Each issue of the CoramClick provides an in-depth focus on timely and practical solutions. In this issue of the Click, we are focusing on chronic pain and bleeding disorder patients. Full, printable issues of the Click are available in the CoramClick archive for easy reference!

	Chronic Pain Chronic pain is an overwhelming, encompassing disease process that affects over 35.5 percent or 105 million people in the United States at any given time. The estimated costs exceed $150 billion a year.		Bug of the Month: Clostridum Difficile Clostridium difficile is a gram-positive, spore-forming anaerobic bacillus associated with a potentially dangerous GI infection. Disease from the bacteria is an ever-increasing threat in both the hospital and community.
	The Pain Trajectory for the Bleeding Disorder Patient Pain is an under-managed, misunderstood and often under-recognized issue in the bleeding disorder population. It has been reported that over 50 percent of patients with Hemophilia A complain of pain throughout the day.		Do You Know? What percentage does pain play in the primary reason for re-hospitalization for GI patients nationally? 10% 35% 41% 85%
	Common ICD-9 Codes A list of certain ICD-9 codes associated with pain. Please note, this list is not all-inclusive.		Resource Center Featuring: World Hospice and Palliative Care Day, American Pain Society and the National Hemophilia Foundation.
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Chronic Pain

Chronic pain is an overwhelming, encompassing disease process that affects over 35.5 percent or 105 million people in the United States at any given time. The estimated costs exceed $150 billion a year. More than 99 million patients seek care for acute pain every year, which brings the total impact of patients suffering from pain to over 200 million people. More than 150 million adults consume monthly pain management prescriptions, including opioid as well as non-opioid medications.

These numbers are staggering when calculated at this level. However, education on this disease process continues to lack at the medical and nursing school levels. Within disease management, pain is a leading cause of all visits to a medical professional, as well as the leading cause of rehospitalizations and increased lengths of stay in the hospital.

The science behind the disease is becoming more refined every year. The goal is to translate this science to applicable therapies for treatment. The therapy trajectory encompasses oral, transdermal, transcutaneous, intraspinal, intravenous and subcutaneous medications. The drugs vary, as do the routes of administration. The goal for controllable pain exists and requires proper identification of the stimulus, location of the damage, type of pain the patient is experiencing and proper administration of the treatment model.

Pain is not only a physical ailment, but also carries a tremendous emotional burden. It impacts not only the patient, but family and friends that support those suffering as well. A comprehensive model of care is required for management, including proper assessment, treatment schedules, non-pharmacologic modalities and psychosocial support.

The continued growth of this epidemic needs to be realized and challenged. Coram’s Pain and Palliative Care program provides a comprehensive model that supports the treatment strategies for those suffering from unrelieved pain. We provide modalities to return the patient to their home. Our goal encompasses not only pain, but those suffering from symptoms such as nausea, vomiting, shortness of breath, etc. Our overall model is palliative, which means “to make feel better.” This strategy focuses on those with chronic ailments as well as those with life threatening illnesses.

The Pain Trajectory for the Bleeding Disorder Patient

Pain is an under-managed, misunderstood and often under-recognized issue in the bleeding disorder population. It has been reported that over 50 percent of Hemophilia A patients complain of pain throughout the day. The biggest concern is prompt recognition of what is causing the pain, what level of damage there is and applying the correct modalities to manage the pain. There is not only the initial bleed and pain associated with the inflammatory response, but also the chronic damage from blood going into the joints repeatedly. This continued mechanism leads to development of fibrosis and arthropathies within the joint. These patients suffer from nociceptive pain, as well as neuropathic input.

Both mechanisms of pain should be addressed when choosing the best modalities of treatment. Nociceptive pain can be managed by safer categories of non-acetylated salicylates, as well as opioids. Adjuvant medications, such as anticonvulsant therapy or antidepressant management are used primarily for neuropathic pain. Methadone is a common drug that is considered an opioid and an NMDA receptor antagonist, thus effective with both types of pain input.

There is also the emotional and psychological impact of pain that needs recognition. Physiologically, the pain message ascends into the sensory cortex of the brain and is perceived in the limbic system, which controls emotional output. The limbic system impacts mood, appetite, sexual desires, REM-cycle sleep patterns and more. If there is a constant negative input into that limbic system, its emotional output is negatively impacted. There is a great correlation with depression, fatigue, decreased appetite and isolation. When you aggressively and properly manage the pain, you will actually see a change in these emotional outputs.

The philosophy behind proper pain management is that pain is an actual disease process and needs to be addressed in that manner. Pain is no longer considered a symptom to the condition we battle, but actually a co-morbid disease that compounds the underlying disease landscape. When pain is left unrelieved, the nervous system actually remodels itself in correlation to pain input.

The proper management of pain for patients with bleeding disorders will dramatically affect the perceived outcomes for patients, and positively promote patient satisfaction and their overall quality of life.

Common ICD-9 Codes

Below is a list of certain ICD-9 codes associated with pain; this list is not all-inclusive. Please note that ICD-9 codes are updated on a regualr basis. Always double check that you are using the current and correct code.

Bug of the Month: Clostridum Difficile

Gram-positive C. difficile bacteria. The bacteria can be spread or contaminate surfaces through hand contact.; image courtesy of the CDC/ Lois S. Wiggs.

Clostridium difficile (C. difficile) is a gram-positive, spore-forming anaerobic bacillus associated with a potentially dangerous gastrointestinal infection. Clostridium difficile-associated disease (CDAD) is an ever-increasing threat in both the hospital and community with both an increased incidence and severity. In addition, CDAD appears to be increasingly difficult to treat, potentially due to a more virulent and resistant strain of C. difficile.

C. difficile accounts for 15 percent to 25 percent of all episodes of antibiotic-associated diarrhea, causing gastrointestinal infections. These infections range from asymptomatic colonization, mild disease, severe diarrhea, pseudomembranous colitis, toxic megacolon, intestinal perforation, and death. C. difficile should be suspected in any adult with antimicrobial-associated diarrhea, even if antibiotic treatment was completed days or weeks prior. It is important to recognize that mild CDAD can quickly progress to moderate or severe disease and the lines of distinction are not always clear.

Clinical Presentation

C. difficile is shed in feces and spread via the fecal-oral route. A significant number of patients are colonized with C. difficile and while asymptomatic themselves, can spread the pathogen. C. difficile spores are difficult to eradicate with standard environmental cleaning solutions and any surface that becomes contaminated with feces, such as commodes, light switches, sinks and hospital equipment, may serve as a reservoir. C. difficile spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item.

C. difficile spores are resistant to stomach acids so once taken in orally, they pass through the stomach intact. They change to their active form and multiply in the colon.

Two things have to happen in order for C. difficile to establish itself in the colon and either colonize or cause disease: the spores must be ingested and the normal flora of the colon must be disrupted. This disruption is a response to antibiotics.

The C. difficile spore produces two toxins that actually cause the disease and symptoms. Toxin A attracts neutrophils and monocytes, while toxin B degrades the colonic epithelial cells. Together they cause fluid and mucous secretion. In addition to mucosal inflammation and damage, this results in diarrhea or colitis.

Only toxigenic strains of C. difficile produce clinical disease, but even in the presence of toxins A and B, clinical disease may not present. Other host factors such as colonization or altered immunity likely contribute.

Risk Factors for CDAD
The most significant risk factor for the development of CDAD is the use of antibiotics. More than 90 percent of healthcare-associated C. difficile infections occur after or during antimicrobial therapy, and almost all antimicrobial agents except for aminoglycosides have been associated with CDAD. The risk is greater when patients receive multiple antimicrobial agents and undergo a longer course of therapy. Length of hospital stay is a risk factor as well. The rate of C. difficile acquisition is estimated to be 13 percent in patients with hospital stays of up to two weeks, and 50 percent in those with hospital stays longer than four weeks. Additional risk factors include age greater than 65 years, severe underlying illness, nasogastric intubation and antiulcer medications.

Diagnosis
Diagnosis of CDAD is based primarily on symptoms and the patient’s history of antibiotic use. Patients typically present with foul smelling, watery diarrhea (more than three episodes in 24 hours) and other GI symptoms as identified above. Importantly, symptoms can appear immediately after initiating antimicrobial therapy, or they may not develop until several weeks after completion of the therapy. In one study of cancer outpatients, the median interval from hospital discharge to CDAD diagnosis was 20.3 days (a range of two to 60 days).

The most sensitive laboratory test for C. difficile is an anaerobic stool culture. The stool sample must be from a diarrheal stool versus a formed stool. Disadvantages of stool culture, however, include its labor intensity and the incidence of false positive or false negative results. C. difficile toxin is unstable and degrades at room temperature. It may be undetectable within two hours after collection of a stool specimen unless the specimen is promptly tested or kept refrigerated until testing can be done.

Anaerobic bacterial culture is not routinely ordered due to its turnaround time, cost and the lack of standardization of culture methods or media. Antigen detection testing for C. difficile is quick, with results in less than an hour, and detects the presence of C. difficile antigen. This must be combined with toxin testing to verify diagnosis.

Toxin testing for C. difficile includes enzyme immunoassay to detect toxins A and B or tissue culture cytotoxicity. Tissue culture cytotoxicity assay detects only toxin B, but does provide specific and sensitive results for CDAD.

standardization of culture methods or media. Antigen detection testing for C. difficile is quick, with results in less than an hour, and detects the presence of C. difficile antigen. This must be combined with toxin testing to verify diagnosis.

Toxin testing for C. difficile includes enzyme immunoassay to detect toxins A and B or tissue culture cytotoxicity. Tissue culture cytotoxicity assay detects only toxin B, but does provide specific and sensitive results for CDAD.

Treatment
Stopping the inciting antibiotic is the key to the treatment of CDAD and often that is enough for patients to recover. Oral antibiotic therapy may also be needed in the form of metronidazole or vancomycin. Historically, metronidazole has proven as effective as oral vancomycin with over a 90 percent response rate, and is less expensive. It also diminishes the risk of vancomycin resistance. Thus, it is typically given as first-line therapy. However, more recent data is showing a lower response rate of 78 percent. Current recommendations are metronidazole as first-line treatment for most cases of CDAD, carefully monitoring response to therapy and oral or intraluminal vancomycin for patients with moderate or severe disease.

Antiperistaltic agents are contraindicated and narcotic agents are to be avoided. Occasionally, if the CDAD progresses, surgery may be needed.

Reinfection or Relapse
Recurrence, whether it be reinfection or relapse, is one of the most frustrating and challenging complications of CDAD. A second episode of CDAD develops in 12 to 24 percent of patients within two months of the initial diagnosis. If a patient has two or more episodes of CDAD, the risk of additional recurrences increases to 50 to 65 percent.

Do You Know?

What percentage does pain play in the primary reason for re-hospitalization for GI patients nationally?

1. a) 10%
2. b) 35%
3. c) 41%
4. d) 85%

Answer – d) 85%

Resource Center

World Hospice and Palliative Care Day — October 11
Saturday, October 11, is World Hospice and Palliative Care Day, which is a unified day of action to celebrate and support hospice and palliative care around the world. Its aim is to raise awareness and understanding of the needs — medical, social, practical, spiritual — of people living with a life-limiting illness and their families. This year’s theme is “Hospice and palliative care: a human right.” For more information or to learn how you can participate, visit www.worldday.org.

American Pain Society
The American Pain Society is a multidisciplinary community that brings together a diverse group of scientists, clinicians and other professionals to increase the knowledge of pain and transform public policy and clinical practice to reduce pain-related suffering. Their website, www.ampainsoc.org, contains links to publications, information about advocacy and a wealth of additional resources.

National Hemophilia Foundation
The National Hemophilia Foundation is dedicated to finding better treatments and cures for bleeding and clotting disorders and to preventing the complications of these disorders through education, advocacy and research. Established in 1948, the National Hemophilia Foundation has chapters throughout the country. Its programs and initiatives are made possible through the generosity of individuals, corporations and foundations as well as through a cooperative agreement with the Centers for Disease Control and Prevention. For more information, visit www.hemophilia.org.

Bibliography

• Turk, D. C. (2006) APS Bulletin, 16, no.1.
• Sunenshine, RH, McDonals, LC (February 2006). Clostridium difficile-associated disease: New challenges from an established pathogen. Cleveland Clinic Journal of Medicine, 73(2), 187- 19.
• Palmore TN, Sohn S, Malak SF, Eagan J, Sepkowitz KA. (2005). Risk factors for acquisition of Clostridium difficile-associated diarrhea among outpatients at a cancer hospital. Infect Control Hosp Epidemiol 2005; 26:680–684.
• Bignardi GE. Risk factors for Clostridium difficile infection. J Hosp Infect 1998; 40:1–15.
• Musher DM, Aslam S, Logan N, et al. Relatively poor outcome after treatment of Clostridium difficile colitis with metronidazole. Clin Infect Dis 2005; 40:1586–1590.
• McFarland LV. (2005). Alternative treatments for Clostridium difficile disease:what really works? J Med Microbiol; 54:101–111.
• Dial S, Delaney J, Barkun A, Suissa S (2005). Use of gastric acid-suppressive agents and the risk of community-acquired Clostridium difficile-associated disease. JAMA 294 (23): 2989–95. doi:10.1001/jama.294.23.2989. Retrieved July 28, 2008.