IASP Interprofessional Pain Curriculum Outline

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Task Force Members

Judy Watt-Watson, RN MSc PhD, Chair (Nursing, Canada), Abrahão Fontes Baptista, BPhysio MSc PhD (Physical Therapy, Brazil), Eloise C. Carr, RN PhD MSc BSc (Hons) (Nursing, Canada), John H. Hughes, MBBS FRCA FFPMRCA (Medicine-Anesthesiology, United Kingdom), Robert N. Jamison, PhD (Psychology, USA),  Hellen N. Kariuki, BDS MSc (Dentistry-Oral Medicine, Kenya), Jordi Miro, PhD (Psycholog,y Spain), Gouri Shankar Bhattacharyya MD PhD (Medicine- Pediatric Oncology, India),  Sigridur Zoëga, RN CNS PhD (Nursing, Iceland)

Outline Summary

Introduction
Principles
Objectives
Curriculum Content Outline

  1. Multidimensional Nature of Pain
  2. Pain Assessment and Measurement
  3. Management of Pain
  4. Clinical Conditions

References

Introduction

The widespread prevalence of pain demonstrates the need for comprehensive pain education for all health-care professionals. Yet not all require the same type of pain-related knowledge and skills. IASP encourages all interprofessional medical programs to utilize the following curriculum outline to embed pain education and training. As with all health professions, an objective of a curriculum is to instill the knowledge and skills necessary to advance the science and management of pain as part of an interprofessional team. The desired outcomes of education emphasize critical competencies that support the humanistic aspects of health care and the learner’s capacity to successfully carry out tasks in the real world. The fundamental concepts and complexity of pain include how pain is observed and assessed, collaborative approaches to treatment options, and application of pain competencies across the lifespan in the context of various settings, populations, and care-team models.

This Interprofessional Pain Curriculum Outline is based on the four components of the Core Curriculum. It is to be used with health science students who are in their first professional program (pre-licensure, undergraduate, entry-practice level) to facilitate shared opportunities for students from more than one profession to learn together (e.g., dentistry, medicine, nursing, occupational therapy, pharmacy, physical therapy, psychology, and/or social work). The outline provides a basic overview of suggested topics for interprofessional learning that can be developed further and in more detail uniprofessionally. It does not replace the uniprofessional curricula that provide additional depth in content required by each individual profession and discipline. The outline can be implemented in a variety of ways considering the professions involved, patient populations being studied, and regional needs.

The outline provides curriculum topics under each component that are common in pain management. An important purpose is to facilitate interprofessional learning; therefore, the detail applied under each component will depend on the student learning tasks. For example, these may include interprofessional team planning for pain assessment and management of cases based on real patients. It is expected that implementation methods will vary. However, a suggested model is to balance selected core lectures with concepts essential to all (e.g., overview of mechanisms, pharmacology) with small-group work to develop interprofessional patient-focused tasks. While all students/learners need to reflect on the various components of the outline, the depth of application of the suggested detail will depend on the professions involved and the specific patient focus of the students’ assignments.

Interprofessional education (IPE) has been defined as two or more professions learning with, from, and about each other to improve collaboration and the quality of care (1,2). IPE is sometimes confused with the intraprofessional model that involves different departments within the same profession (e.g., medical departments of surgery, anesthesia, neurology). Effective pain management can be complex, requiring collaborative approaches that exceed the expertise of any one profession. Research evidence for IPE supports positive health outcomes for patients and health systems from collaborative teams (2,3). However, for health-care professionals to collaborate in meeting patients’ needs, they first must understand each other’s roles and expertise. This understanding is the foundation for valuing and respecting others’ contributions to the management of complex problems, such as those for people with persistent pain. Interprofessional education fosters this understanding through interactive group work unlike multiprofessional education usually delivered in a large-group didactic lecture format (4).

An interprofessional pain curriculum provides a common basis for different professions to learn the same language as well as a basic understanding of pain mechanisms and major biopsychosocial concepts important to all. Interprofessional education provides a basis for collaborative competencies that include (1) recognizing and respecting the roles, responsibilities, and competence of others in relation to one’s own and (2) knowing when, where, and how to involve these other professionals (4,5). Interprofessional group opportunities allow students to learn of one another’s expertise, both shared and unique, that is essential to interprofessional and/or multiprofessional pain management. Working as a team to plan, manage, and monitor care (interprofessional) and/or communicating/coordinating care from individual health-care professionals (multiprofessional) can result in more effective patient outcomes.

From 2010 to 2012, a subgroup of the IASP Education Initiatives Working Group was directed to develop an interprofessional pain curriculum outline based on the four components of the IASP Core Curriculum. The iterative development process included extensive discussion for consensus, cross-referencing with the revised uniprofessional drafts, feedback from the total Working Group, and input from a wide variety of professionals and countries in the IASP Education SIG membership (N=61). The IASP Council approved the original submission on August 14, 2012. In 2017, all curricula were reviewed and updated, including this one. It is expected that ongoing evaluation will occur as curricula are used by the membership.

Principles

  1. All health-care professionals have an obligation to be empathic and to assess and work with patients and families to manage pain.
  2. Interprofessional learning opportunities provide students with an understanding and appreciation of the expertise of professions other than their own.
  3. Comprehensive pain assessment and management is multidimensional (i.e., sensory, emotional, cognitive, developmental, behavioral, spiritual, cultural) and requires health professional collaboration.
  4. Effective pain management outcomes occur when health-care professionals work together with patients, families, communities, and health-care providers (e.g., regulatory, insurance).
  5. Interprofessional pain education is most successful when it reflects real-world practices and is integrated early in the educational experience.
  6. The focus of interprofessional education is patient-centred in the context of team learning.

Objectives

Upon completion of this pain curriculum, the entry-level health care professional student will be able to:

  1. Discuss the multidimensional nature of pain and its components, implications for patient-families, and relationship to clinical interventions.
  2. Discuss clinical assessment and measurement approaches and misbeliefs common to health- care professionals.
  3. Describe multiprofessional and interprofessional strategies for the planning, intervention, and monitoring of pain-management outcomes.
  4. Develop and discuss as part of an interprofessional student group the rationale for patient-centered pain assessment and management plans based on authentic patient cases (actual or scenarios).
  5. Discuss inadequately managed pain assessment and management from an ethical, safety, social, and political perspective.

Curriculum Content Outline

  1. Multidimensional Nature of Pain

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

II. Assessment and Measurement of Pain

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)

III. Management of Pain

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

IV. Clinical Conditions (Examples for application)

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).

  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

References

  1. Barr B, Low H, Howkins E. Interprofessional education in pre-registration courses: a CAIPE Guide for Commissioners and Regulators of Education. London: United Kingdom Centre for the Advancement of Interprofessional Education 2012.
  2. World Health Organization Framework for Action on Interprofessional Education and Collaborative Practice, www.who.int/hrh/resources/framework_action/en/ (Accessed April 22, 2012)
  3. Institute of Medicine of the National Academies (IOM). Committee on Advancing Pain Research Care and Education. Relieving pain in America: a blueprint for transforming prevention, care, education, and research. Washington, D.C.: National Academies Press, 2011.
  4. Watt-Watson J, Lax L, Davies R, Langlois S, Oskarsson J, Raman-Wilms L.The Pain Interprofessional Curriculum Design Model. Pain Medicine 2017; 00: 1–9 doi: 10.1093/pm/pnw337
  5. Fishman SM, Young HM, Lucas Arwood E, Chou R, Herr K, Murinson BB, Watt-Watson J, Carr DB, Gordon DB, Stevens BJ, Bakerjian D, Ballantyne JC, Courtenay M, Djukic M, Koebner IJ, Mongoven JM, Paice JA, Prasad R, Singh N, Sluka KA, Marie BS, Strassels SA. Core competencies for pain management: results of an interprofessional consensus summit. Pain Medicine 2013;14:971-81.

2012 Interprofessional Pain Curriculum Outline Development

Philip J. Siddall, MBBS PhD Co-Chair (Pain Medicine, Australia), Judy Watt-Watson, RN MSc PhD Co-Chair (Nursing, Canada), Eloise C. Carr, RN PhD MSc BSc (Hons) (Nursing Canada/Uk), John H. Hughes, MBBS FRCA FFPMRCA (Medicine-Anesthesiology United Kingdom), Robert N. Jamison, PhD (Psychology USA),  Hellen N. Kariuki, BDS MSc (Dentistry-Oral Medicine Kenya), Jordi Miro, PhD (Psychology Spain), Leila Niemi-Murola, MD PhD (Medicine-Anesthesiology Finland), German Ochoa, MD  (Medicine-Orthopedic Surgery Colombia), Anibal Patricio Scharovsky, PT  Klgo Ftra (Physical Therapy Argentina).

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