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Think outside the meds

Thursday March 20, 2014
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About 76 million Americans suffer from chronic pain, according to information compiled by the National Institutes of Health, costing the U.S. upwards of $100 billion.

Patients who are in chronic pain require regular healthcare visits, multiple medications, experience diminished work productivity and a decreased level of functioning. Karen Doblin, NP, PhD, CCRN, knows this all too well. She runs the Interventional Pain Management Clinic, one of five practices within the Palliative Care and Pain Clinic Department at Beth Israel Medical Center in Manhattan. The practice cares for about 700 patients each year, many of whom have struggled to reach or maintain adequate pain management. Individuals suffering from chronic pain carry a heavy burden, Doblin said, typically experiencing depression, a loss of sense of self and frustration. “Many patients say, ‘you’re the only person who has listened to me,’” she said.

“We see a large volume of patients every day referred from all over the country,” Doblin said. “For many of them it’s the last stop in their pain management treatment. They’ve tried high-dose opioid medications, injections haven’t worked, other pain [professionals] don’t know what to do with them or the patient is on too high an opioid dose for their physician’s comfort level.”

Snail venom a pain killer? Really?

In Doblin’s clinic, interventions for chronic neuropathic pain and complex regional pain syndrome include management with dorsal column stimulators, or internally placed electrodes on the spinal cord. These devices discharge a stimulus that interferes with the pain transmission from the pain center to the brain.
Another common intervention used in the clinic is the intrathecal pump, which allows Doblin and her team to infuse smaller doses of medications that yield more efficient pain control. One such medication used is Prialt, a synthetic snail venom used for treatment of neuropathic pain, in combination with an opioid such as fentanyl, morphine or dilaudid.


Doblin’s pain care tips:

Rotate pain medications
For patients who have been taking opioids for extended periods of time and are experiencing decreased efficacy secondary to a growing tolerance, Doblin recommends rotating medications to help alleviate the problem. She suggests transitioning the patient to another opioid and adding an adjuvant medication to alleviate neuropathic pain, such as Lyrica, Neurontin, or Nortriptyline.

Refer to a psychologist
Doblin said depression and chronic pain often travel together. Untreated depression can slow or halt progress in chronic pain management. She assesses every patient for depression and suicidal ideation. The pain psychologist in her clinic utilizes cognitive behavioral therapy-based interventions to help patients deal with the psychological effects of chronic pain.

Consider educational level
Anecdotally, Doblin has found that individuals of lower educational levels tend to have poorer outcomes. She attributes this to a variety of factors, including a higher incidence of emotional behaviors and a tendency toward ineffective coping skills. These patients may need regular reinforcement to help them understand the nature of chronic pain, as well as psych support and services to improve coping mechanisms.

Tell the truth
Setting appropriate expectations is a key component for optimal outcomes, for both the patient and the practitioner. “You’d be surprised how many patients have never been told that their nerve pain will not go away, that’s it’s permanent nerve damage,” Doblin said. “It’s important to manage the patient’s expectations, to be very realistic about what we can treat and what we can’t treat, so that they don’t feel as if you promised them something that didn’t happen.”

To see what else is trending in pain management, visit www.Nurse.com/Pain-Management.


Meaghan O’Keeffe, RN, BSN, is a freelance writer. Check out her blog at ScrubbedIn.Nurse.com. Post a comment below or email specialty@Nurse.com.