Background: Chronic pain is one of the most prevalent medical conditions, which is also extremely complex to manage and regulate. Over decades, many studies demonstrated effectiveness of opioids in acute and chronic pain. However, several reasons have led to over-prescribing opioids by physicians, which include: the lack of consensus and guidance of how to manage chronic pain, and having limited number of therapeutic alternatives.
Purpose: The purpose of this program was to measure the effectiveness of education, to increased patient engagement, and tapering opioids safely across a continuum of services, resulting in an improvement in patient satisfaction, quality of life, and enhanced functionality.
Sample: Patients selected for this study were enrolled as inpatients during their hospital stay. Eligible patients with a prescription for long-acting opioids or has a history of opioid use for 3 months or more were screened.
Inclusion Criteria: Adult patients with a prescription for extended release or long-acting opioid medications or have a history of opioid use for 3 or more months.
Exclusion Criteria: Any patient age less than 18, hematology patients, oncology patients, or current substance use.
Objective: To initiate a chronic pain management program called “NO PAIN” in order to measure the effectiveness of having a program to interview, discuss patients’ current regimens, and to educate patients on effective ways to decrease pain.
Method: A Prospective Pilot study was used to screen patients enrolled as inpatients during their hospital stay. Upon admission and consent, patients with long acting opioids or opioid use of 3 months or longer had a thorough medical history assessment and a current medication review. The patient’s controlled substance history was reviewed using CURES 2.0 for the assessment of their controlled substance use history. Enrolled patients had a minimum of three follow-up interventions from the team which include one pain clinic visit and two follow-up phone calls on weeks two and six. At baseline, telephone follow up at 2 weeks and 6 weeks, the patient’s opioid usage, quality of life and life satisfaction was assessed using the SF-36. Evaluation of the patient-reported pain was made using Wong-Baker Faces Pain Scale and the Pain, Enjoyment, and General Activity Scale (PEG) questionnaire to determine the extent of pain. Emotion thermometers will also be utilized to assess patient emotional response to pain and daily functions with treatment. Education on the use of the free pain application, Pain Coach by WebMD and recommendations for adjunct and non-pharmacologic alternative therapies was provided.
Results: From October 2017 through April 2018 a total of 51 patients who had undergone orthopedic and abdominal surgical procedures were approached. Of those 51, 18 chose not to participate. The remaining 33 were reduced to a final sample size of 28 patients. The sample consisted of 32% male and 68% female patients ranging in age from 27- 81 years (mean 54.46). Of the 28 participating in the NO-PAIN program, 15 (54%) were followed during their hospitalization but did not have any post discharge follow up as the team was unable to contact them post discharge. Of the remaining 13 subjects, 7 (25%) were followed two weeks post discharge and 6 (21%) were followed for 6 weeks post discharge.
Wong-Baker Pain Scores: Seven (25%) patients had a reduction in their Wong-Baker pain score from their initial to their 2 week follow- up and 3 (11%) had an increase in their pain score at their 2 week follow-up. 2 (7%)patients pain scores were the same and 1 (4%) patient did not have a pain score indicated initially.
Pain, Enjoyment and General Activity Scale (PEG) scores: Initial PEG scores ranged from 3-10 (m, 7.08). 2 week follow up PEG scores ranged from 2.3 -9 (m, 5.34) and 6 week follow up scores ranged from 3.6 -8.6 (m,6.68). 9 subjects had a reduction in their PEG scores from baseline to their 2 week follow-up. 2 (7%) patient’s pain scores were the same and 2 (7%) patient did not have a change in their PEG score.
Emotion Thermometers:
Distress: 15 patients (54%) had a reduction in their distress and anxiety levels from baseline.
Anger: 16 patients (57%) had a reduction in their levels of anger from baseline.
Need Help: In 15 patients (54%) had a reduced need for assistance from baseline.
SF-36 Physical functioning (PF); Role limitations due to physical health (RLH); Role limitations due to emotional problems (RLE) Emotional well-being (EWB); Health Change (HC) showed increases in mean scores and improvements in health at the 2 week follow up, however this was not sustained at the 6 week follow up. The changes in scores were not statistically significant. There was little use of the smart phone application for monitoring chronic pain. Alternative therapies for managing chronic pain were discussed with patients; however no patients reported engaging in any of the alternative therapies recommended. Medication regimens were reviewed and evaluated after interviewing the patients. Changes such as reducing doses and/or frequency of opioid medications, discontinuing medications that patients are not taking, discontinuing duplicate medications and adding adjunct medications were made resulting in a 10% reduction in opioid use.
Conclusions: Patient contact is essential during hospitalization and follow up should be within 2 weeks of discharge. Emotional and functional aspects of pain management must be assessed in addition to dosage in order to have effective pain management.
Implications for practice: Initiation of the use of technology (smart phones, web-based applications, and videos) are needed for patient education. In addition to assessing emotional and functional aspects of pain management the provision of information related to storage and disposal should be incorporated into educational opportunities.
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