american society of pain educators · american society of pain educators ... tions, and took the exam. My heartiest congratulations to ... Outline (which can be found

Vol. 5 No. 1 Spring 09

american society of pain educators

Cannabinoids have a long history of use for medicinal, ceremonial, and recreational purposes; they have been used since 2000 bc for pain.1 In the United States in the 1800s, cannabis was legal in most states and had been used as hemp to make rope, sails, and clothes; it was also used for medicinal purposes. By the 1920s, even though use was restricted to a small percentage of the population, because of reported addiction and other adverse effects, the use of cannabis began to be viewed skeptically; the first regulation on it appeared in Washington, DC, in 1906. Continued on page 4

AmericanSociety of

PainEducators

American Society of Pain Educators

2 Painview Vol. 5 No. 1 Spring 09

Editor in ChiefB. Eliot Cole, MD, MPA, CPE

EditorMary E. McTigue

ASPE Clinical Advisory BoardCharles E. Argoff, MD, CPE Kathleen Broglio, MN, NP, ACHPN, CPE James J. Giordano, PhD David M. Glick, DC, CPE Gregory L. Holmquist, PharmD, CPE Gordon A. Irving, MBBS, FFA, MSc, MMed, CPE Barbara J. Kornblau, JD, OTR, CPE Barry Rosenblum, DPM Michael E. Schatman, PhD, CPE Jeffrey Unger, MD Mark Young, MD, FACP

Art DirectorDarryl Fossa

ASPE Staff

Associate DirectorLiz Stueck

Program DevelopmentDebra Weiner

OperationsJeffrey Tarnoff

Member ServicesDonna Kelley

Corporate Member

Purdue Pharma L.P.

PainView © 2009 is published quarterly by the American Society of Pain Educators (ASPE). More information on the ASPE can be found at www.paineducators.org. Correspondence can be sent to the American Society of Pain Educators to Donna Kelley at 6 Erie Street, Montclair, nj 07042. (973) 233–5570 or [email protected].

The opinions expressed here are those of contributing authors and editorial staff and do not necessarily reflect the positions of the ASPE. The appearance of the ASPE name and logo does not constitute an endorsement of any products, services, or information mentioned. The ASPE does not imply discrimination against other similar products or services.

Executive Director’s Message

Contents

The ASPE

I am delighted to report that we have minted our first group of Certified Pain Educators (CPEs). It took longer than anticipated to go through the job analysis, to write the pool of questions, to prepare the first form, to advertise the availability of the test, and to set the “cut score.” We did it, in large part, through the tenacious work of Liz Stueck, our new Associate Director. There are now CPEs alive and available to provide pain education. Please join me in thanking those who participated in the job analysis, wrote the ques-tions, and took the exam. My heartiest congratulations to those who passed and have earned CPE designation (see page 3 for their names).

The dedicated people who took the CPE exam made the decision to enhance their professionalism and to chal-lenge themselves intellectu-ally. This exceptional group did not have the benefit of a “prep” or review course. They worked from a 9-page Resources List and Content Outline (which can be found in the CPE section of the ASPE Web site). They demon-strated their mastery of pain (anatomy, physiology, pathol-ogy, diagnostic methods, treatment methods), teach-ing (establishing learning objectives, learning theories, Bloom’s taxonomy), and pain/teaching ethics and practices.

When are you going to take the CPE exam? Would you like to take the exam in September during PAIN-Week® 2009 (September 9–12)? Great—then make your plans now! You will be able to take the exam while you are in Nevada. How easy is that? Don’t be intimidated. Sign up for the next round of testing, or come to PAINWeek, and take the test. We want you to be a successful Certified Pain Educator.

Good luck!

As the only organization focusing on pain educator training, the Society teaches healthcare professionals to serve as resources to educate their clinical peers, as well as patients, families, and care-givers, on ways to relieve pain by the safest means possible.

Mission Statement

The American Society of Pain Educators (ASPE) is a nonprof-it professional organization dedicated to improving pain management by providing a standard for certification—the Certified Pain Educator (CPE) credential. The Society works to develop pain educators and support them in their role in providing effective and responsible pain management to their patients and pain-related education to clinical peers, patients, families, and caregivers.

Vision Statement

The Certified Pain Educator (CPE) credential offered by the American Society of Pain Educators (ASPE) is widely recognized and valued by key healthcare stakeholders, and that organizations offering healthcare delivery services will have a Certified Pain Educator on staff.

Cover Story continued 4Cannabiniods and Pain: Does Canada know something we don’t?

Patient Perspective 6What hurts? Snakes or butterflies

Pain Flashes 8Methadone-related OD deaths: report from the GAO

Editor’s Corner 9Memory Shortcuts

Pain Educator “On-The-Go” 10Seven steps to better patient communication

Certified Pain Educators (CPEs)

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www.paineducators.org

Leslie L. Aalund, RN-BC, CPE

Sondra M. Adkinson, BPharm, PharmD, CPE

Joyce A. Archuleta, RN, BSN, BC, CPE

Charles E. Argoff, MD, CPE

Miles J. Belgrade, MD, CPE

Said R. Beydoun, MD, FAAN, CPE

James A. Boesiger, PA-C, MSS, CPE

Kathleen Broglio, MN, NP, ACHPN, CPE

Kathleen Sitley Brown, PhD, CPE

Doreen Bibeau Chimblo, MS, APRN-BC, FNP, RNC, CPE

Barry Eliot Cole, MD, MPA, CPE

David R. Creecy, V, RPh, CPE

Scott G. Donelenko, BPharm, CPE

Robin Downing, DVM, CCRP, DAAPM, CPE

Larry C. Driver, MD, CPE

David M. Glick, DC, CPE

Thomas B. Gregory, PharmD, CPE

Anthony H. Guarino, MD, CPE

Kathryn L. Hahn, PharmD, DAAPM, CPE

Christopher M. Herndon, PharmD, CPE

Gregory L. Holmquist, PharmD, CPE

Robert Lynn Horne, MD, BS, CPE

Angela G. Huskey, PharmD, CPE

Gordon A. Irving, MBBS, FFA, MSc, MMed, CPE

Kenneth C. Jackson, II, PharmD, CPE

Cynthia Johnston, BPharm, PharmD, CPE

Kathryn H. Keller, PharmD, CPE

Leonette O. Kemp, PharmD, CPE

Harvey Klein, MD, BSME, DAAPM, EEMCP, CPE

Ronald A. Knights, PharmD, CPE

Barbara L. Kornblau, JD, OTR, CPE

Meridith S. Lawrence, MS PREP, RPh, CPE

Sean C. Mackey, MD, PhD, CPE

Bill H. McCarberg, MD, CPE

James McKoy, MD, CPE

Mary Lynn McPherson, PharmD, CPE

Philip Molloy, MD, CPE

William R. Morrone, DO, MS, CPE

Suzanne L. Morse, MSN, FNP, BSN, RNC, CPE

Suzanne A. Nesbit, PharmD, CPE

Charles D. Ponte, PharmD, CPE

Megan S. Potter, PharmD, CPE

Gail Morgan Rockwell, PT, CPE

Michael E. Schatman, PhD, CPE

Michelle Smith, PharmD, CPE

Pamela Squire, MD, CCFP, CPE

Lynn V. Tieu, PharmD, CPE

Sridhar V. Vasudevan, MD, CPE

Kathryn A. Walker, PharmD, BCPS, CPE

Emily Weidman-Evans, PharmD, CPE

Certification serves as a voluntary demonstration of competency and signals a commitment to continued practice in the field, professional growth, and self-improvement. The American Society of Pain Educators (ASPE) is pleased to announce the names of those healthcare professionals who have earned the Certified Pain Educator (CPE) credential. We salute our first-ever Certified Pain Educators and look forward to their continued contribution to their patients, colleagues, and the field of pain education.

Don’t miss the next testing windowThe next administration of the CPE Ex-amination will take place from August 1, 2009, to September 30, 2009. Applications for this testing period are being accepted now through September 16, 2009.

Test at PAINWeek® 2009The CPE Examination will also be ad-ministered during the PAINWeek® 2009 National Conference in Las Vegas (Sep-tember 9–12). Test results will be imme-diately available, and those who pass the

examination will be recognized during the conference and receive an invitation to a reception exclusively for those who have achieved the credential.

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Cover Story continued

Pamela L. Squire, MD, CCFP, CPE

ven while regulation was becoming stronger, during the 1930s, scientists discovered that the cannabis (AKA marijuana)

plant contained over 60 different cannabinoids, and since then scientific progress about the field has been rapid, revealing that humans possess an endocannabinoid system comprising both endogenous endocannabinoids and their receptors, and the past decade has seen a resurgence of the interest in cannabinoids for alleviating pain. The endocannabinoid receptors are labeled CB1, CB2, and, most recently, CGPR55. CB1 receptors are found predominantly at nerve terminals in both the central and peripheral nervous system; CB1 receptors produce hypokinesia, catalepsy, and analgesia. CB2 receptors are found within the immune system and appear to modulate cytokine release and immune cell migration. These have also been found on microglial cells in the central nervous system.

Upregulation of the endocannabinoid system can produce therapeutic reduction in symptoms or slowing of disease progression associated with some disorders, such as multiple sclerosis, certain types of pain, cancer, schizophrenia, posttraumatic stress disorder, some intestinal and cardiovascular diseases, excitotoxicity, and traumatic head injury. Alternatively, upregulation of the endocannabinoid system may cause unwanted effects such as obesity, cystitis, cerebral injury in stroke, endotoxemic shock, ileitis, and paralytic ileus.2

Cannabinoids have therapeutic potential in neuropathic pain, cancer pain, fibromyalgia, posttraumatic stress disorder, appetite stimulation, spasticity, and lower urinary tract symptoms in multiple sclerosis. They are variously recommended as either second-line3 or fourth-line3,4 treatment options in neuropathic pain guidelines. Numerous clinical studies have examined the effectiveness of tetrahydrocannabinol derivatives for acute pain, pain caused

by chronic nonmalignant disease, and pain from cancer. Evidence of the effectiveness of cannabinoids is strong for treating cancer pain, central pain, and spasticity-related pain; the evidence is mixed for treating acute pain and weak for treating peripheral neuropathic pain.1 From an experiential perspective, cannabinoid medications have been most effective in patients with central neuropathic pain, as seen, for example, in multiple sclerosis and spinal cord injury.

Steps to Prescribing

1 Determine if appropriate diagnosis2 Rule out contraindications3 Evaluate current psychiatric status4 Review psychosocial issues5 Complete a substance-abuse risk

assessment6 Develop an individual treatment plan

and decide the outcome measures you will be evaluating

7 Ensure that traditional approaches have been considered or tried

8 Consider a treatment agreement. It should provide informed consent; outline the risks concerning driving or operating machinery, sharing the prescription with others, and use of other medications; and define what both parties consider acceptable with regard to where the prescription is filled and who can refill it.5

Formulations Available in the United States and Canada

Worldwide, there are currently 4 different prescription formulations available. In the United States, only 2 cannabinoid medications are FDA-approved and are Schedule III medications, one form is pending FDA approval, and the fourth (smoked/inhaled) is legal in 13 states but is federally illegal.

1 Nabilone (Cesamet®) is a delta-9-THC analogue. It has been available in Canada since 1985 and in the United States since 2006. On-label usage is limited to suppressing chemotherapy-induced

nausea and vomiting. It is supplied as powder in capsules of 0.25 mg, 0.5 mg, and 1 mg in Canada, but only as 1 mg capsules in the United States. The usual dose is 0.25 mg to 3 mg twice a day, but it is rare for patients to use more than 5 mg/day. Nabilone can be easily compounded to dispense smaller doses by preparing a mixture of 5 grams of nabilone in 50 mL of simple syrup to give 0.5 mg/5 mL. Note: Of all the formulations, Nabilone alone will not produce a positive test result in urine drug testing.6

2 Dronabinol (Marinol®) is a synthetic delta-9-THC. It has been available in both the United States and Canada since 1985. On-label usage is limited to suppressing chemotherapy-induced nausea and vomiting and for stimulating appetite in AIDS patients. It is available as 2.5 mg, 5 mg, and 10 mg capsules (10 mg of dronabinol is roughly equivalent to 1 mg of nabilone). Clinically, dronabinol seems to produce more dysphoria than other cannabinoid formulations, and also requires dosing 3 times a day.

3 THC/CBD oromucosal spray (Sativex®) contains a nearly 50:50 mixture of botanically extracted THC and cannabadiol. It is licensed in Canada as adjunctive treatment for central neuropathic pain in multiple sclerosis and cancer pain unresponsive to optimized opioid therapy. This product is Schedule I and although currently illegal in the United States, it is pending FDA approval.

4 Smoked cannabis is available by physician prescription in Canada for certain indications (severe pain, muscle spasms associated with multiple sclerosis or spinal cord injury or disease, cachexia, anorexia, weight loss associated with HIV or cancer, severe nausea, seizures, and symptoms at end of life) under a federally controlled program. In the United States, smoked cannabis is legal for medicinal use under the state-level laws of 13 states, but federal laws making cannabis illegal remain in effect in these states.

Dr. Pam Squire practices in North Vancouver, British Columbia, Canada, where she has a consultative practice in complex pain. She is also an assistant clinical professor at the University of British Columbia.

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www.paineducators.org Painview Spring 09

As a result, the US federal government can prosecute violators under federal law in the 13 states where state law has decriminalized use or possession. It should be noted that, in a turnaround from the Bush administration, US Attorney General Eric Holder recently said that medical dispensaries that provide marijuana for medical purposes will no longer be prosecuted by the government.

Contraindications, Addiction Risks, Side Effects

Contraindications include a history of adverse reactions to cannabinoids, recent history of acute psychosis or unstable psychiatric disease, severe liver or cardiac disease, and pregnancy. Caution should be used in patients who are elderly and at risk for falls secondary to sedation and dizziness, in patients who are already sedated or who have cognitive impairment, who have a previous history of a seizure disorder, or who are deemed at high risk for addiction.

There is no risk of death from cannabis; it does not cause central respiratory depression and a lethal dose of delta-9-THC has not been reported.7,8 Most doses of cannabinoids are modest. There is no maximum dose; rather, the dose should be individualized, and response is not universal. Pain, sleep, mood, and functional status may all be affected and should be reviewed in follow-up. Common side effects include drowsiness, dizziness, dysphoria, dry mouth, and depression. Daytime use is sedating for most patients and, therefore, the dose is often given at night. On the other hand, for patients with insomnia, sedating effects can be useful. Impairment caused by cannabinoids, which include slower reaction times and drowsiness, seems to be within the range of other pharmaceutical agents commonly used for similar conditions.

In terms of addiction, smoked cannabis is significantly more reinforcing than all other cannabis compounds, regardless

of an individual’s drug-abuse history.9 Unfortunately, addiction to smoked cannabis is increasing. US data show rates of 17% in 1991/1992 and 35% in 2001/2002.10 This may be the result of both increased concentration of THC (concentration was 1% in the 1980s but now ranges from 3% to 30%, with an average of 10%) and use in younger age groups. Aside from smoked cannabis, generally speaking, tolerance appears to be uncommon.

Conclusion: It would appear that cannabinoids, which are synthetic cannabis in a controlled formulation (pill form, spray) at a controlled dosage, are safe and effective for the use of pain, and are more effective for certain types of pain than others. The jury is still out on the risk: benefit of smoked/inhaled cannabis for pain, and although legal in several states, smoked cannabis is still illegal under US federal law. Whether that will ever change remains a subject of controversy. ■

1 Cohen SP. Cannabinoids for chronic pain. BMJ. 2008;336(7637):167–168.

2 Pertwee RG. Cannabinoid pharmacology: the first 66 years. Br J Pharmacol. 2006;147(suppl 1):S163–S171.

3 Attal N, Cruccu G, Haanpaa M, et al. EFNS guidelines on pharmacological treatment of neuropathic pain. Eur J Neurol. 2006;13(11):1153–1169.

4 Moulin DE, Clark AJ, Gilron I, et al. Pharmacological management of chronic neuropathic pain—consensus statement and guidelines from the Canadian Pain Society. Pain Res Manag. 2007;12(1):13–21.

5 Clark AJ, Lynch ME, Ware M, Beaulieu P, McGilveray IJ, Gourlay D. Guidelines for the use of cannabinoid compounds in chronic pain. Pain Res Manag. 2005;10(suppl A):44A–46A.

6 Heit HA, Gourlay DL. Urine drug testing in pain medicine. J Pain Symptom Manage. 2004;27(3):260–267.

7 Vachon L, FitzGerald MX, Solliday NH, Gould IA, Gaensler EA. Single-dose effects of marihuana smoke: bronchial dynamics and respiratory-center sensitivity in normal subjects. N Engl J Med. 1973;288(19):985–989.

8 Smith DE, Mehl C. An analysis of marijuana toxicity. Clin Toxicol. 1970;3(1):101–115.

9 Gourlay D. Addiction and pain medicine. Pain Res Manag. 2005;10(suppl A):38A–43A.

10 Compton WM, Grant BF, Colliver JD, Glantz MD, Stinson FS. Prevalence of marijuana use disorders in the United States: 1991–1992 and 2001–2002. JAMA. 2004;291(17):2114–2121.

Teaching Tips

1Cannabinoids have thera-

peutic potential in acute pain, pain caused by chronic nonmalignant disease, cancer pain, central pain, spasticity-related pain, fibromyal-gia, posttraumatic stress disorder, appetite stimulation, and lower urinary tract symptoms in MS. Evidence of the effectiveness of cannabinoids is strong for treat-ing cancer pain, central pain, and spasticity-related pain.

2The FDA has approved two

cannabinoids: nabilone (on-label for chemotherapy-induced nausea and vomiting) and dronabinol (on-label for chemotherapy-induced nausea and vomiting and stimulat-ing appetite in AIDS patients).

3Although legal in 13 states by

state laws, smoked cannabis is still illegal in those same states under federal law, although the govern-ment recently announced that it will not prosecute medical dispen-saries that provide marijuana to relieve patients of chronic pain.

4Of all the formulations, nabi-

lone alone will not produce a posi-tive test result in urine drug testing.

5Most doses of cannabinoids

are modest and tolerance appears to be uncommon; no lethal doses have been reported.

Cannabinoids have therapeutic potential in neuropathic pain, cancer pain, fibromyalgia, posttraumatic stress disorder, appetite stimulation, spasticity, and lower urinary tract symptoms in multiple sclerosis.

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Patient Perspective

Mary Dymond, FNP

Mary Dymond is a family nurse practitioner at New Hope Community in upstate New York

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s a Family Nurse Practitioner in a large multi-specialty practice, I serve in several roles. While house calls and urgent care fall into my domain, 90% of

my practice consists of ministering to the needs of mentally retarded adults ranging in age from 20 to 93. Within the scope of my practice, I see many patients who suffer from varying degrees of pain: children with strep throat, athletes with torn ligaments, mothers with crying babies, and even couch potatoes with arthritic thumbs caused by remote control abuse. They all share a common thread—PAIN.

Toward the end of one busy night in Urgent Care, I had three interesting cases. First, I picked up the chart with the following information: 4-year-old boy with temp of 102ºF. I looked into the room and observed a young child sitting on his mother’s lap in a chair. He was quietly listening to her read a book. As I entered the room, the little boy, Tommy, looked up at me and began to scream loudly. As I moved to stand next to the chair, Tommy stopped screaming but started sobbing. I leaned down next to him and in a soft voice said, “Tommy, my name is Mary, and I’m not going to hurt you.” After a few minutes he calmed down. I asked him if anything hurt and he began crying again, telling me through his sobs that I had just stepped on 57 of his turtles and I killed them. His mother explained that he has imaginary turtles that comfort him when he’s afraid. What a dilemma! I now have a sick little boy and 57 dead turtles.

After speaking with Tommy for a few minutes he agreed that we could perform “CPR” on the turtles and bring them back to life. The staff in Urgent Care became concerned when they saw Tommy and me on our knees on the floor scooping up air and then blowing on it (our imaginary version of turtle CPR). After reviving 56 turtles—one didn’t

make it despite our valiant efforts—I was able to examine Tommy and diagnose an otitis, which was causing his fever.

Next on my list was a 5-year-old boy, Joey, who appeared to be in pain. After explaining that I was going to look in his ears, he put his hands up and began shaking his head. I finally convinced him to allow me to look in his ears by telling him that I wanted to see if he had any butterflies in them. He said, “No butterflies, just snakes.” His tympanic membranes were fire-engine red. After completing the exam, I explained to his dad that he had an ear infection and Joey said, “I told you I have snakes in my ears. Snakes bite. They hurt.”

The last person to be seen that night was one of my own regular patients. Jimmy was a 52-year-old with Down’s syndrome. He has an expressive disorder and was unable to adequately explain what he was feeling. Jimmy has a history of osteoarthritis, GERD, and diabetic neuropathy. It had always been a challenge to ascertain not only where Jimmy’s pain was, but also if it was related to a prior diagnosis or was something new, and additionally, the intensity and duration of the pain. Over the past several months, it appeared that Jimmy’s pain had intensified and the degree of difficulty managing that pain had increased as well.

This particular night Jimmy came to Urgent Care because of an elevated temperature, refusal to eat dinner, and “walking funny.” Jimmy had a wide (albeit pained) smile on his face when he saw me. He initially answered my questions with, “It’s all right. I’m okay.” As I began to palpate his abdomen, he started yelling loudly, “Snakes, snakes!” I left the cubicle in a state of confusion. I began to enter an order for an abdominal CT when I realized that Jimmy was in the cubicle next to Joey’s. While Jimmy was unable to express himself well, there was nothing wrong with his hearing. Staff reported that Jimmy had heard Joey say, “Snakes hurt.” Jimmy

was diagnosed with an ileus, which resolved during a brief hospital stay. Two weeks later Jimmy’s roommate, who is nonverbal, came to see me because of a swollen foot. He entered my office and handed me a magazine picture of a snake and pointed to his foot.

Snakes and butterflies are now an integral part of my pain assessment. One snake—not so bad. Three snakes—not so good. Five snakes—awful. I learned two very important lessons that night in Urgent Care. Snakes hurt, butterflies don’t. It takes 3½ minutes to successfully resuscitate 56 turtles. ■

Teaching Tips

1When dealing with children

(and sometimes even adults), always validate what they tell you and how they describe their pain. It may be an important clue to the type of pain and where it is.

2Children may describe pain

with a word they know. Don’t take it literally; ask for more information about what they are telling you, using their own vocabulary.

3Nonverbal adults (or even

verbal ones) with mental disorders may have been taught to “smile through the pain,” but that does not mean they are not in pain.

4Don’t assume that a patient

with a number of prior diagnoses does not have a new one. Always treat new symptoms as a potential new disease state or comorbidity.

It takes 3½ minutes to successfully resuscitate 56 turtles.

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Pain Flashes

B. Eliot Cole, MD, MPA, CPE

he United States Government Accountability Office (GAO) recently released a report titled “Methadone-Associated Overdose Deaths: Factors Contributing to Increased Deaths and Efforts to Prevent Them” (March 2009, GAO-09-341). Methadone-associated overdose deaths occurred in a number of ways: intentional overdoses, suicide, and accidental deaths due to improper dosing, abuse, patient misuse, and combining methadone with other agents. There was no standard, nationwide method to document detailed information about methadone-associated overdose deaths, so defining the role of methadone in any death was difficult because of inconsistencies in determining and reporting cause of death, presence of other drugs in the deceased person’s system, and lack of information about the deceased person’s level of opioid tolerance.

Basically, the GAO found that information on methadone-associated overdose deaths was limited, but that available data suggest that methadone’s use for pain management had increased its availability, contributing to the rise in methadone-associated overdose deaths. Methadone prescriptions for pain management had grown from 531,000 in 1998 to 4.1 million in 2006, a nearly eightfold increase. Drug Enforcement Administration (DEA) records showed a 262% increase in methadone-related seizures between 2001 and 2007. Critically, the specific circumstances of methadone-associated overdose deaths were variable because of drug combinations and unknown sources of methadone.

In reality, the bulk of information in the GAO report came from only 5 states: Florida, Kentucky, Maine, New Mexico, and West Virginia. These states were selected because they met 4 or more of the following criteria: a “top 10” rate of increase in methadone-associated overdose deaths from 1999 to 2004, a “top 10” number of methadone-associated overdose deaths per 1 million people in 2004, a state or district medical examiner system, an operational prescription monitoring program, and state-focused, methadone-specific research. Diving deep into the data, one can find that Florida had 1095 methadone-associated overdose deaths in 2007, but 11% were with methadone only and 89% involved methadone taken in combination with other drugs. Between 2000 and 2004, there were 176 methadone-associated overdose deaths in

Kentucky, but only 6% involved methadone alone while a total of 94% involved methadone in combination with other drugs: antidepressants (40%), benzodiazepines (32%), and other opioids (28%). New Mexico had 143 methadone-associated overdose deaths between 1998 and 2002, with methadone alone accounting for 22% of the deaths and 78% involving polypharmacy with licit prescription medications (24%) and illicit drugs (50%) West Virginia in 2006 had 112 methadone-associated overdose deaths with 26% involving methadone only, while 63% involved methadone in combination with other prescription medications ; 13% involved use of illicit drugs and 10% involved use with alcohol. Maine had 88 such deaths between 1997 and 2002, with methadone deemed to be a significant contributing factor in 12%, but a primary or secondary causal factor in the remaining 88% of deaths.

The GAO recommended selected efforts to prevent methadone abuse and overdose focusing on education, safety, and monitoring. They cited the efforts of Substance Abuse and Mental Health Services Administration (SAMHSA) to create a physician clinical support system for methadone and label changes made by the US Food and Drug Administration (FDA) modifying the dosage instructions for patients beginning pain-management treatment with methadone. Instead of allowing up to 80 mg/day as the starting dose, the FDA’s revised methadone label limits the dose to 30 mg/day and recommends starting doses of 2.5 mg to 10 mg taken up to three times daily. The report mentioned the 3-year $1.5 million grant given to the American Society of Addiction Medicine (ASAM) to educate physicians and other practitioners on the appropriate use of methadone to treat pain and opioid addiction; the proposed Physician Clinical Support System would offer free support to prescribers. SAMSHA has several planned educational initiatives focusing on opioid treatment programs (OTPs).

Importantly, the GAO noted that methadone relieves pain, needs to be taken every 4 to 8 hours to maintain its analgesic effects, and may take up to 3 to 5 days to achieve full pain relief, ie, dosage increase should be done more slowly than with other opioids. Because of the unique pharmacokinetics of methadone if taken too often in too high a dose, or with other medications or supplements altering its metabolism, it may accumulate in the body to a toxic level. This variability in absorption, metabolism, and relative pain relief potency requires prescribers of methadone for pain to individualize dosing of the medication.

Methadone is an effective analgesic for the control of pain. It should continue to be used by clinicians, but those who prescribe it should have a better appreciation for its unique characteristics, and they need to start with lower doses that are titrated slowly. Pain educators should expect many questions about methadone use for the treatment of pain and its compatibility with other medications and substances. ■

Methadone-related OD deaths: report from the GAO

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Editor’s Corner

A Ask about pain regularly. Assess pain systematically. B Believe the patient and family in their reports of pain and

what relieves it. C Choose pain control options appropriate for the patient,

family, and setting. D Deliver interventions in a timely, logical, and coordinated

fashion. E Empower patients and their families. Enable patients to

control their course to the greatest extent possible.

To remember these basics of a care plan for pain, here’s a mnemonic: PAINBASE. A mnemonic is a way to remember things of interest; one of the best-known is APGAR (for rating a newborn). The word mnemonic is taken from the Greek word mneme, which means memory. The mnemonic PAINBASE stands for:

P Place location of painA Amount/severity of pain I InteractionsN NeutralizersB BreakthroughA ActivitiesSE Side Effects

Since all of our readers are interested in pain and pain education, word shortcuts are helpful ways to remember what to think about and ask about every time the word “pain” is mentioned. We must encourage our patients to be proactive, and, at the same time, we must be proactive in helping others learn easy ways to remember diagnosis and treatment of pain. Hope you can pass these two on. ■

1 Children’s Pain Management Service, RCH, Melbourne, Australia. Recommended by the Agency for Healthcare Research and Quality (AHRQ), http://www.ahrq.gov, USA.

ducators have passed down to students (and students have created their own) memory shortcuts throughout modern history as a way to recall the various parts of the body, symptoms of disease,

treatments (eg, RICE), and thousands of other multiple-memory lists. The PainView editors have recently discovered two helpful shortcuts to remember when dealing with pain. One is an acrostic, the other a mnemonic. Acronyms, acrostics, and mnemonics are still recalled by practitioners who need to remember long lists under stressful situations (like tests, or when a patient is crying in pain).

One acrostic that may be familiar to many is the ABCs of Pain Management. Fully expanded, the acrostic is ABCDE,1 which stands for:

Memory Shortcuts

“To know what kind of person has the disease is as essential as to know what kind of disease a person has.”

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Pain Educator “On-The-Go”

Kathleen Broglio, MN, NP, ACHPN, CPE

–F.S. Smith

ffective communication is a key skill for building relationships with patients and is essential for the provision of meaningful patient education. Without effective communication, it is impossible to accu-rately diagnose, develop a treatment plan for, care for, or educate patients. Effective communication decreases patient distress and provides an environment conducive to education. Studies show that

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challenges exist with communication while interviewing patients in the clinical setting. For example, patients often do not have a chance to tell their story, and find themselves interrupted by clinicians after speaking for only 23 seconds1; when patients are interrupted the first time, the chance is only 1 in 50 that they will return to talk about their concerns.2

Patients may not directly disclose their distress, and many times clinicians miss important cues or do not attend to the manifested psychological distress.3 Differences may exist between patient and clinician goals.4 Opportunities for trust-building, goal-setting, and education are lost if the patient’s story is not heard, concerns are not elicited, or distress goes unrecognized. Educational endeavors are ineffective if clinicians do not develop shared goals with patients. At a minimum, communication is not effective if the patient does not agree with or understand the proposed treatment plan.

What simple things can one do to improve communication with patients? Communication skills used in interviewing and education require practice and refinement. Interviewing skills such as active listening, adaptive questioning, empathetic responses, reassurances, nonverbal communication, and validation5 are used daily by clinicians without thought about the process. Asking oneself, “How do I really interview patients, or teach on a one-to-one basis?” can be an eye-opening experience. As an experiment, 1 Choose one of the techniques just noted (active listening, adaptive questioning, empathetic responses, reassurances, nonverbal communication, and validation) and observe your own use of these skills during discussions with patients.

The key behavior a clinician can exhibit during an interview or educational endeavor is to pay attention to, attend to, and demonstrate respectful attention to the patient or student. Trust is built when one demonstrates respect and attention, allowing patients to tell their stories in an uninterrupted manner. 2 Observe yourself during this next week when interviewing or educating patients. Watch how long it takes before you interrupt, question, or redirect them.

Develop mindfulness in questioning and in practice.6 Biases affect the interview process and relationships with patients. Recognizing biases helps you adjust behaviors to enhance communication. 3 Be mindful and aware of your own biases; that will help you be present and attentive in the interview and educational process instead of being distracted and distant.

The physical environment must also be conducive to effective communication. One needs to meet a patient at eye level to maintain eye contact (unless culturally inappropriate). Imagine how intimidating it is for patients in hospital beds to be surrounded by clinicians in white coats looking down on

them. Beyond the hierarchical aspect of body positions, there is the challenge, for both patient and clinician, of not being at eye level. 4 Observe your physical environment and eye contact with patients during the next week.

Body position is a very strong nonverbal communication tool. One may observe body language and know if a person is uninterested, distracted, or disengaged from the conversation. Get into the habit of observing your own body language. Does your body language change when you are feeling defensive? Do you cross your arms, move away from patients, look away, or even verbally redirect patients during the interview? 5 Observe your own body positions and recognize what positions you unconsciously adopt during the interview.

Recognize and acknowledge patients’ emotions. Eliciting unexpressed concerns is vital because patients may not disclose them. Two of the most important phrases in one’s armamentarium are, “Anything else?” or, “What else?”7 In a time-constrained setting, 6 Elicit the patient’s concerns and then negotiate a future time for discussion. This fosters trust and relationship-building.

Finally, 7 Summarize key points at the end of patient interviews or educational sessions. Allow patients to clarify information, thus ensuring shared understanding. Provide written material when appropriate and ensure it is written in easily understandable language.

Effective communication improves our educational endeavors. Patients will be more satisfied if they feel heard, cared for, and understood. As clinicians, we will be more satisfied if our patients are able to understand and follow shared treatment plans. As F.S. Smith said, “To know what kind of person has the disease is as essential as to know what kind of disease a person has.” Practice refining communication skills to enhance patient education and ultimately improve outcomes. ■

1 Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient’s agenda: have we improved? JAMA. 1999;281:283–287.

2 Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med. 1984;191:692–696.

3 Suchman, AL, Markakis K, Beckman H, Frankel R. A model of empathic communication in the medical interview. JAMA.1997;277:678–682.

4 Maguire P, Pitceathly C. Key communication skills and how to acquire them. BMJ. 2002;325:697–700.

5 Naumburg EH. Interviewing and the health history. In: Bickley LS, Szilagyi PG, eds. Guide to Physical Examination and History Taking. 8th ed. Philadelphia: Lippincott Williams & Wilkins; 2003:21–56.

6 Epstein RM. Mindful practice. JAMA. 1999;282:833–839.

7 Barrier PA, Li TC, Jensen WM. Two words to improve physician-patient communication: what else? Mayo Clin Proc. 2003;78:211–214.

Patients are interrupted by clinicians after speaking for only 23 seconds1; there is a 1 in 50 chance patients will return to talk about their concerns once interrupted.2

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