Patricia Bruckenthal

Implications of Opioid Analgesia for Medically Complicated Patients

Opioid analgesics have an established role in the management of postoperative pain and cancer pain, and are gaining acceptance for the management of moderate to severe chronic noncancer pain, most notably chronic low back pain and osteoarthritis, that does not respond to other interventions. Many patients with chronic pain have co-morbid medical conditions that may complicate opioid therapy. Selecting the appropriate opioid requires knowledge of how individual opioids differ with respect to metabolism and interaction with concurrent medications, as well as the reasons why specific medical conditions may influence their efficacy and tolerability. Polypharmacy is a common complicating condition in the elderly and in patients with psychiatric illness, cancer, cardiovascular disease, diabetes mellitus or other chronic illnesses. Polypharmacy, though often necessary for patients with multiple medical conditions, also multiplies the risk of drug interactions. Pharmacokinetic drug interactions can increase or reduce exposure to the opioid or concurrent medications, reducing efficacy and/or tolerability and increasing toxicity. Pharmacodynamic interactions can enhance the depressive effects of opioids, compromising safety. Patients with impaired renal or hepatic function may have difficulty clearing or metabolizing opioids and concurrent medications, leading to increased risk of adverse events. Patients with cardiovascular, cerebrovascular or respiratory disease (including smokers of ≥2 packs/day with no other diagnosis) may be more susceptible to respiratory depression, bradycardia and hypotension with any opioid, and a few specific opioids pose additional risks. Patients with cerebrovascular disease, dementia, brain injury or psychiatric illness are more susceptible to opioid effects on the CNS, which can include euphoria, cognitive impairment and sedation. Appropriate opioid selection may mitigate these effects. Even in older patients, addiction, abuse and misdirection of prescribed opioids are of concern. Higher risk exists for patients with psychiatric illness, history of substance abuse, and identifiable substance abuse risk factors. Screening for abuse potential and vigilant patient monitoring should be routine. Opioids differ in their ability to produce euphoria, based on opioid receptor agonism, but substance abusers may be more influenced by availability, familiarity and cost factors. Consequently, opioid selection has limited influence on abuse potential but can facilitate ease of monitoring. This review provides an overview of opioid use in medically complicated patients and recommendations on how to optimize analgesia while avoiding adverse events and drug interactions in the clinical setting. Articles cited in this review were identified via a search of EMBASE and PubMed. Articles selected for inclusion discussed characteristics of specific opioids and general physiological aspects of opioid therapy in important patient populations.

Special Issues in the Management of Chronic Pain in Older Adults

Pain syndromes are prevalent among older individuals and generally increase in incidence as the population ages. Yet, pain often is undertreated in older patients, sometimes due to difficulties in assessing pain intensity and the effectiveness of treatment in the context of age-related cognitive impairment and physiologic changes. As a result, older patients with chronic pain conditions are more likely to experience greater functional limitations and decreased quality of life due to these and other barriers to appropriate care. This article discusses the epidemiology, assessment, and management of pain in older adults, and reviews special issues in the treatment of this population, such as adverse effects due to changes in drug metabolism and drug-drug interactions.

Nurse practitioners can effectively deliver pain coping skills training to osteoarthritis patients with chronic pain: A randomized, controlled trial

Summary A multisite, randomized, controlled trial showed that nurse practitioners can effectively deliver pain coping skills training to osteoarthritis patients with chronic pain. ABSTRACT A multisite, randomized, controlled clinical effectiveness trial was conducted for osteoarthritis patients with chronic pain of the knee or hip. Adult health nurse practitioners provided a 10‐session intervention, pain coping skills training (PCST), in patients’ doctors’ offices (N = 129 patients); the control group received usual care (N = 127 patients). Primary outcomes assessed at baseline, posttreatment, 6‐month follow‐up, and 12‐month follow‐up were: pain intensity, physical functioning, psychological distress, self‐efficacy, catastrophizing, use of coping strategies, and quality of life. Secondary measures included fatigue, social functioning, health satisfaction, and use of pain medication. Methods favoring external validity, consistent with pragmatic, effectiveness research, were utilized. Primary ITT and secondary per‐protocol analyses were conducted. Attrition was within the expected range: 11% at posttreatment and 29% at 12‐month follow‐up; rates did not differ between groups. Omnibus ITT analyses across all assessment points indicated significant improvement for the PCST group compared with the control group for pain intensity, physical functioning, psychological distress, use of pain coping strategies, and self‐efficacy, as well as fatigue, satisfaction with health, and reduced use of pain medication. Treatment effects were robust to covariates (demographics and clinical sites). Trends in the outcomes across the assessments were examined. All outcomes, except for self‐efficacy, were maintained through the 12‐month follow‐up; effects for self‐efficacy degraded over time. Per‐protocol analyses did not yield greater effect sizes. Comparisons of PCST patients who were more vs less treatment adherent suggested greater effectiveness for patients with high adherence. Results support the effectiveness of nurse practitioner delivery of PCST for chronic osteoarthritis pain.

Assessment of Pain in the Elderly Adult

The goals of a clinical assessment for pain in the elderly adult may be similar to those established for younger patients; however, unique characteristics of aging make this assessment more challenging for clinicians. The overarching goal of pain assessment in the elderly is to provide successful pain management. This article provides the clinician with the foundation to perform a successful pain assessment for older adults who are able to communicate by self-report. This provides a comprehensive base on which to build a relevant plan of care.

Pain Assessment in Nursing Home Residents With Dementia: Psychometric Properties and Clinical Utility of the CNA Pain Assessment Tool (CPAT)

OBJECTIVES To examine the psychometric properties and clinical utility of the CPAT, an instrument to assess pain in nursing home residents with dementia. DESIGN Instrument development and testing. SETTING Three regional skilled nursing facilities. PARTICIPANTS One hundred forty-five residents of 3 skilled nursing facilities. MEASUREMENTS The inter-rater reliability, test-retest reliability, construct validity, and criterion validity of the CPAT was measured after initial CNA training. Measurement of inter-rater reliability and test-retest reliability was repeated after modified CNA training. Internal consistency (Cronbachs alpha) was calculated for all reliability measures. The clinical utility/feasibility of the CPAT was measured by means of a practicality survey. RESULTS The CPAT was found to have acceptable levels of both interrater reliability (ICC=0.71) and test-retest reliability (ICC=0.67). Construct validity as measured by a paired t test was statistically significant (P=.043). Criterion validity as measured by Spearmans rank correlation coefficient was also statistically significant (P=.048). Internal consistency was acceptable for all measures as calculated by Cronbachs alpha, which ranged from 0.72 to 0.84. As determined by a practicality survey, the CPAT was shown to be a clinically useful and feasible instrument. CONCLUSION This study provides evidence that the CPAT is a reliable and valid pain assessment instrument when used in nursing home residents with dementia. It has also been shown to be a tool with suitable clinical utility and feasibility. Further study is warranted to ascertain if its use will lead to improved resident function and quality of life and whether the results of this study are reproducible in other dementia populations. The CPATs ability to quantify pain and measure treatment response has not been determined.

Treatment expectation for pain coping skills training: relationship to osteoarthritis patients' baseline psychosocial characteristics.

ObjectivesThis study examined predictors of treatment expectation among osteoarthritis (OA) patients in a multisite clinical trial of pain coping skills training (CST). MethodsPatients (N=171) completed a pretreatment assessment battery that asked questions about treatment expectations, pain coping variables, pain, physical function, psychological distress, quality of life, and depression as well as background demographic and medical variables. ResultsRegression analyses indicated that several variables accounted for 21% of the variance in treatment expectations (P<0.0001). Patients who were classified as adaptive copers, reported higher self-efficacy and social interaction, had higher quality of life, and who had lower levels of affective distress and depression had more positive expectations about engaging in pain CST. Variables that were not associated with treatment expectation were level of pain and physical dysfunction, duration of disease, and disability status as well as demographic variables. DiscussionAlthough many OA patients will approach pain CST with positive expectations, others have lower expectations. This study suggests that a multidimensional assessment of OA patients with chronic pain can identify those who have higher expectations versus lower expectations. The results suggest that patients who are psychologically distressed are less optimistic about engaging in treatment and that these patients, in particular, may benefit from and need pretreatment motivational interviewing to enhance their uptake of pain coping skills.

Assessing treatment fidelity in pilot studies assist in designing clinical trials: an illustration from a nurse practitioner community-based intervention for pain.

Treatment fidelity refers to the degree to which treatment is administered as intended, and it is key to interpreting and translating research into practice. As an illustration, we report the benefits of examining treatment fidelity in a pilot study of nurse practitioner–delivered Coping Skills Training for chronic pain. Analysis revealed both strengths and weaknesses of protocol design and treatment delivery. This pilot work formed the basis for subsequently modifying the design of a large-scale clinical trial. Monitoring treatment fidelity throughout the pilot and trial phases of research can dramatically improve the research enterprise and facilitate successful dissemination.

Options for treating postherpetic neuralgia in the medically complicated patient

Patients with postherpetic neuralgia (PHN) are often of advanced age or immunocompromised and likely to have ≥1 comorbid medical condition for which they receive ≥1 medication (polypharmacy). Comorbidities affecting renal or hepatic function can alter pharmacokinetics, thereby impacting the efficacy or tolerability of PHN analgesic therapies. Cardiovascular, cerebrovascular, or psychiatric comorbidities may increase patient vulnerability to potential adverse events associated with some PHN analgesic therapies. Because PHN is a localized condition, localized therapy with a topical analgesic (lidocaine patch 5% and capsaicin 8% patch or cream) may provide adequate efficacy while mitigating the risk of systemic adverse events compared with oral analgesics (eg, tricyclic antidepressants, anticonvulsants, opioids). However, combined therapy with a topical and an oral analgesic or with >1 oral analgesic may be needed for optimal pain management in some patients. This review summarizes how comorbidities and concomitant medications should be taken into account when selecting among available pharmacotherapies for PHN and provides recommendations for the selection of therapies that will provide analgesia while minimizing the risk of adverse events.

Complementary and Integrative Therapies for Persistent Pain Management in Older Adults: A Review

Management of persistent pain in older adults is challenging given the prevalence of multiple comorbid painful conditions, polypharmacy, age-related changes restricting pharmacological options, and socioeconomic factors. The influences of these factors along with current concern for the use of opioid analgesics highlight the importance of incorporating complementary and integrative medicine approaches. Evidence suggests efficacy and satisfaction with integrating complementary pain management strategies for older adults, especially yoga, massage, and natural products. Nurses and other providers, given their emphasis on holistic care, are in a unique position to lead the transformation of pain management to a patient-centered, self-management style that integrates complementary therapies. [Journal of Gerontological Nursing, 42(12), 40-48.].

Nurse Practitioner Confidence and Attitudes towards Brief Motivational Interventions to Improve Compliance with Health and Wellness Recommendations

Background: Health behavior risks prevail in older patients and can include unhealthy diet and nutrition, sedentary lifestyle and physical inactivity, alcohol use and abuse and poor oral hygiene. According to the Centers for Disease Control (CDC), most of the sickness, dependency, disability, use of resources, institutionalization and premature morbidity and mortality associated with chronic disease can be avoided through preventive measures and risk reduction. Preventive care is more effective in improving health than routine health care, yet research indicates that many patients do not seem to receive preventive strategies due to provider barriers. Evidence supports that training and education significantly improve practitioner knowledge, their decision to use strategies for behavior change and increases confidence.The emerging body of evidence supports brief motivational interventions as effective strategies that can help patients change health behaviors and affect outcomes. The purpose of this study was to assess nurse practitioner student confidence and attitudes in using a brief motivational intervention. A secondary aim was to assess the degree of completion of each patient’s selected behavioral plan. Methods: This investigator-initiated pilot study examined relationships among 15 nurse practitioner student confidence and attitudes toward delivery and implementation of a Brief Action Planning (BAP) intervention to 104 older adults. Nurse practitioner students received a BAP educational program and delivered BAP to older adults in an inter-professional collaborative practice that addresses the oral health, health promotion, clinical prevention and social services needs of community-dwelling older adults.Results: Findings showed a significant change (p<0.05) in NP effectiveness, confidence, belief in and the ease of learning and incorporating BAP and the value of adding BAP to care. Forty two percent of patients fully completed, 35% partially completed and 23% did not complete their selected plan to change a health behavior.Conclusion: An educational program increased NP confidence, effectiveness and belief in value and use of a brief motivational technique to change a health behavior. Provider training helps decrease barriers to implementing motivational techniques and prevention strategies. BAP shifts thinking about how to help motivate patients toward change, is easy to learn and feasible.