It must be pain management week here at the Nursing Show. After last week’s episode of the Nursing Show, I found this press release from a new resource for nurses and other health professionals.

The results of the survey in the article underlines the need to improve our communication skills, learn to ignore our own preconceptions about pain, and focus not just on hearing the words spoken by our patients but truly listening to the context and meaning.

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Nashville, TN (Sept 8, 2008) - A nationwide survey found a sizable gap exists between patients and healthcare professionals when it comes to understanding and discussing pain. To address this discrepancy, a new coalition of leading pain management organizations has formed to improve how patients and healthcare professionals communicate with each other.

The Let’s Talk Pain Coalition is the first of its kind to unite the perspectives of patients, caregivers, and healthcare professionals to encourage people to talk more about pain, listen actively, and act in ways that improve care for the millions of people who live with pain. The organizations behind Let’s Talk Pain have created a new interactive Web site, www.letstalkpain.org, to provide visitors with comprehensive information and tools to help enhance the dialogue between those affected by pain and healthcare professionals.

“Pain is one of the nation’s leading public health problems, and it often goes under-treated. It is difficult to diagnose and challenging to talk about,” said Dr. Scott Fishman, Chair and President of the American Pain Foundation and Chief of the Division of Pain Medicine and Professor of Anesthesiology at the University of California at Davis. “Open lines of communication and strong patient-professional relationships are what healthcare professionals strive for, and in pain management this is absolutely vital. This Coalition is exciting because it aims to help professionals and patients communicate better in order to help improve pain management.”

The Let’s Talk Pain Coalition debuts this week at the American Academy of Pain Management (the Academy) annual meeting in Nashville, TN. The Academy is one of the founding members of the Coalition along with the American Society for Pain Management Nursing (ASPMN) and the Coalition’s lead organization, the American Pain Foundation (APF). PriCara™, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc. is the sponsor of the Coalition.

One of the Coalition’s first activities was a national online survey of pain patients and physicians. It revealed the need for an increase in open and direct conversations about pain and highlighted the impact pain has on patients’ quality of life. The findings also underscored a disconnect between how patients and physicians are communicating with each other. Additional barriers such as lack of trust and not enough time for office visits can affect communications, and ultimately may influence pain management. According to the survey:

• Sixty percent of patients strongly agreed that they can be open and honest about their pain with their physician. Yet, the same survey found that less than 10 percent of physicians strongly agreed that their patients tell them the truth about their pain.
• While the majority of physicians, 97 percent, strongly agreed that there is enough time to discuss pain with their patients, less than half of patients surveyed, 46 percent, felt the same way.
• Pain has a substantial impact on the lives of patients and interferes with their ability to work outside the home and to exercise.
• Treatment-related side effects can have a negative impact on the management of pain, causing some patients and physicians to discontinue using pain medicine.

“Having pain is challenging and has significantly affected my daily life, to the point where I have had to stop working,” said Andrea Cooper, a Maryland-based artist who suffers from chronic pain and is featured in a video on the Let’s Talk Pain Web site. “Pain is an invisible condition. I have learned that the best way to improve my health and my treatment outcome is through engaging in an open and personal dialogue with my healthcare professional and connecting with others to talk about pain.”

Andrea’s story and the Let’s Talk Pain Web site were previewed during the ASPMN annual conference in Tucson, AZ, for pain management nurses this past weekend. Several Web features were highlighted, including:

• Talk: an interactive section where visitors-pain patients and healthcare professionals alike-can learn strategies for opening up the lines of communication about pain. Housed here are video success stories from real patients and healthcare professionals as well as an interactive Q&A with pain experts.
• Listen: a clearinghouse of essential, credible information about pain. Here people with pain, healthcare professionals, caregivers, and family members can become familiar with pain terms and conditions as well as learn more about how pain is assessed so that it is easier to start an informed dialogue.
• Act: a section with up-to-date information on how the Coalition is improving communication within the pain community.

“Let’s Talk Pain offers the first pain resource that will effectively equip people to improve how they discuss pain so that the actions taken improve pain outcomes,” said Nancy Eksterowicz, MSN, RN-BC, Department of Anesthesiology Acute Pain Service, University of Virginia Health System, and President-Elect of ASPMN. “The pain community has never had one online location for credible information, nor have we had a place where patients and healthcare professionals can connect to learn from each others’ experiences.”

About the Survey
The Let’s Talk Pain Coalition commissioned a national, Internet-based survey of 500 pain patients and 275 physicians treating pain, including primary care physicians, oncologists, pain specialists, neurologists, rheumatologists, surgeons, and psychiatrists. Analytica International, a research firm based in New York, NY, conducted the survey from April 3 to 11, 2008.

American Pain Foundation
Founded in 1997, the American Pain Foundation (APF) is an independent nonprofit 501(c)3 organization serving people with pain through information, advocacy, and support. APF’s mission is to improve the quality of life of people with pain by raising public awareness, providing practical information, promoting research, and advocating to remove barriers and to increase access to effective pain management. For more information, visit www.painfoundation.org.

American Academy of Pain Management
The American Academy of Pain Management (the Academy) is a nonprofit organization serving a broad range of clinicians who treat people with pain through education, information, and advocacy. Founded in 1988, the Academy has approximately 5,300 members and is the largest interdisciplinary/integrative pain organization in the United States. Visit www.aapainmanage.org for more info.

American Society for Pain Management Nursing
American Society for Pain Management Nursing’s mission is to advance and promote optimal nursing care for people affected by pain by promoting best nursing practice. This is accomplished through education, standards, advocacy, and research. Visit www.aspmn.org.

PriCara™, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc.
PriCara™, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc., is a major health care company in the United States dedicated to the needs of primary care providers who serve a vital role on the frontline of medicine. For more information about the company, please visit www.PriCara.com.

The Nursing Show, the number one nursing and nursing student podcast, is proud to announce a new sponsorship agreement with Lexi-Comp and their innovative suite of electronic nursing tools. Lexi-Comp is the perfect partnership for us here at the Nursing Show.

As innovators in the marketplace, Lexi-Comp’s Nursing Suite offers a unique package of frequently updated drug and patient care information.  Available for PDAs, smart phones, and via wireless interfaces, the Lexi-Comp suite for nurses and nursing students offers a wide array valuable services to subscribers.

We have been using these nursing tools for almost 6 months and have been very pleased with the quality, thoroughness, and innovative nature of the products. We also found the Lexi-Comp PDA connection and sync tools to be much easier and smoother to use with our palm devices than other nursing suites we have used in the past. This exciting partnership will provide an opportunity for the Nursing Show listeners to find out more about Lexi-Comp’s line of products and where they can go to listen to special listener-only expert advice from Lexi-Comp’s professionals.

Plus, visitors who visit via the Lexi.com/NursingShow link will be able to use a coupon for 10% of their purchase!

Over at this week’s MedicCast podcast for EMS providers, we take a look as some of the special considerations in the treatment of geriatric patients. First, a look at geriatric trauma considerations and why special care is needed to ensure that the elderly trauma patient is taken to the most appropriate facility just like younger patients. A recent study by the State of Maryland found that geriatric trauma patients were not being taken to trauma centers as much as younger patients with similar injuries.

The show also includes a look at polypharmacy and how it affects the geriatric population. Polypharmacy is the presence of at least 5 to 7 prescribed medications for a patient.  Each additional med increases the risk for adverse drug interactions, compounded side effects and endangers the patient.  Encourage patients to review their medications at least annually with their physicians.

Any person may experience problems with polypharmacy, but an elderly person will have more issues due to decreased metabolism, reduced renal and hepatic function, and slowed GI clearance and absorption.

Visit the MedicCast Episode show notes pages here.

Paul Bond posted this Cipro black box warning posted by the FDA recently. Check out this posting and all of his other articles over at EmergencyNursingToday.com now.

I’m so glad that Paul decided to start podcasting and blogging. His years of experience both in and out of the hospital are a valuable addition to the online nursing space.

Drug companies are back in the news again and probably not in the way they would have liked. A group of 43 states plus the Federal Government joined together to charge drug companies with improperly marketing antipsychotic drugs to pediatric Medicaid patients when the drugs were not approved for use in children.

The states started to notice the improper marketing programs when the cost of anti-psychotic drugs soared from one year to the next. The drug company involved in this case was Bristol-Myers Squib and the settlement cost them $515 million.

Read the article here about the New Hampshire view of the settlement.

What strikes me most about this article is that the drug companies constantly complain that the high cost of medications is because of the cost of research. However, the cost of marketing seems to be pretty ridiculously high when they end up paying an extra $515 million for the cost of their screw up.

Who will ultimately pay for this error? Why the people who buy the next high priced drug the company releases, of course. Fining a company for something like this is not enough, especially when they will simply turn around and pass the cost back to the states in the following years.

The solution seems much simpler to me — allow the states to participate in collective bargaining for drug purchasing, create a national health care program that actually pays the real cost of these drugs without the hyperinflated prices. Finally, the state and Federal Governments need to hold the executives at the top accountable for the profit at any cost attitudes seen recently in the pharmaceutical industry.

It’s an election year in the U.S., folks. Talk to your local, state, and federal candidates to determine what they plan to do to repair the collapsing U.S. health care system. Visit the American Nurses Association site on health care reform and find out the issues and key points from your national nurses’ representative organiztion.

And last but not least, VOTE!

Recently, I have received some requests for a review of complementary medicine practices and research and information on the Nursing Show podcast and blog. This topic area is so broad as to require it’s own series of podcasts. However, I think that there are some good resources for authoritative information out there on alternative and complimentary medicine.

One that has recently come to mind is rVita.com. The site presents information is an easy to read format, features links to authoritative studies and seems to tell it like it is. We all know that some of the claims of the herbal and complementary medicine producers lack scientific backing and thorough research, but there are products out there that have a positive effect on health and wellness, when used as directed.

The biggest question for most nurses is “who and what do you believe?” I think rVita solves this problem. They summarize the currently available research and provide links back to their sources so that you can check for yourself. They include links to specific studies as well as to reports from the NIH and CDC. There is also an option to provide feedback directly from visitors so that you may supply your own opinion.

I am talking with the content director for rVita and hope that she will be able to occasionally post pertinent information here on the Nursing Show site about complementary medicine and alternative therapies for you to use in your nursing practices every day.

My goal is that this will continue to expand the information available here at the Nursing Show and provide the listeners and visitors a chance to learn more about this area of patient care.

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Full disclosure: I was asked to review this site by it’s authors but did not receive any compensation to do so.

I read an interesting article over at WebMD.com on the increase in prescription sharing going on out there.  About 25% of the 700 people interviewed said that they had either loaned another person their prescription medications or had taken someone else’s prescription medications.  This is an alarming number when you think about it.

1 in 4 people out there may be taking or giving others medications not on their prescription list.  This is why you always conduct a full assessment on a patient and don’t assume that they have the same med list as the last time they visited.  In fact, 1/4 of them may be on something new.

This is also a great opportunity for the nursing community to educate patients on medication safety. When you are passing along discharge instructions, make a plug for safe medication usage.  Urge patients to clean out old medications that are expired or no longer needed.  It will protect against medication abuse and overdose in both the patient’s home and in the community at large.

Got a comment, contact me directly at Comments@NursingShow.com

This is from the most recent Maryland Poison Control ToxTidbits Newsletter. You can subscribe by email here.

Author Bryan Hayes was interviewed on the Nursing Show last month.

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Buprenorphine ingestions in pediatric patients are usually well tolerated, but can cause serious toxicity. The few published cases show conflicting outcomes.

In one case report a 4-year-old girl who ingested 4 mg of buprenorphine experienced only miosis. In another published report, a 2-year-old boy experienced 1 episode of spontaneous emesis and became drowsy en route to the emergency department (ED) 30 minutes after an ingestion of up to 8 mg. He was observed in the ED, no interventions were necessary, and the child was discharged asymptomatic and stable 6 hours post ingestion.

More serious toxicity developed in a small case series in which 5 children <2 years of age ingested buprenorphine doses estimated to be between 4 and 10 mg. All of them developed respiratory and CNS depression. Naloxone was administered in 4 patients, and the fifth patient required intubation with mechanical ventilation.

This month, a much larger case series out of the Maryland Poison Center was published (Hayes BD, Klein-Schwartz W, Doyon S. Toxicity of buprenorphine overdoses in children. Pediatrics. 2008;121(4):e782-6).

This retrospective analysis of national poison center cases reported on 86 patients <6 years of age who unintentionally ingested buprenorphine. Thirty-two patients (37%) remained asymptomatic, 48 patients (56%) had a minor effect, and 6 patients (7%) developed severe effects (respiratory depression and significant CNS depression). There were no fatalities.

The most common clinical effects in patients who developed toxicity were drowsiness/lethargy (55%), vomiting (21%), and miosis (21%). The study analyzed dose data and concluded that any child ingesting >2 mg (in the form of Suboxone® or Subutex®) or an unknown amount should be referred to the ED. Additionally, children <2 years of age ingesting more than a lick or taste should be referred to the ED.

Pediatric patients with a suspected buprenorphine exposure should be monitored in an ED setting for a minimum of 6 hours. Naloxone can be used to reverse respiratory depression, although more than one dose may be required.

The Maryland Poison Center is available 24-7 to answer all questions and assist in the management of all poisoned patients. Please call 1-800-222-1222 to reach one of our certified specialists in poison information.

Bryan D. Hayes, PharmD, Clinical Toxicology Fellow

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See Also - these poisoning and overdose segments on the Nursing Show:

Insecticide Poisonings

Household Cleaner Poisonings

Dextromethorphan OD

Snakebites and Venom (pt 1)

Snakebites (pt 2)

Phenytoin OD (Dilantin)

Poison Control Centers

Poison Center Nursing Careers

In a recent article on military amputees and their experiences with phantom limb pains, an unusual treatment cropped up — Mirror Therapy!

Read the article here.

Phantom pain is caused by mismatched signals to the brain from the affected limb.  The motor and pain neural pathways are still there down to the point of amputation.  It is believed that the mismatch between the visual signals that the limb isn’t there anymore, bumps up against the remaining nerves that are still acting as if the limb is still receiving and and sending signals to them.  These conflicting signals result in pain felt in a limb that is no longer there.

Looking for a solution, an army neurologist turned to a older study that looked at the use of mirrors to fool the visual cortex into thinking the limb was still present.  Many were skeptical, but after dealing with pain that was unresponsive to pain killers, most were willing to give it a try and signed up for the clinical trials set up by the military.  The results were pretty amazing.

90 percent of the patients using the mirror therapy had a reduction in pain and within a few months, most had significantly reduced their narcotics load.  Read the article for more information.  It’s cool stuff!

I’m hoping my fellow science podcaster, Ginger Campbell over at the Brain Science Podcast picks up on this one.  I’d like to hear her take on it.

I got this information via Maryland Poison Control’s monthly newsletter Toxtidbits.

You can download your own copy or subscribe here:

http://www.mdpoison.com/publications/current.html

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Phenytoin (commonly known by the brand name Dilantin® ) has been used since the 1930’s as an anticonvulsant and is still a first-line drug used for some seizure disorders. Many overdoses with phenytoin are reported to poison centers, but fatalities are rare.

Absorption of oral doses of phenytoin is often erratic and delayed. It’s not unusual to see gastrointestinal absorption continue for several days. Phenytoin is highly protein bound and rapidly distributed to all tissues. Therapeutic levels are 10-20 mcg/mL.. Labs routinely test for total phenytoin; however, only free or unbound phenytoin is responsible for clinical effects. More than 95% of the drug is metabolized by the liver. The half-life of phenytoin is 6-24 hours with therapeutic doses but is prolonged in overdoses, to 20-60 hours.

Acute phenytoin toxicity produces mainly neurologic symptoms that may persist for days to a week or more. Phenytoin concentrations greater than 15-20 mcg/mL are associated with horizontal and/or vertical nystagmus, ataxia is seen with levels greater than 30 mcg/mL , and slurred speech, confusion and lethargy appear at levels greater than 40-50 mcg/mL. Large overdoses may also result in tremor, delirium, hyperreflexia, dyskinesias, hallucinations, and coma. Nausea and vomiting can occur following phenytoin ingestions because of the large amount of undissolved drug in the stomach. Respiratory depression rarely occurs. High doses of intravenous phenytoin or rapid infusions can result in hypotension, bradycardia and dysrhythmias due to myocardial conduction depression. These cardiovascular effects are thought to be due to the propylene glycol diluent in the parenteral form of phenytoin. Cardiovascular toxicity following oral overdoses has not been reported; therefore, patients who ingest large amounts of phenytoin do not need cardiac monitoring.

Treatment consists of supportive care and activated charcoal. Repeat doses of charcoal are often recommended to prevent further absorption of any drug that persists in the GI tract. Ataxic patients should be observed closely and steps taken to prevent falls. Because of its erratic absorption, phenytoin levels should be repeated every six hours after an acute overdose.

See Also - these poisoning and overdose segments on the Nursing Show:

Insecticide Poisonings

Household Cleaner Poisonings

Dextromethorphan OD

Snakebites and Venom (pt 1)

Snakebites (pt 2)

Buprenorphine OD

Poison Control Centers

Poison Center Nursing Careers