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Chapter 15 Pain Management.

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Presentation on theme: "Chapter 15 Pain Management."— Presentation transcript:

Pharmacology and the Nursing Process in LPN Practice

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TREATMENT OF NEUROPATHIC PAIN

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1 Pain. 2 Types of Pain Acute Pain Acute Pain –Complex combination of sensory, perceptual, & emotional experiences as a result of a noxious stimulus –Mediated.

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Pain Management.

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• About : Professor, College of Nursing and Health Sciences
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• Country : United States of America

HEALTH A TO Z

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New treatments offer much-needed hope for patients suffering from chronic pain

Associate Professor of Anesthesiology, University of Colorado Anschutz Medical Campus

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Rachael Rzasa Lynn receives funding from National Institutes of Health, Department of Defense, Institute of Cannabis Research at Colorado State University - Pueblo

University of Colorado Anschutz Medical Campus provides funding as a member of The Conversation US.

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Hundreds of millions of people around the world experience chronic pain – meaning pain that lasts longer than three months . While the numbers vary from country to country, most studies estimate that about 10% of the global population is affected, so more than 800 million people.

The Centers for Disease Control and Prevention estimates that in 2021, about 20% of U.S. adults – or more than 50 million people – were experiencing chronic pain . Of those, about 7% experienced what’s called high-impact chronic pain , which is pain that substantially limits a person’s daily activities.

In the past, physicians have been quick to prescribe medication as an easy solution. But the opioid crisis in the U.S. has led doctors to reevaluate their reliance on drugs and look at new treatments for patients with chronic pain.

The Conversation spoke with Rachael Rzasa Lynn , a pain management specialist from the University of Colorado Anschutz Medical Campus for our podcast The Conversation Weekly . She explains some of the new developments in pain treatment and why there’s hope for patients with chronic pain.

What is the cause of chronic pain, at the most basic level?

In general, pain is a complex interplay between tissue injury or inflammation, nerves and brain processing.

There are several different biological processes that can result in pain. The one that’s happening to most people when they experience acute pain is called nociceptive pain . This is pain that occurs when tissue is being injured or potentially harmed in some way, which triggers the activation of surrounding nerves. These nerves are like electrical wires that send signals from the injured tissue, through the spinal cord and to the brain, where pain is ultimately perceived.

But activation of those nerves alone does not equal pain, because those electrical signals are amplified or diminished at multiple points throughout their transit to the brain. The brain’s perception of pain is critical because pain does not occur when people are unconscious.

Nociceptive pain can also result from ongoing tissue injury or inflammation, as in the case of arthritis . With these injuries, the peripheral nerves are chronically reporting to the brain, resulting in an ongoing perception of pain.

There are other disease processes, such as diabetic peripheral neuropathy , in which nerves themselves become injured. In these cases, the nerves send pain signals to the brain that are reflective of injury to the nerves themselves, not the tissues they report from. This is called neuropathic pain .

In other forms of chronic pain called nociplastic pain , the initial tissue injury may fully heal, but the brain and nervous system continue to generate pain signals.

Many chronic pain conditions actually involve a combination of all three of these phenomena – nociceptive, neuropathic and nociplastic pain – which adds to the difficulty of diagnosis and treatment.

How do doctors like you measure pain?

I think everybody who’s been to a hospital, at least in the United States within the past decade, is familiar with the numerical scale where you’re asked to rate your pain. That is a one-dimensional assessment of pain that only asks how severe it is.

But pain is a very complex phenomenon that has a lot more pieces to it than just the severity. So a single numerical value based on severity of pain really misses the impact that pain may be having on a patient’s daily life, such as their activities, their relationships, their ability to sleep, their happiness and their overall satisfaction with their life.

I think the most difficult thing about all pain, truly, but especially many forms of chronic pain, is that you cannot see it. There’s no external, validated way to really know how much pain someone is in. We do have newer methods for measuring pain that attempt to get at some of those more complex aspects, but it’s still a very incomplete science. It’s all still subjective based on what the patient tells you their experience is.

What are some of the most promising new pain treatment options?

One newly popular treatment is called pain reprocessing therapy , which takes a behavioral approach to eliminating pain.

Here at our medical campus, therapists guide patients in understanding what causes chronic pain and then reevaluating the sensations they experience as painful – for example, while engaging in typically painful movements. The goal of pain reprocessing therapy is to help patients perceive the pain signals being sent to their brain as less threatening, so that their brain “unlearns” the pain.

Another approach being applied in new ways is called nerve ablation , a procedure in which the nerves around an area of pain are numbed with medication and then purposely damaged. In those cases, doctors inject a chemical around the nerves or gently heat them so they can no longer effectively send pain signals for months or even years. This approach has been used for spine pain for decades, but it is now being applied more widely to pain from other areas of the body.

A similar approach is to use electricity to stimulate the nerves serving a painful area in order to alter or block the way pain signals flow through them. This method involves placing a tiny electrical device alongside the nerve to deliver the low level of electricity. This is an example of neuromodulation , which is increasingly being used to treat a wide variety of chronic pain conditions throughout the body, from foot pain to migraines. It has even shown promise in the management of acute pain after surgeries like knee replacement.

A classic example of neuromodulation is spinal cord stimulation, which is used to treat a variety of conditions that cause chronic pain. A surgeon places wires underneath the bones of the back, but outside of the spinal cord and the spinal fluid. The wires connect to a battery, much like a pacemaker battery, that delivers electrical signals to the nerves in the spinal cord in order to scramble the pain signals.

What role has the opioid crisis played?

These new treatment options for patients with chronic pain may not have progressed as quickly as they have if not for the opioid crisis .

For decades, opioids were too widely prescribed for chronic pain. However, there are some patients with chronic pain for whom opioids truly provide benefit in terms of pain relief and quality of life. In my view, doctors have overcorrected a bit to the point where it can now be difficult for such patients to gain access to the opioid therapies that have worked so well for them. Due in part to a slowdown in manufacturing opioids over the past several years, in some parts of the U.S., many patients are no longer able to access these drugs at all.

As a result, researchers are now working to identify new drugs that relieve pain without the risks of addiction and overdose that opioids present, including cannabinoids . The focus in patient care in recent years has shifted away from medication and toward behavioral and procedural interventions, including neuromodulation.

Looking ahead: What’s next?

I think the holy grail of pain medicine is trying to figure out which patients with the same condition are going to respond to the same treatment. For example, two patients with a degenerative tissue disease like osteoarthritis of the knee can have nearly identical X-rays and yet their pain experience and response to treatments are completely different. One patient may do well with physical therapy, while another might fail to improve with physical therapy alone and require multiple medications, injections and ultimately surgery – and could potentially still be living with pain.

Researchers like me don’t yet know what the defining characteristics are of one patient versus another in terms of those outcomes. This means current treatment plans involve a lot of trial and error, which can be slow and frustrating for patients in pain.

So my goal and my No. 1 hope for the future of pain medicine is that researchers find a better way of predicting who is going to respond to a particular treatment, which would allow them to match each patient to the right treatment regimen the first time.

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Mayo Clinic School of Continuous Professional Development

You are here, updates in pain management 2025.

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This course offers Live (in-person) and Livestream (virtual) attendance options

Course Directors: Susan M. Moeschler, M.D., Oludare O. Olatoye, M.D., and Richard H. Rho, M.D.

April 10 - 12, 2025 - Ritz Carlton Half Moon - Half Moon Bay, California

This course highlights pain conditions across multiple disciplines to improve pain control and patient outcomes. The course includes a review of the evaluation and treatment of common pain syndromes, such as spine pain, neuropathic pain, headache, fibromyalgia, chronic fatigue syndrome, and arthritic pains.

Target Audience

This course is designed for physicians, physician assistants, nurse practitioners, nurses, residents, fellows, and allied health professionals in primary care and family medicine.

Learning Objectives

Attendance at any Mayo Clinic course does not indicate or guarantee competence or proficiency in the skills, knowledge or performance of any care or procedure(s) which may be discussed or taught in this course.

A block of guest rooms has been reserved for attendees and their guests with special course rates at the Ritz Carlton, Half Moon, CA. To receive the special rate of $360.00 (plus applicable taxes and fees) for a standard room, reservations must be made before the room block is filled or before the expiration date of March 18, 2025, whichever comes first. After March 18, 2025, reservations will be taken based on space and rate availability. Please identify yourself as a participant of the Mayo Clinic Pain Management course when making your reservation. You may call (650) 712-7000 to make your reservation or click on the link to make a online reservations.  Resort Experience Fee Please note that there is an additional charge of $25.00 per room per night plus tax that is not included in the above room rates. The following amenities are bundled into this charge for up to two guests: • Daily in-room high-speed internet access • Access to tennis courts, racquets, and ball machines • Putter and wedge rental for use on the practice green at Half Moon Bay • Golf Links • Fitness center classes at The Colony Club • Bicycle rentals • Coastal walk experience with a tour guide • Daily transportation service to downtown Half Moon Bay • A glass of wine or non-alcoholic beverage offered at check-in

All travel and lodging expenses are the sole responsibility of the individual registrant.

For disclosure information regarding Mayo Clinic School of Continuous Professional Development accreditation review committee member(s) and staff, please go here to review disclosures .

Please update your profile to let us know if you have dietary restrictions or access requirements.

To claim credit for livestream participation in this course, learners must view the content during the hours posted for the live activity. This course is not approved for on-demand delivery.

Commitment to Equity, Diversity and Inclusion

Mayo Clinic School of Continuous Professional Development (MCSCPD) strives to foster a learning environment in which individual differences are valued, allowing all to achieve their fullest potential.

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Researchers explore potential for AI to predict patients’ pain management support needs after surgery

Vincent Jacobbi

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A Mayo Clinic retrospective study of 9,731 patients explored the potential of artificial intelligence (AI) to predict a patient's need for opioid refills after surgery. The study used deep learning models, a form of AI, to predict which patients are most likely to require additional opioid refills after surgery while ensuring adequate pain management and minimizing the risk of opioid dependence. Refills were defined as any opioid prescribed from one to 30 days after hospital discharge.

Researchers looked at a wide range of surgeries, including 280 thoracic, 1,680 abdominal, 1,575 pelvic and 5,952 musculoskeletal or orthopedic procedures. The study also examined 507 breast surgeries, 1,243 head and neck procedures and 133 vascular surgeries. Notably, 2,086 of the surgeries involved minimally invasive techniques.

With the assistance of AI, the findings revealed that the type of surgery, a patient's reported pain level during hospitalization and the initial number of opioids prescribed were the key predictors of needing refills. Knee replacement surgery emerged as the most significant predictor.

Researchers emphasize that identifying patients who may need prescription refills does not mean simply prescribing more opioids. Rather, through the AI models, healthcare professionals can work with patients to consider non-opioid pain control strategies.

"Numerous opioid-based medications, non-opioid-based medications and non-pharmacologic strategies exist to manage postoperative pain," says senior study author  Cornelius A. Thiels, D.O. , a surgical oncologist at Mayo Clinic. "This predictive model is intended to help physicians identify when the current strategy is insufficient and augment that strategy with these tools as needed."

Overall, the researchers agree that a personalized approach to pain management can help minimize reliance on opioids. They underscore that the key to success is using these AI models as supportive healthcare tools, with clinicians working in tandem with AI, rather than using it as a replacement for decision-making.

"These systems work as an assistant to healthcare professionals, and the final decision is ultimately by them based on the overall opinion about the patient," says lead study author Hojjat Salehinejad, Ph.D. , a healthcare systems engineering researcher in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery . Dr. Salehinejad also focuses on applied AI in healthcare, particularly multimodal patient representation and learning.

While the mathematical modeling used in the study is more advanced, the overall concept is something physicians have relied on for years, the researchers say. Although further validation is needed before implementing this into practice, they note that clinicians must use AI as a supportive tool to improve patient treatments rather than as a substitute for judgment.

"The goal has never been to replace the physician discretion and decision-making but rather to provide evidence-based data and analytics to help with the decision-making," says Dr. Thiels. "The primary advantage here is the models’ ability to use larger quantities of data automatically, without relying on manual input from physicians, which is how predictive models have traditionally been built."

Dr. Thiels is an alumnus of the Surgical Outcomes Research Fellows Program in the  Mayo Clinic Kern Center for the Science of Health Care Delivery . He provides mentorship for other fellows and continues to conduct surgical outcomes and quality research — like the current study — in collaboration with the center. Review the study  for a complete list of authors, disclosures and funding.

About Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery

The  Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery  collaborates with clinical areas across Mayo to create and evaluate data-driven solutions to transform the experience of health and healthcare for patients, staff, and communities. It drives continuous improvement of Mayo Clinic as a learning health system, enabling always safe, evidence-based, high-quality care.

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Pain Management

Sep 13, 2014

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Pain Management. for Patients in OTPs. Pain Prevalence. Study of (2) populations 1 (390) pts in MMT (531) pts in short term residential

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Presentation Transcript

Pain Management for Patients in OTPs

Pain Prevalence • Study of (2) populations1 • (390) pts in MMT • (531) pts in short term residential • Prevalence of chronic severe pain, defined as pain that persisted > 6 months and was moderate to severe intensity or that significantly interfered with daily activities • Brief Pain Inventory (BPI) 1. Rosenblum A, et al Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities; JAMA May 14, 2003 Vol 289: 2370-2375.

Pain Prevalence • Higher prevalence of chronic pain in MMT population compared with residential • 37% vs 24%, higher than general population • Compared with surveys of cancer patients • Great variability in experience of pain • Relatively high scores on items of BPI pain interference scale, 55% to 73% for pts in MMT • In MMT pts chronic pain was associated with both physical and psychiatric illness • Less evidence of an association between substance use and chronic pain among inpatients than among MMTP patients 1. Rosenblum A, et al Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities; JAMA May 14, 2003 Vol 289: 2370-2375.

Pain Prevalence • Patient Characteristics (MMT) • Mean age 43 • 38% female • 25% white • 35% black • 33% hispanic 1. Rosenblum A, et al Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities; JAMA May 14, 2003 Vol 289: 2370-2375.

Pain Prevalence • Under treatment of pain is a significant concern in populations with substance use disorders • Barriers as potential reasons for inadequate pain management • Institutional practices • Inadequate training and skills of clinicians • Lack o access to health care, pain management care • Reluctance of physicians to prescribe opioids, treat • Reluctance of patients to seek medical care, stigma and fear of relapse 1. Rosenblum A, et al Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities; JAMA May 14, 2003 Vol 289: 2370-2375.

Pain Prevalence • MMTP patients have been shown to have lower pain thresholds compared with matched controls1, 2 1. Compton M, Cold-pressor pain tolerance in opioid and cocaine abusers: correlates of drug type and use status J Pain Symptom Manage. 1994;9462-473. 2. Comptom P, et al. Pain intolerance in opioid-maintained former opiate addicts. Drug Alcohol Depend. 2001; 63:139-146.

Principles • Distinction between opioid tolerance and physical dependence and opioid addiction • Pain patients without addiction should not be treated in OMTPs • Addiction patients without pain disorder should not be treated in pain clinics • Chronic pain patients with addictive disease may be treated in both

Opioid Addiction • Opioid tolerance and physical dependenceAND • Loss of Control Indices: • Continued use despite adverse consequences • Illicit or inappropriate drug seeking behavior • In response to craving or drug hunger • In the absence of pain or withdrawal

Spectrum of Pain Disorders • Acute Pain • Chronic Pain • Neuropathic pain • Non-cancer / non-malignant pain

Acute Pain • Caused by soft tissue damage, infection and/or inflammation among other causes • “Restorative” nature, serving as signal of injury or malfunction of the body • Treated simultaneously with analgesics and appropriate techniques • Failure to treat acute pain properly may lead to chronic pain1 1 Dahl JB, Moiniche S (2004). "Pre-emptive analgesia". Br Med Bull71: 13-27. PMID 15596866

Neuropathic pain • According to the most widely accepted definition, neuropathic pain is "initiated or caused by a primary lesion or dysfunction in the nervous system. • Disorders of the peripheral and central nervous system • Common disorders, diabetes, HIV-related neuropathy, cancer

Chronic Pain Disorder • Opioid Tolerance • Opioid Physical Dependence • Absence of illicit drug use and aberrant drug seeking behavior • No drug hunger in absence of pain • No loss of control • No “doctor shopping” • Little tendency to escalate doses over time

Chronic Pain • Chronic pain is defined as pain that persists longer than the temporal course of natural healing, associated with a particular type of injury or disease process. • May be psychosomatic or psychogenic in etiology.1 • May have no apparent cause or may be caused by a developing illness or imbalance • May trigger multiple psychological problems that are confounding, leading to various differential diagnoses • Chronic pain is sometimes referred to as the "disease of pain" 1 Sarno, John E., MD, et al., The Divided Mind: The Epidemic of Mindbody Disorders 2006

Pseudo-Addiction • Chronic Pain Patient • Inadequate pain treatment • “Apparent” drug seeking behavior • Effort to achieve adequate analgesia • Early refill, doctor shopping, etc. • Manipulation seen as “addictive behavior” • Viewed as non-compliant • “Cured” by adequate treatment of pain

Non-cancer / non-malignant pain • Other diseases as stated • “non-malignant”, unassociated with life threatening events or consequences • Typically thought of in the context of acute or chronic conditions

Program Guidelines for Hospitalized Maintenance Patients • Discuss methadone treatment prior to admission • Have a clear understanding regarding: • Uninterrupted maintenance treatment • Adequate treatment for pain • Note: The recovery room is not the place to negotiate pain management • Program physician should be available to hospital staff

Pain Management During Maintenance Pharmacotherapy • Continue maintenance without interruption • Provide short-acting opioid analgesics as needed • Higher doses may be required at increased frequency-titrated for relief of pain • Do not use Mixed Agonists/Antagonists or partial or weak agonists • Monitor prescriptions closely

Universal Precautions • Gourlay D, Heit H, Almahrezi A • (Infectious disease model) • Biopsychosocial model for risk assessment, 3 categories • Appropriate boundary setting within the clinician-patient relationship, respectful approach • Recommendations for management and referral • Stigma can be reduced, patient care improved, and overall risk contained. Gourlay D, Heit H, Almahrezi A, Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005 Mar-Apr;6(2):107-112.

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How to incorporate ai to solve agency clients’ pain points.

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With AI technologies being deployed in novel ways across all industries, agencies can take a limitless number of approaches to incorporate it into their operations to enhance their capabilities and streamline processes. By integrating AI into their workflows with a strategic aim to improve client services, agencies can not only tackle time-consuming tasks and solve complex problems more efficiently, but also unlock new creative possibilities and data-driven insights to execute more effective campaign strategies for their clients.

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To be successful, John Wooden famously said, “Be quick, but don’t hurry.” This sentiment is important for agencies evaluating AI benefits, as there is often an “artificial” sense of urgency to do something. My advice? Unplug. Take the time to develop a strategy that considers your clients, their customers and your employees. Lead with purpose, authenticity and empathy. The rest will fall into place. - Thomas Zawacki , Data Axle

10. Analyze Creator And Influencer Databases

To enhance an agency’s capabilities and increase efficiencies, one strategy is to use AI to address clients’ needs and challenges. For example, in influencer marketing, AI can analyze vast databases of creators and select influencers based on key parameters critical to the client’s marketing goals. - Michael Kuzminov , HypeFactory

11. Write Page Titles And Meta Descriptions

We have found that AI can help write page titles and meta descriptions if you give it the content of a page. This gives our writers more time to write substantive content, increase the volume of content posted and optimize the content we do create for search. - Trey Robinson , Story Amplify

12. Repurpose Long-Form Into Short-Form Content

List out the most time-consuming, repetitive projects and processes and look for potential AI solutions that could do the heavy lifting—by creating YouTube Shorts or Instagram Reel content, for example. Manually editing long-form content into short-form content can take hours, or even days, but there are AI platforms that can automate this process and give your client and agency more time for other projects. - Bernard May , National Positions

13. Analyze First-Party Client Data

Utilizing AI to analyze first-party data can revolutionize an agency’s capabilities. By having it analyze client data, you can use AI to personalize marketing strategies, deliver predictive analytics and automate routine tasks. This leads to highly targeted campaigns, optimized resource allocation and increased efficiency, ultimately enhancing both agency performance and client satisfaction. - Alex Yastrebenetsky , InfoTrust

14. Gain New Perspectives On Problems

AI tools are fantastic at providing a different opinion. AI technology often works best when it has something to start from. When a client has a problem, it’s extremely helpful to get the AI to summarize or rewrite the problem statement so that you can see the issue from a different angle. Another use is to get AI to review different solutions you have created and suggest improvements or alternatives. - Mike Maynard , Napier Partnership Limited

15. Execute Project Management Tasks

AI tools are incredibly helpful for note-taking, task creation and post-meeting follow-up, but we especially love them for project management. Today’s tools can send documents to clients for review, solicit feedback, create tasks based upon the clients’ responses and assign them to the appropriate users—enabling our account managers to focus on nurturing relationships instead of busy work. - Hannah McNaughton , Metric Marketing

16. Enhance The Visibility Of Critical KPIs

Strategic decisions often fall between the cracks when teams are preoccupied with routine daily tasks. AI should primarily enhance the visibility of critical key performance indicators that inform strategic decisions in agency-client collaborations. Additionally, AI can automate repetitive tasks, allowing the team to concentrate more on strategic decisions related to media, creative and marketing. - Oksana Matviichuk , OM Strategic Forecasting

17. Challenge Assumptions And Fit-Test Ideas

AI can be a powerful conversationalist and devil’s advocate. Use it to challenge assumptions, fit-test an idea, poke holes in your strategy, offer alternative perspectives and uncover hidden connections between things. This not only saves time and money, but it also improves critical thinking and inspires innovation in the humans using it. Evidence-based decision-making combined with expert intuition wins. - Shanna Apitz , Hunt Adkins

18. Use AI Note-Takers In Client Meetings

I’m a big fan of using AI note-takers in client meetings, with permission from the client, of course. These tools allow me to stay completely present and focused. They provide me with a transcription I can reference after the fact to confirm details, and I’ve had clients tell me that the transcriptions and meeting notes these tools generate are equally helpful to their team. - Evan Nison , NisonCo

19. Generate Customized SOPs For Each Client

One powerful strategy is using AI to generate standard operating procedures. For your employees and assistants to be able to help you work well, you need SOPs, but creating them can take a while. AI can quickly create customized, optimized workflows for each client based on their specific needs and goals, saving your agency time while delivering efficient, tailored solutions. - Frederik Bussler , Bussler & Co

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