Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive...

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Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center Rajesh Chandra, M.D. Division Chief General Internal Medicine & Geriatrics UH Case Medical Center Todd M. Zeiger, M.D. UH Sharon Center Family Medicine Regional Medical Director UH Sharon and Medina Health Center Mariel Harris, M.D., J.D. Medical Director for Senior Services UH Richmond Medical Center Geriatric Medicine, Hospice & Palliative Care UH Center for Geriatric Medicine David Cogan, M.D. Senior Medical Director UHMP Robin Rowell, RN, CNP VP, Institute and Medical/Surgical Clinical Operations UH Case Medical Center Hildy Pearl, MS, RD, LD Clinical Systems Liaison UH Case Medical Center Debbie Horan, RN, BSN Clinical Systems Liaison UH Case Medical Center Helen C. Foley, MSN, RN Adult Oncology CNS Seidman Cancer Center UH Case Medical Center Kim F. Bixenstine, Esq. Vice President and Deputy General Counsel University Hospitals

Transcript of Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive...

Page 1: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

Pain – Healing It Without Feeling ItElizabeth Weinstein, M.D., M.S.Medical Director Supportive OncologySeidman Cancer CenterUH Case Medical Center

Rajesh Chandra, M.D. Division Chief General Internal Medicine & Geriatrics UH Case Medical Center

Todd M. Zeiger, M.D.UH Sharon Center Family MedicineRegional Medical DirectorUH Sharon and Medina Health Center

Mariel Harris, M.D., J.D.Medical Director for Senior ServicesUH Richmond Medical CenterGeriatric Medicine, Hospice & Palliative CareUH Center for Geriatric Medicine

David Cogan, M.D.Senior Medical DirectorUHMP

Robin Rowell, RN, CNPVP, Institute and Medical/Surgical Clinical OperationsUH Case Medical Center

Hildy Pearl, MS, RD, LDClinical Systems LiaisonUH Case Medical Center

Debbie Horan, RN, BSNClinical Systems LiaisonUH Case Medical Center

Helen C. Foley, MSN, RNAdult Oncology CNS Seidman Cancer CenterUH Case Medical Center

Kim F. Bixenstine, Esq.Vice President and Deputy General CounselUniversity Hospitals

Page 2: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Pain – Healing it Without Feeling itAccording to the Institute of Medicine, the numberof Americans who suffer from Chronic Pain isestimated to be:

A B C D

0% 0%0%0%

1. 25 million

2. 45 million

3. 75 million

4. 100 million

Page 3: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Objectives

• Understand the basic principles of pain management

• Understand the barriers to and myths of pain management

• Understand regulations regarding prescribing/dispensing pain medications

• Understand hospital specific resources for pain management

October 27, 2012 University Hospitals

Page 4: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Case presentation

• CC: Fell off bicycle

• HPI: 55yo WM competing in 4 day fundraising bicycle ride who fell off bicycle and now presenting with 10/10, constant, sharp, localized left hip pain. Patient has chronic tingling in hands and legs which is overshadowed by current pain.

• PMH: OA- shoulders, spine, hips - s/p injections, wears soft cervical collar to sleep; Carpal Tunnel syndrome- wears wrist splints to sleep

• NKDA

October 27, 2012 University Hospitals

Page 5: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Case presentation

• Meds: – Pregabalin 100mg po TID x 2 years– Duloxetine 60mg po daily– Oxycontin 40mg po BID x 2years– Sennosides/ docusate 2 tabs po qhs– Cyclobenzaprine 5mg po qhs prn

• FamHx: Non-contributory

• SocHx: interventional radiologist, swims and/or bicycle rides 6 days a week; married to PM&R MD; no known addiction history

October 27, 2012 University Hospitals

Page 6: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Case presentation

• ROS: as per HPI, otherwise negative• PE: Afebrile, HR- 120, RR- 18, BP- 140/ 75

– Remarkable for externally rotated and shortened L LE with pain on hip flexion

• Labs: BMP, CBC, INR, LFTs within normal limits• Imaging: Left sided intertrochanteric hip fracture• Plan in ED:

– Ortho consultation– Pain control– Admit

October 27, 2012 University Hospitals

Page 7: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Question 1

You recognize patient is not opiate naïve. You need to give him something for pain. He is NPO for possible surgery. A reasonable first dose would be:

1 2 3 4

0% 0%0%0%

A) Morphine 5mg IV

B) Hydromorphone 2mg IV

C) Oxycodone 5mg po

D) Ketorolac 30mg IV

Patient’s Home Meds: Pregabalin 100mg po TID x 2 yearsDuloxetine 60mg po dailyOxycontin 40mg po BID x 2yearsSennosides/ docusate 2 tabs po qhsCyclobenzaprine 5mg po qhs prn

Page 8: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Best response: A

• Route of choice• Drug of choice• Dose of choice

– Acute on chronic pain- chronic pain meds are now baseline/ background

– Convention in terms of reasonable breakthrough dose- 5-15% of daily long-acting

– Must calculate equianalgesic doses

A) Morphine 5mg IV

B) Hydromorphone 2mg IV

C) Oxycodone 5mg po

D) Ketorolac 30mg IV

October 27, 2012 University Hospitals

Page 9: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Equianalgesic Dosing

OPIOIDOPIOID PARENTERALPARENTERAL

(mg)(mg)ORAL (mg)ORAL (mg)

MorphineMorphine 1010 3030

OxycodoneOxycodone 20-3020-30

HydromorphoHydromorphonene

(Dilaudid)(Dilaudid)

1.51.5 7.57.5

October 27, 2012 University Hospitals

Page 10: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Question 2

He is admitted with plans for surgery the next day. You need to control his pain overnight. The most reasonable option is:

1 2 3

0% 0%0%

A) Morphine 5mg IV q4h prn

B) Continue Oxycontin and Pregabalin and add Morphine 5mg IV q4h prn

C) Continue Oxycontin and Pregabalin and add Morphine PCA

Page 11: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Best response: C

Practical aspects of choosing prn pain meds

• Is patient going to be able to ask?

• Will patient ask?

• Is RN going to be able to get to patient in a timely manner?

• Do we need to do some dose finding?

• Pharmocokinetics

• A) Morphine 5mg IV q4h prn• B) Continue Oxycontin and

Pregabalin and add Morphine 5mg IV q4h prn

• C) Continue Oxycontin and Pregabalin and add Morphine PCA

October 27, 2012 University Hospitals

Page 12: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Best response: C

Practical aspects of choosing to use a PCA

• Is patient going to be able to safely use PCA? (not delirious, using opiates appropriately)

• Do we need to do some dose finding?

• We use less opiate with PCA than without

• Continuous aspect of PCA- is equivalent to long-acting opiate

• How to do PCA dosing - continuous, patient push and RN bolus

• A) Morphine 5mg IV q4h prn

• B) Continue Oxycontin and Pregabalin and add Morphine 5mg IV q4h prn

• C) Continue Oxycontin and Pregabalin and add Morphine PCA

October 27, 2012 University Hospitals

Page 13: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Best response: C • Takes more medicine to get pain under control than to keep it under control

• Delirium in hip fractures more often from pain than opiates*

* Relationship between Pain and Opioid Analgesics on the Development of Delirium Following Hip Fracture.

Morrison et. al, Journal of Gerontology : Medical Sciences 2003, Vol. 58A, No. 1, 76-81.

• A) Morphine 5mg IV q4h prn

• B) Continue Oxycontin and Pregabalin and add Morphine 5mg IV q4h prn

• C) Continue Oxycontin and Pregabalin and add Morphine PCA

October 27, 2012 University Hospitals

Page 14: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Question 3

Patient is now post-op. Continues to use PCA. He has fallen asleep. Nurse is concerned that his cell phone rings and he sleeps right through it. The nurse notifies you of this. You should:

A B C D

0% 0%0%0%

A) Give all the Narcan you can find on the floor

B) Discontinue all opiates

C) Hold opiates and restart at lower dose

D) Assess patient and develop a ddx for the patient’s sedation

Page 15: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Best responses: C & D

• There is no set amount of opiate associated with sedation, respiratory arrest/ death

• You get sedation first- safety of PCA with no continuous dosing (see graph)

• RR drops slowly- not abrupt cessation of breathing

• Catching up on sleep

A) Give all the Narcan you can find on the floor

B) Discontinue all opiates

C) Hold opiates and restart at lower dose

D) Assess patient and develop a ddx for the patient’s sedation

October 27, 2012 University Hospitals

Page 16: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Safety mechanism of PCAs with NO CONTINUOUS DOSE

October 27, 2012 University Hospitals

Seru

mCo

ncen

trati

on

Time

Sedation

Respiratory Depression

Page 17: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Best responses: C & D

• Don’t want to get behind on pain which will happen if holding long-acting med --- liken this to other scheduled meds (e.g. beta blockers)

• Abbey Pain Scale or other for assessing pain in non-communicative patient

A) Give all the Narcan you can find on the floor

B) Discontinue all opiates

C) Hold opiates and restart at lower dose

D) Assess patient and develop a ddx for the patient’s sedation

October 27, 2012 University Hospitals

Page 18: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Assessing Pain in Patients Who Can’t Communicate -Abbey Pain Scale

October 27, 2012 University Hospitals

Page 19: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Question 4Hospital day 3

Patient’s pain is well controlled. He is doing well with PT and is going to be discharged home with home PT. He has had no BM since admission. What do we need to think of before he goes home?

A B C D E F G

0% 0% 0% 0%0%0%0%

A) Which intern is responsible for d/c summary

B) What his opiate dose will beC) What adjuvants he should be

onD) What resources are available to

him and you as you continue to manage his pain

E) Who do we need to give a handoff to

F) Fixing his constipationG) All of the above

Page 20: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Best response: G

Opiate dosing

– Long-acting is 50-75% of total daily Oral Morphine Equivalent

• varies for incident pain, expected changes to pain

– Short-acting dose• Convention in terms of

reasonable breakthrough dose - 5-15% of daily long-acting

A) Which intern is responsible for d/c summary

B) What his opiate dose will be

C) What adjuvants he should be on

D) What resources are available to him and you as you continue to manage his pain

E) Who do we need to give a handoff to

F) Fixing his constipation

G) all of the above

October 27, 2012 University Hospitals

Page 21: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Basic Principles of Opiate Prescribing

• Make it simple: oral route, one drug

• Prescribe an adequate dose

• Do the math! Use equianalgesic conversion table

• Use a correct dosing interval

• Prescribe around-the-clock (long-acting opiate) - when warranted

• Provide a breakthrough dose (short-acting opiate)

• Treat common opiate side effects

• Use appropriate adjuvants

October 27, 2012 University Hospitals

Page 22: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Do the math!

• Calculate 24 hour oral morphine equivalent (OME)• Consider adequacy of pain control

– Calculate - expected total oral morphine equivalent

– Increase current 24 hr OME by 25-50% for moderate pain control

– Increase current 24 hr OME by 50-100% for poor pain control

• Determine the opiate that will be given• Use equianalgesic conversion table• Correct for incomplete cross-tolerance when rotating to

different opiate – Reduce dose by 25 – 50 %

• Calculate short and long-acting doses

October 27, 2012 University Hospitals

Page 23: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Equianalgesic Dosing

OPIOIDOPIOID PARENTERALPARENTERAL

(mg)(mg)ORAL (mg)ORAL (mg)

MorphineMorphine 1010 3030

OxycodoneOxycodone 20-3020-30

OxymorphoneOxymorphone 11 1010

HydromorphoHydromorphonene

(Dilaudid)(Dilaudid)

1.51.5 7.57.5

FentanylFentanyl 0.10.1

HydrocodoneHydrocodone 3030

October 27, 2012 University Hospitals

Page 24: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Best response: G

ADJUVANTS– Inflammation/ post-op -NSAIDS/ steroids– Neuropathic –

TCA, anti-epileptics, SNRI, anesthetics– Complementary therapies - heat/ice, massage, physical therapy, acupuncture etc.

A) Which intern is responsible for d/c summary

B) What his opiate dose will be

C) what adjuvants he should be on

D) What resources are available to him and you as you continue to manage his pain

E) Who do we need to give a handoff to

F) Fixing his constipation

G) all of the above

October 27, 2012 University Hospitals

Page 25: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Best response: G – Talk to Team assuming

care - re: course and plan for meds and what is being written for at d/c

A) Which intern is responsible for d/c summary

B) What his opiate dose will be

C) What adjuvants he should be on

D) What resources are available to him and you as you continue to manage his pain

E) Who do we need to give a handoff to

F) Fixing his constipation

G) all of the above

October 27, 2012 University Hospitals

Page 26: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Guidelines for Dictating Pain Management History

• Describe pain syndromes patient suffered

• For each complaint, describe:– Type of pain and severity reported– Provoking factors– Relieving factors– Procedures completed/ attempted and result– Medications tried, what worked and at what dose– Medications tried that were ineffective– Medications with adverse reactions, how treated (remember to

distinguish intolerance, such as nausea or sedation, from true allergy)

Page 27: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Guidelines for Dictating Pain Management History

Detailed description of

– Discussion with patient and family on how to manage analgesics after discharge

– Prescriptions given, including # of pills of each Rx and whether any refills were authorized

– What doctor or doctors will be responsible for follow-up

– If appropriate, what OARRS or pharmacy investigation was done

– If appropriate, what REMS information was given to patient and whether a contract was or should be made for use of long-acting opiates in chronic non-cancer pain syndromes

Page 28: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University HospitalsOctober 27, 2012 University Hospitals

Definition of Terms

Katz NP, et al. Clin J Pain. 2007;23:648-660.

Misuse• Use of a medication (for a medical purpose) other than as directed or as

indicated, whether willful or unintentional, and whether harm results or not

Abuse• Any use of an illegal drug• The intentional self administration of a medication for a nonmedical

purpose such as altering one’s state of consciousness, eg, getting high

Addiction

• A primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations

• Behavioral characteristics include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, craving

Pseudoaddiction

• Syndrome of abnormal behavior resulting from undertreatment of pain that is misidentified by the clinician as inappropriate drug-seeking behavior

• Behavior ceases when adequate pain relief is provided• Not a diagnosis; rather, a description of the clinical intention

Page 29: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University HospitalsOctober 27, 2012 University Hospitals

Definition of Terms

Katz NP, et al. Clin J Pain. 2007;23:648-660.

DependenceA physiological state of neuro-adaptation which is characterized by

WITHDRAWAL if…The drug is stopped, the drug is decreased abruptly, an antagonist is administered

ToleranceThe need to increase the dose of opioids to achieve the same level

of analgesia

Page 30: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

FDA – REMS(Risk Evaluation and Mitigation Strategy)

• Are regulatory requirements on medications that have a high threshold potential for harm

• The FDA mandates that the Drug manufacturer develop a REMS program in order to continue sale of those medications

• REMS programs may include any of the 4 following components:– Medication Guide– Communication Plan– Elements to Assure Safe Use (ETASU)– Implementation System

• ETASU requires practitioners to complete one or all of the following:

Prescriber Certification:

Register and obtain/renew by completing drug company online training

Medication Guide:

Must be provided to all inpatients as well as outpatients prior to receiving the first dose

Register the Patient

Patient informed consent:

Must be signed prior to administration of the drug

October 27, 2012 University Hospitals

Page 31: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

FDA – REMS(Risk Evaluation and Mitigation Strategy)

Some commonly used ETASU drugs

• Oxycontin

(soon to be all extended release narcotics)

• Epogen/Procrit (ESA non-ESRD use)

• Aranesp (ESA non-ESRD use)

• Avandia

• Zyprexa Relprevv

• Entereg

• Revlimid

• Lumizyme

• Tikosyn

Page 32: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

FDA – REMS

ETASU REMS Drugs

Pop-up notifications for ETASU drugs which will include all need-to-know compliance information

Pop-Up Notifications

October 27, 2012 University Hospitals

Page 33: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

WHERE TO FIND UH OPIOID GUIDELINES, ED OPIOID GUIDELINES and PAIN MANAGEMENT AGREEMENT

Page 34: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University Hospitals

Pain Management Referral Resources• General: Fast Facts- http://www.eperc.mcw.edu/EPERC/FastFactsandConcepts

UH System Referral Resources

October 27, 2012 University Hospitals

University Hospitals Case Medical Center Palliative care consult service, Pager 35614

Pain consult service, Pager 35879

Seidman Cancer Center Symptom Management and Supportive Care clinic 216-844-3951 Option 1

Roger Goomber, M.D. 216-844-7335

Salim Hayek, M.D. 216-844-3771

Ali-Amin Khalil, MD 216-844-3552

Binit Shah, M.D. 216-844-3771

Henry Vucetic, M.D. 216-844-7335

UH Ahuja Medical Center Joshua Goldner, M.D. 216-844-3771

Patrick McIntyre, M.D. 216-844-3771

UH Richmond Medical Center Al-Amin Khalil, M.D. 216-844-2552

Sami Moufawad, M.D. 440-786-9885

UH Bedford Medical Center Sami Moufawad, M.D. 440-786-9885

UH Conneaut Medical Center

UH Geneva Medical Center

Arpan Desai, M.D. 440-593-0203

(Interventional only)

UH Geauga Medical Center Henry Vucetic, M.D. 216-844-7335

UH Conner Integrative Medicine Network Francoise Adan, M.D. 216-285-4070

St. John Medical Center Abdallah Kabbara 440-827-5058

Southwest General Health Center David Sfeir, M.D. 440-816-8990

Page 35: Pain – Healing It Without Feeling It Elizabeth Weinstein, M.D., M.S. Medical Director Supportive Oncology Seidman Cancer Center UH Case Medical Center.

October 27, 2012 University HospitalsOctober 27, 2012 University Hospitals

Thank You.

References:

American Academy of Pain – Facts and Figures on Painhttp://www.painmed.org/patientcenter/facts_on_pain.aspx

Relationship between Pain and Opioid Analgesics on the Development of Delirium Following HipFracture, Morrison et al. Journal of Gerontology Medical Sciences 2003, Vol. 58A, No. 1, 76-81.

The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia,Abbey et al. Int Journal of Palliat Nurs 2004 Jan;10(1):6-13

Definition of Terms, Katz NP, et al. Clin J Pain. 2007;23:648-660