management Strategies
  • Give a trial of analgesics to relieve the pain
    and break the pain cycle reassess to determine
    effectiveness of selected treatment
  • Use same basic approach for infants / pre-verbal
    toddlers
  • Ability to self-report existence of pain appears
    at 2 years
  • In children lt2 years, use behavioral observations

17
First-line Therapy for Pain
  • Acetominophen 60 mg/kg/d in 4 divided doses
    maximum dose 4 g/d for children gt12 years
  • Ibuprofen 5-10 mg/kg up to 6 hourly
  • Naproxen 2 years old not recommended
  • gt2 years old 10 mg/kg in 2 divided dose
    (higher doses can be used)
  • Ketorolac gt6 months 0.5 mg/kg IM/IV q6 hours up
    to 72 hours

Currie JM. Management of chronic pain in
children. Arch Dis
Child Ed Pract. Dec
200691ep111-ep114. Used with permission.
18
Other Agents
  • Opioids may be oral or parenteral
  • Age-based variations in pharmacokinetics of
    opioids
  • Pre-term infants may have a paradoxical
    respiratory response
  • Common side effects at any age include nausea and
    vomiting
  • For neuropathic pain, gabapentin may be used
  • Titrate slowly and taper if discontinued
  • Dosing recommendations in children
  • Age 3-12 years start 10-15 mg/kg/day divided tid
    max dose 50 mg/kg/day
  • Age gt12 years start 300 mg tid max dose 3600
    mg/day
  • lt3 years Not recommended

19
Evidence-based Recommendation
  • RecommendationLocal anesthetics can be useful
    for procedural pain EMLA cream for circumcisions
    reduces pain and is safe for a one time use.
  • Source Cochrane
  • Web Site www.cochrane.org
  • Strength of Evidence Meta-analysis

Taddio A, et al. Lidocaine-prilocaine cream for
analgesia during circumcision in newborn boys.
Cochrane Database of Systematic Reviews 1999,
Issue 3. Art. No. CD000496.
20
Pain Assessment Tools
for Infants
  • Neonatal Infant Pain Scale
  • CRIES tool Measures crying,
    oxygen requirement, vital signs,
    expression of pain, and sleeplessness
  • Premature Infant Pain Profile (PIPP)
  • Limited evidence of equivalent
    validity of CRIES and PIPP

American College of Clinical Pharmacy 2005 Annual
Meeting. Howard R. JAMA. 20032902464-9.
21
Pain Assessment Tools for
Older Children
  • Visual Analog Scale
  • Pictorial Pain Scale
  • Adolescent Pediatric Pain Tool
    (also in Spanish)
  • Behavioral Observational Pain Scale
    (validated in post-operative children
    1-7 years of age)

Hasselgard K, et al. Pediatr Crit Care
Med. 20078102-8.
22
Pain Evaluation Scales
0
100
Visual Analog Scale (VAS)
Complete pain relief
No pain relief
0
100
Pictorial Pain Scale
Pain Intensity Numerical Rating Scale (PI-NRS)
No pain
0
1
2
3
4
5
6
7
8
9
10
23
Module 1 Summary Points
  • Misinformation about pain in children contributes
    to its undertreatment
  • Understanding medications, their interactions and
    side effects, as well as differences in dosing is
    critical
  • A comprehensive approach to pain management
    includes a careful assessment, utilizing
    available tools, and engaging family and schools
    in developing the pain management plan

24
Module 1 Summary Points (cont.)
  • Although self-report is reliable, clinicians
    should not wait for patients to complain of pain
  • Inquire directly about pain and anticipate
    situations where pain is likely, intervening as
    necessary

25
Pain Management in the Elderly
  • Module 2

26
Module 2 Educational Objectives
  • Discuss general issues of pain in older adults,
    including
  • Pathophysiology of pain
  • Differences in perception and expression of pain
  • Differences in response to and acceptance of pain
    treatment
  • Physician attitudes and beliefs
  • Barriers to pain management
  • Strategies to improve management
  • Assessment tools

27
Prevalence of Pain
  • Prevalence of chronic non-malignant pain
  • 75 of those living in long-term care facilities
  • 50 of those living in the community
  • Estimates of patients experiencing pain that
    isnt controlled
  • 2540 of frail adults living in the community
  • 4580 of the elderly living in nursing homes
  • Elderly patients often have diseases that
    cause pain (e.g.,
    arthritis) along with other
    diagnoses that complicate pain management

Landi F, et al. Arch Intern Med.
20011612721-4. Shapiro K. 2001 Annual Meeting
of the American Pain Society.
28
Pain Duration in the Elderly
29
Pathophysiology of Pain
  • Changes in the brain and nervous system may have
    an impact on the experience of pain
  • Increased pain threshold for pain
  • Decreased tolerance for pain
  • Slower resolution of the increased sensitivity to
    pain after injury

Buckalew N, et al. Pain Med. 20089240-8. Gibson
SJ, et al. Clin J Pain. 200420227-39.
30
Perception and Expression
of Pain
  • There may be an age-related decrease in pain
    perception and reporting
  • Painless manifestations of problems painful in
    other age groups
  • Studies show the elderly experience pain
    intensity as much as other age groups

Bruckenthal P, et al. Topics in Advanced Practice
Nursing eJournal. 20077(1). Gladjechen M. J Am
Board Fam Pract. 200114178-83.
31
Why Elderly Patients May
Not Report Pain
  • Misperception that pain is part of aging
  • Reluctance to become a burden
  • Fear of outcome (e.g., expensive tests,
    hospitalization)
  • Perception of lower priority compared to other
    problems
  • The demented elderly is a special
    challenge

32
Important Considerations
When Managing Pain
  • Malnutrition may have depleted protein stores
  • Use of multiple medications
  • Impaired GI motility, kidney function, or cardiac
    output may impact absorption, metabolism, and
    clearance of pain medications
  • Some medications are known to cause mental status
    changes in the elderly
  • Patients may fear addiction to opioids,
    tolerance, or medication side effects

Bruckenthal P, et al. Topics in Advanced Practice
Nursing eJournal. 20077(1).
33
Barriers to Pain Management in the
Elderly
  • Physician beliefs
  • Natural part of aging
  • Cant tolerate strong medications
  • Concern about addiction
  • Less prevalent
  • Patient attitudes
  • Reluctant to report
  • Fear
  • Cognitive impairment

Elderly with pain
  • Physician knowledge
  • Dont understand pain
  • Lack of training
  • Practice issue
  • Time

Taylor A, et al. JAMA. 200829989-91. Monti D,
Kunkel E. Psychiatric Services. 1998491545-8.
34
Challenges in Pain Management in Older People
Physician Poll Results
Online survey of family physicians conducted by
the
AAFP August/September 2008.
35
Managing Side Effects
  • A 12-month study of adverse drug events in an
    ambulatory practice (gt30,000 patients) identified
    1523 drug-related events
  • 27.6 overall considered preventable
  • 42 of serious or life-threatening events were
    considered preventable

Gurwitz J, et al. JAMA 2003 289(9) 1107-1116.
36
Classes of Drugs Used Associated with
Adverse Events
Gurwitz JH, et al. JAMA. 2003289(9)1107-16.
37
Causes for Adverse Drug Events
Gurwitz JH, et al. JAMA. 2003289(9)1107-16.
38
Principles for Optimizing Drug Use
  • Consider whether drug therapy is necessary
  • Promote the use of a small number of drugs to
    treat common problems (don't prescribe newly
    marketed products)
  • Adjust doses, dosage intervals for medications,
    or both
  • Establish reasonable therapeutic endpoints and
    monitor for desired outcome

Medication-Related Adverse Patient Events Among
Older Adults Are
Focus of 2007 Henderson
State-of-the-Art Lecture AGS News
Third
Quarter 2007 Volume 38 Number 3
39
Principles for Optimizing Drug Use (cont.)
  • Monitor for medication-related adverse patient
    events
  • Encourage adherence (but only after ensuring
    optimal medication prescribing)
  • Regularly review chronic medications and take a
    thorough "brown bag" drug history

Medication-Related Adverse Patient Events Among
Older Adults Are
Focus of 2007 Henderson
State-of-the-Art Lecture AGS News
Third
Quarter 2007 Volume 38 Number 3
40
Strategies to Improving Pain Management
  • Ensure good lighting
  • Have large print materials
  • Have equipment to amplify hearing
  • Use pain logs or diaries to monitor pain and
    effectiveness of treatment
  • A team care approachpatient, family, nurses,
    physiciansmay be needed to achieve pain
    management goals

Gladjechen M. J Am Board Fam Pract.
200114178-83.
41
Evidence-based Recommendation
  • Recommendation Initial evaluation should include
    a description of pain in relation to impairments
    in physical and social function (e.g., activities
    of daily living, sleep, appetite, energy,
    exercise, mood, cognitive function, interpersonal
    and intimacy issues, social and leisure
    activities, and overall quality of life). (IIA)
    The patients attitudes and beliefs regarding
    pain and its management, as well as knowledge of
    pain management strategies, should be assessed.
    (IIB)
  • Source American Geriatrics Society
  • Web Site http//www.americangeriatrics.org/
  • Strength of Evidence IIA (II Evidence from at
    least one well-designed clinical trial without
    randomization, from cohort or case-controlled
    analytic studies, from multiple time-series
    studies, or from dramatic results in uncontrolled
    experiments. A Good evidence to support the use
    of a recommendation clinicians should do this
    all the time.) IIB (II Evidence from at least
    one well-designed clinical trial without
    randomization, from cohort or case-controlled
    analytic studies, from multiple time-series
    studies, or from dramatic results in uncontrolled
    experiments. B Moderate evidence to support the
    use of a recommendation clinicians should do
    this most of the time.)

AGS Panel on Persistent Pain in Older Persons.
JAGS. 200250(6Suppl).
42
Evidence-based Recommendation (cont.)
  • Recommendation For the older adult who is
    cognitively intact or who has mild to moderate
    dementia, the physician should attempt to assess
    pain by directly querying the patient. For the
    older adult with moderate to severe dementia or
    who is nonverbal, the physician should attempt to
    assess pain via direct observation or history
    from caregivers. (IIA)
  • Source American Geriatrics Society
  • Web Site http//www.americangeriatrics.org/
  • Strength of Evidence IIA (II Evidence from at
    least one well-designed clinical trial without
    randomization, from cohort or case-controlled
    analytic studies, from multiple time-series
    studies, or from dramatic results in uncontrolled
    experiments. A Good evidence to support the use
    of a recommendation clinicians should do this
    all the time.)

AGS Panel on Persistent Pain in Older Persons.
JAGS. 200250(6Suppl).
43
Pain Management Recommendations
  • Acetaminophen, around the clock, is useful in
    controlling mild-to-moderate musculoskeletal pain
  • With normal kidney and liver function and no
    history of alcohol abuse, maximum dose 4000 mg
    in 24 hr
  • Reduce dose in the presence of these problems or
    use other options, such as NSAIDs

AGS Panel on Persistent Pain in Older Persons.
JAGS. 200250(6Suppl).
44
Pain Management Recommendations (cont.)
  • There is an unacceptable rate of
    life-threatening GI bleeding with use of NSAIDs
    in older patients with multi-system
    disease, especially if used persistently
  • If no relief, opioids may be considered
  • Although physical dependence may result, this can
    be managed by tapering when discontinued

AGS Panel on Persistent Pain in Older Persons.
JAGS. 200250(6Suppl).
45
Pain Assessment Tools for the Cognitively Intact
  • Pictorial Pain Scale
  • Nonverbal Visual Analog Scale
  • Pain Intensity Scale
  • Numeric Rating Scale
  • McGill Questionnaire (short form)
  • Verbal Rating Scale
  • Pain diary may also be useful

Krulewitch H, et al. J Am Geriatr Soc.
2000481607-11.
46
Pain Assessment Tools for the Cognitively Impaired
  • Pain Intensity Scale
  • More likely to identify pain and also easier to
    use by patients in one study
  • Behavioral observations are an important part of
    the pain assessment
  • Signs include wandering, outbursts, aggressions,
    and tearfulness

Krulewitch H, et al. J Am Geriatr Soc.
2000481607-11.
47
Module 2 Summary Points
  • Misinformation about pain in older adults
    contributes to undertreatment
  • Understanding medications, their interactions and
    side effects, as well as differences in dosing,
    is critical
  • A comprehensive approach to pain management
    includes a careful assessment, using available
    tools

48
Module 2 Summary Points (cont.)
  • Although self-report is reliable, clinicians
    should not wait for patients to complain of pain
  • Inquire directly about pain and anticipate
    situations where pain is likely, intervening as
    necessary

49
Pain Management in Women
  • Module 3

50
Module 3 Educational Objectives
  • Discuss general issues of pain in women,
    including
  • Pathophysiology of pain
  • Differences in perception and expression of pain
  • Differences in response to and acceptance of pain
    treatment
  • Physician attitudes and beliefs
  • Barriers to pain management
  • Strategies to improve management
  • Assessment tools

51
Pain Sensitivity by Gender
From Marcus DA. Chronic Pain A Primary Care
Guide to Practical Management. 2nd Edition.
Totowa, N.J. Humana Press, 2008.
52
Pathophysiology of Pain
  • Different patterns of cerebral
    activation in response to laser
    stimulation were found in
    women and men
  • In women, pain is associated with greater
    activity in the limbic regions
  • Men given the same pain stimulus have greater
    activity in the cognitive regions

Science Daily. November 2003.
53
Estrogen Effects on Pain-modulating Neurochemicals
From Marcus DA. Chronic Pain A Primary Care
Guide to Practical Management. 2nd Edition.
Totowa, N.J. Humana Press, 2008.
54
Response to and Acceptance
of Pain Therapy in Women
  • Evidence of gender differences in response to
    some medications (e.g., women respond better to
    kappa opioids)
  • Women are more likely to use non-pharmacologic
    measures
  • Women are more likely than men to use coping
    strategies, such as reaching out to family and
    friends
  • Women with high stress levels may respond more
    poorly to therapy

Gear RW, et al. Nat Med. 199611124850. McCool
W, et al. J Midwifery Womens Health.
200449473-81.
55
Physician Attitudes and Beliefs
  • Gender stereotyping may influence prescribing of
    opioids
  • Post-operative men receive a higher initial dose
    of opioids
  • Female gender is a predictor of inadequate pain
    management in patients with metastatic cancer
  • Physicians select optimal pain management
    strategies more often for metastatic prostate
    cancer patients vs metastatic breast cancer
    patients (though actual percentages were low for
    both)
  • Women may be at greater risk than men of having
    their pain attributed to psychogenic causes

Gladjechen M. J Am Board Fam Pract
200114178-83. Green CR, et al. Pain Med.
200341-3.
56
Barriers to Managing Pain
  • Gender differences driven by differences in how
    men and women communicate
  • Women are more likely than men to be uninsured

Gladjechen M. J Am Board Fam Pract.
200114178-83. CDC. National Health Interview
Survey, 2007.
57
Strategies to Improve Pain Management
  • Comprehensive approach
  • Education, behavioral strategies
  • Team approach is helpful
  • Womens health clinics show improved patient
    satisfaction and improved quality of care
  • Provide a comprehensive approach to care

Brittle C, et al. U.S. Department of Health and
Human Services,
Office on Womens Health, 2007.
58
Management Recommendations
  • History and physical exam to determine source of
    pain treat the underlying cause
  • Pain management is a collaboration between
    clinician and patient
  • Comprehensive treatment plan
  • Set goals
  • Including non-pharmacologic as well as
    pharmacologic modalities
  • Women experience more opioid side effects such as
    vomiting and dry mouth

Fillingim R, et al. Journal of Pain.
20056116-24.
59
Pain Assessment Tools
  • Same tools as for other adults
  • Visual Analog Scale
  • Verbal Pain Intensity Scale
  • Numeric Pain Intensity Scale
  • Each has strengths and weaknesses
  • The Numeric Rating Scale has been found to be
    only modestly accurate and may miss up to
    one-third of patients with significant pain

U.S. Department of Health and Human Services,
Office on Womens Health. Clinician.
200523(3)1-17. Krebs EE, et al. J Gen Intern
Med. 2007221453-8.
60
Module 3 Summary Points
  • Women are at high risk for undertreatment of pain
  • Women are more likely to report pain and
    experience pain that is more severe and of longer
    duration
  • Hormones influence the experience of pain at both
    the central and peripheral nervous system level
  • Comprehensive approaches result in better patient
    satisfaction as well as improved clinical
    outcomes

61
Pain Management in Racial and Ethnic Minorities
  • Module 4

62
Module 4 Educational Objectives
  • Discuss general issues of pain in minorities,
    including
  • Pathophysiology of pain
  • Differences in perception and expression of pain
  • Differences in response to and acceptance of pain
    treatment
  • Physician attitudes and beliefs
  • Barriers to pain management
  • Strategies to improve management
  • Assessment tools

63
Disparities in Pain
  • Documented racial and ethnic disparities in a
    variety of health care settings
  • It is often believed that minority patients tend
    to report more pain than white patients

Gladjechen M. J Am Board Fam Pract.
200114178-83.
64
Disparities in Pain (cont.)
  • Undertreatment seems unrelated to diagnosis
  • In patients with fractures, Hispanics are less
    likely than whites to receive analgesics
  • Minority patients with cancer are commonly under
    treated for pain

Todd K, et al. JAMA. 1994271925-8.
65
Differences in Pain Response by Race
From Marcus DA. Chronic Pain A Primary Care
Guide to Practical Management. 2nd Edition.
Totowa, N.J. Humana Press, 2008.
66
Perception and Expression of Pain
  • African-Americans and Hispanics exhibit lower
    pain tolerance
  • African-Americans report higher levels of pain
    associated with a variety of diseases such as
    glaucoma, arthritis, and migraines

Edwards R, et al. Psychosom Med. 200163316-23.
67
Response to and Acceptance of
Pain Therapy
  • Variations in response to medications is based on
    genetic differences Differences demonstrated in
    metabolism, absorption, and excretion
  • Differences demonstrated in metabolism,
    absorption and excretion
  • Doses and timing may need to be adjusted

Burroughs V, et al. J Natl Med Assoc. 200294(10
Suppl)1-26.
68
Racial Differences in Treatment
of Osteoarthritis
COX-2 selective cyclooxygenase inhibitors.
NSAIDs nonsteroidal
anti-inflammatory drugs.
p lt 0.001.
From Marcus DA. Chronic Pain A Primary Care
Guide to Practical Management. 2nd Edition.
Totowa, N.J. Humana Press, 2008.
69
Use of Complementary and Alternative Medicine by
Ethnic Group
From Marcus DA. Chronic Pain A Primary Care
Guide to Practical Management. 2nd Edition.
Totowa, N.J. Humana Press, 2008.
70
Example of Genetic Variation
in Response to Codeine
  • Variations in the gene CYP2D6 are involved in the
    metabolism of codeine
  • Patients with the poor metabolizer phenotype
    get little relief from codeine
  • Ultra-metabolizers convert the drug rapidly and
    have an enhanced response
  • Prevalence of the poor metabolizer phenotype is
    not isolated to a specific racial group, but is
    higher in Caucasians and sub-Saharan Africans

Burroughs V, et al. J NMA. 200294(10 Suppl)1-26.
71
Physicians Attitudes and Beliefs
  • Little research to explain disparities in pain
    management
  • Variability in clinical decision-making exposes
    it to influences of social context, thus
    contributing to disparities
  • Potential for racial and ethnic bias in pain
    management must be considered in light of studies
    demonstrating the influence of race / gender on
    treatment recommendations in other disorders

Green C, et al. Pain Med. 20034277-94.
72
Barriers to Managing Pain
  • Providers often have opinions about how people of
    different backgrounds and cultures express pain
  • There is no uniformity in response among people
    of the same culture
  • Providers also respond to expressions of pain in
    comparison to their own response to pain

Weissman D. End-of-Life Physician Education
Resource Center. October 2002
www.eperc.mcw.edu. Todd K, et al. JAMA
1994271925-8.
73
Barriers (cont.)
  • Evidence that physician bias may explain some
    differences in pain treatment
  • System barriers also exist

Morrison RS, et al. N Eng J Med. 20003421023-6.
74
Strategies to Improve Pain Management
  • Educate patients regarding pain
  • Increase research that includes racially and
    ethnically diverse populations to provide
    evidence-based recommendations
  • Use culturally-sensitive, language-appropriate
    assessment tools

Green C, et al. Pain Med. 20034277-94. Kalauokal
ani D, et al. Pain Med. 2007817-24.
75
Evidence-based Recommendation
  • Recommendation Studies have shown that African
    Americans and Hispanics are more reluctant to
    complain of pain, and more likely to believe in
    stoicism and be concerned about opioid addiction.
    Physicians should make an effort to ask every
    patient about pain or discomfort. This may
    require asking more open-ended questions or using
    descriptors other than the word pain, such as
    discomfort, ache, or soreness, with which
    patients who are stoic may be more comfortable.
  • Source Cintron A, et al. Pain and ethnicity in
    the United States A systematic review. Journal
    of Palliative Medicine 20069(6)1454-1473.
  • Web site http//www.ncbi.nlm.nih.gov/pubmed/17187
    552?doptAbstract
  • Strength of evidence Systematic review

76
Pain Management Recommendations
  • Basic strategies are no different than for other
    groups
  • Genetic differences exist in responses to some
    medications just as there are differences in pain
    perception these should be kept in mind when
    creating the treatment plan
  • Goals for pain relief appear to be an important
    predictor for quality of pain management

77
Pain Management Recommendations (cont.)
  • Understand both the culture and beliefs of the
    patient
  • Clinicians should be aware of their own beliefs
    about pain
  • Strive for cultural competence
  • Research is needed to identify evidence-based
    strategies for improving pain management in
    racial and ethnic minorities

Weissman D. End-of-Life Physician Education
Resource Center. October 2002. www.eperc.mcw.edu
Green C, et al. Pain Med. 20034277-94.
78
Pain Assessment Tools
  • Tools assessed for use in older minority
    patients
  • Pictorial Pain Scale Revised
  • Verbal Descriptor Scale
  • Numeric Rating Scale
  • Iowa Pain Thermometer
  • All were found to be valid

Jowers Ware L, et al. Pain Manag Nurs.
20067117-25.
79
Module 4 Summary Points
  • There is a pathophysiological basis for
    differences in pain experience in racial and
    ethnic minorities
  • There are genetic differences in how medication
    is metabolized, absorbed, and excreted
  • Establishing goals for pain management is an
    essential part of effective treatment
  • Clinicians should be aware of their own beliefs
    about pain and strive for culture proficiency to
    better manage pain in their patients
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