PA_MaryAnne: Welcome to American Pain Foundation’s (APF) PainAid chat with Micke Brown, Director of Advocacy for APF. We’re very pleased to have Micke as our guest speaker tonight. The topic for this evening is "Pain 202: Assessment and Treatment of Pain.” Micke will share what she has learned in the clinical setting and reflect on lessons she has learned from those living with pain.

Micke’s responsibilities at APF include coordinating publications, public outreach programs and cultivating relationships with community groups, networking with associations, thought leaders and decision-makers. She works closely with the Executive Director on policy issues that affect pain management and assists the Pain Information Center by serving as a clinical resource for public inquiries and contributing to publications.

Micke has been a registered nurse for over thirty (32) years with over fifteen (17) years experience as a pain management nurse, program coordinator, educator and advocate. She has served as a clinical nurse specialist, case manager and director of pain services during her tenure within the healthcare industry. Her public speaking experience is extensive to both professional and consumer audiences.

Micke is an active member of the American Society for Pain Management Nursing (ASPMN) and served as their President for 2003-2004. She was the President of the ASPMN Maryland chapter for 2005-2006, on the Board of Directors for the Hospice of Washington County in Maryland (from 1997-2002) and the Maryland Pain Initiative (2002 – current). Ms. Brown is the 2006 recipient of the Richard S. Weiner Pain Education Fund Advocacy for People with Pain Award from the American Academy of Pain Management.

This chat is provided for educational and information purposes only. APF is not engaged in providing medical advice or professional services. This information should not be used for diagnosing or treating a health problem. Always consult with your health care providers before starting or changing any treatment.

Please remember that this is a protocol chat. If you have a question for Micke, please indicate by typing a “?” and if you have a comment, please so indicate by typing a “!”. The Pain Aid moderators will be keeping track of your place in line to ask questions or make comments and will call on you in turn.
Please have your question already typed and ready to send when you are called upon. When you are finished with your question or comment, please type “ga” (stands for “go ahead”) or “end.” All of this will help us to keep the chat moving right along and will allow us to get the most number of questions answered for you.

Ok! I’ll turn it over to Micke for her presentation. GA Micke.

Micke: I am so honored to be back with all of you tonight!

You may recall from the Pain 101 Chat we talked about the basics to pain management, which included the definition of pain, pain types and how pain impacts you and those around you. I also talked about the common myths and misconceptions around pain and its treatment that lead to mis-understanding, mis-information and mis-interpretation of pain issues as they are confronted by those living with pain and those trying to treat it. Tonight, I will talk with you about pain assessment and pain treatment.

First of all, it must be emphasized that APF and others in the pain field support the principle that individuals with pain have a “basic human RIGHT” to obtain optimal pain relief. This principle requires that the healthcare provider (HCP) must honor the primary tenets of medical ethics. These tenets provide the framework so that professionals are essentially obligated to minimize the suffering of those entrusted in their care.

Unfortunately, far too many doctors, nurses, pharmacists, therapies and others do not have the training or skills required to adequately manage pain. Therefore, this inadequacy sets the stage for suboptimal pain care and the dishonoring of your pain rights. To date, regretfully there are no current laws that support the right to pain care. For more information about pain rights, see the APF Pain Care Bill of Rights in the publication section of our website at: http://www.painfoundation.org/page.asp?file=Publications/Index.htm.

Remembering that, the most popular definition of pain states that “Pain is whatever the experiencing person says it is, existing whenever the person say it does” (Margo McCaffery 1968) requires that individuals with pain must convey the pain experience to their HCP in a meaningful way. HCP’s must be willing to listen, comprehend and formulate an opinion as to the possible pain problem and pain treatment options that may be most appropriate. The pain assessment is one of the most critical steps towards pain relief.

As discussed in Pain 101, a prevailing myth is that the best judge of pain is the physician or nurse. Studies have shown that there is little correlation between what doctors or nurses might “guess” about someone’s pain. The person with pain is the authority on the existence and severity of his/her pain. The self-report from the person with pain is the most reliable indicator. The MOST common reason for the undertreatment of pain is the failure to assess pain. Therefore, learning how to communicate your pain severity, location, sensation, occurrence and responses to pain remedies is a high priority.
There are several pain assessment tools that are commonly used in hospitals, clinics and medical offices. They have common features to know about. Most use a number based scale such as 0-10 (Zero means no pain and 10 means the top of the scale—the absolute worse pain level you can imagine or the worse you may have already experienced in your life) or 1-5. Other tools have visual prompts, like faces, thermometers, colors, etc. that help you identify with the number rating system.

Another may also ask you to rate your ability to sleep, walk, work, mood, etc. One of my favorite tools combines the numeric scale with words like mild or distressing associate to the number, faces (smiles to cry) and how that pain level interferes with the ability to perform activities (no impact on activity to unable to perform).

Another feature of the pain assessment is to identify with common pain descriptor, like sharp, dull, pressure, burning, etc. These descriptors are important features of your pain. Knowing more about the pain sensation—how you describe how it feels, also provides clues to the type of pain and help direct what pain treatment options may be more suitable than others.

It is important to remember that these are tools to help ask the right questions and provide more insight about your pain. Pain assessment tools should NOT be used as a onetime question, such as what I refer to as “the rate your pain” game. These tools are meant to start the conversation.
Additionally pain changes, so it is helpful to know what your pain level is at the time of the interview, what level it is during the day when you are the most comfortable or when the pain is at its best; then when you are the most uncomfortable or when it is at its worse. In the hospital after surgery, for example, you could be asked to rate your pain when you are at rest compared to when you are performing an activity like changing your position, sitting, walking, etc. Knowing these changes are important as they give clues to the HCP about the pain type or if a treatment option in use is effective or problematic.

I strongly urge you to keep track of your pain over time. A few times a week or at least weekly may be all that it takes. By keeping a pain journal, like the APF’s Pain Notebook: http://www.painfoundation.org/page.asp?file=Publications/Target.htm which is easy-to-use , you can keep a record of your pain and help guide your communication with your healthcare provider. You and your HCP will be able to see the nature of your pain when you are not just sitting in front of them during your routine visit. When you work together with your HCP and take an active role in your pain management, you will get the best results possible—less pain and more involvement in life.

Pain assessment tools have been created for newborns, infants & children, seniors and those who cannot express themselves or unable to think clearly enough to provide a self-report. Many pain assessment tools have been published in other languages, too.

Pain is complex and unique to each of you. When mapping out a pain treatment plan, your HCP will consider many aspects of your pain and daily life before recommending options. To review, the following considerations should be made:
 Type of pain (whether it is acute or chronic)
 Category of pain (nociceptive or neuropathic)
 Intensity of your pain
 Your physical condition, coping ability and challenges
 Your lifestyle and preferences for treatment

Common pain problems can often be managed by your primary care provider or treating healthcare professional. This individual could be a physician, nurse practitioner or physician’s assistant. When pain is more difficult to treat help from additional healthcare professionals and others with specialized training in pain may be required. Some of these disciplines may include, but are not limited to:
 Specialty physicians from the fields of neurology, neurosurgery, physical medicine, anesthesia, orthopedics, psychiatry, rheumatology, for example.
 Nurses
 Pharmacists
 Social Workers
 Psychologists
 Case Managers
 Chiropractors
 Physical Therapists, Occupational Therapists
 Complementary/Alternative Medicine Practitioner

Remember, a therapeutic relationship is a two-way street. It develops over time and trust and open communication are essential. Be sure to find a HCP who is not only trained to treat your pain disorder, but is also willing to work with you to manage your pain. At each follow-up visit, a re-assessment of your pain and pain management plan is very important in order to evaluate the effectiveness of your treatment.
At the conclusion of Pain 101, I stated that pain treatment requires Action! The overarching goals of pain treatment are:
• Lessen your pain severity
• Improve your ability to function in your everyday life
• Enhance your quality of life

The creation of an effective pain management plan begins with screening, recognition & reporting. The most effective treatment plans are those that are “multi-modality”, meaning a variety of options. How to balance the risks with benefits of the preferred treatment choices should be discussed as each option is recommended.

The pain treatment plan should include options from the following categories:
• Medication Therapy
• Rehabilitative Methods
• Psychosocial Support
• Non-Drug Options (CAM)
• Interventional Techniques: Injections, Infusions, Implantables and other “invasive” options.

Your HCP may not have experience in using or performing every treatment option available. Some pain treatment options require special areas of expertise or training. Referrals to those specialists may be required. Insurance coverage of pain treatment options vary widely, if covered at all.

Medication Therapy Highlights: Medications do play an important role in the treatment of pain but are not the only option. Many different medicines can be used to help relieve pain. A few, such as aspirin, ibuprofen and acetaminophen, can be purchased in a pharmacy or supermarket without a prescription, but the stronger pain relievers are only legally available with a prescription from your HCP. Some medications used to treat pain are not usually thought of as pain medicines, but they have been shown to relieve specific types of pain. For example:
 Some drugs used to manage depression or seizures can be used to treat neuropathic or nerve pain.
 Some steroid medications, such as prednisone and dexamethasone, may be used to treat pain caused by inflammation or bone disease.
 Some medications used to relax muscles or treat insomnia or anxiety may be used in the overall management of pain.

The primary types of medications used for pain relief are:
 Non-opioids: non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen -- NSAID’s help relieve mild to moderate pain and inflammation. They are commonly used with pain conditions that are caused by inflammation, like after a sudden injury or surgery, arthritis, headache, menstrual cramping. There is no evidence that one NSAID is a better pain reliever than another; however, you may get better pain relief from one than from another. Finding the right NSAID to treat persistent pain is a matter of trial and error--it may take awhile for the medication to work. An adequate trial of the medication chosen may be needed before judging its benefit. NSAIDs have ceiling dose, which means that taking doses above the upper limit can increase the risk of serious side effects, such as kidney failure, which can be life threatening. In the case of NSAID’s, more is NOT better.

 Opioids (the term “narcotic” is discouraged as this is a law enforcement term that lumps legal controlled substances with illegal drugs): codeine, morphine, hydrocodone, oxycodone, fentanyl are common examples. Opioids are an essential option for treating moderate to severe pain associated with surgery or trauma, and for pain related to cancer. In select cases, they are an effective option for reducing persistent pain in conditions unrelated to cancer. These medicines block pain messages in the body, but they also affect the way one feels and tolerate pain. Opioid pain medicines are not all alike. They differ in how well they control pain, how much you have to take, how long they last and in the routes by which they can be given.

Some individuals are at a higher risk of developing substance abuse vs. misuse of these medications than others. Your HCP should be evaluating that risk with you and compare the benefits of this choice before the medication is selected and continue to monitor its effect over time. If you have a history of past/present substance abuse or addiction, it is important to work with a HCP who is familiar with managing pain and addictive disease (or has a referral source able to work with you) before this option is considered. This issue is complex and should be a separate chat. For more information, see the APF Key Proceedings on Opioids: http://www.painfoundation.org/publications/KOLKeyProceedings.pdf.
 Adjuvant analgesics: a loose term referring to the many medications originally used to treat conditions other than pain, but now also used to help relieve specific pain problems; examples include some antidepressants and anticonvulsants. Some of these have been shown to work well for specific types of pain. Medications that have no direct pain-relieving properties may also be prescribed as part of a pain management plan. These include medications to treat insomnia, anxiety, depression, and muscle spasms. They can help a great deal in the overall management of pain in some persons.

Rehabilitative techniques offer a vast array of options that you may naturally use at home without thinking, like heat or cold packs, creams, tub baths, hot showers, walking around to those that require specialty evaluation, manipulation and monitoring. Whether you are working with a physical therapist, undergoing osteopathic manipulation from your physiatrist, wearing a TENS unit or participating in a therapeutic pool therapy class…you are using this treatment option for as part of your pain treatment plan. Learning how to move around without causing more damage that may result in more pain and becoming more flexible and fit from a time when even getting out of bed is a challenge is a major feat for many who live with pain. Though this can be a scary road to travel, it often leads to independence and claiming your life back.

Psychosocial support is the gift that often we fail to give to our own self—whether living with pain or not. Living with pain can evoke a range of feelings from fear and anger to hopelessness, confusion and isolation. Family and others in your life may have similar feelings. The emerging science of pain is showing evidence of a biological link between the brain systems involved in depression and pain regulation. Interventions used to influence emotions, thinking and behavior can aid in the reduction of pain and associated distress. Some people experience depression or anxiety due to chronic pain while others may have a history of depression or anxiety which re-emerges or becomes worse once a pain problem occurs.

A referral for a psychological evaluation and testing may be warranted. Treatment options in this category have a broad range of choices from relaxation therapy (relaxation, mindfulness, imagery), biofeedback training, behavioral modification classes, stress management training, hypnotherapy to counseling (individual, family or group). You could be working with a psychiatrist, psychologist or a social worker. Many issues that complicate your life as well as your pain can be worked out. So, why not go for it???

You may believe that referral for psychological pain treatment means that your pain is not physical, or feel you are being labeled as having a mental illness rather than a physical problem. You may feel hesitant to try psychosocial therapies due to the associated stigma, or the fear that your provider will no longer treat the physical symptoms of your pain or try new treatment options. Don’t let these fears interfere with your willingness to try a broad class of potentially safe and effective treatments.

Complementary Alternative Methods (CAM) is used more and more by Americans to help manage and treat various health problems, including pain and stress. The National Center for Complementary and Alternative Medicine (NCCAM) defines CAM as “a group of diverse medical and healthcare systems, practices, and products that are not presently considered to be part of conventional medicine.” Most CAM therapies take a holistic approach to care -- treating the mind, body, and spirit. Some of these approaches, such as acupuncture, mind-body therapies (e.g., biofeedback), yoga and massage are widely used and accepted. For this reason, they have been integrated into medical care. Integrative approaches may be the most effective for people living with pain. For example, acupuncture, mind-body techniques, energy therapies and chiropractic care can be used along with analgesics (pain medication) to reduce pain. Other CAM therapies are not widely accepted by the medical community and some carry risks, so make sure to speak with your HCP about CAM. Judith Fouladbakhsh RN, PhD has covered this topic quite well in previous chats. Research is helping the growth of quality CAM options and its further acceptance into medical care practices.

Interventional Techniques include Injections, Infusions, Implantables and other “invasive” options. Injection therapies or sometimes called nerve blocks are now associated with any procedure that involves placing a needle into a muscle, joint, spine, or around a specific group of nerves, followed by the injection of medication(s) or delivery of some other treatment such as electricity, heat or cold. The most common medications injected include local anesthetics, corticosteroids, and neurolytic drugs:
 Local anesthetics can numb a painful area by “blocking” sensory and pain pathways.
 Corticosteroids reduce inflammation around the nerves to decrease pain.
 Neurolytic drugs destroy nerve pathways to produce a more permanent effect.

Neuroablative therapies usually produce a longer lasting effect than nerve blocks. These therapies use thermal (heat or cold) or chemical agents (alcohol or phenol) to “destroy” certain nerves or nerve chain pain pathways, thereby providing you with prolonged pain relief.
Infusion therapies range from those most commonly used after surgery/trauma that deliver pain medications through a catheter placed in your vein, under your skin, along a major nerve, within the epidural space or along the spine in the intrathecal space to special anesthetic infusions used to help “re-set” pain signaling with certain neuropathic (nerve related) pain conditions.
Minimally invasive surgery are procedures that target the boney spine like the percutaneous vertebroplasty which is used to stabilize vertebrae damaged by compression fractures by injecting bone cement into the collapsed vertebrae. The aim of a vertebroplasty is to improve the strength and stability of the injured vertebrae and to eliminate pain. Another similar procedure is called a kyphoplasty which includes an additional step when compared to vertebroplasty. Prior to injecting the cement-like material, a special balloon is inserted and gently inflated inside the fractured vertebrae. The goal of this step is to restore height to the bone thus reducing deformity of the spine.

Implantable infusion pumps and stimulators have been designed so they can be surgically placed under the skin. This helps reduce the risk of infections that is more common with external devices and provides targeted pain relief to major nerves and the spinal cord, depending on the system selected. External devices tend to be recommended for short-term pain problems when pain relief is expected to decrease over time. Internal (implantable) devices may be more appropriate for persistent pain problems that require long-term pain reduction.

More options are on the horizon. For more information refer to our publication, Treatment Options: http://www.painfoundation.org/Publications/TreatmentOptions2006.pdf.

Remember pain management is an ongoing process! It is not just a one-time concern. Finding the right combination of therapies may take time, but often makes the critical difference in your care.

Tonight’s Pearls: As someone who is living with pain, it is important to speak up and speak out about how pain impacts your life. You are the expert on your pain. Share your experience with your healthcare provider(s) and those who care about you. Discuss what goals you would like to achieve as your pain is lessened. Learn about pain treatment options that are most suitable for your pain condition and work with your healthcare professional(s) design a treatment plan that works for you. Decide that you will manage your pain rather than have your pain manage you.

PA_Carolina: Ok – We’re now open for questions. Go ahead, emhinma

Emhinma: My husband has chronic pain from a car wreck in 1999. He is in constant pain. He's tried injections, P/T, psychology, TENS, other stuff. The only thing that works is opioid treatment. Now the state is shutting down his doctor. What next??

Micke: If the state is shutting down the physician, then a referral to a new provider is indicated.

Emhinma: That’s not happening. Doctors are not taking on pain patients due to fear. We found one clinic that would take him at half of his maintenance dose, but they are the only ones in state who will take him.

Micke: You have the right to request a referral. You can post this type of question on the discussion board and perhaps a separate chat on this issue can be conducted in the near future.

Omieljaniuk: My question is this: I am post 2 lumbar surgeries, one discectomy, one fusion - L5-S1 area. I am in constant pain. My pain management is Fentanyl Patch 75mcg every 3 days, MSContin 100mg: 3X day and Percocet 10mg 6-8 times a day, Lyrica 75mg once every night and believe it or not I am in such agony, back pain, leg pain, sleeping in a sitting position because I can't lay down for the last 5-6 months. What are my doctor's doing wrong? Or am I just out of luck? What would you suggest? I also had another spinal surgery for my cervical spine (fusion) and that turned out ok, NO PAIN there. Would I benefit from a pain pump or neurotransmitter as I've been hearing lately and if so, which of the two? I've had everything else done, Shots, accupuncture, pressure point massage, reiki, I'm miserable.

Micke: I cannot provide a medical opinion especially since I have not had the priviledge of performing a pain assessment, review your records or perform an examination. Have you considered asking for a second opinion?

Omieljaniuk: I have and it seems that the doctors are completely stumped as to what will finally give me relief. I know that the doses of the medicine I take now could kill another.

Micke: Again, I cannot add anymore wisdom as stated before..........I clearly do not have the information required. I know this is not what you want to read, but I cannot advise you this way............no pain assessment, no records, etc. There is a process that I just shared with you this evening that must take place before a responsible clinician can make recommendations for a treatment plan.

Rxalvarez: Will this info be available on the site? TYVM (thank you very much)! This info HAS been helpful! /end.

Micke: Yes, the transcript will be posted on the APF website.

Mrspock08: I have CFS & Fibromyalgia, along with a couple of other conditions typically affiliated with CFS (NMH, etc) - I was lucky, back when I was first diagnosed, to find a couple of excellent doctors, who believed in treating pain aggressively, which included opioids when we'd tried everything else to no effect. Over the years (it's been 7 now) the opioids have become progressively less effective - first Oxycontin, then Kadian, now I'm on Fentanyl, which is working reasonably right now, but I'm wanting to explore some non-opioid options to help with my pain -- but my problem is that I'm on Medicare & Medicaid, and it seems like even in the limited cases where they'll cover chiropractic or other options, I can't find any providers willing to accept new patients on them... And of course, when it comes to anything else alternative - accupuncture, etc., they won't cover at all. It seems like I've gotten stuck into the position of my only choices being to continue strictly on medications, and have that covered by the insurance, or pay out of pocket for alternatives that might help, but which the insurance refuses to cover for some reason... Is there any way to apply pressure or something to get Medicare/Medicaid/etc to begin covering some of the alternative treatments?

Micke: It is problematic when insurance companies fail to pay for options that would help people live better lives. There is action at the Federal level to improve pain education, treatment and research for civilian, military, and veteran populations. First, they must pass into law........then we can put more pressure on CMS (who funds Medicare) to pay for treatment options more equitably.

Margaret Coshan: Hi. I have read about new research that has isolated pain centers in the brain and used a new substance in rat experiments which have changed their PERCEPTION of pain, and this will soon be going forward to clinical trails. Any comments on this?

Micke: We are learning more and more in spite of poor research funding from NIH. We have so far to go.

ravenstar7: Is there going to come to light more on Myofacial Pain Syndrome & is it the same as Fibromyalgia?

Micke: If only I had a crystal ball.

GeekyGranny: Is there a way a person can get funds to pay a doctor for facet injections? I have no insurance and no income except for my husband's disability. And I am too young for Medicare and such.

Micke: You may have some success talking with the Patient Advocacy Foundation. Sometimes, they have been able to help with financial challenges. We are looking to work on financial access issue as one of our next projects in 2009. It is a HUGE problem.

Ekielian: Is there any type of imaging or screening device currently being developed that could see tissue damage that MRIs cannot see?

Micke: There is great promise with functional MRI's and I would not be surprised to know that others are looking at better diagnostics. Pain is tough because in essence chronic pain is a disease of the central nervous system. Our nerves, spinal cord and brain are so complex and hold many mysteries.

PA_MaryAnne: Unfortunately, that is all the time we have for this evening. We would like to invite everyone to take advantage of the wonderful resources here at the American Pain Foundation. The chat room you are in tonight is part of our PainAid Online Community. We have daily chats, Monday-Friday at 11:00am EST, as well as evening chats Mondays at 9:00pm EST and Wednesday at 7:00pm EST. The PainAid discussion boards (http://painaid.painfoundation.org) are also available to you 24/7 for support from your fellow pain patients, caregivers and medical professionals.

Our home page (www.painfoundation.org) has numerous resources, publications, opportunities for advocacy and a great pain information library.

Thank you, Micke, for sharing such an informative and inspirational chat this evening. Thank you all for coming this evening. We will be posting a transcript of this chat on our home page and on the PainAid discussion boards for your convenience. You are all welcome to stick around and chat amongst yourselves. Good night, everyone!