CORE CURRICULUM OUTLINE

CURRICULUM CONTENT OUTLINE

 

I. Multidimensional Nature of Pain

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What is pain?

1. Epidemiology

   1. Pain as a public health problem with social, ethical, legal, and economic consequences

   2. Epidemiology with overview of statistics related to acute, recurrent, and/or persistent (chronic) and cancer pain for people across the lifespan

   3. Barriers to effective pain assessment and management: individual, family, health professional, society, culture, political institution

2. Development of pain theories

   1. Historical development of pain theories and basis for current understanding of pain

   2. Definition of pain and pain terms

   3. Classification systems of pain

   4. Differences between nociception, pain, suffering, and harm

   5. Pain and behavior

3. Mechanisms

   1. Anatomy and physiology to include neural mechanisms (e.g., peripheral pain mechanisms, dorsal horn processing, ascending and descending modulation, and central mechanisms)

   2. Multiple dimensions of pain to include physiological, sensory, affective, cognitive, behavioral, social/cultural/spiritual/political

   3. Pathological consequences of unrelieved pain and implications of being a multidimensional experience (e.g., biological, psychological, social, spiritual)

   4. Factors influencing neurophysiology (e.g., genetics, age, sex, ethnicity)

4. Ethics

   1. Ethical standards of care (e.g., provision of measures to minimize pain and suffering) for health- care professionals

   2. Ethical standards and guidelines related to the appropriate use of analgesics (e.g., inadequate analgesic prescribing; over-medication; confusion regarding physical dependence, tolerance, and addiction; substance use screening, use of placebos)

   3. Inadequate pain management for specific groups, including infants, children, elders, those with communication difficulties and/or learning disabilities

   4. Legal issues related to disability, compensation

   5. Political and societal issues related to access to pain management and beliefs about marginalized populations

   6. Experimental pain issues related to appropriate and meaningful measures and methods

 

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II. Assessment and Measurement of Pain

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How is pain recognized?

1. Interprofessional and multi-professional collaboration

   1. Assessment of patient priorities as a team where possible (interprofessional) and/or communication of planning between individual health-care professionals (multiprofessional) to ensure:

      1. Comprehensive assessment, especially when pain problems are complex (e.g., pain sensory characteristics, treatment history, impact of pain on functional status, perception of self/relationships, and past pain experiences)

      2. Clear documentation of pain assessment and measurement data

      3. Ongoing communication to ensure comprehensive and consistent approaches

      4. Ongoing evaluation of efficacy and effectiveness of management plan

      5. Modifying or changing plans to other similar (e.g., different analgesic) and/or different strategy (e.g., physical) if patients’ report significant adverse effects and/or an ineffective response

      6. Consideration of appropriate assessment and measurement approaches for people with special needs (e.g., infants, children, older adults, developmentally challenged, cognitively impaired, addiction history)

      7. Development of interprofessional consultant networks (informal/formal) when needed for adequate assessment with complex patients

2. Assessment

   1. History

      1. Pain location, onset, duration, severity, quality, alleviating and aggravating factors

      2. Impact on mood, usual activities/function/quality of life/sleep

      3. Previous pain and treatment history

      4. Ongoing response to treatment, adverse effects

      5. Comorbidities impacting pain (e.g., chronic disease, surgery, trauma, mood, cognitions, substance use disorder, medications)

      6. Personal characteristics (e.g., age, sex, race, religion, culture, language)

      7. Expectations of pain management and current understanding of the condition

   2. Physical examination

      1. Neurological and musculoskeletal assessment

      2. Posture and range-of-motion evaluation

      3. Focused according to the presenting condition

   3. Review of clinical records

   4. Investigations

      1. Laboratory tests

      2. Imaging studies (e.g., X-rays; flexion/extension views, if needed; Ultra Sound; MRI; CT; bone scan)

3. Measurement

   1. Approaches

      1. Qualitative

      2. Quantitative

   2. Testing issues

      1. Feasibility

      2. Validity

      3. Reliability

      4. Sensitivity

      5. Clinical utility

   3. Tools (unidimensional and multidimensional)

      1. Numerical Rating Scales (NRS)

      2. Visual Analogue Scales (VAS)

      3. Verbal/categorical scales

      4. Faces scales

      5. Pain drawings

      6. Comprehensive pain questionnaires

      7. Functional measures (e.g., pain-related disability, specific activities, health status)

      8. Measures of psychological status (e.g., depression, anxiety, beliefs)

      9. Measures for special populations (e.g., nonverbal, infants, cognitively impaired)

      10. Measures of global and health-related quality of life

      11. Screening measures for substance use disorder risk (e.g., alcohol, opioids, cocaine, sedatives, benzodiazepines)

 

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III. Management of Pain

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How is pain relieved, reduced, or prevented?

1. Goals of pain management

   1. Prevention and/or reduction of pain intensity

   2. Enhancement of physical functioning

   3. Improvement of psychological functioning

   4. Promotion of return to work/school and/or role within the family/society

   5. Improvement of health-related quality of life

2. Pain management planning decisions

   1. Develop, monitor, and modify the management plan that is patient-centered as an interprofessional and/or multiprofessional team

   2. Involve patient and family caregivers in clarifying their expectations and establishing clear, realistic goals

   3. Use combinations of methods where appropriate, including physical, psychological, pharmacological, and interventional

   4. Provide patient information/education, including communication methods, management options, strategies for potential adverse effects, clarification of misbeliefs, sources of information

   5. Develop transparent treatment plan with realistic goals

3. Treatment considerations

   1. Type(s) of pain

   2. Multidimensional nature of pain (e.g., biological, psychological, social)

      1. Use of combinations of pharmacological and non-pharmacological methods

4. Patient issues

   1. Access to clinics, treatment center, advantages of early intervention

   2. Patient involvement/understanding of planning/motivation to support self-management strategies

   3. Cultural/societal limitations

5. Caregiver issues

   1. Understanding of pain (e.g., false beliefs)

   2. Fears and anxieties (e.g., drug addiction, adverse effects)

   3. Understanding of patient goals/needs

6. Health professional issues

   1. Understanding of pain (e.g., false beliefs)

   2. Fears and anxieties (e.g., drug addiction, adverse effects)

   3. Understanding of current evidence supporting management strategies

   4. Understanding of patient goals/needs versus adherence expectations

7. Political issues

   1. Pain management as a human right

   2. Access to pain clinics, treatment centers

   3. Access to pain-relieving medications

   4. Access to non-pharmacological and/or interventional treatment

   5. Access to prevention (e.g., herpes zoster vaccine)

   6. Access to related mental health treatment centers

8. Substance use disorder/misuse issues

   1. Understanding aberrant drug-related behavior and substance dependency (use disorder/misuse)

   2. Careful assessment and screening for risk of harm

   3. Assessment of benefits of prescribed analgesics, recognizing potential adverse effects (e.g., unwanted physical, psychological, and social effects)

9. Consider and use non-pharmacological/interventional strategies in combination where appropriate

10. Pharmacological methods

    1. Include for each analgesic selected the following:

       1. Mechanisms of action

       2. Indications for use

       3. Pharmacokinetics, including mechanisms of toxicity where appropriate

       4. Adverse effects and their management

       5. Equianalgesic dosing

       6. Interactions with other drugs

       7. Formulations (short and long acting)

       8. Administration routes

       9. Age-specific therapies (including neonate, infant, and elderly)

       10. Disease, surgery, cancer, and/or trauma pain-specific strategies

11. Clarify tolerance, physical dependence, and psychological dependence

12. Use combinations of alalgesics and adjuvants where appropriate:

    1. Over-the-counter medications (e.g., acetaminophen/paracetamol)

    2. Nonsteroidal anti-inflammatory drugs (NSAIDS)

    3. Opioids

    4. Antidepressants

    5. Anticonvulsants

    6. Local anesthetics

    7. Topical agents

    8. Other

13. Knowledge of legislative requirements and current guidelines regarding controlled drugs

14. Non-pharmacological and interventional methods

    1. Use combinations of physical and psychological strategies:

       1. Clinician therapeutic use of self (e.g., active listening, being empathic)

       2. Physical strategies to support home and occupational function and activity (e.g., heat, cold, positioning, exercise, massage, wound support, exercise, mobilization, manipulation, reach devices, other comprehensive rehabilitation approaches)

       3. Psychological and behavioral strategies (e.g., cognitive-behavioral strategies, coping strategies, biofeedback, patient-family education and counseling, mindfulness meditation, acceptance and commitment therapy [ACT])

       4. Interventional methods where appropriate:

          1. Neuromodulation (e.g., transcutaneous electrical nerve stimulation [TENS], acupuncture, brain and spinal cord stimulation)

          2. Neuroablative strategies (e.g., neurolytic nerve blocks, neurosurgical techniques)

          3. Procedural/Interventional (e.g., injections)

          4. Surgery

          5. Palliative radiotherapy (e.g., cancer pain)

    2. Complementary alternative medicine (CAM)

    3. Information and communication technologies (e.g., virtual reality, computer-assisted interventions, smartphones, innovative technology [e.g., activity trackers, apps, text messaging])

15. Evaluation of outcomes

    1. Monitor management outcomes related to pain severity and function levels, adverse-effect management, and impact on mood, family, and quality-of-life issues

    2. Utilize an interprofessional and multiprofessional team approach to ensure integration and coordination of care

    3. Consider barriers related to treatment availability and costs at the patient-family, institution, society, and government levels

 

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IV. Clinical Conditions (Examples for application)

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How does context influence pain management?

    This domain focuses on the role of the clinician in applying the knowledge, assessment, and management planning in Domains 1-3 in the context of a variety of patient populations, settings, and care teams. The choice of clinical condition and detail will depend on the learner and specific patient populations to be studied. All patient cases for interprofessional work will not be relevant to every group and context. Also, combinations of pain issues can be used to increase case complexity and learner involvement (e.g., cancer pain focus with a pregnant woman, management of a diabetic man with neuropathy and a substance use disorder, or an adolescent with juvenile arthritis).

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1. Taxonomy of Pain Systems

   1. Distinction between acute, recurrent, incident, and or persistent (i.e., long-term, chronic) pain (may have a combination of more than one type)

   2. Distinction between nociceptive (somatic, visceral), nociplastic, and non-nociceptive (neuropathic) pain (may have nociceptive, nociplastic, and neuropathic pain)

   3. Distinction between commonly used pain terms in clinical practice (e.g., allodynia, analgesia, dysesthesia, hyperalgesia, paresthesia, pain threshold, pain tolerance)

   4. Involvement of biological, psychological, social, cultural, and spiritual factors influencing the perception of pain

2. Pain in Special Populations

   1. Pain in infants, children, and adolescents

   2. Pain in older adults

   3. Pain in individuals with limited ability to communicate

   4. Pain in pregnancy, labor, breast feeding

   5. Pain with psychiatric disorders

   6. Pain in individuals with substance use disorder

   7. Pain related to violence (e.g., war, torture, urban violence)

   8. Pain with HIV/AIDS

   9. Pain in rare diseases

3. Acute Time-Limited Pain

   1. Surgery

   2. Trauma

   3. Infection

   4. Inflammation

   5. Burn

4. Cancer Pain

   1. Primary pain

   2. Local invasion

   3. Metastatic spread

   4. Treatment-related

   5. End-of-life

5. Visceral Pain

   1. Referred patterns

   2. Cardiac and non-cardiac chest pain

   3. Abdominal, peritoneal, retroperitoneal pain

   4. Pelvic pain (male and female)

   5. Sickle cell crisis

6. Headache and Facial Pain

   1. Headache

   2. Orofacial pain

   3. Trigeminal neuralgia

7. Neuropathic Pain

   1. Primary Lesion Central

      1. Multiple sclerosis

      2. Post-stroke

      3. Spinal cord injury/myelopathies

      4. Traumatic brain injury

      5. Syringomyelia

   2. Primary Lesion Peripheral

      1. Degenerative disc disease with radiculopathy in neck and low back

      2. Peripheral neuropathies (diabetes, cancer, alcohol, HIV)

      3. Post herpetic neuralgia

      4. Acute disc herniation with radiculopathy

      5. Complex Regional Pain Syndrome II (CRPS II) (causalgia)

      6. Phantom limb

   3. Mixed or unclear origin

      1. Complex Regional Pain Syndrome I (CRPS I) (reflex sympathetic dystrophy)

      2. Irritable Bowel Syndrome

      3. Fibromyalgia

      4. Other

8. Musculoskeletal

   1. Rheumatoid arthritis, osteoarthritis

   2. Neck pain, whiplash, and referred pain

   3. Low back pain and referred pain

   4. Injuries from athletics, dance, and similar

   5. Myofascial pain syndrome