Pain Management with Substance Abusing Clients
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This document summarizes treatment options for chronic pain management, including pharmacotherapy, psychosocial interventions, rehabilitation, complementary and alternative medicine (CAM), injections/infusions, and implantable devices or surgery. It discusses options such as opioids, non-opioids, and adjuvant analgesics for pharmacotherapy; counseling, hypnosis, and stress management for psychosocial support; physical therapy and exercise for rehabilitation; and mind-body practices, dietary supplements and energy therapies for CAM. Surgical interventions include implantable devices that can help reduce long-term pain. The overall goal is effective long-term pain relief through a multidisciplinary approach.
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Pain Management with Substance Abusing Clients
- 1. Treatment Options for People Living in Pain Instructors: Stephanie Adams, LPC Dr. Dawn-Elise Snipes PhD, LMHC, NCC, CRC Copyright AllCEUs.com 2011 Unlimited CEUs $99/year
- 2. Explain why pain management matters. List drug and non-drug treatment options. Name goals of therapy. Identify benefits and drawbacks of various treatments. Learn about promising new treatment options. Course Objectives Copyright AllCEUs.com 2011 Unlimited CEUs $99/year
- 3. Pain interferes with enjoyment of life Pain management can improve quality of life The first step is diagnosis Assessing your pain Keeping track Descriptive language Numerical Scales Verbal Scales Visual Scales Managing Pain Copyright AllCEUs.com 2011 Unlimited CEUs $99/year
- 4. Complex equation Some treatment might involve a team of professionals Pain therapy goals Multimodal approach Treatment interference Holistic/complementary care Treat the cause Mapping a Treatment Plan Copyright AllCEUs.com 2011 Unlimited CEUs $99/year
- 5. Available treatment options include: Pharmacotherapy Psychosocial Interventions Rehabilitation Techniques Complementary & Alternative Medicine (CAM) Injection/Infusion Implantable Devices and Surgical Interventions Mapping a Treatment Plan (Cont’d) Copyright AllCEUs.com 2011 Unlimited CEUs $99/year
- 6. Using medicine to control pain OTC or Prescription Special programs available to assist people who cannot afford their medication 3 Classes of Analgesics Non-Opiods Opiods Adjuvant Analgesics Pharmacotherapy Copyright AllCEUs.com 2011 Unlimited CEUs $99/year
- 7. Two main groups: NSAIDS Function by reducing prostaglandins Often used in combination with opiods to lessen risk of dependence on opiods. Available topically, orally and by injection. Acetominaphen Few side effects Doesn’t reduce inflammation Non-Opiods Copyright AllCEUs.com 2011 Unlimited CEUs $99/year
- 8. AKA Narcotics Used for treatment of pain related to surgery or cancer Work by blocking pain signals Potentially addictive Can be delivered in many different ways Pain relief generally lasts several hours, unless it is an “extended-release” dose Physical dependence is normal and does not mean a person is addicted Opiods Copyright AllCEUs.com 2011 Unlimited CEUs $99/year
- 9. Corticosteroids Muscle Relaxants Topical Analgesics Local Anesthetics Drugs for Anxiety, Depression and Sleep Adjuvant Analgesics Copyright AllCEUs.com 2011 Unlimited CEUs $99/year
- 10. Pain affects thoughts, beliefs and emotions Emotional stress can cause flare-ups Psychosocial Interventions Consultation Cognitive techniques Stress management Hypnotherapy/Hypnosis Counseling Psychosocial Interventions Copyright AllCEUs.com 2011 Unlimited CEUs $99/year
- 11. Physiatry Physical Therapy Occupational Therapy Exercise Physiology Physical Rehabilitation for Pain Management Copyright AllCEUs.com 2011 Unlimited CEUs $99/year
- 12. Exercise Hydrotherapy Myofascial Therapy Osteopathic Manipulation Treatment (OMT) Splints Transcutaneous Electrical Nerve Stimulation (TENS) Chiropractic Rehabilitation Methods Copyright AllCEUs.com 2011 Unlimited CEUs $99/year
- 13. Craniosacral Therapy Feldenkrais/Functional Integration Rolfing The Trager Approach Self-care Techniques Rehabilitation Methods Cont’d Copyright AllCEUs.com 2011 Unlimited CEUs $99/year
- 14. CAM theories are now gaining repute among more traditional medical practices. Holistic Complementary vs. alternative v. integrative Complementary & Alternative Medicine Copyright AllCEUs.com 2011 Unlimited CEUs $99/year
- 15. Alternative Medical Systems Homeopathic, Naturopathic, TCM Mind-Body Interventions Prayer, Guided Imagery, Pilates Biologically Based Therapies Aromatherapy, Dietary Supplements, Nutrition Manipulative and Body-Based Methods Chiropractic Care, Massage, Osteopathic Medicine Energy Therapies Biofield, Qigong, Healing Touch, Reiki, Therapeutic Touch 5 Categories of CAM Therapies Copyright AllCEUs.com 2011 Unlimited CEUs $99/year
- 16. Acute or chronic pain Injection Diagnostic, predictive, preventative, and pain relief Neuroablative Minimally Invasive Surgery Infusion Subcutaneous, IV, Intraspinal, Anesthetic Injection and Infusion Therapies Copyright AllCEUs.com 2011 Unlimited CEUs $99/year
- 17. Come in the form of pumps and stimulators Reduces risk of infections Appropriate for persistent & long-term pain Spinal Cord Stimulation Implantable Pulse Generator Radiofrequency Implanted Intraspinal Drug Delivery Implantable Devices and Surgical Interventions Copyright AllCEUs.com 2011 Unlimited CEUs $99/year
- 18. What’s next? Longer-acting opiods Patch therapy Effervescent delivery Unique mechanisms Emerging medical technology Looking Forward With Hope Copyright AllCEUs.com 2011 Unlimited CEUs $99/year
- 19. Pharmacotherapy options: opiods, non-opiods and adjuvant analgesics. Psychosocial interventions: consultation, counseling and hypnotherapy. Rehabilitation treatment: physical, occupational and exercise. CAM: mind-body, biological and energy therapies. Injection/Infusion: diagnose, prevent and treat pain. Implantable devices/surgical options are long-term solutions. Summary Copyright AllCEUs.com 2011 Unlimited CEUs $99/year
Editor's Notes
- Persistent pain impacts sleeping, working and socialization. The person experiencing chronic pain is not always able to go about their normal life and can be more susceptible to depression. Correctly diagnosing persistent pain may include a physical exam, a pain assessment, a lifestyle questionnaire, blood work, X-rays or tests. A pain assessment test might involve description of location, intensity, sensation, and nature of your pain, as well as information about the time of onset, how long the pain generally lasts, and what tends to help it improve or deteriorate. Unfortunately, correct diagnosis is not always a guarantee, some people may never have their questions completely answered. In order to share this kind of information with their health care provider, it can be helpful to keep a pain journal. Describing words: shooting, pinching, tender, aching, throbbing, crushing..Numerical: 0-10 intensityVerbal scales: Mild, moderate, severeVisual: Body diagrams to pinpoint location of pain, Wong Baker Faces Pain Rating Scales uses pictures of facial expressions to rate severity of pain.
- Might include whether it is acute or chronic, nociceptive /no-sis-sep-tive/ (originating from potential or actual tissue damage) or neuropathic (nervous system pain response which may exist even if actual damage to tissue is not present)Outside of primary care providers, others who might be involved in helping relieve pain: specialists, nurses, pharmacists, social workers, case managers, psychologists, chiropractors, physical therapists, occupational therapists, and alternative medical practitioners. Goals: Lessen pain Improve functioning, and enhance quality of lifeOften pain is best managed with several different approaches, such as interventions designed for stress relief, efforts to improve muscle flexibility, aid sleep and more.Personal habits such as smoking could interfere with treatment, or even the food a person east. Potential drug and treatment interactions should also be considered.The idea of treating a person holistically simply refers to seeing the patient as a whole person who experiences pain in the mind, body and spirit. Accepting this often involves supporting unconventional treatments like acupuncture, bio-feedback and massage. Diabetics need to control blood sugar, some people need surgery or medication.
- With or without prescription, important to get detailed instructions about how to take it, what might interact, and why your particular medication was prescribed.The 3 Classes Are: Non-opiods, (NSAIDS) Opiods, (coedine, morphine) Adjuvant analgesics (not used primarily to treat pain but might help pain, antidepressants and anticonvulsants)
- NSAIDS – Stands for non-steroidal anti-inflammatory drugsReducing prostaglandins lessens the sensation of pain and reduce inflammation. Prostaglandins are produced at the site of injury or inflammation and promote sensitivity to pain.Aspirin is the oldest NSAIDThe “dose ceiling” is a point of consideration for non-opiods; this is the point at which the NSAID is significantly more likely to cause a major side effect, such as kidney failure. Side effects of Non-opiods include gastrointenstinal problems, kidney damage, and possibly an increased risk of heart attack or stroke.Acetominaphen can cause liver or kidney damage in excess. It is also possible to take too much. More than 4 grams in a 24-hour period is an overdose.
- Narcotics is not always an accurate term for opiods, because this is a term used by police officers for illegal drugs like cocaine and heroin. There are also many legitimate uses for treatment of severe pain. However, because of the negative connotation of this word, most in the medical community choose to use the word “opiods” when referring to this class of drugs.Because they are potentially addictive, people who have struggled with addiction in the past should consult with their doctor to see what other options might be available to control their pain. Some patients might take opiods at home on an “as-needed” basisExtended-release doses can last 8-24 hours. Because the time release function only works in the original prescription, a person must never crush or chew opiod pills. Fentanyl is another extended-release option, in the form of a patch that lasts 72 hours. However, the patch must be kept away from extreme heat, because heat on the patch can cause it to be released too quickly into the bloodstream, a potentially fatal condition.Side effects are often short-lived, can include nausea, vomiting, dizziness, mental cloudiness and respiratory depression. Drug abuse happens when the person no longer needs the drug and continues to use it to their own detriment or the detriment of others. A way to fight illegal and unhealthy use of opiods is by Opiod Agreements, signed by the patient and the doctor. The agreement usually consists of a commitment to only obtaining medication from one doctor, having prescriptions filled at a single pharmacy, bringing in pills to be counted on regular visits, and agree to periodic drug testing.
- Corticosteroids: used to treat severe inflammatory pain, this medication can be taken orally or by injection. Prednisone is an example of a corticosteroid. Side effects can be serious, so providers generally choose to use the lowest effective dose for the shortest amount of time.Muscle relaxants can cause sleepiness. They are used short-term to treat muscle spasms or muscle injury.Topical Analgesics are ointments applied to the skin to reduce pain, such as a menthol patch for muscle pain.Lidocaine is a well-known example of a local anesthetic, administered before a dental procedure. Patches, creams, ointments and spine catheters are all common drug delivery methods.Drugs for anxiety, depression and sleep can be used to treat the symptoms they were designed for, as people with chronic pain often also suffer from troubled sleep, anxiety or depression. This group includes medication such as SSRIs, antihistamines, and benzodiazapines.
- Relationship between pain and depression – depression can be caused by pain, and depression can result in physical pain as well. The co-existence of pain and depression together is a dual burden on the person experiencing it. It’s important to encourage those who are being referred for psychosocial interventions that this does not mean that their pain is “all in their head” or not real. It is simply that it is another way to try to help their pain. Consultation: using knowledge to figure out what isn’t working for you and what things might be functioning as stressors.Cognitive Interventions that fight stress include relaxation therapies, which is especially helpful when fear is accompanied by fear or anxiety, and mindfulness meditation such as focusing on breathing. Another cognitive technique is guided imagery, used to treat stress by lowering blood pressure and heart rate. This might be recommended for chronic neck pain, high blood pressure and headaches, among other things. It also might help boost the immune system. Biofeedback training turns the focus inwards, teaching the individual to recognize changes in their own bodies to moderate stress and anxiety. Behavioral modification, also known as operant conditioning, helps to remove harmful influences from the person’s life.Stress management might mean setting up a better structure for the person’s life, to increase medication compliance and opportunities for rest. It could also be engaging in regular exercise, using positive self-talk and finding balance. Hypnosis can reduce pain perception, but the methods are unclear. It might also be linked to lower levels of depression and anxiety. A hypnotherapist might also teach a client self-hypnosis, which they could then use on their own for the purposes of pain management. Family or individual therapy can teach useful skills, promote understanding, and deal with fear, anger and hopelessness. Some counselors in addition, specialize in pain management.
- Physiatrists are often considered experts in back pain, since they focus on the musculoskeletal system. Another name for physiatry is Physical Medicine and Rehabilitation. Those who treat this might be a MD or a DO. Dos have extra training in Osteopathic Manipulative Medicine. PTs restore function and mobility through exercise training, deep tissue massage, hot packs and electrical stimulation. They teach people to use crutches or wheelchairs, and carefully monitor and adjust treatment as necessary. Occupational Therapists focus on movement and thinking skills, and deal with practical concerns like helping people eat and dress themselves. They also help in people in finding work, and in modifying the work environment to provide the most use out of it.EPs, as they are known, teach others about the positive outcomes of exercise and develop specialized exercise
- For exercise to be an effective rehabilitative tool, it’s helpful to first consult a trainer who has had experience working with individuals with chronic pain. Besides increasing flexibility and endurance, exercise can reduce stress, improve mood, and decrease pain over time.Hydrotherapy uses the water’s natural buoyancy to cushion the muscles and joints while building strength in a pool of water. Different forms of water therapy are hot water bottles, cold compresses, and whirlpools. Myofascial therapy combines massage and stretching for people with fibromyalgia, sports injury, recurring headaches, and back pain. Treatment is given 1-3 times a week and the therapist might also assign stretching routines for the person to complete at home.OMT is a form of specialty medicine practiced by some D.O.s This might include spinal manipulation, soft-tissue techniques and connective tissue release. OMT has several things in common with chiropractic practice, but is considered more comprehensive. Splits, casts and braces are well-known methods to treat and protect injured bones. A split might also allow relief for someone with arthritis pain or to protect from repetitive motion injurty. Light compression gloves or socks, which reduce swelling and protect sensitive nerves, also fall under this category.TENS interrupts the pain signals in the body by providing opposing stimulation to compete with the feelings of pain. It is a device that the person in pain wears strapped to their body during times when they might normally experience pain. It is very safe, and commonly used but it is still not understood how exactly it works. Chiropractic care will be covered in more detail in the next section on Complementary and Alternative Medicine but it can also be classified as a physical method of relieving pain.
- These rehabilitation methods are physical relief of pain symptoms, but are not generally performed by medical professionals but paraprofessional specialists or complementary practitioners. Craniosacral therapists believe that pain results from blocked spinal fluid, and their methods re-establish that flow through massage. This is contrasted with cranial osteopathy, which is diagnostic and only performed by osteopathic physicians.TheFeldenkrais Method asks for clients to increase self-awareness of their body through movement. If done successfully, the patient should demonstrate increased range of motion, flexibility and coordination.Rolfing is a form of myofascial massage that places deep pressure on the patient’s body designed to shift bones into proper alignment for increased range of motion. However, it can be a painful process.The Trager Approach, in contrast, is a gentle, passive procedure that intends to relieve muscle tightness without pain. It can show relief for patients as early as the first session. In addition to or instead of the above methods, self-care techniques such as icing, compresses, sitz baths, cold friction rubs, and more can also be used as part of physical pain relief methods.
- Reasons for the adoption of these methods might be because they are more in line with patient’s personal belief systems. Approximately 7 out of 10 Americans now use some form of CAM. CAM treats mind, body and spiritComplementary medicine is used in conjunction with traditional medicine, like massage therapy. Alternative medicine is used instead of conventional methods – such as treating cancer with a special diet rather than surgery or chemo. Integrative combines the theories of medicine and CAM to produce specific and unique results.
- Alternative theories are complete and separate medical approaches that replace traditional approaches, such as homeopathic and naturopathic medicine. Another well-known example is Traditional Chinese Medicine, (TCM) like Acupuncture or Acupressure. This might also include reflexology or ayurveda. Mind-body therapies focus on using the mind to to overcome bodily pain. This might be in a spiritual sense, like meditation or prayer, or through mind discipline techniques, like yoga and tai chi. It might also be conditioning the body through Pilates. The central tenet of these interventions is that a person can influence the pain center of the brain through changes in self-talk, behavior, breathing, etc. Biological therapies focus on what is already found in nature, like herbs, vitamins and natural foods. It can also include substances that may or may not have been validated by an outside source, such as using shark cartilage to treat cancer. Aromatherapy uses essential oils applied topically, or used in a bath, a vaporizer or spritzer water.Manipulative therapies, as would be expected, involves moving body parts around to relieve pain. Chiropractice treatment focuses on the relationship between bodily structure and function. They also use spinal manipulation as a primary treatment tool. A core belief of chiropractic treatment is that the body is designed to heal itself. Massage is used to enhance circulation, increase range of motion, relieve secondary pain, and stimulate joint lubrication. Therapeutic massage often also incorporates music therapy, aromatherapy and special massage lotions, while simple massage is focused on a specific area and performed by a family member, friend or the patient himself.Energy Therapies use energy fields to heal. Biolfield energy therapy is also known as the “laying on of hands” or “sharing of energy” which the person being treated may either accept or reject. Qigong combines “qi”, the breath of life or air, meaning the vital body energy, and “gong” which revolves around meditiation, relaxation, physical movement and mind-body integrations. Regular practice of Qigong is supposed to rid the body of toxins and reduce stress and anxiety. Healing touch balances energy by light touch or running hands along the energy field above the body. Reiki means Universal Life Energy, and the person utilizing Reiki to heal taps into the “life force energy” to improve health. Therapeutic Touch is similar technique to Healing Touch, in that it also passes the hands over the body, but it also identifies energy imbalances.
- A diagnostic injection therapy is a discogram, which determines which disc in the back is causing pain. Other kinds of injections might be Botox used to relax the muscles for pain relief rather than beauty purposes, trigger point injections, local anesthetics, or epidural blood patch, when your own blood is injected into a tear in the spinal cord sheath to clot and therefore “patch” the hole.Neruoablative therapies use thermal or chemical agents to destroy certain nerves or nerve pathways. However, the downside is that they could possibly end up making the pain even worse by damaging the nerves. Minimally invasive surgery might be an injection into the spine to stabilize bone structure.Infusion therapies use a catheter inserted in the vein or spine to directly deliver drugs to their intended source
- SCS – Chronic pain, especially nerve damage. Suitable if pain has been confirmed in the neck or arms, chest, mid to low back or legs. SCS delivers electrical impulses to a “lead” (catheter with electrodes along the tip) placed near nerves along the spinal cord. These impulses interfere with pain signals to the brain, often actually replacing pain signals with pleasant sensations instead. IPG – internal system, everything is implanted under the skin. Comes with a rechargeable battery, which is helpful for people who want to avoid repeat surgeries to replace the batteries. IPG systems can be used even when showering, bathing or swimming. RF – “external system”. Also uses a rechargeable battery, located in a transmitter. Since it is external, it can’t be used while showering bathing or swimming. The transmitter and antenna must always be worn outside of the body to be effective. Implanted Intraspinal DDS – coninuous infusion of pain medications, possibly including opinods, local anesthetics, or other drugs into the spinal fluid. This is most often used for chronic pain due to cancer. Drug delivery is facilitated via catheter, and delivered by computer-controlled pump.
- Effervescent delivery could greatly decrease the amount of time it takes for the medication to work.Unique: Drugs that work on nicotine and capsaicin receptor sites. Drugs that “turn off” parts of nerve cells that become irritatedEMT – better technology such as smaller, more compact pumps. A new method in development is the brain stimulator device, which is now in clinical trials.