Bemaj Pharmacy

What are the 3 Ps of pain management?

Skip to main content Close We are committed to providing the best pain management and promotion of comfort for all persons. Research shows that people who experience high quality pain management while in hospital have shorter recovery periods and fewer hospital return visits.

1. Supporting Pain There are many different types of pain; pain can be sudden, ongoing, related to procedures, illness or injury, or not have an identifiable cause.
2. This page provides information, resources, and links to help support children and youth experiencing pain.
3. When a child comes into the hospital, they can undergo a wide range of treatments, tests, surgeries, and procedures which can sometimes cause distress, pain and fear.

This information will help you to prepare for a hospital visit and support a child’s pain at BC Children’s Hospital. When communicating with someone in pain, we want to provide a supportive partnership and messages that are simple, accurate, and focuses on coping.

• Children and youth require special considerations when it comes to communication during healthcare encounters.
• Relationship and rapport : Children and youth are supported by voices they know, people they trust, and environments that feel safe.
• Words and terminology : Medical jargon can be confusing.
• Use words that are simple and age appropriate.

Non-verbal cues: We communicate just as much verbally as we do non-verbally. Adults can provide emotional and physical comfort through tone of voice, body language, and facial expression.

• O ne voice should be heard during the procedure
• N eed for parental involvement
• E ducate patient before the procedure about what is going to happen
• V alidate the child’s feelings
• O ffer the most comfortable, non-threatening position
• I ndividualize your game plan
• C hoose appropriate distraction to be used
• E liminate unnecessary staff not actively involved with the procedure

One Voice Website The words we choose have a significant impact on the person in pain. Below are some examples that you can use to communicate with your child: When your child is undergoing a procedure: “Some kids say it feels like _ (use soft language such as pressure, uncomfortable, pinch) I’m not sure what it will feel like for you, you can tell me what it felt like when we’re done.

If we use the strategies we talked about, it won’t bother you so much.” Remind the child/youth what their job is and acknowledge successes “You are doing such a great job keeping your arm still, let’s keep taking those deep breaths.” Provide encouragement, validate feelings, and redirect to positive coping behaviours: “I know you were feeling uncomfortable but you did a great job of staying focused on your game, taking deep breaths, and squeezing your stuffed animal.” Here at BC Children’s Hospital, we are making comfort a priority by offering the Comfort Protocol – an approach to support infants, children, youth and families with procedures.

There are five approaches that BC Children’s Hospital uses to promote comfort and reduce pain when possible.

• Preparation is helping the person and family/caregivers understand what is happening. Preparation helps reduce stress before a procedure and improves outcomes. Check out the Help Your Child Manage Medical & Surgical Procedures handout for suggestions that can help you and your child manage stress before, during and after their procedure.
• Communication provides information non-verbally and verbally, considering tone of voice, body language, and volume. Communication can influence comfort because what you say is as important as how you say it.
• Comfort Positions are secure hugging holds that can reduce stress and ensure safety during a painful procedure. Check out how our animal friends show some examples in our Paw-sitions for comfort handout,
• Alternate Focus (distraction) works by engaging the person in a task or activity that can redirect their attention during a procedure. The person chooses what they want to focus on, examples are: focusing on the procedure, stress ball, bubbles, books, or electronic devices.
• Medication is used in combination with the approaches listed above to optimize comfort and reduce pain when needed.

View our one-page summary of how and why we promote comfort. The use of opioids is not uncommon at BC Children’s Hospital. We are committed to helping all persons and caregivers understand how to safely and effectively manage pain with the use of opioids when needed.

• Always follow the directions on the medication label unless your healthcare provider has told you to take the opioid differently.
• Never share your medication with others.
• Store medication at room temperature, away from heat, moisture, and direct light.
• Store the medication out of reach of children and pets.
• Return unused or expired medication to a pharmacy. Your pharmacy can dispose of it in a safe way.

• Ask your healthcare provider before taking any other medication, including non-prescription medications, vitamins, and herbal products.
• Opioids can be sedating. Do not participate in potentially dangerous activities until you know how this medication will affect you.
• Do not stop taking this medication suddenly without talking with your healthcare provider.
• If you miss a dose of your medication, take the dose as soon as you remember or skip the missed dose if it is almost time for your next dose. Do not take any extra medication to make up for a missed dose.

• Opioids have possible side effects that you should be aware of. Not all side effects happen to all people, and many people do not have any side effects.
• Less serious side effects often improve during your first few days taking the opioid. These include:
• Dizziness, light-headedness, or drowsiness: try moving slowly when you sit or stand
• Nausea or vomiting: try taking medication with a bit of food
• Constipation: try increasing fluids, fruits and vegetables, foods with fiber. and laxatives if you need them
• Dry mouth: try chewing gum, or sucking on ice chips
• Nervousness or restlessness: avoid caffeinated drinks
• Blurred or double vision
• Nightmares or unusual dreams
• Difficulty with urination
• If these side effects continue, or cause distress, talk with your healthcare provider or pharmacist.

• Difficulty or slow breathing
• Seizure
• Confusion or hallucinations
• Severe dizziness
• Severe drowsiness
• Difficulty walking or weakness

• BC Children’s Hospital Family Resource Pain Guide – Medications
• Opioid Medicines – Information for patients and families/ Health Canada
• Stollery Children’s Hospital – So you have been prescribed an opioid?

At BC Children’s Hospital, we have specialized teams that provide pain services for the‎ children and families of British Columbia. The Pain Services include the Acute Pain Service (APS) and the Complex Pain Service (CPS). When in the hospital, your child can access the APS if managing their pain becomes hard to manage.

1. The CPS is a team of healthcare professionals that helps those with chronic and complex pain.
2. Learn more about the Acute Pain Service Learn more about the Complex Pain Service Learn more about Canuck Place Children’s Hospice Certified Child Life Specialists at BC Children’s Hospital make hospitalization a more positive experience for persons and caregivers through play, therapeutic interventions, preparation, and creative arts.

Find out more about their role facilitating comfort at the hospital and how to get them involved. Learn more about Child Life Services Supporting you at home After a child is seen at the hospital, it can feel overwhelming to know how to manage pain and provide comfort without the daily support of healthcare professionals.

• Skin-to-skin contact: Infant is placed naked (except for a diaper) on mothers or family member’s chest and covered with a blanket.
• Breastfeeding : If you are breastfeeding your infant, your infant may seek to breastfeed more often if they are experiencing pain.
• Non-nutritive sucking: If unable to initiate breastfeeding you may encourage infant to suck on their clean finger or a soother.
• Swaddling: Safely swaddle infant in a blanket to provide comfort. Watch this video for hip safe swaddling tips.
• Sensory-stimulation: Rocking, holding, singing, touching.

Pain strategies can be combined to optimize better pain relief, for example, skin-to-skin contact together with breastfeeding and/or non-nutritive sucking. Medication: If medication is prescribed, always follow the directions on the medication label unless your healthcare provider has told you to take it differently.

• Ask your child regularly if they are comfortable
• Don’t wait to treat pain, If medication is prescribed, always follow the directions on the medication label unless your healthcare provider has told you to take it differently. Provide over-the-counter medication as the pharmacist or healthcare provider has instructed.
• Provide comfort approaches,
• Provide a calm and relaxed environment.
• Offer activity that your child enjoys.
• Gradually increase activity to normal levels as instructed by your healthcare team and as your child feels more comfortable.
• Offer pain management approaches such as: use of heat and cold compress, deep breathing, and relaxation techniques (e.g. music and distraction).

• BC Children’s Hospital Family Resource Pain Guide – Comfort Approaches
• Pain Relief: Comfort Kit (SickKids Hospital)
• Guide to Chronic Pain in Students

Providing support at home will be different for each youth. It’s important to let your youth know that you are there to support them. Collaborate with your youth and make decisions together to manage their pain.

• Ask your youth regularly if they are comfortable.
• Don’t wait to treat pain, If medication is prescribed, ensure your youth follows the directions on the medication label unless your healthcare provider has told you to take it differently. Encourage your youth to take over-the-counter medication as the pharmacist or healthcare provider has instructed.
• Encourage your youth to express when they are in pain so that you can support them with coping strategies and ways to self manage their pain.
• Promote a calm and relaxed environment and encourage youth to get enough rest.
• Encourage youth to engage in activities and routines that they enjoy.
• Let your youth know that their pain is real and you believe them.
• Encourage and facilitate pain management approaches such as: use of heat and cold compress, deep breathing, and relaxation techniques (e.g. music and distraction).

• Pain Took Kit for Youth
• My Care Path
• Pain BC Toolbox
• Guide to Chronic Pain in Students

If your child’s pain gets worse, or if recommended medicine doses and timing does not help, these options may help: Phone your BCCH healthcare provider supporting your child’s follow up care. Please use the phone number you received at time of discharge.

Phone your family doctor or nurse practitioner (NP). If you have any questions about the medicines, selecting the appropriate product(s), the doses or how to measure, a pharmacist can assist you. If you cannot reach any of the above, call HealthLink BC (8-1-1) to speak to a registered nurse. Tell them your child’s current pain medicine is not working.

www.healthlinkbc.ca Contact information for families If you have recently been to the hospital, and are experiencing unmanageable pain, please contact your healthcare team and they can consult the Acute Pain Service (APS) or direct you to emergency services if needed,

• Managing Pain The most effective pain management employs a comprehensive multimodal approach,
• This multimodal approach manages pain using multiple strategies together: comfort approaches, mind-body strategies, and pain medication.
• There are different types of pain: acute, acute on chronic, chronic, and complex pain.

The most effective pain management for all types of pain uses p sychological, p hysical and p harmacological strategies. This is known as the “3 Ps” approach. When these strategies are used together, they optimize pain relief. Mind body strategies are techniques designed to enhance the mind’s positive impact on the body.

These strategies support our thoughts, feelings, beliefs, and attitudes which can positively or negatively affect our bodily functions. This is a back-and-forth communication between our brain and body. Psychological strategies include school reintegration/adaptations, parent/caregiver presence, relaxation, deep breathing, supportive communication, distractions (watching TV, reading books, playing video games, visiting with friends, music).

BC Children’s Kelty Mental Health has great resources for children, teens, and families. Check out their videos, app, podcasts, and more. Kelty Mental Health Breathr: This mindfulness app was developed by BC Children’s Kelty Mental Health Resource Centre and BC Children’s Centre for Mindfulness.

This free app, designed for youth and young adults, guides you through a variety of mindfulness practices and can be used anywhere. Breathr App My Care Path: The Mind-Body Connection explains what mindfulness is and teaches belly breathing. My Care Path The Mind Body Connection and Somatization Family Handbook is an in-depth resource focusing on somatization.

Somatization Family Handbook Physical strategies can help relieve pain by promoting healing and restoring function and movement. Physical strategies include heat, cold, use of supportive devices, massage and pressure, cuddling, hugging, paced movement (starting slow and building tolerance), breastfeeding, non-nutritive sucking, skin-to-skin contact, sleep and rest.

Disclaimer: This information does not replace the advice of your healthcare provider. If you have questions, talk to your healthcare provider. The use of medication is one strategy used to treat pain. Medications are most effective when used alongside physical and psychological supports. All medications have side effects but most can be managed.

Some medications are over-the-counter (e.g. acetaminophen, ibuprofen) while other medications are prescribed by your doctor (e.g. opioids, corticosteroids). To learn more about opioids see the “Pain at the Hospital” section above. Contact information for fam ilie s If you have recently been to the hospital, and are experiencing unmanageable pain, please contact your healthcare team and they can consult the Acute Pain Service (APS) or direct you to emergency services if needed,

• A physical and emotional experience that is unique to everyone.
• A natural warning sign to your body that support is needed.

When a person experiences pain, signals are sent from the body to the brain through the nervous system. Pain is felt differently by everyone and each person has unique ways of experiencing and coping with pain. Visit the International Association for the Study of Pain ‘s website to learn more about the definition of pain. This page provides general information about pain. BC Children’s Hospital is guided by a person-centred approach and is committed to the best possible health outcomes for all people. We strive to minimize pain for persons, support children in return to daily activities as soon as possible and provide tools to live with chronic pain.

• Our goal is to minimize pain to the best of our ability with a focus on function (i.e., getting back to daily activities) and coping.
• Childhood pain experiences can create memories that have long-term impact in children’s lives.
• We believe pain must be managed to promote positive lifelong healthcare experiences.

It is everyone’s role at the hospital to partner with the person and family to understand their experience and the many ways pain is expressed, both verbally and non-verbally. To provide the best pain care possible for persons at the hospital, BC Children’s and Women’s hospital is applying for ChildKind certification,

1. An institutional commitment to pain prevention, assessment, and treatment.
2. Ongoing education programs and awareness initiatives on pain for staff, trainees, patients and any of their caregivers.
3. Use of evidence-informed, developmentally appropriate processes for assessment of acute and chronic pain.
4. Specific evidence informed protocols for pain prevention and treatment including pharmacological, psychological, and physical methods.
5. Regular institutional self-monitoring within the framework of continuous quality improvement.

Here is a summary of the work BC Children’s and Women’s hospitals has done for ChildKind certification:

• Access to clinical documents for health care providers to follow when providing pediatric pain care.
• Support for patients and families during clinical procedures using the Comfort PACT (Pain Addressed Comfort Tended) Protocol,
• Ability for health care providers to monitor a pain experienced by a child in the hospital in the hospital’s record system.
• Information on webpages to publically communicate BC Children’s Hospital’s commitment to pediatric pain care and assist families with finding and accessing information and resources.
• Pain Management and Comfort
• Pediatric Pain Guide for Caregivers
• MyCarePath
• Kelty Mental Health Resource Centre
• Access to eLearning courses, in-person sessions, new staff orientations and other educational training opportunities for hospital staff to learn about pediatric pain care.

We invite families to use these education resources to understand how they can support their child while at the hospital. These resources were created by patient and family partners and health care providers.

• How to Minimize the Pain of Needle Pokes with Numbing Cream
• Paw-sitions for Comfort
• Ten Tips for Caregivers of a Child of Youth with Chronic Pain
• Help Your Child Manage Medical and Surgical Procedures Pamphlet
• Comfort PACT Pamphlet
• Alternate Focus (Distraction) My Plan for Medical Procedures
• Comfort PACT (Pain Addressed Comfort Tended) education resources:
• Commitment Summary of the Comfort PACT
• Evidence summary for Preparation
• Evidence summary for Communication
• Evidence summary for Comfort Positions
• Evidence summary for Alternate Focus (Distraction)
• Evidence summary for Medication

We are showcasing our work at BC Children’s and Women’s hospitals to ChildKind representatives on January 30th 2023. Contact information for families If you have recently been to the hospital, and are experiencing unmanageable pain, please contact your healthcare team and they can consult the Acute Pain Service (APS) or direct you to emergency services if needed,

What is the golden rule of pain management?

The key to pain management is to treat your patient the way you’d want to be treated.

What are the 7 parameters of pain?

Patients should be asked to describe their pain in terms of the following characteristics: location, radiation, mode of onset, character, temporal pattern, exacerbating and relieving factors, and intensity.

What are the 7 aspects of pain?

Assessing the seven dimensions of pain Despite advances in pain-management education, many nurses aren’t familiar with the multidimensional aspects of pain—highlighted more than a decade ago by the National Institutes of Health and more recently by the American Society for Pain Management Nursing.

What are the 5 A’s of pain?

TO THE EDITOR – A well-known comprehensive approach to the management of persistent pain is the Five A’s of Pain Management: analgesia, activities of daily living, adverse effects, affect, and aberrant drug-related behaviors. Changes in the 5 A’s during a course of opioid treatment signify complications of treatment, failure of therapy, and/or increased risk of progression toward opioid dependence and addictive disorders. Examples of aberrant behaviors.1, 4 – 7 The presence of aberrant behaviors in a patient who has been prescribed opioids is indicative of several possible problems, and a differential diagnosis should be explored.8 Possible etiologies include addiction, pseudo-addiction, another psychiatric disorder, personality disorder, chronic boredom, mild encephalopathy, and criminal intent to divert substances.8 Aberrant behaviors can also represent genuine undertreatment of pain.8 The behaviors are also present during withdrawal states.

Aberrant behaviors are more common when associated with undertreatment in patients who have a history of prior substance abuse vs patients who are undertreated without a previous history of substance abuse.8 Understanding the patient-specific context associated with aberrant behaviors is therefore crucial in determining whether the behavioral pattern of a patient is a symptom of addiction, undertreatment, or one of many other causes.8 In the lead author’s experience at Ochsner Health between 2002 and 2015, providers varied in their ability to recognize aberrant behavior and their willingness to document it.

There was also a general lack of communication among specialties about aberrant behavior that led to overprescribing and subsequent underdiagnosing of iatrogenic addiction, which, in turn, precipitated an escalation of aberrant behavior, in particular, the verbal abuse of nurses and hospital physician providers.

An objective means of monitoring and documenting aberrant behaviors across provider groups did not exist, and as a result, administrative staff and governing bodies of the institution could not track the patterns of aberrant behavior and prevent such behaviors. A brief survey of physicians revealed that health care professionals may have preconceived notions about patients with different disease states and their pain sources, and aberrant behaviors may be misinterpreted in complex medical illnesses such as acquired immunodeficiency syndrome, sickle cell anemia, cancer, and former intravenous drug abuse.8 Physician perceptions of aberrant behaviors have a great degree of variability.8 Illegal behaviors such as the sale of prescription drugs, forging prescriptions, and altering a route of delivery were perceived to be more problematic than behaviors such as unkempt appearance, unsanctioned dose escalation, and hoarding of drugs.

Because the interpretation of such behaviors is dependent on a provider’s perception and experience—as well as the patient’s clinical context—caution should be taken to avoid making spurious correlations.8 To promote a dispassionate interpretation of a patient’s current state, the pattern of behavior in the setting of opiate use across multiple clinical environments needs to be established over the life course of a patient.

Categorizing and tracking various drug-taking behaviors is necessary to avoid personal bias and offhand judgments of patient behaviors.8 Tracking should be undertaken routinely with each admission and clinic appointment so that behaviors can be monitored during the course of care for which opioid treatment is indicated.

Recognizing deterioration of patterns of behavior in various settings that signify progression on the pathway to addiction is important.4, 9 Aberrant behaviors can signify red flags that have diagnostic significance, but they may also be common in nonaddicts and should be considered within the appropriate clinical context by the physician provider.

1. Behavior monitoring is important to determine the success or failure of treatment, whether for patients receiving proper pain management with appropriate titration of opioids or for intentional withdrawal of opioid-dependent patients. In both clinical scenarios, behavior improves once the opioid dose becomes therapeutic in the former and when the physical dependence (or withdrawal state) is completed in the latter.
2. Early identification of potential opioid-related behavior can lead to proper opioid risk assessments to prevent the transition of chronic pain to opioid dependence and substance use disorder (SUD).9
3. Early identification of potential opioid-related behavior can lead to proper opioid risk assessments to prevent psychiatric disorders such as anxiety and depression.4, 9
4. The provider’s ability to recognize aberrant behaviors can lead to identification of undiagnosed SUD.
5. Aberrant behaviors must be stabilized to achieve proper medical management of acute illness and to improve adherence to medical and psychiatric treatment.
6. Aberrant behaviors must be stabilized for the safety and wellness of health care providers and nursing staff.
7. Aberrant behavior monitoring can help identify patients at high risk for diversion.
8. Aberrant behaviors are important diagnostic criteria for complications of opioid therapy and essential for evidence-based pain and opioid monitoring.

To remove bias, aberrant behaviors need to be objectified and monitored by an array of health care professionals, not just one provider. An honest exchange of information on monitoring adherence and documentation of behaviors over time would assist in decreasing the incidence of one provider simply labeling a patient as “drug-seeking.” 4 Nurses, physical and occupational therapists, advanced practice practitioners, physicians, and psychiatrists should monitor and document aberrant behaviors in a team-based fashion.

Combining this information with the patient’s correct diagnosis allows the physician provider to align functional status, reports of subjective pain, morphine equivalent dose, nonopioid pain treatments, and aberrant behaviors with the expected course of pain treatment and proper adjustments of medication.

Figure 2 illustrates screens in the electronic medical record at Ochsner Health for documenting aberrant behaviors. Displays such as these can assist with proper documentation in a variety of hospital and clinic settings. Aberrant behaviors and other measures important to pain and addiction management could be graphed and monitored over time, combining both inpatient and outpatient settings. Display of aberrant behaviors for nursing in the Epic electronic medical record at Ochsner Health. Aberrant behaviors have been subdivided into 3 categories for easy assessment and documentation: drug-related behaviors (top screen), nonadherence to treatment plan (middle screen), and disruptive behavior observed (bottom screen).

1. No single behavior equals addiction.3
2. Persistent pain creates stressors that interfere with adherence.3
3. Uncontrolled psychiatric illness can contribute to opioid misuse.3

Several screening tools have been developed to monitor for possible abuse and misuse of opioids. No single tool is available that can be uniformly applied to the current practice of pain management.8 At least 12 tools exist for clinical use, including the widely applied Opioid Risk Tool (ORT), the Current Opioid Misuse Measure, Pain Management Questionnaire, Screening Tool for Addiction Risk, and the Screener and Opioid Assessment for Patients with Pain.

All of these tools use aberrant behaviors as an indicator for high opioid risk. These tools can be useful in specific populations but are not without limitations. While some are long questionnaires and more reliable, others are preferred for their brevity but are susceptible to deception.8 The ORT was chosen for use at Ochsner Health because of its brevity and ability to be applied as a systemwide intracommunication device about risk and to stimulate more providers to complete risk assessments.

The ORT, however, is not a complete measure of risk. The presence of aberrant behaviors is a component of an overall diagnosis, but the context, pattern with disease activity, and opioid use need to be considered to gain a holistic understanding of the patient’s state.

Long-term opioid therapy for chronic pain is associated with adverse side effects, as well as the potential for misuse and abuse, illicit drug use, and diversion.8 Given the subjective nature of pain—and its complex picture affected by psychiatric, neurologic, and social conditions—all diagnostic methods and capabilities need to be made available to providers in a transparent and unbiased manner.

This information will allow providers to effectively track patient behaviors over the course of opioid treatment, to better communicate patient care among specialties, and to thereby mitigate the risk of overprescribing opioids or promoting aberrant behavior.

What are the 5 A’s of pain assessment?

Table 4 – The Ten Principles of Universal Precautions for Patients with Persistent Using Chronic Opioid Therapy *

1. Make a diagnosis with appropriate differential including the biopsychosocial-spiritual status.
2. Psychological assessment including risk of addictive disorders. The assessment of the patient uses the biopsychosocial model with the spiritual factors included.
3. Informed consent (verbal or written/signed). Provide patient education regarding management of pain and side effects.
4. Treatment agreement to establish expectations of both the provider and the patient. Establish a therapeutic relationship promoting trust and honesty. This treatment agreement also includes safe storage of medications in the interest of public safety, i.e. Lock Your Meds®; as well as rationale for potential opioid discontinuation or discharge from medication treatment. See box 7 for Suggested Points for Inclusion in a Treatment Agreement.
5. Pre/post intervention assessment of pain level and function. With the use of the bio-psychosocial-spiritual model, the assessment is included in its entirety.
6. Appropriate trial of opioid therapy and/or adjunctive medications. Promote supportive recovery environment with family and significant other involvement. Integrate non-pharmacologic adjunctive therapies such as biofeedback, relaxation training, physical therapy, cognitive therapy and support groups.
7. Reassessment of pain level and function. With the use of the biopsychosocial-spiritual model, the assessment is included in its entirety. Use of adherence monitoring measures are applied and include urine toxicology, screening tools for alcohol/substance use disorders, pill counts, and overall adherence with treatment plan appointments and medication use.
8. Regularly assess the 5A’s which stand for Analgesia, Activity, Adverse Reactions, Aberrant Behavior and Affect **,
9. Periodically review pain diagnosis and comorbid diagnoses, including addictive disorders and mental health.
10. 10. Documentation.

Every person for whom opioids are prescribed has the potential to abuse their medication ( Webster & Dove, 2007 ). A person’s vulnerability to prescription drug abuse is associated with many variables: the specific drug being prescribed, environmental and genetic factors, other illnesses, use of alcohol and other drugs, and the suffering associated with their persistent pain ( Savage, et al., 2008 ; Webster & Dove, 2007 ).

Because it is impossible to predict who may abuse substances throughout the continuum of care, clinicians are compelled to respectfully assess every person before a prescription is written for an opioid ( Heit & Lipman, 2009 ). A systematic approach using the 10-point assessment of the Universal Precautions has been adapted using the biopsychosocial-spiritual model, and is presented in Table 4,

Risk stratification methods include the use of assessment tools to recognize patients at risk for medication adherence problems, and to evaluate problematic behaviors as they impact perceived risk and treatment planning. To assist in risk stratification there are many assessment tools on how to identify those at risk for SUDs, including opioid abuse or addiction ( Adams, Gatchel, Robinson, Polatin, Gajraj, Deschner, & Noe, 2004 ; Belgrade, Schamber, & Lindgren, 2006 ; Butler, Budman, Fernandez, & Jamison, 2004 ; Compton, et al., 1998 ; Ferrari, Cicero, Bertolini, Leone, Pasciullo, & Sternieri, 2005 ; Friedman, Li, & Mehrotra, 2003 ; Kirsh, 2007 ; Li, Katragadda, Mehrotra, Mosuro, & Friedman, 2001 ; Webster & Webster, 2005 ).

1. However, in a recent study of 428 health care providers assessing risk factors for opioid abuse, clinicians often misinterpreted initial presentation of aberrant behaviors, failing to appreciate the wide differential diagnosis ( Miller, Heit, Gourlay, Peppin, Hampton, & Miller, 2011 ).
2. If a patient takes more medication than prescribed, is this an indication of abuse, addiction, undertreatment (pseudoaddiction), anxiety, impulse, or confusion? Behaviors are frequently misunderstood and too often premature assumptions misdirect treatment.

There is significant confusion about what it means to be adherent to an opioid regimen, and the screening tools for recognizing the risk of abuse are rarely used although readily available ( Miller, et al., 2011 ; Passik & Kirsh, 2003 ).

What is a pain management plan?

Through a pain management plan, healthcare providers help people manage all kinds of pain. Pain management approaches include medications, injections, therapy and exercise. Your provider may recommend one approach or a combination of several.

What are the 10 grades of pain?

Numerical Rating Pain Scale – The Numerical Rating Pain Scale is a simple pain scale that grades pain levels from 0 (No pain), 1,2, and 3 (Mild), 4,5, and 6 (Moderate), 7,8, and 9 (Severe) to 10 (Worst Pain Possible). This simple tool assumes a grasp of basic number skills and is recommended for patients over the age of nine.

What are the 4 steps of pain?

Pain Processes – Figure 7-1 illustrates the major components of the brain systems involved in processing pain-related information. There are four major processes: transduction, transmission, modulation, and perception. Transduction refers to the processes by which tissue-damaging stimuli activate nerve endings.

• Transmission refers to the relay functions by which the message is carried from the site of tissue injury to the brain regions underlying perception.
• Modulation is a recently discovered neural process that acts specifically to reduce activity in the transmission system.
• Perception is the subjective awareness produced by sensory signals; it involves the integration of many sensory messages into a coherent and meaningful whole.

Perception is a complex function of several processes, including attention, expectation, and interpretation.

What are the 3 classifications of pain?

Classification according to pathophysiology – Pain can be classified as nociceptive, neuropathic or, in the case of chronic pain only, central sensitisation, depending on the type of injury/insult and the pathophysiological pathway that leads to the perception of pain.1,2 Nociceptive pain describes a normal physiological response to tissue damage resulting from trauma, non-healing injury or inflammatory processes.1,3 The International Association for the Study of Pain (IASP) defines nociceptive pain as “pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors”.4 There are two categories of nociceptive pain: somatic pain refers to injuries of the musculoskeletal system and visceral pain refers to internal organ injury and is often felt indirectly.2 Neuropathic pain is defined as pain caused by a lesion or disease of the somatosensory nervous system and occurs as a result of abnormal neural activity.1,2 Neuropathic pain can be described as central or peripheral, depending on whether the lesion is in the peripheral or central nervous system.1 Central sensitisation (also known as nociplastic pain) is defined as pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors, nor evidence for disease of or lesions within the somatosensory system causing the pain.1–3

What are the 4 A’s of chronic pain?

REFERENCES – 1. National Institute on Drug Abuse (NIDA) NIDA Community Drug Alert Bulletin—Prescription Drugs Bethesda, MD: US Dept of Health and Human Services; 2005. NIH Pub. No: 05-5580 http://www.nida.nih.gov/PrescripAlert/index.html Accessed March 6, 2009 2. Passik SD, Kirsh KL, Donaghy KB, Portenoy RK. Pain and aberrant drug-related behaviors in medically ill patients with and without histories of substance abuse, Clin J Pain 2006; 22 ( 2 ):173-181 3. White AG, Birnbaum HG, Mareva MN, et al. Direct costs of opioid abuse in an insured population in the United States, J Manag Care Pharm.2005; 11 ( 6 ):469-479 4. Paulozzi LJ, Budnitz DS, Xi Y. Increasing deaths from opioid analgesics in the United States, Pharmacoepidemiol Drug Saf.2006; 15 ( 9 ):618-627 5. Birnbaum HG, White AG, Reynolds JL, et al. Estimated costs of prescription opioid analgesic abuse in the United States in 2001: a societal perspective, Clin J Pain 2006; 22 ( 8 ):667-676 6. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain, Pain Med.2005; 6 ( 2 ):107-112 7. Trescot AM, Boswell MV, Atluri SL, et al. Opioid guidelines in the management of chronic non-cancer pain, Pain Physician 2006; 9 ( 1 ):1-39 8. Katz NP, Adams EH, Benneyan JC, et al. Foundations of opioid risk management, Clin J Pain 2007; 23 ( 2 ):103-118 9. National Pharmaceutical Council I. Joint Commision on Accreditation on Healthcare Organizations http://www.scribd.com/doc/7563477/National-pharmaceutical-council-NPC-npcnow. Scribd Web site. Pain: current understanding of assessment, management, and treatments.2001. Accessed March 9, 2009.10. Carr DB, Goudas LC, Balk EM, Bloch R, Ioannidis JP, Lau J. Evidence report on the treatment of pain in cancer patients, J Natl Cancer Inst Monogr.2004;( 32 ):23-31 11. Kirsh KL, Passik SD. The interface between pain and drug abuse the evolution of strategies to optimize pain management while minimizing drug abuse, Exp Clin Psychopharmacol.2008; 16 ( 5 ):400-404 12. Argoff CE. Pharmacologic management of chronic pain, J Am Osteopath Assoc.2002; 102 ( 9 )(suppl 3):S21-S27 13. Passik SD, Kirsh KL. Opioid therapy in patients with a history of substance abuse, CNS Drugs 2004; 18 ( 1 ):13-25 14. Woolf CJ, Hashmi M. Use and abuse of opioid analgesics: potential methods to prevent and deter non-medical consumption of prescription opioids, Curr Opin Investig Drugs 2004; 5 ( 1 ):61-66 15. Webster LR. PTI-821: sustained-release oxycodone using gel-cap technology, Expert Opin Investig Drugs 2007; 16 ( 3 ):359-366 16. American Academy of Pain Medicine. American Pain Society The use of opioids for the treatment of chronic pain: a consensus statement from the American Academy of Pain, Clin J Pain 1997; 13 ( 1 ):6-8 17. Fine PG. The evolving and important role of anesthesiology in palliative care, Anesth Analg.2005; 100 ( 1 ):183-188 18. Harke H, Gretenkort P, Ladleif HU, Rahman S, Harke O. The response of neuropathic pain and pain in complex regional pain syndrome I to carbamazepine and sustained-release morphine in patients pretreated with spinal cord stimulation: a double-blinded randomized study, Anesth Analg.2001; 92 ( 2 ):488-495 19. Dworkin RH, Backonja M, Rowbotham MC, et al. Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations, Arch Neurol.2003; 60 ( 11 ):1524-1534 20. Gimbel JS, Richards P, Portenoy RK. Controlled-release oxycodone for pain in diabetic neuropathy: a randomized controlled trial, Neurology 2003; 60 ( 6 ):927-934 21. Morley-Forster PK, Clark AJ, Speechley M, Moulin DE. Attitudes toward opioid use for chronic pain: a Canadian physician survey, Pain Res Manag.2003; 8 ( 4 ):189-194 22. Gilron I, Bailey JM, Tu D, Holden RR, Weaver DF, Houlden RL. Morphine, gabapentin, or their combination for neuropathic pain, N Engl J Med.2005; 352 ( 13 ):1324-1334 23. Passik S, Portenoy RK, Ricketts PL. Substance abuse among cancer patients, part 1: prevalence and diagnosis, Oncology (Williston Park) 1998; 12 ( 4 ):517-521, 524.24. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool, Pain Med.2005; 6 ( 6 ):432-442 25. Akbik H, Butler SF, Budman SH, Fernandez K, Katz NP, Jamison RN. Validation and clinical application of the Screener and Opioid Assessment for Patients with Pain (SOAPP), J Pain Symptom Manage 2006; 32 ( 3 ):287-293 26. Rohsenow DJ, Colby SM, Martin RA, Monti PM. Nicotine and other substance interaction expectancies questionnaire: relationship of expectancies to substance use, Addict Behav.2005; 30 ( 4 ):629-641 27. Coambs RB, Jarry JL. The SISAP: a new screening instrument for identifying potential opioid abusers in the management of chronic nonmalignant pain within general medical practice, Pain Res Manag.1996; 1 ( 3 ):155-162 28. Butler SF, Fernandez K, Benoit C, Budman SH, Jamison RN. Validation of the Revised Screener and Opioid Assessment for Patients With Pain (SOAPP-R), J Pain 2008April; 9 ( 4 ):360-372 Epub 2008 Jan 22 29. Butler SF, Budman SH, Fernandez K, Jamison RN. Validation of a screener and opioid assessment measure for patients with chronic pain, Pain 2004; 112 ( 1-2 ):65-75 30. Federation of State Medical Boards of the United States, Inc. http://www.fsmb.org/pdf/2004_grpol_Controlled_Substances.pdf. Model policy for the use of controlled substances for the treatment of pain. Published May 2004. Accessed March 9, 2009.31. McCabe SE, Boyd CJ. Sources of prescription drugs for illicit use, Addict Behav.2005; 30 ( 7 ):1342-1350 32. Boyd CJ, McCabe SE, Cranford JA, Young A. Prescription drug abuse and diversion among adolescents in a southeast Michigan school district, Arch Pediatr Adolesc Med.2007; 161 ( 3 ):276-281 33. Wiedemer NL, Harden PS, Arndt IO, Gallagher RM. The opioid renewal clinic: a primary care, managed approach to opioid therapy in chronic pain patients at risk for substance abuse, Pain Med.2007; 8 ( 7 ):573-584 34. Passik SD, Kirsh KL, Whitcomb L, et al. A new tool to assess and document pain outcomes in chronic pain patients receiving opioid therapy, Clin Ther.2004; 26 ( 4 ):552-561 35. Atluri S, Boswell MV, Hansen HC, Trescot AM, Singh V, Jordan AE. Guidelines for the use of controlled substances in the management of chronic pain, Pain Physician 2003; 6 ( 3 ):233-257 36. Passik S, Kirsh K, Whitcomb L, et al. Monitoring outcomes during long-term opioid therapy for noncancer pain: results with the Pain Assessment and Documentation Tool, J Opioid Manag.2005; 1 ( 5 ):257-266 37. Passik SD, Kirsh KL. The need to identify predictors of aberrant drug-related behavior and addiction in patients being treated with opioids for pain, Pain Med.2003; 4 ( 2 ):186-189 38. Weaver M, Schnoll S. Abuse liability in opioid therapy for pain treatment in patients with an addiction history, Clin J Pain 2002; 18 ( 4 )(suppl):S61-S69 39. Friedmann N, Butera P, Klutzaritz D, Gilmore D, Merrigan T, Webster L. Abuse-resistant, long-acting oxycodone treats chronic pain in a large Phase III study Presented at: 12th World Congress on Pain (WCP) August22, 2008; Glascow, Scotland http://www.pslgroup.com/dg/2299aa.htm Accessed March 9, 2009 &author=N+Friedmann&author=P+Butera&author=D+Klutzaritz&author=D+Gilmore&author=T+Merrigan&” target=”_blank” rel=”noopener noreferrer” ref=”reftype=other&article-id=2704131&issue-id=179869&journal-id=849&FROM=Article%7CCitationRef&TO=Content%20Provider%7CLink%7CGoogle%20Scholar”>Google Scholar ] 40. American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders Revised 4th ed.Washington, DC: American Psychiatric Association; 2000.41. National Institute on Drug Abuse (NIDA) http://www.clinicaltrials.gov/ct/show/ NCT00249587 ?order=1. Project Pain—1. Accessed March 9, 2009.42. Passik SD, Hays L, Eisner N, Kirsh KL. Psychiatric and pain characteristics of prescription drug abusers entering drug rehabilitation, J Pain Palliat Care PharmacoTher.2006; 20 ( 2 ):5-13 43. Webster LR, Dove B. Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners North Branch, MN: Sunrise River Press; 2007.44. Gershell L, Goater JJ. Making gains in pain, Nat Rev Drug Discov.2006; 5 ( 11 ):889-890 45. Chindalore VL, Craven RA, Yu KP, Butera PG, Burns LH, Friedmann N. Adding ultralow-dose naltrexone to oxycodone enhances and prolongs analgesia: a randomized, controlled trial of Oxytrex, J Pain 2005; 6 ( 6 ):392-399 46. Webster LR. Oxytrex: an oxycodone and ultra-low-dose naltrexone formulation, Expert Opin Investig Drugs 2007; 16 ( 8 ):1277-1283 47. Spierings EL, Butera PG, Wu N, Moran LV, Friedmann N. Phase III study to assess physical dependence and analgesic efficacy of Oxytrex versus oxycodone Poster presented: 25th Annual Scientific Meeting of the American Pain Society; May4-6, 2006; San Antonio, TX Poster 814 48. Katz NP, Buse DC, Budman SH, et al. Development and preliminary experience with an ease of extractability rating system for prescription opioids, Drug Dev Ind Pharm.2006; 32 ( 6 ):727-746 49. Friedmann N, de Kater AW, Butera PG, et al. Remoxy, a novel drug candidate, deters oxycodone abuse in humans Abstract presented at: 3rd International Congress World Institute of Pain; September21-25, 2004; Barcelona, Spain http://www.lifetreeresearch.com/media/abstracts/RemoxyAbstract.pdf Accessed March 9, 2009 &author=N+Friedmann&author=AW+de+Kater&author=PG+Butera&” target=”_blank” rel=”noopener noreferrer” ref=”reftype=other&article-id=2704131&issue-id=179869&journal-id=849&FROM=Article%7CCitationRef&TO=Content%20Provider%7CLink%7CGoogle%20Scholar”>Google Scholar ] 50. de Kater AW, Friedmann N, Butera PG, et al. Clinical pharmacokinetics of oxycodone after single and multiple doses of Remoxy, a novel, abuse-resistant long-acting oxycodone formulation Abstract presented at: 3rd International Congress World Institute of Pain; September21-25, 2004; Barcelona, Spain &author=AW+de+Kater&author=N+Friedmann&author=PG+Butera&” target=”_blank” rel=”noopener noreferrer” ref=”reftype=other&article-id=2704131&issue-id=179869&journal-id=849&FROM=Article%7CCitationRef&TO=Content%20Provider%7CLink%7CGoogle%20Scholar”>Google Scholar ] 51. Green CR, Ndao-Brumblay SK, West B, Washington T. Differences in prescription opioid analgesic availability: comparing minority and white pharmacies across Michigan, J Pain 2005; 6 ( 10 ):689-699 Articles from Mayo Clinic Proceedings are provided here courtesy of The Mayo Foundation for Medical Education and Research

What are the 6 Ds of chronic pain?

Clinical Features – Recent population surveys suggest that 86 million or more Americans have some type of chronic pain (Moskowitz, 2002). Pain is currently the leading reason for primary care office visits, and accounts for more than 20 per cent of physician visits and 10 per cent of prescriptions (DeBono, Hoeksema & Hobbs, 2013).

Chronic pain costs approximately $100 billion per year in medical expenses, lost productivity and loss of income. Productivity loss alone was recently estimated to cost $61.5 billion annually, about 75 per cent from impaired work performance due to pain. The most common type of pain, that of the low back, will affect 50 to 85 per cent of Americans during their lifetimes (Stewart, Ricci, Chee, Morgenstein & Lipton, 2003).

Despite these substantial costs, there was not agreement until recently on a definition of pain generally, and of chronic pain particularly. There is wide acceptance of the International Association for the Study of Pain definition of pain as “an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (Bonica, 1979).

• There is common but less general acceptance of the definition of chronic pain as that lasting more than 3 months; it has also been suggested that pain of 30 days or less duration is acute pain, while subacute pain lasts from 1 to 6 months and chronic pain persists for more than 6 months.
• Another definition has been pain that “extends beyond the expected period of healing” (DeBono, Hoeksema & Hobbs, 2013).

Chronic pain syndrome is actually a constellation of pain syndromes that is generally refractory to strictly medical management. A wide variety of musculoskeletal, neurological, urological, gastrointestinal, gynecological and cardiovascular disorders can manifest persistent pain.

These patients appear to have in common demonstrable psychiatric comorbity, chiefly depression, and an increased incidence of familial chronic pain and known antecedents to psychiatric disorder such as abuse, neglect and familial substance use disorders. Patients also frequently manifest the ‘6 Ds” described by Sternbach (1977): dramatization of complaints, drug misuse, dysfunction or disuse of the painful part(s), dependency, depression and disability.

Chronic pain has been suggested to be a learned behavioral response, with an initial noxious cause for pain resulting in pain behavior that is internally or externally rewarded and thus reinforced, and which comes eventually to recur without a noxious stimulus (Davoine, Godinat, Petite & Saurer, 2013).

What are the six dimensions of pain?

Abstract – Current theories of pain and clinical experience support a multidimensional framework for the experience of pain that has implications for assessment and management in any setting. Six major dimensions have been identified: physiologic, sensory, affective, cognitive, behavioral, and sociocultural.

Any clinical assessment process must address relevant dimensions of pain in the given setting. In acute care settings, for example, clinicians may focus on physiologic and sensory dimensions, whereas in chronic care settings, the affective, cognitive, and behavioral dimensions might assume priority. Various tools are available for multidimensional assessment of pain, spanning the dimensions of the experience from physiologic to sociocultural.

The clinician in any setting must use appropriate tools that provide useful information. Guidelines helpful in a selection process include identification of relevant dimensions of pain, type of pain, patient population and setting, psychometric properties of the tool, and issues of time, clinical relevance, and feasibility.

What are 3 psychological aspects of pain?

Abstract – Interest in the assessment and management of pain increased dramatically after 1965, when the gate control theory was introduced. This increase is concurrent with enormous advances in our understanding of the plasticity and complexity of pain processing.

• New information about internal pain-inhibitory systems and the factors that trigger them has revolutionized traditional approaches to pain control.
• This article describes some of the new information on the factors that influence human pain perception, specifically the environmental and psychological factors that modify how pain is experienced.

Pain is a complex, multidimensional perception that varies in quality, strength, duration, location, and unpleasantness. The strength and unpleasantness of pain is neither simply nor directly related to the nature and extent of tissue damage. Even newborn infants may experience different pains from the same stimulus, because of the differences in the situations in which it is administered.

Pain experiences can range from an inability to perceive pain, regardless of the strength of stimulation, to the actual perception of pain in a limb that has been amputated. The perception of, expression of, and reaction to pain are influenced by genetic, developmental, familial, psychological, social and cultural variables.

Psychological factors, such as the situational and emotional factors that exist when we experience pain, can profoundly alter the strength of these perceptions. Attention, understanding, control, expectations, and the aversive significance can affect pain perceptions.

What is a 4 on the pain scale?

4 = Moderate pain. If you are involved in an activity, you’re able to ignore the pain for a while. But it is still distracting.5 = Moderately strong pain.

What are 5 barriers to managing pain?

Course Content The committee identified several important barriers to adequate pain care in the United States. These include the magnitude of the problem, provider attitudes and training, insurance coverage, cultural attitudes of patients, geographic barriers, and regulatory barriers.

1. Institute of Medicine, 2011 The complexity of our fragmented healthcare system creates significant barriers to effective pain management in all areas of medicine and across all age groups.
2. Treating pain in a system that is struggling to contain costs means better education and training, better interdisciplinary communication and cooperation, and better reimbursement for proven treatment options are desperately needed.

According to the Institute of Medicine, treatment of pain is often disorganized, ineffective, and inaccessible. Many members of the public, people with pain, and many health professionals are not adequately prepared to take preventive action, recognize warning signs, initiate timely and appropriate treatment, or seek specialty consultation when needed (IOM, 2011).

Costly, inappropriate, or inadequate procedures are sometimes carried out when other approaches—such as counseling, prevention, and self-management—might be more appropriate. There is significant variability among clinicians in applying new and even existing knowledge about pain and its management. This is reflected in the documentation of inappropriate—or indeed lack of—treatment for cancer patients, HIV/AIDS patients, and neonates, and post operative pain (Sessle, 2012).

To address these barriers, the Institute of Medicine (IOM, 2011) has recommended:

Providers should promote and enable self-management of pain. There should be easily accessible and cost-effective educational opportunities in pain assessment and treatment in primary care. Collaboration must be improved between pain specialists and primary care clinicians, including referral to pain centers when appropriate. Reimbursement policies must be revised to foster coordinated and evidence-based pain care. Providers must provide consistent and complete pain assessments.

The inadequate education of healthcare professionals is a major and persistent barrier to effective pain management. Despite the health professions’ development of competencies in pain management, as well as the myriad guidelines and position articles on pain management issued by numerous professional bodies, core pain management competencies for pre-licensure, entry-level health professionals have not yet been established.

1. The limited pain education that is currently provided may be ineffective because it focuses on traditional, impersonal topics such as anatomy and physiology that may have little direct relevance to the complex daily problems faced by patients, families, and clinicians (Fishman et al., 2013).
2. The Institute of Medicine has stated that pain education is critically important and that the federal government is in a position to contribute to improvements in patient and professional education about pain.

The IOM recommends that the medical professionals (1) expand and redesign education programs, (2) improve curriculum and education for healthcare professionals, and (3) increase the number of health professionals with advanced expertise in pain care (IOM, 2011).

The American Academy of Pain Medicine has echoed the IOM recommendations by publishing a set of inter-professional core competencies for pain management, which are categorized within four domains. These domains address (1) the fundamental concepts and complexity of pain; (2) how pain is observed and assessed; (3) collaborative approaches to treatment options; and (4) application of competencies across the lifespan in the context of various settings, populations, and care team models (Fishman et al., 2013).

Understanding of the phenomenon of pain, its immediate and long-term consequences, and its effective management is lacking or is minimal in many health science curricula, including those for nursing. This lack of knowledge and effective translation into a usable form for practitioners raises the following question: Do graduates have sufficient knowledge and skills to be competent in giving appropriate pain management to their patients (Herr et al., 2015)? : Course Content