Case study 1 Maurianne is an 85-year-old woman living in a residence facility for people with Alzheimer disease. Her cognition has deteriorated slowly in the seven years she has lived at the facility and now her speech is often a rambling, incoherent stream-of-consciousness, that she only seldom recognizes as such. Maurianne fell and sustained a right femur fracture requiring internal fixation. On the second day after surgery, the hospital nurse noted that Maurianne had an order for acetaminophen every 6 hours as needed. Although Maurianne was lying still and did not appear to be in distress, the nurse contacted the nursing home nurse who reported that Maurianne rarely lies still. The nursing home nurse explained that they assess pain using the Pain Assessment in Advanced Dementia (PAINAD) tool and emailed a copy to the hospital nurse. A review of the medical chart indicated that Maurianne slept intermittently the previous night, and when she conducted a physical examination, Maurianne seemed rigid and exhibited shallow breathing at a rate of about 20 breaths per minute. The nurse used the PAINAD behavioral tool to assess Maurianne’s pain and the result suggested a positive score for possible pain. The nurse immediately called the surgeon and received an order for 1-2 mg morphine every 8 hours over the next 3 days. After the first dose, Maurianne’s body relaxed, and her breathing became regular at a rate of 14 per minute. Later that evening, Maurianne slept 7 hours. Questions: 1. Do you think the initial script for acetaminophen was appropriate for this patient? If now, what would you have prescribed? _______________________________________________________________________________________________ 2. How might Maurianne’s cognitive impairments affect her pain management plan? _______________________________________________________________________________________________ 3. What other tools or techniques might be used to characterize Maurianne’s level of pain or her response to prescribed analgesics? _______________________________________________________________________________________________
Chronic pain that develops after acute pain A number of factors have been associated with an increased risk for chronic pain following acute pain or surgery including older age, psychological problems, higher levels of pre-procedural pain or pain sensitivity, type and duration of surgery, severity and number of comorbidities, and use of post-procedural radiation or chemotherapy. 25 Some tools have been developed to help clinicians predict the likelihood that a patient will experience Screen for opioid abuse risk factors Screening and monitoring in pain management seeks to identify patients at risk of substance misuse and overdose as well as improve overall patient care. Evaluations of patient physical and psychological history can screen for risk factors and help characterize pain to inform treatment decisions. Screening approaches include efforts to assess for concurrent substance use and mental health disorders that may place patients at higher risk for OUD and overdose. This includes screening for drug and alcohol use and the use of urine drug testing, when clinically indicated. These approaches enable providers to identify high- risk patients so that that they can consider whether to prescribe opioids, engage substance misuse and
chronic pain following acute injury or procedures. The 5-item PICKUP model, for example, showed moderate prognostic performance in a derivation study using data from 2,758 patients with acute low back pain. 26 And Sipila and colleagues developed a 6-item screening instrument for risk factors of persistent pain after breast cancer surgery based on a cohort of 489 women. 27 mental health interventions, and education materials to mitigate opioid misuse. 16 Many tools have been developed for the formal assessment of a patient’s risk of having a substance misuse problem, some of which are appropriate for routine clinical use because they are relatively brief and easily implemented. Table 1 lists the tools that appear to have good content, and face and construct validity for assessing patient risks related to chronic opioid therapy, although to date, no single tool has been widely endorsed or thoroughly validated. 28
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Book Code: MDAZ1124
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