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Article Contents

Introduction, case studies, acknowledgments.

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Case Studies in Breakthrough Pain

  • Article contents
  • Figures & tables
  • Supplementary Data

Larry C. Driver, Case Studies in Breakthrough Pain, Pain Medicine , Volume 8, Issue suppl_1, January 2007, Pages S14–S18, https://doi.org/10.1111/j.1526-4637.2006.00271.x

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Objective. To illustrate the variable presentations of and treatments for breakthrough pain (BTP).

Design. Five cases of BTP were selected by the author, and treatment options were then considered.

Results. Breakthrough pain presents in many different ways in clinical practice. Clinicians must first evaluate patients to identify the subtype, etiology, severity, and pattern of BTP, and then use that information to suggest appropriate interventions. Whenever possible, correctable causes of BTP should first be addressed. A variety of treatment tools are available, including opioid analgesics, nonopioid analgesics, adjuvant agents, nonpharmacologic strategies, and procedural and surgical interventions. In many cases, more than one treatment option will be appropriate, but in all cases, regular communication between patient and clinician will be needed to achieve optimal control of BTP.

Conclusion. Treatment of BTP should be individualized by using a multidisciplinary approach to address each patient's pain profile.

Breakthrough pain (BTP) has been defined as a transitory flare of pain superimposed on an otherwise stable pain pattern in opioid-treated patients [ 1 ], and more broadly as any acute transient pain that flares over baseline [ 2 ]. In general, BTP is abrupt in onset—except in the case of end-of-dose analgesia failure, when it may occur more gradually—and is usually intense and transient. BTP episodes can be predicted in end-of-dose failure and some types of incident pain, and effective treatment strategies can usually be developed that minimize the BTP episodes. In contrast, idiopathic and unpredictable incident pain episodes are not precipitated by a readily identifiable cause and are therefore much more difficult to treat ( Figure 1 ). Most of the currently available opioid analgesic compounds do not adequately relieve these types of BTP because they have an onset of action and duration of effect that does not coincide with the onset and duration of the patient's pain ( Table 1 ).

Breakthrough pain (BTP) subtypes.

Breakthrough pain (BTP) subtypes.

Commonly used opioid analgesics for the treatment of pain and breakthrough pain

Compiled from the 2005 Physicians' Desk Reference , electronic version; not a comprehensive list.

Breakthrough pain should be treated like any other clinical condition: the patient should first be evaluated to determine the subtype, cause, severity, pattern, and location of BTP ( Figure 2 ) [ 3 ]. This information provides a working diagnosis and hence identifies appropriate interventions for that patient. When possible, a surgically correctable cause of BTP should be identified and addressed, which may help to minimize the BTP burden for the patient. Treatment examples include radiation therapy for palliation of secondary bone lesions, surgical debulking of solid tumors, and vertebroplasty for previously undiagnosed compression fractures [ 4–6 ]. Multimodality treatment approaches that may include pharmacologic therapy and various nonpharmacologic interventions, such as physical and psychosocial therapies, are likely to provide the best results [ 2,7 ].

Evaluation and treatment options for breakthrough pain (BTP).

Evaluation and treatment options for breakthrough pain (BTP).

Around-the-clock (ATC) drug therapy should be tailored to control chronic pain as well as minimize the potential occurrence of BTP [ 8 ]. The dose and/or dosing frequency of the ATC analgesic should be adjusted to not only limit the frequency of BTP, but also maximize the patient's activity level and level of alertness and cognition. Thus, the clinical challenge is to find a dose or dosing frequency for the ATC medication that minimizes the level of baseline pain and the frequency and intensity of BTP episodes while not significantly impairing the patient's activity level or cognition. In addition, some predictable causes of BTP can be effectively treated with nonopioid or adjuvant medications, such as antitussives if coughing triggers a BTP episode or laxatives if constipation causes colorectal spasms ( Table 2 ). Treatment of predictable-incident BTP should not depend solely on drug therapy. Behavioral techniques and other nonpharmacologic interventions may be useful in a variety of situations and may help avoid polypharmacy approaches that could prove deleterious to some patients [ 2,7 ].

Nonopioid analgesics and adjuvant agents for breakthrough pain

The practical application of these principles is illustrated in the following five cases. As will be apparent in reviewing the cases, there often are several different ways to effectively treat a specific pain problem, and all are reasonable approaches. It is emphasized that the cases are meant to be illustrative of common BTP problems but do not include the actual medical information of specific patients.

Case Study No. 1: Chronic Low Back Pain

A 62-year-old man presented with a 10-year history of lumbar postlaminectomy pain syndrome. He works full-time as a building contractor on commercial projects, but primarily works at a desk. He underwent two lumbar laminectomies 12 and 4 years ago for disk disease, and ever since, he has had chronic back pain and occasional radiating leg pain. He takes a sustained-release opioid twice daily—at 7 am upon waking and at 7 pm . This provides adequate control of his baseline persistent pain without any adverse effects. He rarely needs any additional medication during the first part of the day. However, in the late afternoon, he often has three to four episodes of moderate-to-severe BTP localized to his back.

What type of BTP does he have? What is the best next step to manage this patient's BTP?

This patient has “end-of-dose” BTP. His baseline persistent pain appears to be adequately controlled during the first part of the workday, but by mid-afternoon, he does not have adequate analgesia. Nonpharmacologic treatment recommendations should include avoiding sitting in one position for prolonged periods; utilizing “back-smart” precautions, such as bending at the knees and not the back when lifting heavy objects; and doing back exercises, such as William's stretching exercises for 15 minutes three times a day. The application of portable ice or heat packs to his low back during the drive home can also help.

If these treatment options are ineffective, he might benefit from “asymmetric” dosing of the sustained-release opioid. This approach would involve a higher morning dose while leaving the evening dose the same, though this could lead to daytime sedation. Another option would be switching to a three-time-daily dosing schedule of the sustained-release opioid or adding a lower dose of short-acting opioid in the mid-afternoon.

Case Study No. 2: Cancer-Related Visceral Pain

A 43-year-old woman with advanced ovarian cancer presented with chronic abdominopelvic visceral pain related to carcinomatosis. She is being treated with transdermal fentanyl patches at a dose of 100 µg per hour, and she changes patches every 3 days. After applying a new patch, she has one or two BTP episodes during the first and second days, but three to four episodes on the third day. Her BTP episodes are intense, sporadic, and may occur at various times during the day. There is no physical activity she can associate with their onset. She takes short-acting oral morphine at a dosage of 15 mg at the onset of her BTP episodes, but complains that the medication does not seem to work fast enough and leaves her feeling sleepy for the next several hours.

What is the best way to manage this patient's BTP?

This patient has end-of-dose-failure BTP and some unpredictable BTP. The first step is to try to adjust the ATC analgesic regimen to better match the patient's pain profile. One way this can be accomplished is to increase the dosage of transdermal fentanyl that is applied every 3 days. If this approach fails or results in unacceptable adverse events such as sedation, another option would be to maintain the same dose but reduce the dosing interval of the transdermal fentanyl to two rather than 3 days. This is reasonable because the prescribed dosage seems to limit the number of BTP episodes during the first 2 days of each patch application. BTP episodes that occur despite these changes are likely to be unpredictable incident or idiopathic subtypes. The ideal pain reliever for these episodes should therefore have a very rapid onset of action and sufficient analgesic strength and duration of effect to match the pattern of severity of the BTP episode, such as oral transmucosal fentanyl citrate.

Case Study No. 3: Tic Douloureux (Trigeminal Neuralgia)

A 65-year-old oral cancer survivor presented with chronic right facial and neck pain that he developed 6 years ago after undergoing cancer treatment with radiation and surgery. Two years ago, he had shingles on the left side of his face, which resulted in left facial postherpetic neuralgia in the distribution of the first and second branches of the trigeminal nerve. He had been obtaining acceptable pain control with gabapentin [ 9 ]. Over the past 3 months, he developed BTP characterized as two to three episodes of paroxysmal lancinating pain each day. Each BTP episode strikes suddenly, is debilitating, and persists for 20–30 minutes. The pain may be precipitated by shaving or brushing his teeth, but more often it occurs without any apparent cause.

What is the best next step to manage this patient's BTP?

Neuropathic pain results from structural changes to the central or peripheral nervous system and may occur spontaneously or in response to specific stimuli [ 10 ]. Spontaneous neuropathic pain is typically described as shooting, electric, burning, or cutting in character [ 3 ]. In this case, one approach is to switch from gabapentin to another anticonvulsant drug such as carbamazepine [ 11 ]. It also is appropriate to consider a surgical intervention, particularly if there is good initial response to the antiepileptic medications. Procedures such as percutaneous gasserian ganglion ablation or microvascular decompression of the proximal trigeminal nerve at the brainstem have led to substantial relief or cure in many patients with trigeminal neuralgia [ 12–14 ].

If these approaches fail to reduce the frequency and intensity of BTP episodes, this patient may benefit from a short-acting opioid with a very rapid onset of action and relatively short duration of effect, such as a transmucosal fentanyl product that could be taken at the first sign of BTP.

Case Study No. 4: Vertebral Compression Fractures

An 80-year-old woman who was healthy and active until the last 2–3 years presented for evaluation and treatment when she developed severe back pain that was exacerbated with walking, bending, or lifting. She has a stooped posture that appears to have worsened over the last several months based on reports from family members. A magnetic resonance imaging scan of her spine revealed 80% loss of height of the bodies of the T7 and T8 vertebrae. She has been obtaining some pain relief with daily use of over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), but the episodic pain is becoming increasingly debilitating, and she is becoming more depressed as the debilitation increases. Treatment with opioids was not tolerated because it caused severe confusion and somnolence.

Vertebroplasty and kyphoplasty are minimally invasive procedures that have been shown to effectively restore the normal height of collapsed vertebral bodies and thereby significantly relieve the pain associated with the collapse [ 4,5 ]. Physical therapy and a back brace are temporizing measures that may help in the short term, but these are unlikely to provide the long-term pain relief associated with vertebroplasty.

Case Study No. 5: Osteoarthritis with Disabling Knee Pain

A 67-year-old woman presented with painful osteoarthritis in both knees. She was previously treated with NSAIDs but experienced burning epigastric pain not associated with gastrointestinal bleeding as an adverse event associated with those medications. She recently began an opioid regimen consisting of sustained-release morphine 30 mg twice daily, with short-acting morphine 15 mg prescribed every 4 hours as needed for BTP. She has been using the short-acting morphine up to five to six times each day, but is concerned that despite these measures, the pain is increasing.

Osteoarthritis is a common condition that affects older individuals and is often associated with significant pain and disability. Treatment strategies usually are designed to minimize pain and improve patient function and quality of life [ 15 ]. In this case, treatment with sustained-release morphine is not adequately controlling the patient's baseline persistent pain, as suggested by the need for short-acting morphine five to six times per day. Several treatment options may be appropriate and include increasing the dosage of sustained-release morphine. Due to the frequent use of short-acting morphine, this patient is already receiving a high daily opioid dose. By raising the sustained-release morphine dosage, it should be possible to achieve a more consistent level of pain control and reduce the need for breakthrough medication. Another reasonable option is to resume NSAID treatment, provided it is given with gastric-acid-reducing therapy. Other options include intra-articular steroid injections, treatment with glucosamine, use of adjuvant medications, opioid rotation, or changing the short-acting opioid formulation.

These patient cases illustrate a variety of treatment approaches available to address the complex array of pain presentations commonly encountered in clinical practice. Opioids are the mainstay of treatment for BTP, but the opioid regimen needs to be tailored for each patient. Moreover, adjuvant drug therapies, nonpharmacologic strategies, and surgical interventions should be considered on a case-by-case basis. Clinicians should regularly evaluate the patient's response to treatment, particularly after any changes in treatment have been made, and should consider further modifications until good control of BTP is achieved. Because a treatment strategy that is effective for one patient with BTP will not necessarily be effective for other patients—even if they have the same type of BTP—it is important that clinicians take a multidisciplinary approach to individualizing treatment of BTP.

I wish to acknowledge the inspiring patients that I have had the privilege of caring for every day and the knowledgeable staff at Fusion Medical Education for their efforts to facilitate pain management education. Sponsored by Boston University School of Medicine Office of Continuing Medical Education. Supported by an educational grant from Cephalon, Inc.

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Sindou M Leston J Howeidy T Decullier E Chapuis F . Micro-vascular decompression for primary Trigeminal Neuralgia (typical or atypical). Long-term effectiveness on pain; prospective study with survival analysis in a consecutive series of 362 patients . Acta Neurochir (Wien) 2006 ; 148 : 1235 – 45 .

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This manuscript is based on the content of the CME symposium “The Scope of Breakthrough Pain in Clinical Practice” held on February 24, 2006, in San Diego, CA, at the Annual Meeting of the American Academy of Pain Medicine.

  • immunologic adjuvants
  • pharmaceutical adjuvants
  • analgesics, non-narcotic
  • opioid analgesics
  • surgical procedures, operative
  • breakthrough pain

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Review article, multidisciplinary firms and the treatment of chronic pain: a case study of low back pain.

pain management case study quizlet

  • 1 Department of Neurosurgery, Albany Medical College, Albany, NY, United States
  • 2 Department of Neuroscience and Experimental Therapeutics, Albany, NY, United States
  • 3 Broadwell College of Business and Economics, Fayetteville State University, Fayetteville, NC, United States

Sixteen million people suffer with chronic low back pain and related healthcare expenditures can be as high as $USD 635 billion. Current pain treatments help a significant number of acute pain patients, allowing them to obtain various treatments and then “exit the market for pain services” quickly. However, chronic patients remain in pain and need multiple, varying treatments over time. Often, a single pain provider does not oversee their care. Here, we analyze the current pain market and suggest ways to establish a new treatment paradigm. We posit that more cost effective treatment and better pain relief can be achieved with multi-disciplinary care with a provider team overseeing care.

Introduction

The cost of chronic pain to our society is staggering and has been quoted as up to $USD 635 billion in health care expenditures, disability and loss of productivity ( 1 ). Pain diagnoses make up 4 of the top 10 reasons people seek medical care ( 2 ). Costs for health care utilization include hospital admissions, emergency department visits, and expensive invasive therapies. Societal costs include missed workdays and impact on family dynamics, which may also have economic ramifications. Chronic pain affects roughly 20 million adults in the United States and has a profound influence on an individual's productivity, quality of life and mental health ( 3 – 7 ). Sixteen million suffer with chronic low back pain.

Chronic pain is defined as pain that lasts more than 3 months despite treatment. Patients with chronic pain are desperate to find a solution for managing their pain, but only half of these patients report having control over their pain ( 8 ). The issues surrounding management of chronic pain are complicated. What works for acute pain often does not work for chronic pain. For the purpose of this article, we will focus on the market for low back pain relief, which exceeds $100 billion USD ( 9 , 10 ). We will begin by defining the patient population constituting the pain relief market and addressing the current state of the consumers and service providers in the market. We will then examine multidisciplinary clinics as a potential solution and address mechanisms of establishing financial sustainability and limiting barriers. Section Introduction describes the current market for pain relief. Section Background presents an alternative model, multidisciplinary firms for comprehensive chronic pain management.

The Consumers in the Market of Pain Relief

Patients with acute low back pain are often desperate to obtain pain relief and will often seek any number of medications or devices to achieve that relief (i.e., over the counter pills or patches, assistive devices and braces and even more expensive alternatives like tilt tables). They may then go for a massage, to a chiropractor, or to an acupuncturist. In the vast majority of patients, the acute pain dissipates within 2 weeks ( 11 ) and they are no longer consumers in the market for pain relief. Those who are unaware of this natural history of the disease, are in extreme pain, and/or are still in pain after 2 weeks, may go to the emergency department or see their primary care doctor who will likely prescribe physical therapy and medications ( 12 ).

Up to 80% of acute pain exacerbations improve within 6 weeks ( 13 ), at which point the consumers leave the market for pain relief. For the subset who have continued pain, they may be referred to a pain specialist who generally focuses on injections ( 14 ). Alternatively or in addition, an MRI may be ordered after a course of physical therapy ( 15 ). The MRI is very rarely read as normal, and though the number of findings on lumbar MRIs in people with pain and without pain are similar ( 16 ), review of an imaging report often leads to a trip to the neurosurgeon or orthopedic spine surgeon. In most conservative spine practices, the majority of patients are not surgical candidates and are referred for injections or other conservative measures.

By 12 weeks, 95% of patients have resolution of pain ( 13 ). Over the course of a lifetime, a person may have acute pain that requires entry into the pain market several times with symptoms of varying intensities (i.e., a trip to a pharmacy for a heating pad/ibuprofen for acute back spasms v. a course of chiropractic manipulation for pain that persists for several weeks v. a spine surgery for acute leg pain associated with a herniated disc). However, in most cases, the pain is acute. The remainder of consumers, that is those who have no relief, are termed chronic pain patients and remain in the market for chronic pain relief services.

The Current State of the Market for Pain Relief in Chronic Pain Patients

Chronic back pain patients become very familiar with multi-modality treatment that consists of medications, physical therapy, alternative therapies, injections, surgery, and/or neuromodulation. Though some medications for the treatment of chronic pain are reasonably priced, they often have notable side effects and are not well tolerated by patients. The relative low cost of opioids, in part, contributes to their overuse ( 17 ) despite significant evidence that these drugs are not appropriate for the majority of chronic pain sufferers. Other types of medications (e.g., pregabalin, lidocaine patches) can be quite expensive, ranging from $USD 250–1,000 per month for treatment.

Often, physical therapy and core-strengthening/stretching may actually be more effective than medications ( 18 , 19 ). However, patients are often more eager to try a medication, than an alternative therapy, as the price of medications is often covered in large by insurance, while alternatives are typically not. Further, there are psychological barriers to such behaviors-people who have difficulty moving fear they will be asked to do just that at therapy. Additionally, it takes a 6–12 week commitment to daily exercises to see a difference. Finally, patients are typically responsible for co-payments associated with physical therapy which can be cost prohibitive (i.e., $40 per visit with visits 3x/week for up to 20 visits).

Other forms of physical manipulation have even greater financial barriers as acupuncture and chiropractic are often not covered by insurance. Biofeedback and cognitive behavioral therapy, though proven beneficial for chronic pain, are often met with resistance by patients who feel like clinicians are telling them their pain is not real. In addition, there are significant barriers for pain patients obtaining psychological evaluation and follow-up due to a relative paucity of psychologists who see patients with chronic pain and psychologists/psychiatrists in general ( 20 ).

Ultimately, for the reasons above and human nature, patients often look for a quick fix which may or may not be beneficial depending on the pathology and the procedure chosen. Patients will often see pain management providers who more commonly offer invasive options instead of medications or body therapies, based on their area of expertise ( 21 ). The co-payment for one visit for steroid injections or radiofrequency ablations is similar to that of one visit at physical therapy. As these injections and ablations are only performed 3–4x a year and have more immediate results, patients have financial benefits for undergoing these therapies. When injections are no longer helpful, surgery is often considered.

If there is a primary issue with the spine, an appropriate surgery may be performed. There is variability in what type of surgery, if any, will be offered from surgeon to surgeon and region to region. Patients often have a co-pay anywhere between $50–1,000. The cost submitted to insurance for the procedure however can range from $USD 10,000 to over 100,000 depending on the type of surgery performed ( 22 ). Despite the above attempts, it is fairly rare that patients with chronic pain have complete resolution of their pain.

After a year or two of repeating the cycle above, patients may then move onto more neuromodulation therapies- that is, treatments that alter their perception of the sensation. These therapies may include spinal cord stimulation or intrathecal pumps. These procedures are successful in 50-80% of people, where success is defined as 50% pain relief ( 23 ). However, failures may occur in up to 30% of patients and 10–15% of the devices are explanted ( 24 , 25 ). These devices cost an average of $30,000 per implant and the total cost of surgery/hospitalization is often ~$50,000. Neuromodulation therapy has experienced a growth rate of 20% a year, which is outside the growth rate for other treatments. Thus, insurance companies are beginning to become more stringent in defining which patients will be covered. Additionally, neuromodulation has been shown to be more cost-effective compared to conservative treatments ( 4 , 26 – 28 ) and spine reoperation in properly selected patients ( 29 ). In these cases, health care resource utilization decreases ( 4 , 6 , 26 , 30 , 31 ), indicating successful exit from the pain market. However, in patients that ultimately do not have success with the therapy and have the device explanted, total costs are higher ( 32 ). Newer technologies are also available. Currently, these include stem cell therapies injected into the spine ( 33 ) or minimally invasive procedures performed by pain physicians ( 34 – 37 ). Evidence remains limited at this point.

Flaws in the Current Market for Chronic Pain Relief

Often, regardless of what therapies the chronic back pain patient has undergone, there is continued healthcare utilization, with the majority of spine and spinal cord stimulation patients requiring multiple medications and/or cycles of injections, physical therapy, and/or surgery over time ( 25 , 38 ). Based on this pattern, the patients that remain in debilitating pain, and the healthcare expenditures associated with this suboptimal care ( 39 ), there is little debate that the market for chronic pain relief is flawed. To analyze the market, we will examine it in economic terms.

The consumer is the patient in pain. The market generally works well for the acute pain patient, as 95% of these patients exit the market by 12 weeks ( 13 ). However, for the 5% who remain in the market, it works less well, and in some cases, leads to debilitating pain that precludes normal activity for decades. The service providers in the market (which will be referred to as “firms” for the remainder of this paper) generally specialize in one type of therapy. This categorization is a slight simplification as there are nuances among different therapies – but they generally fall into the same category of therapies. For example, body work, physical therapy, chiropractic, acupuncture, and/or massage are generally provided by specialty vendors who provide one service. Pain specialists, as a trend in the last 5 years, routinely perform injections and often only provide medications in special cases ( 8 , 38 ). Pain psychologists are few and far between and waiting lists are long ( 20 , 40 ). Surgeons, of course, specialize in surgery. For all firms, the inputs are chronic pain patients and the ideal outputs are chronic pain patients with manageable levels of pain. It is important to note that once patients are in chronic pain, they often will have some degree of pain even when treatment is optimized ( 41 ).

Unfortunately, the output is often not achieved within the current market. More commonly, patients have some degree of pain relief with one therapy and move onto treatment by the next firm, leaving patients to continue in the pain relief market with no single physician specializing in pain management overseeing their care plan. Further, the market is limited by resources. As treatment of chronic pain is difficult and may lead to physician burnout ( 42 ), there are limited numbers of providers willing to take care of these patients. Often, care remains with the primary care physician, who often does not have the time and/or resources to manage these patients.

In the last decade, another barrier has arisen. In some cases, the primary care physician and the patient have found a medication regimen that works “well enough.” A subset of these patients have been treated successfully with low dose opioids for a decade. This option, though not recommended for the vast majority of patients, is highly successful in a small minority ( 43 , 44 ). Recent regulations and stigma related to opioids preclude many providers from continuing medications. Patients are subsequently left without therapy and they re-enter the pain market where they may see a pain specialist. Most physicians consider opioid prescribing a highly undesirable risk-to-benefit ratio (not only for patients but also for them), hence, most primary care and pain practices have become very limited in their ability and desire to prescribe ( 45 ). Prescribing responsibly requires pain contracts, urine drug screens, checking databases for inappropriate use, and frequent appointments to receive a limited supply of medications ( 8 ). Thus, there is a significant transaction cost to firms which prescribe. As the cost of caring for patients on opioids is ~70% higher than for those not on opioids, it is not fiscally wise to continue this practice ( 46 ). The added risk of staff burnout compounds the issue ( 42 ).

What has resulted is patients having more costly procedures that may be less effective. Patients become frustrated, feel deserted, and look for practices which prescribe medications. There are many practices that focus on prescribing opioids in a reasonable fashion and have either found ways to make this financially viable or are part of a tertiary care facility or state facility which focuses on serving public health needs. However, there are also practices that have been described as “pill mills.” In these businesses, the profit associated with writing prescriptions/drug screens may complicate motivation to wean patients to the lowest dose or off medications entirely, even if they have pain relief ( 47 ). Fortunately, these practices have been investigated by law enforcement in the last decade. To be fair, these are not the only pain practices where ethics become complicated. Most firms in the pain market rely on volume due to low revenue margins ( 48 ). Incentivizing physicians or any health care provider to see more patients is similar to examples of factory line workers being incentivized to make more parts ( 49 ). Quality dissipates with this type of incentive ( 50 ).

Taken together, while the current market may work for the acute pain patient with a straightforward problem, it does not fulfill the needs of the chronic pain patient. We posit that concentrating care into comprehensive, multidisciplinary firms would be highly beneficial and would likely lead to improved patient outcomes and reduced healthcare expenditures.

A Proposed Model: Multidisciplinary Firms

We have already seen the overall costs of chronic pain. For the 16 million Americans who have chronic back pain, expenses are estimated at $USD100 billion ( 9 , 10 ). This staggering figure includes both health care expenditures and estimated lost time and wages. Specifically, patients with chronic pain who are not adequately treated are likely to have more disability over time and subsequently will have an increase in healthcare resource utilization (HCRU) compared to patients who have been adequately treated ( 3 , 4 , 51 ). Emergency room (ER) visits can be a surrogate marker of HCRU and it has been found that 42% of visits are due to pain ( 51 , 52 ). Further, chronic pain patients with more disability use the ER more than those who have greater function ( 51 , 53 , 54 ). They may visit as often as twice to three times a month due to uncontrolled pain and/or lack of an established care team ( 52 ). Overall, multidisciplinary pain clinics have been shown to reduce ER visits ( 55 , 56 ).

Outside of the ER, multidisciplinary pain clinics have resulted in cost savings of $6.68 per day in prescription costs ( 57 ). The implementation of a multidisciplinary pain clinic at Geisinger ( 58 ) resulted in decreases in the number of primary care visits, acute inpatient admission rates, opioid prescription fill frequencies, and the use of high-end diagnostic imaging, which corresponded with a reduction in total medical costs ( 59 ). Such collaborative clinics have been found to positively alter patients' care-seeking behaviors ( 57 , 59 ).

Most importantly, patients in multidisciplinary clinics have better outcomes. These patients generally report less pain, have fewer effects of pain on activity and have more appropriate use of non-opioid medications ( 60 , 61 ). They have regularly scheduled outpatient follow-up, ( 60 – 62 ) greater health literacy about pain, and reasonable expectations for relief. However, pain management is often viewed as low priority due to the stigma that pain is a symptom not a disease ( 63 ). Compounded with fears of increased costs for payers and providers ( 57 ), multidisciplinary pain clinics are not prioritized. Currently there is little to no incentive for both payers and providers to be involved in the implementation of these clinics, despite the benefits. However, in order for a multidisciplinary clinic to be successful, thoughtful deliberation between all clinicians involved is necessary to develop a protocol/ pathway for pain patients. We have done this for our pelvic pain patients ( 64 ). Similar could be done with different types of pain leading to low back pain, including SI joint dysfunction, mechanical pain, and neuropathic pain.

Opportunity Costs and Financial Sustainability

When thinking about developing a multidisciplinary pain clinic, it is necessary for all those involved in treatment of chronic pain to reach a consensus on the organizational structure of the clinic. This requires an assessment of internal strengths and weaknesses and external threats and opportunities. Much depends on what already exists in the community and where the needs are. A bit depends on the demographics of the community and appropriately determining who would be a candidate. In a community with limited resources and a large demographic of manual laborers who have performed decades of heavy lifting, there is a mismatch between resources and need. A patient who has undergone three courses of physical therapy, three courses of injections, four spine surgeries and 10 MRIs, would be appropriately served in this clinic. The patient who has only had one of the four interventions, no matter how many times, may or may not be a candidate. In a community with more resources, a patient after one surgery with continued pain may be appropriate. Each community should work together to perform a needs assessment.

This point would warrant discussion and depend on the other firms in the market, the capacity of the multidisciplinary clinic and the number of chronic pain patients the market serves. However, in the majority of markets, it is likely that the input to the firm (e.g., a patient with one spine surgery) would still be too high, based on the firm's resources for achieving the desired output. To avoid overwhelming the system, a more reasonable entry point into the pain market may be after 6 months of pain and the failure of two therapies. Additional data is needed to test this hypothesis and again may vary from community to community. The multidisciplinary firm we discuss in this article focuses on back pain, but it is important to note that the entry point should be altered depending on the disease process and the external market. For example, all patients with pelvic pain that come into care with any of our providers can be entered into the system because there are so few resources available to these patients that they often have been suffering for more than a decade before they seek care ( 64 ). Patients with cancer pain also would need to enter into the system much more quickly ( 65 ). Each region should work together to perform a needs assessment.

Partnerships With Insurance Companies and Other Firms in the Market

Third-party payers are essential stakeholders in the discussion. The most established multidisciplinary program for chronic pain has been at the ( 66 , 67 ). More recently, regions such as Eastern Pennsylvania have insurance companies that have partnered with health systems (2019). In 2012 Piedmont and WellStar healthcare systems created a joint venture called the Georgia Health Collaborative which utilizes a care model with the goal of implementing both prevention and care management programs with higher quality care at lower costs ( 68 ).

Partnerships with insurance companies in these initiatives has increased ( 62 ). Such practices have also helped in monitoring financial risk to manage healthcare spending and potential losses, while also providing patients with better, more well-rounded care ( 69 ). In 2014, Geisinger ( 58 ) implemented a multidisciplinary pain clinic, noting significant reduction in health care utilization and cost of care ( 59 ). Recent partnerships between Southeast MI hospitals and Blue Cross Blue Shield of MI, have resulted in more implementation of multidisciplinary teams, beginning with integrating clinical pharmacists into the patient-care team ( 70 ). These teams have led to improved resource utilization.

However, in most regions, partnerships for development of multidisciplinary clinics for pain have not been pursued presumably due to cost and volume concerns ( 57 ). To determine what is and what is not possible requires discussions among the groups. A discussion would first lead to a better-defined partnership between the insurers and the hospitals. Expectations must be established and the poor results that are achieved with the existing market understood, further, all must accept that adequate pain relief, rather than total pain relief is the goal ( 71 ). Next, the group could determine the need and timing for certain therapies and limit the fairly common “fail first” model prior to granting authorization for some diagnostics and therapies when the model does not promote better care ( 72 ). Clinicians, researchers and economists must show the cost-benefit analysis of these programs for payers to desire them ( 73 – 75 ). Additional payment structure that is mutually agreed upon must be established so that groups providing the care to patients can cover costs and an agreed-upon margin ( 76 ).

Additionally, some degree of intervention from insurance companies and large firms will be needed to encourage providers to use the multidisciplinary clinic. Within geographic regions, how this will be done and which patients will be included will vary. Limiting pre-authorizations or encouragement through pay-for-performance may be some means of promoting the use of multidisciplinary clinics. Ultimately, for this model to be sustainable, the multidisciplinary firm will have to develop a comparative advantage and provide the best outputs. As only 27% of patients with chronic pain have Medicare, the process is likely to start with commercial payers ( 77 ).

Of course, in addition to partnership with insurance companies that mandate their patients participate, the multidisciplinary clinic needs additional patient inputs. Including firms in the process of caring for patients will likely add to this input. Once a care plan is developed by the multidisciplinary clinic as described above, it could be subsequently implemented in combination with other firms to ensure inputs, internal capacity, and financial viability for the surrounding market. This set-up would allow patients to be treated closer to their home when all other factors are equivalent. Alternatively, for niche services, the patients may need to receive the services within the multidisciplinary group. Careful cost analysis must be done to ensure that capacity is appropriate and that the use of internal and external services is a financially sustainable model. Oversight will need to be maintained by the multidisciplinary clinic on patient outcomes. This could be done through semi-annual or annual assessment.

Development of multidisciplinary teams may be hindered by physicians themselves. Sometimes physicians are reluctant to give up patients to a multi-disciplinary center and/or do not have the administrative a number of providers who have very busy practices and necessitates personnel for coordination ( 78 ). Further, some practices may be in direct competition. Additionally, there is limited interoperability between medical records in different practices and systems ( 79 , 80 ). How records will be housed and shared will need to be determined and subject to regulations.

Minimizing Transaction Costs

When establishing a new type of practice, ease of the referral process is essential ( 81 ). Sometimes specialized firms within a tertiary medical center make referrals difficult. In this case, the external firms, which are much more available, maintain considerable market share. Patients face similar challenges obtaining appointments. Put in economic terms, the transaction costs of dealing with a tertiary medical center can be too great for many referring providers and for many patients. The buildings are huge, the waits are long, the providers seem overworked, and the telephone trees are unwieldly. A multidisciplinary clinic may also not serve the needs of the primary care doctor if only recommendations are made and the primary responsibility for patient care still lies with the front line physician. Primary care physicians are often overworked and undercompensated and cannot afford to take care of chronic pain patients, or find it unduly difficult. If pain practices take this burden from them, the output is less important and the referrals grow.

In establishing our multidisciplinary pelvic pain health consortium at our institution-Albany Medical Center, we have found that providing a single contact with an email and phone number works well for providers ( 64 ). Intake is then performed by that one patient navigator, using a form that was developed by the group as a whole and appropriate consultations are embarked upon. We have been able to initiate these plans over the phone, virtually, or in person. Then, in a mature multidisciplinary group, the team should describe what the expected outcomes are for the patient, their family and their primary care physician. The multidisciplinary group should discuss all patients that have entered the clinic and who are not achieving the expected outcomes at weekly and/or monthly conferences. Often, these discussions also help providers stay on message in discussion with patients. For example, patients with lower health literacy may be highly resistant to working with pain psychologists as they feel that referral is a sign that their providers think “the pain is in their head.” They fail to realize that pain is a tridimensional (bio-psycho social) experience involving sensory, cognitive and emotional components ( 82 ) and further do not realize that biofeedback, talking about coping and strategies that empower them to independently control their pain may be valuable ( 8 ). Finally, as pain changes over time and new advances are commonplace, multidisciplinary discussion may prompt new ideas, thus increasing the likelihood of success ( 38 ).

The Importance of Cost-Sharing

An upfront investment is needed to ensure buy-in among all parties and to ensure that the multidisciplinary clinic's resources and capacity is adequate to provide the sources they are meant to provide. Creative means of gaining buy-in and cost-sharing will be needed. Partnerships between hospitals and insurance were discussed above. To hold the physician accountable, it is important to emphasize transparency and accountability of patient outcomes. Medicare Pay for Performance (P4P) strategies can be adapted for pain practices, based on metrics selected by pain providers, rather than metrics which are less relevant. This has been an issue for specialties in the early attempts of P4P. Quality in these metrics should initially be incentivized and, over time, penalized in order to make sure that the outputs are adequate.

Another option is patient cost sharing. which has been shown to reduce health care expenditures. However, it is important to note that the reduction does not differentiate between high- and low-value care ( 83 ). Further, in most areas of medicine, it is difficult to employ patient cost-sharing for all medical care in real life situations, because of the unpredictably of life. As these resources only cover the chronic pain the patient is suffering from and they do not affect the care patients would receive for other chronic conditions or for acute unexpected conditions, this system does not suffer from moral hazards that diffuse cost-sharing plans may suffer from Baicke et al. ( 83 ). Further, it is important to note that patients can become incentivized to suffer in pain (i.e., disability, workman's compensation, beneficial family dynamics). A counter-incentive to improve cost-sharing could better balance the patient's behavioral economics. Elasticities of demand vary by chronic conditions patients suffer from Chandra et al. ( 84 ) and where the elasticity of chronic pain services has not been defined. We know that dental and psychiatric services are more elastic than those of other medical services ( 83 ) for the general population. Interestingly, we would posit that chronic pain care would also be more elastic if there were not a motivation for a subset of patients to seek such services to continue receiving disability and workman's compensation benefits. It is important to note, however, that cost-sharing could be detrimental to patients in lower socio-economic brackets who have fewer monetary and non-monetary resources ( 84 ). A cost-sharing program could be on a sliding scale, depending on income relative to the poverty line [as has been done in Massachusetts ( 84 )].

One potential strategy is to offer different co-payments depending on how likely a patient is to benefit from a therapy. If the patient is likely to benefit based on the medical literature, the co-pay would be lower. If the patient is unlikely to benefit or likely to have only a modest benefit, the co-pay would be higher. Unfortunately, in chronic pain the data is lacking as to which patients are likely to benefit and pain phenotypes are difficult to determine from the medical care as ICD10 codes do not accurately reflect patient status ( 85 ). Insurance companies restrict services when treatments are experimental. Insurance partnership with the multidisciplinary clinic may allow for physician input on low v. high probability of improvement for individual patients, especially where in chronic pain management a satisfactory outcome is considered 50% pain relief in 50% of patients ( 23 ).

Alternatively, patients could be given all the information and review it with their treatment providers and then make decisions in conjunction with their care team. They could be given a certain number of annual resources and determine how they will use those resources based on their pain. This strategy may be effective, as the patient and the multidisciplinary team are most likely to have the best insight into the patient phenotype. It would be essential for patients to be clear on the treatments and the cost sharing; thus, the plan must be straightforward and relatively simple ( 86 ). Additionally, cost-sharing for treatment would need to be done within the construct of a multidisciplinary clinic as care does not involve a single treatment. However, this may negate the draw to complementary services which have lower co-pays ( 83 ). We see this currently with patients opting for more invasive therapies. We also see this in providers when reimbursements for one procedure are far greater than for another. Taken together, cost-sharing could modulate behavioral economics while allowing for improved, more affordable care.

Sixteen million suffer with chronic low back pain at an annual cost of $100 billion. The current market for pain relief does not meet the needs for patients for chronic low back pain. We posit that a multidisciplinary care clinic can be beneficial for the patients, providers, hospitals and insurance companies. Implementation will require appropriate partnerships and organizational structures. Opportunity costs, cost-sharing and relationship with external firms will vary regionally. Future work should examine best practices and expand this model from lower back pain to chronic pain, generally.

Author Contributions

JP conceived of and coordinated the review and assisted in writing the manuscript. OK and NW also assisted in writing the manuscript. All authors contributed to manuscript editing, and approved the final submission.

Conflict of Interest

JP is a consultant for Boston Scientific, Nevro, Medtronic, Saluda and Abbott and receives grant support from Medtronic, Boston Scientific, Abbott, Nevro, NIH 2R01CA166379-06 and NIH U44NS115111. She is the medical advisor for Aim Medical Robotics and Karuna and has stock equity.

The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: multidisciplinary pain clinic, cost sharing, chronic pain market, chronic pain, acute pain

Citation: Pilitsis JG, Khazen O and Wenzel NG (2021) Multidisciplinary Firms and the Treatment of Chronic Pain: A Case Study of Low Back Pain. Front. Pain Res. 2:781433. doi: 10.3389/fpain.2021.781433

Received: 22 September 2021; Accepted: 18 October 2021; Published: 10 November 2021.

Reviewed by:

Copyright © 2021 Pilitsis, Khazen and Wenzel. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Julie G. Pilitsis, jpilitsis@yahoo.com

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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StatPearls [Internet].

End-of-life evaluation and management of pain.

Ankur Sinha ; Himanshu Deshwal ; Rishik Vashisht .

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Last Update: February 26, 2023 .

  • Continuing Education Activity

Evaluation and management of pain at the end of life is a multifold issue with a deep impact on the patient's quality of life. With a better understanding of pain management's key principles at the end of life, caregivers can contribute to providing comfort and solace to their dying patients. This activity outlines the evaluation and management of pain at the end of life with pharmacological and nonpharmacological measures and highlights the role of the interprofessional team in managing patients at the end of their life.

  • Describe the pathophysiology of pain at the end of life.
  • Review both pharmacological and nonpharmacological measures of pain management in the dying patient.
  • Identify the signs of pain and discomfort and provide effective treatment.
  • Identify some interprofessional strategies that can improve pain management at the end of life.
  • Introduction

Pain and discomfort at the end of life are frequently under-recognized and undertreated. With the advent of modalities that help prolong life, there is a constant risk of prolonging suffering. Health care practitioners are entrusted with the responsibility of ensuring their patients' comfort and need a holistic approach targeting pain at the end of life. In their efforts to define the concept of a “Good Death,” narrowed down on 36 studies that addressed the parameters for good death defined by patients at the end of their life. Having a pain-free status was one of the top three priorities noted, with 81% of the studies significantly weighing on its importance. 

Saunders conceptualized the concept of “total pain” in evaluating and managing pain in the dying. The concept of total pain encompasses four components, notably the physical noxious stimuli, emotional discomfort, interpersonal conflicts, and the nonacceptance of one’s own death. To alleviate the discomfort of the dying, all four of these attributes of pain need to be addressed. [1]

Pain at the end of life is most commonly associated with the pathology causing the disease and ultimately leading to death. Based on acuity, pain can be acute or chronic. Acute pain is usually associated with an intervention like surgical interventions, repositioning, or suctioning that may be performed as a palliative measure. Chronic pain is usually a complex interplay between several organ systems. Examples of chronic pain include headaches, joint pain due to arthritis, pain due to skin breaks, decubitus ulcers, etc. Based on the pain fibers' location, the pain can be classified as somatic, visceral, or neuropathic. Each of these classifications leads to a specific character of pain, and this helps guide therapy.

Somatic pain originated from pain receptors in the skin and musculoskeletal tissues and is usually deep and aching in character. Common sources can include the joints, bones, infections like abscesses, and skin breaks. As the name suggests, Visceral pain involves the stimulation of pain receptors of the visceral organs and is generally described as a “squeezing” or “cramping” kind of pain. Palpation of the involved viscera can lead to an aggravation of the intensity of the pain. On the other hand, neuropathic pain is usually described as a sharp pain that is “burning” or like an "electric shock."

Anxiety and depression frequently accompany pain, and addressing this is pivotal to alleviating “total pain.” The anxiety caused by organic causes includes a feeling of impending doom in patients with respiratory diseases causing hypoxia and dyspnea, cardiac diseases, electrolyte imbalances, dehydration, and infection leading to sepsis. Medications like nebulization treatments, corticosteroids (Dosage and rapid tapering) anti-emetics like metoclopramide can cause a feeling of anxiety. Failure to address pre-existing anxiety can lead to significant distress at the end of life.   

Apart from physical noxious stimuli, other factors that can affect individuals at the end of life, as elucidated by the concept of total pain, include emotional discomfort, interpersonal conflicts, and the nonacceptance of one’s own death. The emotional discomfort and interpersonal conflicts go hand in hand in causing suffering at the end of life. Financial instability, marital discord, conflicts with family members, and an inability to get one’s affairs in order before death are common causes of total pain. Nonacceptance of the end of one’s life can result from shock, anger at the prospect of impending death. Counseling and spiritual care can help address these issues and aid in pain management at the end of life.

  • Epidemiology

The pain of varying intensities is a common accompanying factor at the end of life, as evidenced by a recent population-based observational study. [2]  In this study, the researchers found severe daily pain in over 17% of the over 20,000 participants studied. The cause of impending death or the health care setting does not appear to change the involvement of pain at the end of life. Pain is an accompanying factor seen in patients with the commonest causes of death worldwide, namely cancer, heart failure, chronic obstructive pulmonary disease (COPD), and lung cancer. [3]

Pain is seen in patients at home in the community as well as in long-term care facilities. [4] [5] [6]  Unfortunately, pain and its management at the end of life are often inadequate. [7]  The involvement of supportive care/palliative medicine in the care of the dying patient can improve pain relief. [8]  Ethnic and racial disparities were noted in hospice and palliative care utilization amongst minorities. However, there was no difference in the incidence of pain symptoms noted amongst individuals across all races and ethnicities. [9] [10] This healthcare disparity deserves further research and evaluation. [11] [12] [11]

  • Pathophysiology

The pathophysiology of pain rests in the nociceptive pathway, leading to the perception of noxious stimuli in the body. This pathway acts as a protective mechanism in healthy individuals, pointing towards pathologies causing pain and aiding in removing the noxious stimuli or seeking treatment. At the end of life, the activation of this nociceptive pathway leads to pain, distress, and suffering in patients. Most of the interventions are aimed at blocking the nociceptive pathway at various levels.  

Pain perception begins at the level of nerve endings that are unsheathed portions of the nerve. There are two major types of nociceptive nerve fibers, the A-delta fibers, and the C fibers. The A-delta fibers are myelinated and allow for fast transmission of signals, leading to pain's initial perception. The C Fibers are unmyelinated and relay pain intensity. The A-delta fibers release glutamate onto the second-order neurons, while C fibers release neuropeptide neurotransmitters. Both of these fibers end in the dorsal root ganglion. They are associated with the first-order neurons of the nucleus posterior marginalis of the relaxed layer I and substantia gelatinosa of the Rexed layer II. These first-order neurons form the 3 major ascending pain pathways, the neospinothalamic, paleospinothalamic, and archispinothalamic tracts. The body has an innate defense mechanism from pain generated by these pathways in the form of the descending pain suppression pathway.

  • History and Physical

Approach to a patient at the end of life for the management of pain involves a thorough evaluation of the primary diagnosis and the extent of involvement of organ systems. A comprehensive patient interview should be performed to outline the course of the disease—this aids in establishing a rapport between the caregiver and the patient and leads to better communication. The goals of care should be outlined early, and every effort should be made to ensure strict adherence to the patient’s wishes. After an initial evaluation, open-ended questions should help ascertain the patient’s expectations from care. The concept of total pain should guide the discussion, and the history should also focus on the physical and mental well-being.

Physical examination includes a head-to-toe assessment for factors that may contribute to pain. Physical signs of pain include facial grimacing, restlessness, tachypnea as well as tachycardia. Patients who have been in bed for prolonged periods of time can have skin breaks or pressure ulcers in the dependent portions of the body, including the back of the head, shoulder blades, back, sacrum, hips, ankles, and heels.

Dryness of the eyes can lead to painful keratitis as well as infections. Patients on long-term oxygen therapy may have skin breaks around the nares, dryness, and episodes of epistaxis, which can be distressing. Patients who have been using noninvasive modes of ventilation may have pressure ulcers at the nasal bridge and cheeks. In patients who are intubated and mechanically ventilated, pooling secretions and improper oral care can lead to oral ulcers and dental decay. Head positioning and lack of proper support can lead to painful spasms of the neck muscles.

Signs of malnutrition include temporal wasting, supra, infra-clavicular wasting, scaphoid abdomen, and skin dryness. Dehydration signs follow a similar pattern, including dryness of mucosal surfaces, loss of skin turgor, and dryness of the skin. Abdominal fullness points towards constipation or urinary retention, causing significant distress to the patient. Examination of the genitalia, especially in patients with chronic Foley catheters, can shed light on ulcers and signs of infection. All intravenous access sites require frequent evaluation for thrombophlebitis; infiltration of medications or fluids into the subcutaneous tissue can lead to pain, swelling, and infection. Lastly, a general assessment of hygiene and well-being focused on maintaining the patient's dignity at the end of life is essential.

The Evaluation of pain at the end of life follows the general pattern of pain assessment aimed at the site of pain, the onset of pain, character, radiation of pain, exacerbating, and relieving factors. Verbal description of the quality of pain is an important marker of the origin of pain. Somatic pain can be described as aching, whereas visceral pain may be described as cramping. Similarly, neuropathic pain may be burning or shooting in character. An evaluation of the intensity and duration of pain in the last 24 hours helps the caregiver quantify and manage pain. The cornerstone of efficient pain management includes round-the-clock assessment and repeated evaluations, especially following intervention. [13]

Pain scales can help standardize care and provide objective assessment tools that are not provider-dependent. Several pain grading scales have been developed with validation. However, none of these scales is proven to be superior to others. The Likert-type scale for pain grades pain on a scale of 0-10, with “10” being the worst pain imaginable and “0” representing no pain. The Wong-Baker Faces pain scale comprises a series of faces with expressions of increasing distress. This scale provides superior assessment in children with reliability and validation, and its implementation in adults allows for the evaluation of pain in patients who may be unable to communicate verbally. Intensive care units and inpatient hospital units have started to incorporate a board facing the patient with information aimed at keeping the patient informed and oriented. This includes the date, short-term and long-term aims of care, contact details of caregivers, and a visual pain scale.

The patient is educated on admission to point at the pain scale to indicate pain and choose a face that best represents their pain. Using the same scale consistently between providers can help maintain accuracy and effectiveness of care. In patients with cognitive impairment and dementia, there are some scales that incorporate several factors that caregivers can observe at the bedside and evaluate the presence of pain. The Pain Assessment in Advanced Dementia (PAINAD) scale is one such measure that can quantify pain and the response to intervention in patients with dementia.

  • Treatment / Management

The management of pain at the end of life includes nonpharmacological measures, pharmacological measures, and psychosocial measures.

Pharmacological Management of Pain

The World Health Organization (WHO) devised a cancer pain ladder to guide caregivers in selecting pharmacological agents in managing pain. [14]  This is a stepwise process where the initial agents are nonopioids with escalation to incremental doses of opioids and adjuvant agents, ultimately leading to the abolishment of pain. [15]  While this is a good guide in managing pain, individual assessment of each patient should be performed to gauge the initial intensity of pain to avoid delay in therapy.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most commonly used initial pharmacological agents for pain. The mechanism of action of these drugs is based on the inhibition of the synthesis of prostaglandins. The cyclo-oxygenase enzyme COX-1 and COX-2 are inhibited by NSAIDs, with the COX-2 enzyme playing a key role in pain generated by inflammatory cells. Some NSAIDs can also inhibit the lipoxygenase pathway, which is responsible for producing some algogenic (pain-producing) metabolites. NSAIDs also interfere with G-protein mediated signal transduction aiding in analgesia. Increasing evidence suggests that NSAIDs also have a central effect in the CNS mediated by endogenous opioid peptides or blockade of the release of serotonin. [16]  

Acetaminophen is used frequently in divided doses equaling a maximal dose of 4000mg every 24 hours. However, it is frequently associated with hepatotoxicity, and lower dosages may be needed in patients with hepatic disease. Ibuprofen is another NSAID that the FDA has approved for mild to moderate pain; however, it is associated with gastrointestinal bleeding, renal impairment rashes, and hypertension. [17]  Ketorolac is another NSAID that has a higher demonstrated potency than most other NSAIDs. [18]  However, in addition to gastrointestinal and renal side effects, it can cause an increased risk of cardiovascular thrombotic events and strokes. Selective COX-2 inhibitors like celecoxib can help manage pain associated with the musculoskeletal system and theoretically have a favorable side effect profile compared to other NSAIDs. Celecoxib contains the sulfonamide group and can cause severe allergic reactions in patients with sulfa drug allergy. If any of these medications are being used for more than a week, a proton pump inhibitor should be added as gastric prophylaxis.

Opioid analgesics are considered the gold standard of pain management at the end of life, providing the greatest analgesic relief. Opioids act by interacting with the mu, delta, or the kappa opioid receptors by mimicking endogenous opioid peptides. These receptors are coupled to G1 proteins and act in an inhibitory capacity. They cause the closure of N-type voltage-gated calcium channels and open calcium-dependent inwardly-rectifying potassium channels. This causes a reduction in neuronal hyperexcitability due to hyperpolarization. They also decrease the intracellular cAMP and thereby decrease the release of nociceptive neurotransmitters like substance P. The Mu receptors are key in mediating analgesia, euphoria, sedation, gastrointestinal dysmotility, and respiratory depression. Mu receptors can cause respiratory depression by a decreased response to hypoxia and hypercarbia, resulting in decreased stimulus to breathe. However, respiratory depression is preceded by sedation, and the clinicians should perform a constant assessment of mentation to avoid respiratory depression.

The pharmacokinetics of different opiates can be utilized in appropriate pain management at the end of life. The time to peak analgesic effect is important in choosing the right medication. Several routes of administration are available for opioids, including oral, intravenous, subcutaneous, intramuscular, transmucosal, nasal, transdermal, and rectal.  In general, the peak analgesic effect of oral opioids is close to 1 hour, whereas intravenous doses of opiates cause a peak effect around 10 minutes from the administration. Certain newer opiates using the trans-mucosal or intranasal mode of administration can have a faster onset of action and peak effect.

The doses of opiates need individualization and should be titrated per the analgesic effect. Patients who need repeated doses of short-acting opiates may need longer-acting opiates scheduled round the clock. The daily short-acting doses should be added up, and 50% to 75% of the dose should be converted to long-acting opiates. [19]  As needed, opiates should be prescribed to address breakthrough pain caused by interventions like turning, suctioning and changing of dressing, etc.

The FDA approves morphine sulfate for acute or chronic pain with moderate to severe intensity. Morphine is metabolized in the liver and excreted by the kidneys. In patients with renal dysfunction, the active metabolites, namely 3-glucuronide and morphine-6-glucuronide, can accumulate, causing myoclonus and seizures. Oxycodone similarly is another potent opiate that is approved for use in moderate to severe pain. It is available in the immediate release as well as extended-release formulations. Its metabolism is similar to morphine. Hydromorphone is another potent opiate analgesic available in the oral, subcutaneous, or sublingual preparation. Fentanyl has gained popularity due to its several routes of administration and predictable analgesic effects. Apart from being used as an infusion for sedation and analgesia in mechanically ventilated patients, it can be used as a transdermal patch in patients who cannot take medications orally. Care is necessary when removing the used patch before placing a new patch to avoid an overdose. Fentanyl is stored in the adipose tissue and takes 12 to 24 hours to wash out of the system once the patch is removed.

Methadone is a long-acting pure mu-agonist with the advantages of having a long half-life and an inexpensive preparation available orally. Unfortunately, methadone has a curvilinear pharmacokinetic curve leading to exponential effect in higher doses exposing to potentially life-threatening overdoses. It can also lead to QT interval prolongation and should be used cautiously in patients with underlying cardiac conditions. Tramadol has a dual-action at the mu-opioid receptor as well as a weak action as a serotonin-norepinephrine reuptake inhibitor. Its use has been approved for moderate pain to moderately severe pain.

The selection of an opiate agent should take into account the individual needs of the patient. The mechanically ventilated patient can get fentanyl or hydromorphone due to the fast action and easy titration. Patients with renal and hepatic insufficiency should get IV Fentanyl with doses adjusted. Remifentanil can be used as well because its metabolism is not dependent on hepatic or renal function. It is metabolized by nonspecific plasma esterases located primarily within erythrocytes. Patients who require frequent neurological checks can also benefit from remifentanil due to its ultra-short duration of action. Patients with hemodynamic instability or bronchospasm should not receive morphine sulfate as it causes histamine release. Meperidine should be avoided in patients with renal and hepatic failure because of severe neurotoxicity from the accumulation of an active metabolite. Codeine is another medication with limited use at the end of life with a high incidence of constipation. Approximately 10% of the population lacks the enzyme necessary to convert codeine (a prodrug) to morphine, leading to insufficient analgesia. [20]

Patient-controlled analgesia (PCA) via an infusion pump is a modality that can be utilized when the daily dosages required are high, or the patient is unable to tolerate oral analgesia. PCA pumps have a button that allows for a breakthrough dose when pressed by the patient. The pumps can be programmed to allow doses separated by a safety interval. The dose delivered on pressing the button is typically 50 % of the hourly dose. Monitoring for sedation in patients on a PCA pump is important to avoid respiratory depression. In patients with inability, debility, or cognitive decline, the PCA can be replaced with a Nurse controlled analgesia pump (NCA) where the nurse administers breakthrough doses prior to interventions or on observing objective signs of pain in the patient.

Nonopiate medications can be used as an adjunct to opiates or NSAIDs for pain management. Antiepileptic medications like gabapentin and pregabalin can be used for pain from neuropathy and bony metastasis. Both these medications require dose adjustments for renal impairment. Corticosteroids can be used in late disease as an adjunct and can aid in improving appetite and mood. However, severe interactions and adverse side effect profiles warrant a risk vs. benefit discussion with the patient.

Non-Pharmacological Management of Pain

The nonpharmacological measures for the management of pain include measures aimed at avoiding pain triggers and psychosocial assistance in managing the end of life. Proper head positioning and neck support can avoid spasms of the neck, artificial tears and lubricants can help avoid painful keratitis. The use of gel foam pads on the skin-appliance interface can help avoid ulceration, for example, nasal bridge gel pads for noninvasive ventilation. Oral care and proper hydration can avoid painful ulcerations and dental decay. Frequent repositioning and offloading the dependent areas of the body can help avoid decubitus ulcers. In case of skin breaks, non-bulky, non-stinging chemical dressings can be used to avoid pain.

Counseling for getting affairs in order and devising robust goals of care while the patient can still make decisions can help alleviate anxiety and improve interpersonal relations. Daily sponging and grooming, as tolerated, leads to better hygiene and preserves the patient’s dignity and sense of self-worth. Spiritual counseling and pastoral visits can help counter non–acceptance of impending death and help alleviate suffering. Alternative medicinal therapies like acupuncture and Reiki can be offered to support pharmacological measures in managing pain.

  • Differential Diagnosis

Certain conditions can mimic pain at the end of life and need an evaluation to provide appropriate therapy. Severe dehydration can lead to an alteration of mental status, lethargy, and discomfort. This discomfort can be misdiagnosed as pain, and pain medications can worsen the change in mental status. As illness proceeds, multi-organ failure can set in, renal and hepatic impairments can lead to a build-up of toxic metabolites. Long-term use of opiates can lead to dependence, with a drop in dose signs of withdrawal can ensue mimicking pain. Long-term use of opiates can also lead to opioid hyperalgesia leading to a vicious cycle of pain.

With an inherently poor prognosis associated with the end of life, each circumstance's potential life expectancy should be used to guide placement. Patients with an impending demise and good social support may benefit from discharge back to familiar surroundings with family. In case of a lack of social support, inpatient hospice should be considered. Patients suffering from intractable pain and impending demise should be offered palliative sedation.

  • Complications

NSAIDs are commonly used in the management of pain and are frequently associated with side effects. Acetaminophen is associated with hepatic injury, and its use should be limited in patients with underlying hepatic impairment. Other NSAIDs like ibuprofen and ketorolac can lead to severe gastrointestinal side effects, including hemorrhage, ulceration, and perforation. Their prolonged use should be accompanied by proton pump inhibitors for prophylaxis. NSAIDs increase the risk for stroke, myocardial infarction, and renal failure. [21]

Opiates can be associated with overdoses with grave consequences. Lethargy and depressed level of consciousness is the commonest symptom of overdose. Respiratory depression can ensue if the overdose is not countered in time. Respiratory distress, hypoxia, cardiovascular compromise from hypotension are other signs of opiate overdose. In case of a suspected overdose, Naloxone, a pure competitive antagonist of opiate receptor, should be used. It can be dosed subcutaneously or from the intravenous, intramuscular, intranasal, or endotracheal route. Dosage is 0.4 mg to 1 mg in adults. If the patient continues to show signs of toxicity, a dose may be repeated after 3 to 8 minutes, which corresponds to the time to peak effect. [22]  Opiates can cause physical and psychological dependence, and the potential for abuse should be kept in mind while treating pain.

Opioid-induced hyperalgesia (OIH) involves increased sensitivity to pain, with the diffuse extension of pain despite an escalation of opiate dose. It is thought to result from neuroplastic changes to the peripheral and central nervous system leading to sensitization of pain pathways. NMDA receptor activation has been thought to be a predominant mechanism for OIH. It is more often seen in association with morphine and hydromorphone. Treatment is focused primarily on reducing the dose of the opioids, switching the opioid class. The addition of NMDA receptor modulators like ketamine, methadone, and buprenorphine has also been suggested. [23]

Severe constipation can be associated with opiate use due to delayed gastric emptying and peristalsis in the GI tract. Increased fiber in diet and fluid intake can help counter constipation. Methylnaltrexone bromide, a peripherally acting opiate antagonist which does not cross the blood-brain barrier, can be used to treat opiate-induced constipation.

  • Deterrence and Patient Education

Patient and family education plays a key role in the management of pain at the end of life. Patients and their family members should be invited for meetings to have robust goals of care discussions. This has been a proven methodology in bolstering interpersonal relationships between family and aiding in survivor mental health. The topics requiring discussion include the medications prescribed, their potential side effects, toxicity, and allergic reactions. We should also discuss the signs of pain if the patient is nonverbal or unable to communicate effectively.

If the family is considering discharging the patient back to their home surroundings, they should be educated about caring for the patient at home. A good balance between interventions like suctioning and turning should be explained to maintain appropriate comfort without causing undue pain. When the patient and their caregivers are on the same page regarding goals of care, we avoid readmissions or calls to the emergency services, which may lead to further distress.

  • Enhancing Healthcare Team Outcomes

Apart from the medical team caring for the patient, a multidisciplinary approach to management is key to improving outcomes. In patients with advanced pathologies and a relatively short life expectancy, early involvement of palliative care is important. Attempts should be made to document goals of care, and documentation from prior discussions should be easily available to medical professionals. A patient who has a do not resuscitate (DNR) order should have wrist bands alerting the team in case of arrest/demise. A medical order for a life-sustaining treatment (MOLST) form should be considered. This form is brightly colored and is designed to be easily seen amidst papers and clearly documents goals of care. An electronic version of this form is also available.

A team caring for a patient at the end of life should include the primary medical team, palliative medicine, and pain team if separate from the palliative team. If there are skin breaks or wounds, wound care should be consulted for advice regarding dressings and care. Wound care also specializes in detecting infections and can help fight painful infections of decubitus ulcers. Patients who are mechanically ventilated should have respiratory therapists performing frequent adjustments to the ventilator, changing the ventilatory circuit, and suction. Pulmonary medicine should be involved in abolishing ventilator-patient synchrony, which can cause severe distress. Nurses play the most important role in the team with constant pain assessments and delivering the pain medications. They should communicate the patient’s distress, if any, to the entire team.

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Disclosure: Ankur Sinha declares no relevant financial relationships with ineligible companies.

Disclosure: Himanshu Deshwal declares no relevant financial relationships with ineligible companies.

Disclosure: Rishik Vashisht declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

  • Cite this Page Sinha A, Deshwal H, Vashisht R. End-of-Life Evaluation and Management of Pain. [Updated 2023 Feb 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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  1. Post Op Pain Management Case Study

    pain management case study quizlet

  2. N403L Pain Management Case Study

    pain management case study quizlet

  3. Pain Management Case Study

    pain management case study quizlet

  4. Solved Case Study, Chapter 12, Pain Management 1. Mr. Will,

    pain management case study quizlet

  5. Pain Management Case Study.pdf

    pain management case study quizlet

  6. Pain case study with answers.pdf

    pain management case study quizlet

COMMENTS

  1. Case Study: Pain Management Exam Flashcards

    The nurse should ask the client to rate his pain using a pain scale to assess the intensity of the pain. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a left hip fracture and is prescribed a morphine IV bolus as needed for pain. The nurse should monitor the client for which of the ...

  2. RN Pain: Pain Management 3.0 Case Study Test

    Which of the following questions should the nurse ask to determine the intensity of the client's pain at this time? "On a scale from 0-10, how do you rate your pain?" *To assess the intensity of the pain, ask the client to rate his pain using a pain scale.*. A nurse is preparing to administer acetaminophen 1000mg PO every 12 hrs for a client ...

  3. HESI Case Study

    Study with Quizlet and memorize flashcards containing terms like An adult female, mother of two, visits the pain clinic of the regional medical center in her community. She arrives at the pain management clinic with complaints of back pain rated 6 out of 10. She tells the nurse "the pain is so bad at times, that I am unable to take care of my children."

  4. Sheila Dalton case study

    coursework asignment for clinical basic/adult health care medical surgical pain management: day of surgery sheila dalton, 52 years old primary concept pain. Skip to document. University; High School. ... Post-Op Pain Management Case Study. Basic Adult Health Care. Coursework. 95% (38) 2. Basic Week 6 Dosage Calculation Questions. Basic Adult ...

  5. Pain Management-Case Study-Keith RN

    Pain_Management-Case Study-KeithRN. Course. Intro to Nursing Concepts (NUR 101) 152 Documents. Students shared 152 documents in this course. University Owens Community College. Academic year: 2021/2022. Uploaded by: EC. Erica Cieply. Owens Community College. 0 followers. 6 Uploads 162 upvotes. Follow.

  6. Pain Management Nurse Exam Sample Questions

    4. A 53-year-old patient who is receiving ibuprofen 400 mg twice a day for chronic, low back pain develops lower-extremity edema. The pain management nurse suspects that the edema is caused by: a decrease in renal function. a low creatinine level. an increase in glomerular filtration rate.

  7. Case Studies in Pain Management

    Edited by internationally recognized pain experts, this unique book describes 73 real life clinical cases, each followed by discussion of pathogenesis, work-up, differential diagnosis and treatment options. Cases are divided into seven sub-topics: neurologic disorders, spinal disorders, musculoskeletal pain, visceral pain, headache and facial ...

  8. Case Studies in Breakthrough Pain

    Larry C. Driver, Case Studies in Breakthrough Pain, Pain Medicine, Volume 8, Issue suppl_1, January 2007, Pages S14-S18, ... of caring for every day and the knowledgeable staff at Fusion Medical Education for their efforts to facilitate pain management education. Sponsored by Boston University School of Medicine Office of Continuing Medical ...

  9. PDF Cases Scenarios in Pain Management: Don t let first impressions fool you

    Pain is a component of the presenting complaint in up to 78% of ED visits. Medical schools provide minimal training in pain management. Most EDs are overcrowded and patients have a variety of acuity levels, diseases, resources and ages. Toddler in a MVC with fractures to an elderly patient with arthritis and back pain.

  10. 4C The Comfort Wheel: An Interactive Case Study Tool for Pain Education

    Moderation of the discussions include 2-3 individuals from the following: advanced practice nurses (APN) (pain management services, education/practice specialists, accreditation, and professional development), and representatives from the PRN group. Case studies were developed by the PRN group and APNs and are visualized via PowerPoint.

  11. Multidisciplinary Firms and the Treatment of Chronic Pain: A Case Study

    However, pain management is often viewed as low priority due to the stigma that pain is a symptom not a disease ... Pilitsis JG, Khazen O and Wenzel NG (2021) Multidisciplinary Firms and the Treatment of Chronic Pain: A Case Study of Low Back Pain. Front. Pain Res. 2:781433. doi: 10.3389/fpain.2021.781433. Received: 22 September 2021 ...

  12. Pain Case Study Flashcards

    Study with Quizlet and memorize flashcards containing terms like Meet The Client, Section 1 Pain Assessment During the nurse's initial interview, the client shares information about her home, career, and family. The nurse evaluates the information to determine psychosocial factors that may impact pain management. Which information obtained by the nurse is most likely to influence the client's ...

  13. Ch 41 pain management

    Opioid analgesics (morphine fent, codeine) severe pain o Sedation: precedes resp depression, monitor consciousness o Resp depression: monitor rate prior to and following administration. ati notes chapter 41: pain management use of pharmacological and nonpharmacological pain management therapies assess pain categories acute temporary, direct.

  14. Case Study: 32-Year-Old Male Presenting with Right Lower Quadrant

    Case Presentation. A 32-year-old male with no significant past medical history presents to the emergency department with abdominal pain. He states the pain began a few days ago in the right lower quadrant of the abdomen and now feels as though it is spreading to the mid-abdomen. He describes the pain as coming on suddenly and sharp in nature.

  15. Nurses' experiences with health care in pain clinics: A qualitative study

    RNs are often the first health care professional to learn of patients' pain problem, and are most likely to spend more time with patients than any other member of the team at the pain clinic [ 3 ]. Thus, RNs are particularly well positioned to identify gaps and strengths in health care provided at pain clinics.

  16. Goals of Chronic Pain Management: Do Patients and Primary Care

    INTRODUCTION. Chronic musculoskeletal pain is a major cause of suffering and disability in the U.S. and a common reason for primary care visits.[1-4] Effective management of chronic pain requires a therapeutic relationship within which the patient and physician can assess pain, discuss goals of care, and make treatment decisions.[] Patient-physician agreement about goals of care is considered ...

  17. Pain Case Study Flashcards

    Study with Quizlet and memorize flashcards containing terms like Wrenda Fisher, a 35-year-old mother of two, visits the pain clinic of the regional medical center in her community. Wrenda is interviewed by a certified pain management nurse. Her chief complaint is recent onset back pain, which has limited her ability to care for her children. During the nurse's initial interview, Wrenda shares ...

  18. Video case study RN pain

    Video case study RN Pain: Pediatric Pain Assessment 3. Case Study Test 1-A nurse is preparing to perform a heel stick on a 3-day-old infant. Which. nonpharmacological method of pain management should the nurse use to decrease the infant's pain? Administer oral sucrose. Administering oral sucrose to the infant is a biobehavioral method of pain ...

  19. Video Case Studies

    HOW IT WORKS. A learning process designed to develop clinical judgment skills. 1. EXPERIENCE. Students watch short, live-actor video scenarios that simulate situations or issues commonly encountered in clinical practice. 2. PRACTICE. Students apply clinical judgment skills to formulate their own responses to the scenarios they've just viewed ...

  20. case study quiz: pain Flashcards

    The nurse is assessing a patient's level of pain with the use of a scale of 1 to 10, with 10 being the worst pain and 1 being the least pain. The nurse is assessing: severity of pain. using distraction to deal with the pain. You notice that a patient is moaning quietly after undergoing a painful procedure. You check the electronic medication ...

  21. Improving the Quality of Care Through Pain Assessment and Management

    Education about safe pain management will help prevent undertreatment of pain and the resulting harmful effects. Safety includes the use of appropriate tools for assessing pain in cognitively intact adults and cognitively impaired adults. Otherwise pain may be unrecognized or underestimated. Use of analgesics, particularly opioids, is the foundation of treatment for most types of pain. Safe ...

  22. Non-Pharmacological Pain Management Practice and Associated Factors

    A study on pediatric nurses' pain management knowledge and practices in Turkey. Trends in Pediatrics, 2 (4), 159-164. [Google Scholar] Sisay S. (2017). Assessments of nurses knowledge, attitude and practice regarding non-pharmacological pain management and associated factors at Tikur Anbessa Hospital, in Addis Ababa, Ethiopia, 2017. Addis ...

  23. End-of-Life Evaluation and Management of Pain

    Pain and discomfort at the end of life are frequently under-recognized and undertreated. With the advent of modalities that help prolong life, there is a constant risk of prolonging suffering. Health care practitioners are entrusted with the responsibility of ensuring their patients' comfort and need a holistic approach targeting pain at the end of life. In their efforts to define the concept ...