Assessment and Management of Chronic Pain

Practice Summary Handout

1. Scope and Purpose. What are the scope and purpose of this document? What are the objectives, question, and target population (patients, consumers, students, etc.)? In other words, who are the recipients of the services outlined in the document?

The scope of this document addresses pain that persists and comes back often over time with time for extended durations, ultimately leading to lowered quality of life settings and the diminished ability to properly function in daily environments. Such pain can occur within muscles, the nervous system (especially in the extremities), inflammation, and the respiratory system. The purpose of this document centers on treating chronic pain in patients >16 years of age, through assessment and diagnosis implementing the biopsychosocial model. In addition, the writers of the handout aim to better the implementation of opioid and non-opioid medications in the treatment of this age group suffering from the diagnosis.

2. Stakeholder Involvement. What professions are represented in the document? Have members of the target population been consulted in the development of the document? What conflicts of interest are possible?

Various professionals are represented in the workgroup, including "physicians, nurses, pharmacists, and other healthcare professionals" with knowledge of the topic (ICSI, 2011, p.4). Led by a physician, members are recruited from ICSI organizations if at all possible. After a thorough keyword search, it appears that the target population has not been consulted in the development of this document. As a result, certain conflicts of interest such as the implementation of external prescriptions to fix unhealthy daily habits may only dull the symptoms instead of treating them at their core. In the case of this report, propoxyphene, a medication prescribed in good faith ended up being recalled by the U.S. Food and Drug Administration (Riley, 2010) "due to new data showing that the drug can cause serious toxicity to the heart, even when used at therapeutic doses" (ICSI, p. 1).

3. Rigor of Development. Are the methods, criteria, and selection of articles for the document clear and justified? Have benefits and risks for the target population been considered?

The methods, criteria, and selection contributing to the development of this document focus on a perusal of electronic databases. The Institute for Clinical Systems Improvement Protocols (ICSI) calls for a consistent methodology in the gathering of literature for this study. In this study, keyword search terms included "SI joint injection, facet joint injection, intradiscal electrothermal therapy (IDET), epidural corticosteroid injections, vertebroplasty and kyphoplasty, and trigger point injections" (p. 3). All gathered evidence was analyzed with a ranked evaluation system of three tiers and a shorthand set of symbols to designate the quality of each study. In the proposal of this study, analysts also provided a comparison and contrast table between the current ICSI system and the new ICSI GRADE system (p. 3) thereby strengthening the justification for the methods used in assessing appropriate criteria for article selection.

Potential benefits to the implementation of study results in the target population include "improved function of patients with chronic pain, improved assessment and reassessment of patients with chronic pain utilizing the biopsychosocial model, appropriate use of Level I and Level II treatment approaches, and effective use of non-opioid . . . [and] opioid medications" (p. 13). Risks for the target population have also been considered. As mentioned in section two, propoxyphene has potentially mortal side effects; in addition, the prescription of acetaminophen may also cause serious skin reactions (Stevens-Johnson Syndrome) and should be avoided in patients with a history of liver issues. In fact, the list of adverse effects in medications, when compared to potential benefits, is quite long. Non-steroidal Anti-inflammatory Drugs (NSAIDs), Selective Cyclooxygenase-2 (Cox-2) Inhibitors, Tricyclic Antidepressants, Topical Capsaicins, Muscle Relaxants and Antispasmodics, Tizanidine, Medical Cannabis, and Opioids all carry potentially serious side effects from inducing seizures and product addiction to weight gain and cardiac dysrhythmias. Even more therapeutic remedies such as herbal treatments, acupuncture, epidural injections, and transcutaneous electrical nerve stimulation carry marked risks. In the broad range of treatments, specialist care must be implemented in order to properly service the needs of the target population.

4. Recommendations. If you were writing a plan based on the document, what are the major recommendations for practice? What would be the nursing role in carrying out the recommendations and what resources would be needed?

Guiding directives exist for the treatment of chronic pain among mature adults >16, which must be distinguished from acute pain as a result of disease or injury (Grichnik & Ferrante, 1991, 217). Essentially, two grades of evidence-based pain management implementation are possible. Level I treatment focuses on "intervention management . . . [and] complementary medicine management" while Level II treatment is reserved for patients unresponsive to such conservative methods (p. 9). Before arriving at either, a thorough assessment must be implemented that records "pain location, intensity, quality, onset/duration/variations/rhythms, manner of expressing pain, pain relief, what makes it worse, [and] effects of pain" (p. 5). In addition, the patient medical history should be consulted along with a current physical examination to gain a comprehensive understanding of the current situation and possible solutions (p. 6). Since "there is no diagnostic test for chronic pain," practitioners must focus on a functional assessment that highlights personalized goal setting and the development of a care plan (p. 6).

It is at this point that the guiding care of nurses is most needed. The report highlights that "teamwork and empathetic listening in the development of a treatment plan is critical" (p. 9). In addition, nurses can assist in documenting the location and level of chronic pain to give a full report for the physician. The sensitive nurse will recognize that chronic pain can elicit emotional responses of frustration and can respond with encouragement (p. 9).

5. Application. What are the potential barriers to implementing the recommendations? What are potential costs of following the recommendations? How would you measure whether outcomes would be improved if the recommendations were carried out?

Barriers to implementing the recommendations could include bi-lingual difficulties leading to incomplete assessments (p. 6). Costs may include the price of pharmacological, herbal, and surgical remedies. To measure the outcomes of prescribed recommendations, the patient's quality of life must be taken into account. Chronic pain makes people miserable; therefore, its elimination, especially with minimal low side effects, is self-evident.

References

Assessment and management of chronic pain. (2001). Institute for Clinical Systems Improvement, 1, 1-12.

Grichnik, K., & Ferrante, F. (1991). The difference between acute and chronic pain. Mt Sinai J Med, 58(3), 217-220.

Riley, K. (2010, November 19). News & Events. Xanodyne agrees to withdraw propoxyphene from the U.S. market. Retrieved February 14, 2014, from http://www.fda.gov/newsevents/newsroom/ pressannouncements/ucm234350.htm