I am Wendy Green, Professor of Surgery and Critical Care at Emory University, and I want to thank the Society for Critical Care of Medicine Program Committee for the opportunity to present on Smart Narcotic Management, Coaching the Patient Through the Pain. Let's look at the background of this problem, and this will be based upon a review that's taken from the American College of Surgeons Pain Management Guidelines for Trauma Patients. The majority of trauma victims experience pain. Acute pain can impact respiratory function, increase metabolic demand, impair wound healing, suppress immunity, and reduce mobility. Inadequate acute pain management after trauma delays return to work, lowers quality of life, and increases post-traumatic stress disorder risk, triggering a trauma pain distress feedback loop. Poorly managed acute pain also increases the risk of chronic pain development. Pain is associated with decreased self-efficacy and increased risk of depression. This effect may be more pronounced after trauma because traumatic events cause distress that can exacerbate pain. Pain management changed over the last decade, in large part due to the opioid crisis in the United States. The scope of the opioid crisis and the impact of prescription drugs resulted in a call from the American Medical Association, the Orthopedic Trauma Association, and the American College of Surgeons, among others, to minimize opioid use. Let's consider the pain assessment tools. The pain assessment tools should be multidimensional in nature. When we're selecting a pain assessment tool, during pain assessment, we must account for the patient's cognition and ability to communicate, which may be affected by injury, extent of illness, age, and other factors. We must reassess pain systematically, ideally using the same appropriate tool. We must reevaluate significant changes in pain promptly to identify missed, new, or developing injuries. Non-pharmacologic pain management strategies are recommended as adjuncts for pain and anxiety management in trauma to minimize opioid use and chronic pain development. While the risk benefits support wide use of non-pharmacologic pain management, the evidence base is stronger for cognitive rather than physical strategies. Although the evidence supporting the use of many non-pharmacologic pain management strategies in the setting of acute injury is not expansive, the interventions themselves are generally low risk. We also must tailor the specific treatments chosen to the needs of patients and resources available in each facility. Multiple small, single-center studies reported beneficial effects of music therapy, hypnosis, and virtual reality environments, as well as other techniques to reduce pain and distress. However, as in adults, minimal high-quality evidence exists. Music therapy is a passive distraction technique that is self-explanatory, low risk, and requires minimal to no caregiver expertise. Hypnosis is a cognitive technique designed to heighten an individual's responsiveness to suggestion in an effort to alter behavior, feelings, thoughts, or perceptions. Virtual reality, at present, the majority of studies evaluating virtual reality are from the burn population, but many suggest improvement in pain control, improved performance in physical therapy, and high patient satisfaction with use, especially among young children and adolescents. Animal Assisted Therapy. Animal Assisted Therapy, or pet therapy, is the use of animals in the inpatient and outpatient setting for the purpose of improving mood and distracting patients from acute anxiety and pain. Simple in-hospital pet visitations, animal-assisted activities, or planned visits with clearly defined goals and measured results using a trained pet therapist can be very helpful. Mindfulness. Mindfulness trains an individual to observe painful situations as they arise and to consciously let go of the anxiety and struggle associated with the painful event. Studies demonstrated mindfulness interventions can reduce perceived pain, intensity, and complicating factors such as anxiety, anger, and depression in the acute setting. Likewise, approximately a third of patients taught meditation and mindfulness techniques obtain pain relief equivalent to 5 mg of oxycodone. Cognitive Behavioral Therapy, CBT. CBTs aim to improve a patient's control over their perception of pain. Examples include setting expectations before surgery, teaching relaxation techniques, using guided mental imagery for diversion, coaching family members, and using active distraction through conversation. Randomized studies demonstrated reductions in post-traumatic stress disorder symptoms in trauma victims following organized sessions of CBT. CBT sessions have been shown to significantly reduce pain and pain-associated disability for spinal cord injury patients. Multiple preoperative interventions can reduce the amount of analgesia required after surgical procedures. Trauma centers are encouraged to integrate these techniques as part of any multimodal approach to management of pain. When we look at patient coaching, this offers promise as a means of reducing racial, ethnic disparities in pain control. Larger studies, however, are needed to validate these findings and to explore possible mechanisms. Multiple patients in one study received a 20-minute individualized education and coaching session to increase knowledge of pain, self-management, to redress personal misconceptions about pain treatment, and to rehearse an individually scripted patient-physician dialogue about pain control. The control group received standardized information on controlling pain. Minorities in the experimental group compared with minorities in the control group and all whites experienced an additional reduction in average pain equal to 1.73 points on a 10-point scale. Larger studies are needed to validate these findings and to explore possible mechanisms. While the presence of racial disparities in pain management is well-documented, the reasons are unclear. Both patient and physician factors have been examined, focusing on pain perception, response to pain, and disparities in pain treatment. As effective change agents, minority patients may modify physicians' communication behavior, inducing a more participatory style that is less likely to support patient passivity. Thus, clinical outcomes, including pain control, may be influenced not only by changes that occur within the individual, such as enhanced self-efficacy, increased coping skills, but also by a potentially transformed iteration with their physician. Thank you.

smart narcotic management

coaching patients through pain

acute pain management

opioid crisis

non-pharmacologic pain management