Activity 4: Disparities in Care: Special Populations in Pain Management

Two algorithms are referred to in this series. They were created by the Institute for Clinical Systems Improvement (ICSI) to accompany their guideline ‘Assessment and management of chronic pain.’ The algorithms are available from the ICSI website:

On the ICSI website you can also find these tools:

  • Brief pain inventory (short form)
  • Patient health questionnaire (PHQ-9)
  • Functional ability questionnaire
  • Personal care plan for chronic pain

Recommendation #1: Distraction and hypnosis are effective interventions for procedures in children and adolescents (age 2-19)

Listening to music may have a small effect, but is not recommended because of its limited benefit.

Source: Cochrane Reviews

Eccleston C, et al. Psychological therapies for the management of chronic and recurrent pain in children and adolescents. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD003968.
http://www.cochrane.org/reviews/en/ab003968.html

Cepeda MS, et al. Music for pain relief. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD004843.
http://www.cochrane.org/reviews/en/ab004843.html

Strength of Evidence: Meta-analysis

Recommendation #2: Local anesthetics can be very useful, particularly for procedural pain EMLA cream for circumcisions reduces pain and is safe for a one time use.

Source: Taddio A, et al. Lidocaine-prilocaine cream for analgesia during circumcision in newborn boys. Cochrane Database of Systematic Reviews 1999, Issue 3. Art. No.: CD000496.
http://www.cochrane.org/reviews/en/ab000496.html

Strength of evidence: Meta-analysis

Recommendation #3: Initial evaluation should include a description of pain in relation to impairments in physical and social function (e.g., activities of daily living, sleep, appetite, energy, exercise, mood, cognitive function, interpersonal and intimacy issues, social and leisure activities, and overall quality of life). (IIA) The patient's attitudes and beliefs regarding pain and its management, as well as knowledge of pain management strategies, should be assessed. (IIB)

Source: American Geriatrics Society

The Management of Persistent Pain in Older Persons. Journal of the American Geriatrics Society 2002;50(6Suppl):S205-S224.
http://www.ncbi.nlm.nih.gov/pubmed/12067390?dopt=Abstract

Strength of Evidence:

IIA (II = Evidence from at least one well-designed clinical trial without randomization, from cohort or case-controlled analytic studies, from multiple time-series studies, or from dramatic results in uncontrolled experiments. A = Good evidence to support the use of a recommendation; clinicians "should do this all the time".

IIB (II = Evidence from at least one well-designed clinical trial without randomization, from cohort or case-controlled analytic studies, from multiple time-series studies, or from dramatic results in uncontrolled experiments. B = Moderate evidence to support the use of a recommendation; clinicians "should do this most of the time".)

Recommendation #4: For the older adult who is cognitively intact or who has mild to moderate dementia, the physician should attempt to assess pain by directly querying the patient. For the older adult with moderate to severe dementia or who is nonverbal, the physician should attempt to assess pain via direct observation or history from caregivers.

Source: American Geriatrics Society

The Management of Persistent Pain in Older Persons. Journal of the American Geriatrics Society 2002;50(6Suppl):S205-S224.
http://www.ncbi.nlm.nih.gov/pubmed/12067390?dopt=Abstract

Strength of Evidence:

IIA (II = Evidence from at least one well-designed clinical trial without randomization, from cohort or case-controlled analytic studies, from multiple time-series studies, or from dramatic results in uncontrolled experiments. A = Good evidence to support the use of a recommendation; clinicians "should do this all the time".

Recommendation #5: Studies have shown that African Americans and Hispanics are more reluctant to complain of pain, and more likely to believe in stoicism and be concerned about opioid addiction. Physicians should make an effort to ask every patient about pain or discomfort. This may require asking more open-ended questions or using descriptors other than the word "pain", such as "discomfort", "ache", or "soreness", with which patients who are stoic may be more comfortable.

Source: Journal of Palliative Medicine

Cintron A, et al. Pain and ethnicity in the United States: A systematic review. Journal of Palliative Medicine 2006;9(6):1454-1473.
http://www.ncbi.nlm.nih.gov/pubmed/17187552?dopt=Abstract

Strength of Evidence: Systematic Review

Download PDF with Recommendatons

Children

Elderly

Minorities

Approved and Off-label medications for Chronic Pain: Download PDF

The first file contains a PDA version of the lecture notes for the material covered in the first six Learning Link activities.
Download Lecture Notes: Chronic pain-AAFP learning link.zip

The second file (OpCalc) is an equianalgesic opioid calculator. This PDA tool allows easy and accurate conversion when switching from one opioid medication to another opioid and uses standard equianalgesic dosing.
Download Opiate Calculator for Palm OS, Pocket PC (Windows Mobile) and PC Windows: OpCalc.prc

Installation Instructions
RediReader for Palm OS
RediReader for Pocket PC

Presentation Slides for Disparities in Care: Special Populations in Pain Management.

Functional MRI: Gatchel RJ et al. Pain and the Brain. Practical Pain Management. 2008; 8(5):28-40

Toombs JD, Kral LA.
Methadone treatment for pain states. American Family Physician. 2005;71(7):1353-8: http://www.aafp.org/afp/20050401/1353.html

 

Pomm HA, Pomm RM. Management of the Addicted Patient in Primary Care. NY: Springer Science, 2007.

Chronic Pain: A Primary Care Guide to Practical Management. Marcus DA. 1st Edition, HumanaPress, Totowa, NJ, 2005

Anxiety Screen: Download PDF
CAGE AID: Wisconsin Medical Journal 1995;94:135-140.
COMM tool: http://www.painedu.org/soap.asp
Documentation Charting Sheets for Treatment of Chronic Pain: Download PDF
Drug Abuse Screening Test (DAST): http://www.projectcork.org/clinical_tools/html/DAST.html
Methadone Fact Sheet: Download PDF
Opioid Risk Tool: http://www.painknowledge.org/physiciantools
Pain Agreement: Download PDF
Pain Severity Assessment Tool: Download PDF
Pain Scale Comparison: Download PDF
Patient Health Questionnaire (PHQ): www.phqscreeners.com Download PDF
Release of Information Form: Download PDF
SOAPP: http://www.inflexxion.com/offerings.aspx?id=260

Pain Scales

 

 

 

 

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