Pain: Understanding & Assessment

1. Pain: Understanding & Assessment Cathleen Rawlings MS, CRNP Interventional Radiology 443-481-1385

2. Objectives • Define the terms pain, addiction, dependence and pseudo addiction. • Identify the Joint Commission guidelines for pain assessment and management. • Review the following topics covered in AAMC pain management policies: • Pain assessment policy • Range order policy • PCA policy with respect to PCA by proxy & PCA orders • IVP Dilaudid restrictions and Dilaudid PCA prescribing restrictions • Multiple narcotic orders

3. Definitions of Pain International Association for the Study of Pain and The American Pain Society: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage.” International Association for the Study of Pain (www.iasp-pain.org) Margo McCaffery, RN, Pain Management Educator and Consultant “What the patient says it is.” McCaffery, M. & Pasero, C. (1999). Pain: Clinical Manual, 2nd ed. St. Louis: Mosby.

4. Commonly Misused and Misunderstood Terms • Addiction • Addiction is a primary, chronic, neuro-biologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. • Physical Dependence • Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. • Pseudo addiction • Pseudo addiction is a term which has been used to describe patient behaviors that may occur when pain is undertreated. Patients with unrelieved pain may become focused on obtaining medications, may “clock watch”, and may otherwise seem inappropriately “drug seeking” Even such behaviors as illicit drug use and deception can occur in the patient’s efforts to obtain relief. Pseudo addiction can be distinguished from true addiction in that the behaviors resolve when the pain is effectively treated

5. JC Mandate #1 • Recognize the patient’s right to appropriate assessment and management of their pain. AAMC Pain Assessment Policy • Patients will be initially screened for the presence of pain upon entering AAMC utilizing the appropriate tool. • Pain screening data will be documented according to the location in which the patient enters the AAMC system. • If pain is identified during screening, pain is subsequently assessed by a licensed healthcare provider which may include nurse, physician, Nurse Practitioner or Physician Assistant. NAP12.1.18 - Pain assessment, management and resources

6. JC Mandate #2 Screen ALL patients for painAAMC Pain Tools: • PAINAD • Used for cognitively impaired or non verbal adults • PAINAD evaluates 5 non-verbal behaviors and scores them according to severity. The computed score provides an indication for the presence of pain. NAP12.1.18 - Pain assessment, management and resources • Neonatal/Infant Pain Scale (NIPS) • Behavioral assessment tool for measurement of pain in preterm and full-term neonates. • Children's Hospital Eastern Ohio Pain Scale(CHEOPS) • Behavioral assessment tool for measurement of pain in children ages 1-7 years.

7. JC Mandate #3 • Administer EFFECTIVE Pain Control • If pain is not being effectively controlled in your patient, you may collaborate, as indicated, to formulate and implement an effective pain management plan. • Request/Obtain order for a Pain Management Service or PharmD consult for pain management. A Pain Management Service consult requires an MD, DO, CRNP or PA-C order either entered by the requesting medical staff provider or entered on their behalf as a verbal order. A Pain Management Service consult may not be ordered “per protocol.” PharmD pain consults may be ordered “per protocol” when appropriate. NAP12.1.18 - Pain assessment, management and resources

8. JC Mandate #4 • Reassess pain at an appropriate interval. • It is AAMC policy that if pain is documented during the initial pain assessment, pain will then be assessed at least every 8 hours or more often if necessary. • Reassessment of pain will occur within one hour of PRN pain medication • The documentation of pain reassessment in the medical record is regularly audited by the quality team.

9. JC Mandate #5Patient, family , SO are provided with Pain Management Education • Risks for pain • Importance of effective pain management • Assessment process • Management plan

10. AAMC Range order Policy • The order must contain all the elements of a complete medication order. • The maximum allowable difference between the high and the low dose is 4x the lowest dose. Exception: Post Anesthesia Care Unit (PACU) orders may contain ‘prn’ opioid dose ranges greater than 4x the lowest dose at the Anesthesiologists’ discretion. • Orders containing time interval ranges are to be discouraged. For range orders that are written containing a time interval, AAMC will interpret the order as the medication being available for administration at the lowest time interval. MED16.1.04 - Range orders

11. AAMC PCA Policy • PCA orders must utilize the standard PCA order set. • When a PCA is ordered, all other narcotics are automatically discontinued unless the order specifically indicates otherwise. • AAMC does NOT allow PCA by Proxy per our PCA Policy. Please educate family members, friends and significant others about the increased risk of respiratory depression when anyone but the patient pushes the bolus button. • AAMC does not allow nurse proxy dosing. MED16.1.16 - Patient controlled analgesia

12. AAMC Dilaudid Policy • The administration of IVP and IM Hydromorphone/ Dilaudid at are only approved for administration in the ED, OR, PACU, CCU and Interventional Radiology. • To facilitate timely pain management, a physician who is not privileged to order Hydromorphone PCA may only order the standard dose setting. Then they must consult the PharmD after initiation. • Physicians privileged to order Hydromorphone PCA can write for any dose and/or setting, and may or may not consult for the Clinical Pharmacist as the follow-up provider.

13. AAMC Dilaudid Policy • Only Dilaudid Credentialed providers and PharmD’s may make changes to a Dilaudid PCA • Providers may complete the Dilaudid competency by accessing the global share drive and searching for Dilaudid Competency. Follow the directions at the end of the competency for submission and approval. MED16.2.08 - Hydromorphone parenteral administration

14. Multiple Narcotic Orders • There are two situations in which multiple narcotics may be ordered: • To offer the patient several short-acting options for analgesia. • To treat breakthrough pain for a patient on one or more long-acting narcotics • Requirements for Offering Several Short-Acting Options • Multiple short-acting narcotic options are to be used one at a time.

15. Multiple Narcotic Orders • The orders must indicate the following: • Medication, Dose, Route • Interval between doses • Date order written • The indication(s) for use. • Guidelines for which option to use under what circumstance • That only one option may be given at a time. • MED16.1.29 - Use of multiple narcotics

16. References and Resources • AAMC Policies (Available on AAMC Intranet): Pain Assessment, Management & Resources policy; Range Orders policy; PCA policy; Multiple Narcotics policy; Continuous opioid infusion policy; Narcotic storage, security , documentation and waste policy. • McCaffery, M. & Pasero, C. (1999). Pain: Clinical Manual, 2nd ed. St. Louis: Mosby • McCaffery, M. & Pasero, C. (1999). Pain: Clinical Manual, 2nd ed. St. Louis: Mosby. • Pasero, C. McCaffery, M. (2000). When patient’s can’t report pain. AJN, 100(9): 22-23 • Pasero, C. McCaffery, M. (2001). The patient’s report of pain. AJN, 101(12): 73-74 • Weissman, D. E. (2002). Is it Pain or Addiction? Fast Facts #068. Available at End of Life Physician Education Resource Center: www.eperc.mcw.edu. Accessed March 3, 2003 • American Pain Society (www.ampainsoc.org) • American Pain Foundation (www.painfoundation.org) • American Academy of Pain Management (www.aapainmanage.org) • American Academy of Pain Medicine (www.painmed.org) • National Foundation for the Treatment of Pain (www.paincare.org) • The Pain Society (www.painsociety.org) • Partners Against Pain (www.partnersagainstpain.com) • Pain Medicine and Palliative Care (www.stoppain.org) • Pain and Policy Study (www.medsch.wisc.edu/painpolicy) • Pain Net, Inc. (www.painnet.com)