IASP Curriculum Outline for Pain in Social Work

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Task Force Members

Terry Altilio (Co-chair, USA), John Cagle (USA), Kerryn Coombe (Australia), Maris Pasquale Doran (Co-Chair, USA), Andy Sim Gim Hong (Singapore)

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 programs in social work to use the following curriculum outline to embed pain education and training. As with other health professions, an objective of curricula 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 carry out tasks successfully 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.

The social work discipline has historically employed a biopsychosocial, strengths-based approach of assessing a person within the environment and honoring the subjective experience as the initial entre into the lives of those served. These values are a fundamental platform upon which social workers can build necessary skills to understand and influence the social, cultural, political, ethical, psychological, and spiritual aspects of pain.

Pain is both a societal and policy issue as well as an individual challenge for those experiencing it. Comprehensive pain assessment is individualized, patient and family-centered, multidimensional, and the focus of attention of clinicians, advocates, and political and regulatory institutions across the world.

Principles

Pain encompasses physical, emotional, cognitive, behavioral, spiritual, cultural, and interpersonal layers. Social workers who develop pain-specific knowledge are better able to assess and advocate for appropriate care and employ evidence-informed interventions that contribute to the team management of pain and related suffering. The multiple facets that converge around pain are relevant for social work intervention whether at the level of clinical care, research, policy, ethical analysis, advocacy, or education. With pain-specific knowledge, social workers are equipped to identify the need for referrals from pain specialists and to assess and intervene to reduce the negative impact that pain may have on an individual’s life.

Because pain is the most common reason a person seeks clinical care, and social workers are present in a variety of clinical settings, social workers are well positioned to identify patients’ unique needs when versed in pain’s presentation and impact. Untreated and undertreated pain represents a health problem demanding attention and advocacy, as the social work profession’s ethical commitment to social justice is challenged by a lack of access on the part of many individuals to comprehensive pain treatment and professional expertise; this reality is compounded among underserved and vulnerable populations.

A concurrent public health concern is the abuse of controlled substances, including opioids. This challenge requires expert assessment of the complex intersecting aspects of the pain experience as well as advocacy for access to multidimensional treatment modalities to balance the ethical obligation to manage pain properly with the safety of patients, the public, and prescribers.

Objectives

Social workers at the end of this entry-level pain curriculum will be able to:

  1. Identify opportunities to function as advocates, care managers, clinicians, educators, and coordinators of treatment plans for persons living with pain, including preventing unrelieved pain and minimizing its social and behavioral consequences
  2. Demonstrate a basic understanding of pain terminology and mechanisms
  3. Integrate the relationship between types of pain and related emotional and functional challenges
  4. Describe barriers to the reporting and management of pain and the consequences of unrelieved pain on individuals, families, and society
  5. Demonstrate familiarity with screening and assessment tools and evidence-informed interventions 
  6. Discuss how the social work discipline’s historical commitment to vulnerable populations, social justice, and to the relief of suffering apply to the under-treatment of pain
  7. Identify the myriad factors, including unique cultural factors, racial disparities, and substance misuse, that can contribute to a person’s pain experience, assess how these factors influence an individual’s and family’s response, and inform interventions 
  8. Demonstrate an understanding of the complex public health, political, and regulatory climate surrounding opioid medications, including the impact of medication diversion, global access, and prescribing practices for persons living with pain
  9. Identify and address ethically challenging situations that undermine an individual’s ability to access adequate pain and symptom management and relief
  10. Design, facilitate, and promote effective and culturally sensitive communication practices within institutions and among health-care providers and patients and their families 
  11. Recognize and influence the ethical discernment and decision-making processes that inform public policy and treatment of persons living with pain

Curriculum Content Outline (entry-level, pre-licensure)

  1. Multidimensional Nature of Pain
    1. Epidemiology
      1. Prevalence of pain
      2. Impact of pain on individual, family, society
      3. Disparities in pain assessment and treatment
    2. Definitions
      1. Pain
      2. Acute, acute on chronic
      3. Persistent (chronic)Breakthrough
      4. Pain in serious illness
      5. Pain in the imminently dying
      6. Suffering
    3. Types
      1. Nociceptive (somatic, visceral)
      2. Nociplastic
      3. Neuropathic
    4. Dimensions of pain experience and suffering
      1. Physical/sensory
      2. Cognitive
      3. Behavioral
        1. Pain-related disability
        2. Medication-related behaviors
      4. Affective
        1. Interrelationship of pain, depression, and anxiety
      5. Cultural
      6. Social
      7. Familial
      8. Spiritual
    5. Ethical principles
      1. Access to care
        1. Political, policy, public health, and regulatory factors
      2. Advocacy
        1. Global and national initiatives (e.g., IASP Declaration of Montreal, U.S. Joint Commission Pain Management Standards, Institute of Medicine Report, 2014)
      3. Right of patient to appropriate assessment and pain treatment
        1. Public health concerns related to medication abuse
      4. Principles of biomedical ethics
  2.  Pain Assessment and Measurement
    1. Common pain scales
      1. Visual analogue, numerical, and categorical scales
      2. Pictorial scales and body charts
      3. McGill Pain Questionnaire
      4. Brief pain inventory
      5. Daily function and activity interference scales
      6. Psychological scales (e.g., Mood, Pain Catastrophizing Scale)
    2. Assessment of pain
      1. Patient report and clinician’s valuing of and efforts to understand subjective experience
        1. Empathic and compassionate communication throughout assessment
        2. Nonjudgmental or delegitimizing of patient’s narrative and experience
        3. Awareness of communication barriers (e.g., stoicism)
      2. Pain quality descriptors (e.g., burning, shooting, stabbing)
      3. Nonverbal pain behaviors (e.g., guarding, grimacing)
      4. Behaviors of patient (e.g., use of medications, ADLs, sleep disturbance); responses of family, social network, and clinicians
      5. Patient’s preferences, values, goals, and priorities as related to treatment
      6. Bearing on self: self-concept, mood, sleep, social roles and isolation, sexuality
      7. Influence on family: communication, roles and structure, finances
      8. Attributed meaning by patient, social network, and the larger community/society
      9. Coping styles
      10. Age and gender differences and the impact on various aspects of pain, including assessment and treatments
      11. Cultural variables impacting reports (e.g., stoicism)
      12. Effect of pain on attention and ability to process information
      13. History of pain experiences and current impact (personal, familial, cultural, spiritual)
    3. Social work focus on biopsychosocial assessment of person in environment as basis for understanding the pain experience, informing treatment plans, and framing interventions
    4. Biomedical focus on diagnosis and treatment versus understanding the attributed meaning and experience for person and his or her intimate network
  3. Management of Pain
    1. Basic medical and pharmacologic management
      1. Classes of medications used to manage pain
      2. Procedural interventions
      3. Care coordination
        1. Primary care
        2. Community support services
        3. Mental health resources
        4. Access to care
    2. Patient and identified support network participate in treatment plan
      1. Evaluation of benefits and risks of available treatments
      2. Monitor and adjust care plan as necessary for individual and family
      3. Differentiate between treatment of acute pain, acute-on-chronic pain, chronic/persistent pain, and pain at the end of life
    3. Barriers to adequate pain management
      1. Practical challenges (e.g., cost, availability of educated professionals)
      2. Clinician biases emanating from cultural and socioeconomic differences
      3. Cultural, family, and personal values and fears (e.g., stoicism, fear of being a burden, stigmatization)
      4. Impact of provider’s cultural values and beliefs on patient care
      5. Medication-related concerns of clinicians, patients, and families
        1. Inadequate education about communicating pain and treatment effects
        2. Stigma associated with pain medications
        3. Explain differences between physical dependence, substance use disorder, misuse, tolerance, addiction, and nonadherence
        4. Concerns related to fears of addiction
        5. Concerns about adverse effects
        6. Fear of developing tolerance
        7. Fear of overdose
        8. Clinician fears of doing harm expressed through implied mistrust of patients
      6. Political, policy, public health, and regulatory factors
      7. Addiction history
        1. Personal history and screening
        2. Risks of medication misuse or diversion
        3. Reluctance of patient (or support system) in recovery to accept opioids for fear of relapse
      8. Fatalism
      9. Untreated and undertreated pain
        1. Vulnerable and marginalized populations such as women, children, older adults, poor and underprivileged, undocumented, minority racial and ethnic groups, individuals with substance use disorder, psychiatric illness, prisoners, persons with disability, nonverbal or speakers unfamiliar with the native language, and those who are terminally ill
        2. Access to pain-specialized care
          1. Financial and insurance barriers
          2. Remote and rural areas
          3. Lack of integrated health-care systems
    4. Skills and strategies to enhance pain relief, self-efficacy, and outcomes
      1. Education
      2. Identifying barriers to adherence to a pain management treatment plan
      3. Motivational interviewing
      4. Self-management strategies and tools
      5. Relaxation techniques
      6. Breathing exercises
      7. Pacing and goal setting
      8. Journals and diaries (e.g., paper or electronic monitoring of symptoms, emotional and cognitive responses)
      9. Use of technology to identify applications for relaxation and distraction techniques
      10. Problem solving
      11. Acceptance
    5. Pain accompanied by change in employment, social and family role, ADLs, recreation, sleep, sexuality
      1. Identify resources
      2. Teach skills to mediate the effects of life changes
      3. Family-focused interventions to mediate impact of pain-related changes
        1. Address impact on familial roles and equilibrium, communication patterns, sexuality, finances
        2. Integrate respect for cultural values in decision making and treatment plans
    6. Empowering
      1. Assist in redefinition of sense of self to encourage continued engagement in life
      2. Intervene to enhance self-efficacy and self-determination
      3. Mediate culturally sensitive communication between patient, family, and health-care providers
      4. Use of interpreters when first language of provider and patient are different
    7. Group-focused interventions to reduce isolation, share strategies, sources of meaning, enhance motivation
    8. Evidence-based non-pharmacological interventions
      1. Cognitive therapies (e.g., CBT, ACT, MBCT)
        1. Addressing maladaptive beliefs
      2. Biofeedback
      3. Guided imagery
      4. Mindful meditation
      5. Relaxation therapy
      6. Hypnosis
  4. Clinical Conditions
    1. Interdisciplinary teams and roles
      1. Prescribing clinicians
        1. Varying specialties (e.g., palliative care, oncology, chronic illness, surgery, orthopedics, neurology)
      2. Nursing staff
      3. Mental health
      4. Chaplains
      5. Support staff
      6. Ethics committee
    2. Pain presentation across environments
      1. Primary care, community settings, mental health settings, emergency departments, methadone maintenance programs
    3. Acute pain associated with trauma, surgery, or acute medical conditions
    4. Common chronic pain conditions associated with diseases such as chronic obstructive pulmonary disease (COPD), end-stage renal disease, end-stage heart failure, liver diseases, diabetes, dementia, arthritis, multiple sclerosis, and cancer
    5. Recognize need for clinical intervention during transitions in care settings to ensure continuity of pain-management plan
    6. Assessment and management of special populations, particularly vulnerable populations: women, children, older adults, poor and underprivileged, minority racial and ethnic groups, individuals with substance use disorder, psychiatric illness, LGBTQ, prisoners, persons with disability, nonverbal or speakers unfamiliar with the native language, and those who are terminally ill
    7. Role of social worker as advocate to help patient meet individualized treatment goals
    8. Relationship of somatic and psychological factors in chronic pain
    9. Comorbidity of chronic pain and mental health diagnoses
    10. Management of pain when patients or caregivers have a history of addiction or substance use

References

Altilio, T., & Doran, M.P. (2013). Pain. Encyclopedia of Social Work. Retrieved from http://socialwork.oxfordre.com/view/10.1093/acrefore/9780199975839.001.0001/acrefore-9780199975839-e-276

Altilio, T., Doran, M.P., Leimena, M.L. “Pain Management.” In Oxford Bibliographies in Social Work. Ed. Edward J. Mullen. New York: Oxford University Press, 2016-10-27 http://www.oxfordbibliographies.com/view/document/obo-9780195389678/obo-9780195389678-0242.xml?rskey=JjaSnP&result=141

Cagle, J. G., & Bunting, M. (in press). Patient reluctance to discuss pain: Understanding stoicism, stigma and other contributing factors. Journal of Social Work in End-of-Life & Palliative Care. doi: 10.1080/15524256.2017.1282917

Green, C. R., Anderson, K. O., Baker, T. A., Campbell, L. C., Decker, S., Fillingim, R. B., et al. (2003). The unequal burden of pain: Confronting racial and ethnic disparities in pain. Pain Medicine, 4(3), 277–294.

Lasch, K.E. (2002). Pain clinical updates: Culture and pain. International Association for the Study of Pain, 10(5).

Mendenhall, M. (2003). Psychosocial aspects of pain management: A conceptual framework for social workers on pain management teams. Social Work in Healthcare, 36(4), 35-51.

Otis-Green, S., Lucas, S., Spolum, M., Ferrell, B., & Grant, M. (2008). Promoting excellence in pain management and palliative care for social workers. Journal of Social Work in End-of-Life & Palliative Care, 4(2), 120-134.

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