Pain Management

Pain Management 150 150 Tony Guo

Pain Management

  • Pain is a complex, multidimensional experience that can cause suffering and decreased quality of life 
  • One major reason people seek health care

 

Definition of Pain

  • “Whatever the person experiencing pain says it is, existing whenever the person says it does.” Margo McCaffery
  • “Unpleasant sensory and emotional experience associated with actual or potential tissue damage.” IASP

Magnitude of Pain problem

  • 25 million people experience acute pain from injury or surgery 
  • Chronic pain affects over a million American adults
  • 60% of cancer patients experience pain during treatment
  • Despite the prevalence of pain, many studies document inadequate pain management across care settings and patient populations
  • Consequences of untreated pain
    • Unnecessary suffering
    • Physical and psychosocial dysfunction 
    • Immunosuppression 
    • Sleep disturbances

 

Description of Pain

  • Subjective: Patient’s experience and self-report are essential
    • Can be problematic when dealing with special populations (coma or dementia)
  • Nonverbal information such as behaviors aids the assessment of pain

 

Dimensions of Pain

  • Biopsychosocial Model of Pain
    • Physiologic
    • Affective
    • Cognitive
    • Behavioral
    • Sociocultural

Pain Mechanisms

  • Nociception: Physiologic process that communicates tissue damage to the CNS
    • Involves 4 processes:
      • Transduction – occurs when there is release of chemical mediators
        • Noxious stimuli cause cell damage with the release of sensitizing chemicals
  • Prostaglandins
  • Bradykinin
  • Serotonin
  • Substance P
  • Histamine
  • These substances activate nociceptors and lead to generation of action potential
  • Transmission – involves the conduct of the action potential from the periphery (injury site) to the spinal cord and then to the brainstem, thalamus, and cerebral cortex
    • Action potential continues from
  • Site of injury to spinal cord
  • Spinal cord to brainstem and thalamus
  • Thalamus to cortex for processing
  • Perception – conscious awareness of pain
    • Conscious experience of pain
  • Modulation – involves signals from the brain going back down the spinal cord to modify incoming impulses
    • Neurons originating in the brainstem descend to the spinal cord and release substances (e.g., endogenous opioids) that inhibit nociceptive impulses

 

Classification of Pain

  • By underlying pathology
    • Nociceptive: Somatic or Visceral
    • Neuropathic: CNS or PNS Damage
  • By duration 
    • Acute
    • Chronic

Acute Pain

  • Sudden onset
  • Less than 3-month for normal healing to occur
  • Mild to severe 
  • Generally a precipitating event or illness can be identified
  • Manifestations reflect sympathetic nervous system activation:
    • Increased heart rate
    • Increased respiratory rate
    • Increased blood pressure

Chronic pain

  • Persistent pain and causes may be unknown
  • Gradual or sudden onset
  • More than 3-month duration; may start acute but continues past normal recovery time
  • Does not go away; characterized by periods of waxing and waning
  • Behavioral manifestations
    • Decreased physical movement/activity
    • Fatigue
    • Withdrawal from others and social interaction
  • Can be disabling and accompanied by anxiety and depression
  • Treatment goals
    • Control to the extent possible
    • Focus on enhancing function and quality of life

 

Nursing Roles

  • Assess pain and communicate with other health care providers
  • Ensure initiation of adequate pain relief measures
  • Evaluate effectiveness of interventions
  • Advocate for those in pain

 

Pain Assessment

  • Elements (multidimensional)
    • Direct interview
    • Observation
    • Diagnostic studies
    • Physical examination
  • Characteristics
  • Onset
  • Pattern
  • Duration
  • Location
  • Associated symptoms
  • Intensity
  • Factors increasing or relieving pain
  • Quality

 

  • Intensity of pain
    • Reliable measure for determining treatment
    • Rated using scales 
    • 0 to 10
    • Use observational skills for nonverbal patients
  • Quality
    • Pain quality
      • Nature or characteristics
  • Sharp, aching, burning, numbing, stabbing, electric shock-like, throbbing
  • Associated symptoms
    • Can worsen pain
      • Anxiety
      • Fatigue
      • Depression

Pain Treatment Principles

  1. Follow principles of assessment
  2. Use a holistic approach to pain management
  3. Every patient deserves adequate pain management
  4. Treatment based on patient’s goals
  5. Use drug and nondrug therapies
  6. Address pain using an inter-professional approach
  7. Prevent and/or manage medication side effects
  8. Incorporate patient and caregiver teaching throughout assessment and treatment

 

Documentation

  • Documentation is critical to ensure effective communication pain assessment tools
  • Multidimensional pain assessment tools

Pain Reassessment

  • Critical to reassess at appropriate intervals, guided by
    • Pain severity
    • Physical and psychosocial condition
    • Type of intervention
    • Risks of adverse effects
    • Institutional policy

Drug Therapy

  • 3 categories of medications
    • Non-opioid
      • acetaminophen, aspirin and other salicylates, and NSAIDs
    • Opioid
      • Produce their effects by binding to receptors in the CNS categorized according to their physiologic action (i.e., agonist, antagonist) and binding at specific opioid receptors (e.g., mu, kappa, delta).
    • Adjuvant
      • Analgesic adjuvants are drugs that can be used alone or in conjunction with opioid and non-opioid analgesics. 
      • Generally, these agents were developed for other purposes (e.g., anti-seizure drugs, antidepressants) and found to be effective for treating pain.

Administration

  • Scheduling
    • Focus on prevention or control
    • Do not wait for severe pain
    • Constant pain requires around-the-clock administration (not PRN)
    • Fast-acting drugs for breakthrough
  • Titration
    • Dose adjustment based on assessment of analgesic effect versus side effects
    • Use the smallest dose to provide effective pain control with fewest side effects
  • Administration Routes
    • Oral
      • Route of choice with functioning GI system
      • Doses are larger due to first pass effect
    • Trans-mucosal and buccal route
      • Fentanyl lozenge on a stick
      • Cannabinoid extract spray
    • Intranasal route
      • Delivery to vascular mucosa, avoiding first-pass effect
    • Rectal
      • Useful in the case of severe nausea or vomiting
    • Transdermal route
    • Parenteral routes
      • IM (Intramuscular), SQ (Subcutaneous), and IV (Intravenous) 
    • Intra-spinal delivery
      • Highly potent (smaller doses necessary)
    • Implantable pumps
    • Patient-controlled analgesia (PCA)
      • A dose of opioid is delivered when the patient decides a dose is needed
      • Patient pushes a button to deliver a bolus dose of opioid IV
      • Teach patient that they cannot “overdose”
    • Intra-spinal delivery
      • Epidural space (epidural)
      • Subarachnoid space (intrathecal)
      • Intermittent bolus or continuous infusion
      • Delivered close to receptors in the dorsal horn
  • Nondrug Therapy
    • Massage
    • Exercise
    • TENS or PENS
      • Transcutaneous/ percutaneous electrical nerve stimulation (TENS/PENS) involves the delivery of an electric current through electrodes applied to the skin surface over the painful region, at trigger points, or over a peripheral nerve
    • Acupuncture
      • Traditional Chinese medicine
    • Heat or cold therapy
    • Cognitive therapies
      • Hypnosis and Distraction
      • Relaxation strategies

 

Nursing and Inter-professional management

  • Effective communication
  • Patient’s report of pain is believed, is not perceived as “complaining”
  • The nurse communicates concern and affirms her commitment to the patient
  • Common concerns
    1. Tolerance
      • Occurs with chronic exposure to a variety of drugs
      • Very high opioid doses can result in opioid-induced hyperalgesia (OIH) rather than pain relief, thus increase in the dose can lead to higher pain levels.
  • Need for increased dose to maintain same degree of pain control
  • Rotate drug if tolerance develops, as increasing dose could result in opioid-induced hyperalgesia (OIH)
  1. Physical dependence
    • It is manifested by a withdrawal syndrome when the drug is abruptly decreased.
  • To avoid withdrawal, drug should be tapered
  1. Pseudo-addiction
    • Inadequate treatment of pain where the patient exhibit behaviors commonly associated with addiction and commonly labelled as “drug seeking” resulting in mistrust between them and caregivers.
  2. Addiction
    • Neurobiological condition with drive to obtain and take substances for other than prescribed therapeutic value
  • Tolerance and physical dependence are not indicators of addiction

Reducing barriers to pain management

Barrier Nursing Consideration
Fear of addiction
  • Explain that addiction is uncommon in patients taking opioids for pain.
Fear of tolerance
  • Teach that tolerance is a normal physiologic response to chronic opioid therapy. If tolerance does develop, the drug may have to be changed (e.g., morphine in place of oxycodone).
  • Teach that there is no absolute upper limit to pure opioid agonists (e.g., morphine). Dosages can be increased, and patient should not save drugs for when the pain is worse.
  • Teach that tolerance develops more slowly to analgesic effects of opioids than to side effects (e.g., sedation, respiratory depression). Tolerance does not develop to constipation. Thus a regular bowel program should be started early.
Concern about side effects
  • Teach methods to prevent and to treat common side effects.
  • Emphasize that side effects such as sedation and nausea decrease with time.
  • Explain that different drugs have unique side effects, and other pain drugs can be tried to reduce the specific side effect.
Fear of injections
  • Explain that oral medicines are preferred.
  • Emphasize that even if oral route becomes unusable, transdermal or indwelling parenteral routes can be used rather than injections.
Desire to be “good” patient
  • Explain that patients are partners in their care and that partnership requires open communication by both patient and nurse.
  • Emphasize to patients that they have a responsibility to keep you informed about their pain.
Desire to be stoic
  • Explain that although stoicism is a valued behavior in many cultures, failure to report pain can result in under treatment and severe, unrelieved pain.
Forgetting to take analgesic
  • Provide and teach use of pill containers.
  • Provide methods of record keeping for drug use.
  • Recruit caregivers to assist with the analgesic regimen.
Concern that pain indicates disease progression
  • Explain that increased pain or the need for analgesics may reflect tolerance.
  • Emphasize that new pain may come from a non–life-threatening source (e.g., muscle spasm, urinary tract infection).
  • Institute drug and nondrug strategies to reduce anxiety.
  • Ensure that patient and caregivers have current, accurate, comprehensive information about the disease and prognosis.
  • Provide psychologic support.
Sense of fatalism
  • Explain that pain can be managed in most patients.
  • Explain that most therapies require a period of trial and error.
  • Emphasize that side effects can be managed.
Ineffective medication
  • Teach that there are multiple options within each category of medication (e.g., opioids, NSAIDs), and another medication from the same category may provide better relief.
  • Emphasize that finding the best treatment regimen often requires trial and error.
  • Incorporate nondrug approaches in treatment plan.

 

Ethical Issues – Pain Management

  • Fear of hastening death by administering analgesics 
  • Requests for assisted suicide
  • Use of placebo in pain assessment and treatment
  • Gerontologic consideration
    • Persistent pain is a problem associated with physical disability and psychosocial problems
    • 50% to 80% of older adults are estimated to have chronic pain problems
    • Most common painful conditions
      • Musculoskeletal 
  • Osteoarthritis 
  • Low back pain
  • Chronic pain often results in 
    • Depression
    • Sleep disturbance
    • Decreased mobility 
    • Decreased health care utilization 
    • Physical and social role dysfunction.

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