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UnderstandingPainManagementPracticeinPatientExperience

Presenter:SusanE.Mazer,PhD

SusanE.Mazer,Ph.D.

UnderstandingPainManagementPracticeinThePatientExperience

BerylInstitutePXConference2018

1. Whatispaintothepatient?2. Historyofpain:themanymyths3. Painrelief:fromopiumtoopioids4. PainTheory:relevancetoday5. Handingthepowerofreliefbacktothepatient

WhatI’llCoverToday

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WhatEveryoneKnowsAboutPain

ThisisPain

MostCommonResponse

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ResponsetothePainofOthers

WhatisPaintothePatient?

2018:WhatisPain?

Whatever thepatientsaysitis!

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2018:WhatisPain?

Noticeable

2018:WhatisPain?

“…canbeoverwhelming,demandsimmediateattention,anddisruptsongoingbehaviorandthought…”

Melzac,R.1968

Painis#1motivator…• “TodoorNottodo,”thatisthedilemma• “TotellornottoTell”• “Totakemoreortakeless(ortakenothing)”• “Totry,tonottry,andtotrystillmore”

Pain:TheBig“P”

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Painreliefdemotivatesalltheabove.

PainRelief:TheLittle“p”

OpioidEpidemic:HowDidWeGetHere?

Opioids:• Prescribedasneeded• Ondemand• TosecureHCAHPSrating• Easiest/mosteffective*?

Hint:*Thedefinitionofanaddiction.

• Homer:“ArrowshotfromGod”

• Aristotle:“Painisapassionofthesoul”

• Plato:“Painisanemotion,notasensation”

TheMythologyofPain?

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Thestimulationgoesstraighttothebrain(“PainCenter”).Isfullyofthebody,notthemind.

Breakthrough:ReneDescartes

TheCartesianDivide:“Ithink,thereforeIam.”

• Acutevschronic• Knownvsunknown• Expectedvsunexpected• Mildvsdebilitating• Other?

NotAllPainsAreAlike

Thecausemaybeobjective,buttheexperienceisalwayssubjective.

NotAllPainsAreAlike

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HistoryofPainRelief

Mandragora:• Hallucinogenic,hypnotic,

poisonous,etc• Analgesicforrheumaticpain• 2ndcenturyBCto7thAD:

Mainlyusedwithopium.

Andinthebeginning…

Dodoens,Rembert,1583.Stirpium historiae pemptades sexsivelibri XXX.Antverpiæ,exofficina Christophori Plantini.(scannedfromReprint1979,Uitgeverij deForel,Nieuwendijk(Netherlands).,PublicDomain,https://commons.wikimedia.org/w/index.php?curid=21709570

• Opium• NitrousOxide• Laudenum• Ether• Cannabis• Morphine• Codeine• Opioids

FromOpiumtoOpioids

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FirstuseoffullanesthesiainBoston*,1846

PainRelief:Anesthesia

*CrawfordW.Long,Columbus, GA

• Bayer!!• AcetylsalicylicAcid,

1899

PainRelief:Potions

Tylenol,1955• Children’s• Adult

PainRelief:Acetaminophen

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PainManagementTheories

• Patientcanmodulatepain• Pathwayfromcentralnervoussystemtothebrain• Non-painfulstimulicaninhibitpainfulstimuli• Mayindicatetissuedamage,butmaynot

Melzack/Wall:GateControlTheory(1965)

Melzack/Casey:ExperienceofPain(1968)

• Somatic, orsensationofpain• Perception ofpleasantnessorunpleasantness(whichcanleadtothefightorflightresponse)

• Evaluation or“appraisal,culturalvalues,context,andcognitivestate”

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Melzack/Casey:MechanismforSelf-Management(1968)• Meaningmaking• DirectedAttention• ActiveDistraction

“Thereignofpainliesmostlyinthebrain.”

Melzack/Casey:MechanismforSelf-Management(1968)

--Cathryn Jakobson Ramin

Whatinfluencestheexperienceofpainandwhetheritisrelieved?

• PainExpectancy:Isitavoidableornot• PainAcceptance:Ifunavoidable,preparationforit• PainApprehension:Anticipatorysuffering• PainAnxiety: Thegreaterthefear,thegreaterthe

pain

MarkZborowski (1908– 1990)MedicalAnthropology

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Involvestheimmediacyoftheexperienceanditsexpressionconstrainedbysocialcontextandenvironmentalsetting.

Craig,K.D.:SocialCommunicationModelofPain(2015)

• Distinguishesintrapersonalandinterpersonalsourcesofinfluenceonbothsufferingpersonsandobservers

• Emphasizes(Intrapersonal)whattheindividualbringstothepainfulexperience

SocialCommunicationModelofPain

SocialCommunicationModelofPain

KennethD.Craig,2015

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Timeline:ChronologyofPain

AntecedentPain

ExperiencePain

Expression

Timeline:ChronologyofPain

Decoding/Response

Action-DeliveryofCare

Antecedent

PainDenial:BeingMetWithDisbelief

• Illness/Pain:deviantbehavior• Judgement:abarriertorelief• Cultural/socialnorms:informself-report/

medicationuse• Under-reporting:under-treatment

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Autonomousresponsebasedon:• Beliefs

• Anticipation

• Expectancy

ThePlacebo-NoceboResponse

“… themeaningresponse[isthe]physiologicorpsychologicaleffectsofmeaningintheoriginsortreatmentofillness;meaningresponseselicitedaftertheuseofinertorshamtreatmentcanbecalledthe“placeboeffect”whentheyaredesirableandthe“noceboeffect”whentheyareundesirable.”

MeaningResponse

Moerman,D.D.,Jonas,W.B.(2002)

Pain’sImpactonthePatientExperience

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Thesumofapatient’spriorexperienceswithpain,shapedbyapatient'sbeliefs,expectations,andtheirsocial/culturalcontextthatinformthepatient’sresponsetopainanditsmeaning.

ThePatientExperienceofPain

Painbeliefsfullyinfluencepatients’painthreshold,participationintheircare,andinformtheirsuccessinself-regulation.

• Agitation• Anxiety• Stress• Suffering

HowPainisthePatientExperience

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• Environmentalstressors

• Expectancy• Placebo/nocebo effects• Social/culturalvalues

HowPainBecomesthePatientExperience

• Minimizeenvironmentalstressors• Provideaccesstobeauty,nature,including

mediatednature• Minimizeclutter• Assessandadjusttheenvironmentwithevery

patientinteraction

CreateaHealingEnvironment

• Asenseofpleasantness• Makestimemovefaster• Musicpacestime,providesanemotionalcontext

Whatdoestalktelevisionprovide?

PositiveValence

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APositiveDistraction“…anenvironmentalfeaturethatelicitspositivefeelingsandholdsattentionwithouttaxingorstressingtheindividual,therebyblockingworrisomethoughts.”

Isthisscary?Isthistheendorthebeginning?Isithotorcold?Isthisgoodorbad?Whatdoesthismeannow?Arewesafe?AmIsafe?Howlongwillthislast?

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• Notoneelementworksforeveryone• Notoneelementworks24/7foranyone• Habituation• Variety• Stimulating

PositiveDistraction

• Nature(variousforms)• Music(bothpatientpreferenceandnew)• Conversation(hopeful,personal)• Media

PositiveDistraction

VirtualReality• Cedars-Sinai:24%drop

inpainscores• Universityof

Washington:76-22%dropinamountoftimethinkingaboutpain

VirtualReality/ImmersiveInterventions

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• 29%reductioninpainmeds

• Fewersideeffects• 1.5dayaverage

reducedlengthofstay

Non-PharmaceuticalInterventions

Theidentificationandmanagementofpainisanimportantcomponentof[patient]-centeredcare.[Patients]canexpectthattheirhealthcareproviderswillinvolvethemintheirassessmentandmanagementofpain.Bothpharmacologicandnonpharmacologic strategieshavearoleinthemanagementofpain.

• Engagesmindandbodytoreduceanxiety,increasecopingskills

• Providespositivedistraction• Providesrespitefrommental/emotionalfatigue• Providestooltousebeyondthehospital

GuidedImagery

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NightsareDifficult

• Elusiverest

• Unfamiliarenvironment(includingnoises)

• Limitedresources• Isolation

• Loneliness• Ruminations

PainIsWorseatNight

• Isolating• Influencedbythemeaningattributedtoit• Ismitigatedbypositivedistractions,evenatnight

NightsDoNotHavetoBeasDifficult

• Planinadvancew/patient-family• Optionsforpatient• Restfulnessshouldbeofferedthroughtheday• Patientandfamilyshouldcoordinate• Whatworksforthispatient?

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• Acupuncture• Chiropractictherapy• Osteopathicmanipulativetreatment• Massagetherapy• Physicaltherapy• Relaxationtherapy• Immersiveexperiences• Cognitivebehavioraltherapy

Non-pharmacologicInterventions

HandingthePowerofHealingBacktothePatient

• Attheleast,Unpleasant• Notalwaysavoidable,notalwaysbad• Influencedbyphysicalandnon-physicalfactors• Informedbymood,attitude,beliefs,values,

social/familialcontext,andthemeaningattributedtothepainbythepatient.

PainIs…

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Patientsneedmorethantheblurofactivity.

Painbeliefsinformpatients’painthreshold,participationintheircare,andinformtheirsuccessinself-regulation.

• Aninformedcaregiver/bedsidestaff

• Involvementofthebedsideteamwiththepatient

• Anenvironmentthatminimizesstressors

• Positivedistractions,includingaccesstonature,variety

• Supportofthefamily/closesocialcircle

WhatdoesManagingPainRequire?

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• Equanimitybetweenpatient/caregiver

• Alignmentbetweensocialvaluesandtreatment

• Acknowledgementandsupportbetweenpatient/caregiver

• Altruisticpracticesembeddedinclinicalexcellence

WhatdoesManagingPainRequire?

Summary

• Communicatesupportandempathy• Createahealingenvironment• Providepositivedistractions• Offerguidedimagery• Offerimmersivetechnologies• Beawareofpositive/negativemedia• Planfornights

• Gate-ControlTheory:Positivedistractionisprimarytoself-managementandincreasingpaintolerance

• SocialCommunicationTheory:Painmanagementusesthesymbiosisbetweenpatient/others

• Painreliefissubjectiveandobjective• Painisephemeral:livesandchangesovertime• Combinationofbiomedicalandpsychosocial

strategiesisrequisiteCaution:Addictionisalwaysariskwhenthegoalisself-medication/management

Summary

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Howfaryougoinlifedependsonyourbeingtenderwiththeyoung,compassionatewiththeaged,sympatheticwiththestrivingandtolerantoftheweakandstrong.Becausesomedayinlifeyouwillhavebeenallofthese.

GeorgeWashingtonCarver

Theonlydifferencebetweenthepatientandthecaregiverisacuity.

PatLinton

SusanE.Mazer,Ph.D.President&CEO,HealingHealthCareSystems

Email: smazer@healinghealth.comBlog:www.healinghealth.com/susan-mazer-blogLinkedIn:www.linkedin.com/in/susanmazer

QuestionsandThankYOU!

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BreakoutSession5:00PM

WinachanceforaComplimentary2019ConferenceRegistrationbycompletingtheevaluationforeachsessionyouattend. JustaneasyclickontheFeedbackIconfoundonyourmobileappandafew

momentsofyourtimetocompletetheevaluation.Yourfeedbackisveryimportanttous.

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PainManagementandthePatientExperience2018References

SusanE.Mazer,PhDsmazer@healinghealth.com

Keywords:Pain,Painmanagement,paintheory,historyofpain,Gate-ControlTheory,SocialCommunicationsModelofPain,Placebo,Meaning-response,psychologyofpain,ReneDescartes

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