[BLANK_AUDIO] We're here today, we're going to talk with Dr. Mary Ersek. Thank you for being here with us. >> You're welcome. >> She's a nurse faculty member at the University of Pennsylvania School of Nursing. And she's also affiliated with the VA Health System. Where she works and has expertise in pain and palliative care. And I think today's discussion will be helpful because she's going to talk to us something about why it's so important to treat pain. And I know that you all have some questions of your own. But I just want to start by asking you if you could just explain you know, beyond keeping somebody comfortable. >> Mm-hm. >> Why else is it so important to treat pain? >> Okay. I actually want to first emphasize, thanks. That's a great question. I do want to emphasize and I know that the audience is a broad audience. But I want people to know that at least for physicians and nurses we make an ethical and professional commitment to decrease suffering and promote comfort. So when you're talking with your, if your patient out there and you're talking with your care provider remember that that is a commitment they make. But there are other reasons. So I think first and foremost is to bring comfort to people. But, there are many consequences of unrelieved pain, both in the short term and in the long term. And there are numerous studies that show this. So without going into all the detail, I'll give you some examples. For example, someone who let's say, has a major surgery and their pain is unrelieved and their experiencing acute severe pain. They over time, and actually in, in fairly short order may have decreased immune function. They may have their autonomic nervous system activated and now remember that's what causes the flight or fight response. And that is good, in the short term to get us to help, but it's, in the long term can cause lots and lots of metabolic problems. So those are just a couple of examples. The other thing is, for example, let's say someone who had surgery and needs to get out of bed and move around to have a rapid recovery. If we don't treat their pain, they're going to be less likely and less able to get out of bed and engage in physical therapy or other therapies that will get them out of the hospital and home and healed faster. So it has consequences for physiologic outcomes. So the immune system but it also has really important outcomes for function. And lets then if we look at chronic pain. So that pain that we sort of arbitrarily say last more than a few months. I work with a lot of older adults who have chronic pain. And what happens there is people may get depressed if their pain isn't managed. They engage less socially. They may miss work. So there are many, many psychosocial consequences of untreated pain as well. So lots of important reasons to treat pain. >> Why is is important to assess a patient's experience with pain? >> We always start with self report and if you look at the definition of pain, that comes from the International Association for the Study of Pain. And that's probably the definition that's more broadly used professionally and for research purpose. It's, it's a longer definition. I won't go into all of it but it starts with pain is an unpleasant experience. And that's a really interesting definition. Okay, because years and years ago we focused on, pain is what, you know, is a signal that goes up to the nerve and you know if you stick your finger on a fire you're going to withdraw it and you're going to say ouch that hurts and hopefully you'll know what to do with it. But there are many, many, many components. We now have a much more robust model of pain that incorporates lots and lots of new research okay? And essentially, we know that, that what we call a no susceptible signal, okay? Just a nerve signal. That goes up to the brain, moves through the limbic system, which we know is, is associated with emotions, goes into the frontal cortex so we have cognitions about pain. And the way it's manifested is perhaps through psychologic monitoring. So maybe your blood pressure goes up. If it's severe and it's acute we may look at people's behaviors maybe they don't move around very much because their in pain. But to tap into that really, really complex experience the best way we have to do that is simply ask someone. Because, it's that description of pain involves so many components. So, we start with, are you in pain? Yes, no. Okay? But there are many components, and you can imagine how that changes. So imagine you're willingness to describe pain, or the meaning of that pain if you're a woman in labor, versus whether you are experiencing pain in your abdomen because you think that you have a recurrent cancer. [BLANK_AUDIO]. Wow, those are two really different experiences, and we know that pain is a very individual experience. So we have real challenges when people can't self report pain, but we always start there. >> Now, what if someone looks like they're in pain, but they deny it, or the opposite. If they say they're in pain, but it doesn't look like they're in pain. Okay, that's a great question and one that we often, concerns us as clinicians but also has very important ramifications for how patients, work with their care providers. So, first of all, all right, am I in pain? Do I look like I'm in pain? >> No. >> No. >> How do you know? >> You're not grimacing or anything. >> Okay. [LAUGH]. Actually, I am in pain, and what people can't see is that below this table I have an ice pack wrapped around my left ankle because I have a sprained ankle. And, actually it does hurt. And, you're right I'm not grimacing. And, you know why, because I'm in front of a camera. I don't want to look like a weenie. I'm a professional, I don't show that I'm in pain. I'm strong. So, it's there sometimes is a disconnect and what I deal with because I work with older adults. I work with people with dementia. And they're, less likely to report pain, because there's so many things that go into that report. Always start with self report when you can and every patient should know they should be asked about pain. Okay. So, what do I do if I see a mismatch? And let me go with an example of an older person who is grimacing, okay? That's a great, that's a great nonverbal sign for pain. And I might say, Gee, Aubrey, you know, I asked you if you were in pain, and you said no. But you, you're kind of grimacing. And I'm just kind of wondering what's going on with you. So I might get a lot of responses to that. One might be, well I'm not in pain. But my knee is sore. They don't even use the term pain. So we ask, we use different words about that. again, it might be because or this is what is what happens with older adults a lot. You know, you've got a group of people. And I'm not talking about old people, me. I'm a baby boomer. But I'm talking about the next generation. They've been through the depression. They've often lived lives that are much less comfortable than ours. So for them, many older adults will say unless they're in excruciating pain that prevents them from going to work, or doing what they want to do, they're not in pain. Whereas if I feel a twinge in my ankle I'm going to tell you that's pain. So lots and lots of different things and so lets go back to you know, what if there's a mismatch. You always want to explore further. One reason that many people, that some people will say they're not in pain, but they are, is they're worried about the consequences. You know, will you think that I'm a weenie. You know, will you, will you do something that hurts me? Oh you're in pain. Well let's send you down to dusted a dust house. And may be I actually really don't want to know the results of those test, because maybe it'll show I've cancer. So, you want to explore further and you want to look for potential barriers, in the case where you gotta, you kind of have got response that someone might be experience discomfort. So is it because they don't define pain the way you do? Is it because they're worried about the consequences? You know, is it because there are other barriers to reporting pain? You know what I hear a whole lot from older adults? I'm not in pain. But, of course, I'm in pain. I'm 85. And they even bother to mention it. It's just part of living. Well, actually that's pain that we should be talking about. Does it have an impact on their function? Now the flip side, you know, what if someone doesn't look like they're in pain? Think about the reasons they might want to shield that. Their, their, their families visiting, they don't want to upset their family. So, there is a disconnect but again, come back to the self report and try to uncover what's going on. >> So then is the point of therapy for the pain to hit zero or to lessen the pain, or does it vary patient by patient? >> Oh, it very much varies by patient to patient. And you know, it's like, it's making the decision that you would for any therapy. There are risks and benefits, okay? So, we, we typically with payment, pain go to the risk and benefits of pain medicine. Remember that there are many, many none drug, very effective none drug therapies for pain and again we can't go into that but, let's stick with, let's stick with the medicine. So pain therapy should be directed should be patient focused just like healthcare should be patient focused or person focused. And what I would do is if someone experienced pain I would negotiate. Where's your pain now? What level would you like to see it at? We can get pain to zero, but it might mean that you're going to be very, very sleepy from the medicine. And, for example, so if I work with someone in hospice, they may say, wait a minute, you know, I want to be able to talk with my family. So, why don't you give me just enough pain medicine to take the edge off, but don't put me to sleep. Don't make me sleepy. So, it's a give and a take. And it also differs on the context. So an acute pain, we want to get that pain to a level where let's say someone after surgery can get out of bed and go to physical therapy. Or, they're not lying in bed acquiring complications of that surgery. Like not getting a pneumonia because they're lying in bed, and not, and not getting out, and kind of breathing deeply. So, we might ask them about that. But every time it's a, you know, it's a balance. It's where is it now, where do you want to be? And to inform people, okay, well. You tell me you want your pain to be zero, this is what we can do. And are you, where's your balance of, you know, are,are you willing to accept the risks or the side effects? And, that's where non drug therapies are really wonderful because they typically have, very [UNKNOWN] massage therapy. Massage therapy has been shown to be effective for certain types of pain. The risks for most patients are much less than the risks of side effects of our pain medicines, and I would include there not only narcotics or opioids, such as Morphine or Percocet, but also nonsteroidal anti-inflammatory agents. So all the things that we can get in our drugstore without a prescription those carry with them very serious side effects. Massage therapy for one, has very few of those serious side effects. However, I need to check with you. Have you ever had massage? Do you like massage? Are you comfortable with people touching you? Do you have insurance for massage? How would you cover the expense of massage? So, all those go into a comprehensive pain management plan. For, if you will, simple or simpler pain management plans. The person who had surgery, we know that they're going to heal with time, they, we need to get their pain manageable so they can get up and out of bed and go home. Or, that might be a, a si, a couple of simple, non drug therapies but it might really focus on okay let's give you Tylenol, let's give you Percocet and get you out the door. Whereas for chronic pain, that balance of how do we help you reach your goal whether that's probably not zero but, whether that's a four out of ten, whether it's the ability to work. Whether it's I want to be able to pick up my grandchildren without feeling so painful that I, I can't, I don't want to do it, we work with that and look at the pros and cons. We try things, we have to go back and, and the things that work great, the things that don't work, we go back and, and redesign the plan. [BLANK_AUDIO] >> Do you guys have anymore questions before we wrap up? [INAUDIBLE]. >> I think this has been really helpful. You have some really great insight, you know, that you've provided. I,and I think I have a better understanding of treating pain and, and what it means and how important it is. And I hope that everybody else does too. >> Great. Thanks. Thanks so much for inviting me. [BLANK_AUDIO]
