Pain Assessment and Management

According to the Joint Commission Statement on Pain: "The hospital assesses and manages the patient's pain." The current Joint Commission standard requires that facilities implement pain assessment policies, treat pain, and carry out staff education to ensure the implementation of proper policies (Joint Commission, 2017).

Regardless of the patient setting, the intensity of pain should be assessed and documented:

1. During the initial evaluation of the patient
2. After any known pain-producing procedure
3. With each new report of pain, and
4. At suitable intervals after pharmacologic (45-60 minutes after an oral intervention; 15-30 minutes after parenteral intervention) or non-pharmacologic intervention to evaluate the current pain treatment plan

Pain threshold refers to the minimal level at which an individual senses pain as a harmful stimulus. The level at which the patient first states that what they are feeling is painful, and as such, varies significantly from patient to patient. Pain tolerance refers to the degree of pain a person can tolerate before it becomes unbearable. Pain tolerance differs from patient to patient and varies for the same individual depending on numerous factors, including time, setting, and stimulus. Healthcare providers must resist the temptation to compare patients' pain threshold and tolerance, especially those with similar procedures.

Measuring the severity of pain is often done on scales. Pain scales compare the patient's pain at different times, not to compare one person's pain. The use of pain scales assists the healthcare provider in determining the effectiveness of pain treatment.

The best scales are brief, valid, require minimal training, and use behavioral and descriptive pain measures. When selecting a scale, it is important to consider which scale would work best for the individual patient. Patient education regarding pain assessment is also important; for example, before a surgical procedure, the nurse needs to discuss how their pain will be assessed after the surgery and demonstrate how the Numbering Rating Scale and the Wong-Baker FACES Pain Rating Scale work. After explaining each to the patient, allow the patient to choose which scale will work better.

A "0 to 10" numerical scale is the most widely used measure to assess pain intensity. When using the Numerical Rating Scale (NRS), patients rate their pain from 0 to 10, with "0" equaling no pain and "10" equaling the worst possible pain they can imagine. This numeric pain scale has become widely used. Still, an unexpected result of its use is the practice of prescribing specific doses of opioid pain medication centered exclusively on pain intensity. Prescribing pain medication in this way is a practice that is commonly referred to as "Dosing to Numbers" and has become an issue for several reasons: pain ratings are a completely subjective finding, pain cannot be measured objectively, and pain ratings are frequently not a repeatable finding even for the same patient.

No research indicates that a given dose of opioids will produce pain relief for a specific pain intensity level in all patients. In a position paper released by the American Society of Pain Management Nursing (ASPMN), the organization states that "prescribing doses of opioids based solely on a patient's pain intensity should be prohibited." The ASPMN believes that this practice does not consider other facets of pain management assessment, and basing opioid administration entirely on a numeric value on a pain intensity scale results in poor pain control. The ASPMN advocates that "safe and effective opioid dosing is dependent on the careful assessment of multiple objective measures," and they include in these findings the following (American Chronic Pain Association, 2020):

• Age of the patient
• Other existing healthcare conditions
• Level of sedation
• Patient's respiratory status
• Other sedating medications being used
• Patient's previous response to opioid medication
• A subjective measure of pain intensity

Another scale allows the patient to rate their pain as "no pain, mild pain, moderate pain, severe pain, or unbearable pain." Pain maps can be used for those who have a difficult time speaking. In a pain map, there is a front and rear view of the body on a piece of paper, and the patient draws on the pain's location and rates the pain's severity.

Since we have no instrument to measure pain intensity, like a sphygmomanometer measures blood pressure objectively, the only valid measure of pain is the patient's self-report (a subjective measure). Sometimes, healthcare providers may believe they are the best judges of a person's pain; however, many studies demonstrate that healthcare providers either over or underestimate a patient's pain.

Patients who are NOT cognitively impaired but cannot respond verbally can rate their pain numerically using face scales, with happy faces representing no pain and progressively sadder faces representing increasing pain intensity. The patient chooses the face that best depicts how they are feeling. Being unable to report pain reliably makes a patient vulnerable to under-appreciation of their pain and the possibility of under-over-treatment. Nurses are essential in ensuring that pain is accurately assessed and treated in these vulnerable populations.

It is also important to document pain's impact on quality of life. Key questions to ask include:

• Does pain affect sleep?
• Does the pain lead to mood alterations?
• Does the pain lead to reduced energy?
• Does the pain reduce the patient's ability to participate in activities and socializing?
• Does the pain affect relationships?
• Does the pain limit or affect activity or exercise?
• Is the patient able to participate in daily living activities such as bathing, dressing, feeding, toileting, or brushing their teeth?
• Does the pain impact daily living (IADL) instrumental activities, such as using the telephone, doing the laundry, handling medications, or handling the finances? IADLs are less important in the nursing home setting as many are impaired at baseline, which is why there was nursing home placement.

Understanding how pain was treated in the patient will help the clinician treat the current pain. A review of past medical records will help the pain management team evaluate the condition. Reviewing all previous history, diagnostic testing, treatment options, and the efficacy of those treatment options will help the team make an accurate diagnosis and manage pain appropriately. Certain treatment modalities, including specific medications, are often more effective in one individual when compared to another based on individual genetic variations.

Having a full understanding of all medical and surgical conditions can help ensure patient pain management. Chronic disease may have a substantial impact on the management of pain. Chronic kidney disease, for example, reduces medication excretion. Using non-steroidal anti-inflammatory medications can lead to kidney failure in chronic kidney disease patients.

A mental health evaluation can help the clinician understand the best way to manage pain. Mood or cognitive disorders can affect the way the pain is managed. Chronic pain cannot be adequately managed in those with unidentified and untreated mental illness. A history of drug abuse is essential to ascertain, which could profoundly affect chronic pain treatment. Personal characteristics may have a substantial effect on pain management. Factors influencing pain include race, age, culture, religion, sex, or language.

A review of the patient's perception of the pain is essential. Why does the patient believe they have persistent pain? Does the patient feel there was adequate workup done on their condition? What does the patient expect from treatment, and what are the patient's goals? Psychological factors contributing to the pain should be assessed to help assess the patient's expectations. Patients need to have realistic expectations about pain management.

A complete physical exam is an essential part of the management of pain. It is vital to have a baseline examination so subsequent evaluations will allow the healthcare team to determine pain management and functional capacity progress.

The physical exam should include a detailed neurological exam, including the patient's ambulation ability. Observing hygiene, posture, dress, and appearance is essential. Those with severe pain often have poor hygiene, unkempt dress, and appear to be in pain. Observe for any splinting, which may suggest a painful body part. Assessing skin and joints for redness, swelling, or deformities helps determine the location and etiology of pain. Perform an abdominal exam for any tenderness or distention. Also, checking joints for a full range of motion is essential to the physical exam in chronic pain. The exam should include an evaluation of functional capacity, strength, endurance, and any pain-related limitations.

Ongoing monitoring for the efficacy and effectiveness of the implemented plan is essential. Utilizing similar assessment tools, the healthcare provider can document the effectiveness of the pain management plan on the patient, including improving the quality of life.

Diagnostic testing can help evaluate painful conditions. It is essential to realize that an abnormal diagnostic test does not confirm the source of the pain. Blood tests can be helpful in some conditions to determine or monitor specific causes of pain. For example, an elevated C-reactive protein or an erythrocyte sedimentation rate may be seen in those with polymyalgia rheumatica, infection, or rheumatoid arthritis (all conditions that may cause pain).

Imaging may be necessary for some situations of chronic pain. X-rays, computed tomography, and magnetic resonance imaging can help define the etiology of the pain. Use caution when imaging, as many abnormalities that are not the pain source may be seen in imaging tests.

An electromyogram (EMG) or nerve conduction studies are often done to assess the cause of pain. The EMG measures the muscle's electrical activity and can help find damaged muscle, nerves, or neuromuscular abnormalities such as a herniated disc or myasthenia gravis. The nerve conduction study measures the nerves' ability to send electrical signals and helps diagnose carpal tunnel syndrome or other neuropathies.

Numerous non-pharmacologic therapies manage pain. These may include a combination of physical and psychological techniques. Some methods used other than medications include physical therapy, exercise, massage, ultrasound therapy, heat/cold application, chiropractic manipulation, psychotherapy, biofeedback, relaxation therapy, acupuncture, transcutaneous electrical nerve stimulation (TENS), music therapy, injections, neuromodulation, spinal cord stimulation, deep brain stimulation, and radiofrequency ablation of nerve tissue.

For those with pain, a physical or occupational therapy trial can be helpful. With the help of a physical therapist, exercises targeting a specific type of pathology can help manage pain. Occupational therapists can help recommend devices that can enhance daily living activities. With chronic pain, there is a tendency not to move, which leads to deconditioning and other incapacities—deconditioning results in greater pain with any form of movement. Maintaining muscle mass prevents this downward spiral. It has also been shown that the more an individual participates in exercise, the less probability they develop back pain. Physical activity has been shown to improve their overall health significantly for those with lower back pain. Exercise, especially those performed in water, benefits patients with arthritis pain, and aerobic exercise has effectively decreased pain connected with fibromyalgia (Moller, 2014).

Yoga and Pilates have also become popular alternative treatments, especially for back pain. However, some yoga poses can be a potential cause of injury, especially those that involve overstretching of the neck. Tai Chi, another Chinese practice involving slow, gentle movements, deep breathing, and relaxation, has positive effects on pain relief for several conditions, including fibromyalgia, arthritis, and low back pain (Moller, 2014).

Massage is soothing and relaxing, both physically and mentally. Massage may decrease pain by relaxing muscle tension and increasing capillary circulation, thereby improving general circulation.

Vibration is a form of electric massage. When vibration is applied lightly, it may have a soothing effect similar to massage. Vibration applied with moderate pressure may relieve pain by causing numbness, paresthesia, and anesthesia of the area stimulated.

Heat and cold therapies can assist in the management of pain. Heat reduces inflammation and promotes relaxation. It can be in the form of hot tub baths, heating pads, or heat packs. Cold is often more effective in relieving pain than heat. The application of cold reduces muscle spasms secondary to underlying skeletal muscle spasms, joint pathology, or nerve root irritation. Cold application methods include ice massage, ice bags, and gel packs. Alternating heat and cold may be more effective than using either one alone.

Multiple psychological techniques can aid in reducing pain. The basis for using these methods is that thought influences feelings, and if thought (and behaviors) can be changed, so can feelings and even sensations, such as pain. Cognitive-behavioral methods require the patient's active participation. Cognitive-behavioral therapy (CBT) has proven to be an effective coping skill for those with chronic pain. CBT emphasizes the present moment, where individuals become aware of their thoughts, feelings, and behaviors and journal these perceptions. CBT helps decrease the emotional distress associated with chronic pain by focusing on how one perceives pain and adjusts to it. CBT has decreased pain in chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, and back pain. It has also been used successfully to prevent headaches (Moller, 2014).

Relaxation is a state of relative freedom from anxiety and skeletal muscle tension, a quieting or calming of the mind and muscles. Although relaxation is a learned technique, it can be achieved quickly in a motivated patient.

Imagery/Visualization involves mentally creating a picture by using one's imagination. This mental picture may focus on a close person, a place of enjoyment, a past event, or anything that brings pleasure. An occupied mind does not focus on the pain.

Distraction from pain is focusing on stimuli other than the pain sensation. The stimuli focused upon can be auditory, visual, or tactile-kinesthetic (hearing, seeing, touching, and moving). Focusing on stimuli other than pain moves the pain to the periphery of awareness. Distraction does not make the pain go away, nor does the effectiveness of distraction indicate the absence of pain. Music and humor are good means of distraction.

Transcutaneous Electrical Nerve Stimulation (TENS) provides low-voltage electricity to the body via electrodes placed on the skin. TENS may help with acute or chronic pain. Electrical stimulation of sensory nerves helps block pain signals going to the brain. TENS is contraindicated in patients with pacemakers, electrical implants, cardiac arrhythmias, circulation problems, and pregnancy (DeSantana et al., 2008).

Biofeedback is a technique to harness the mind's power to allow the patient to be more aware of the body's sensations. The exact mechanism is unclear, but it promotes relaxation and helps reduce pain (NIH, 2018).

Acupuncture is a neurostimulation technique that treats pain by inserting small, solid needles into the skin at varying depths. Various theories exist to explain how acupuncture works. The Chinese acupuncture theory is that it allows the release of blocked energy in the body. In Chinese medicine, this energy source is known as Qi, and its ability to flow freely through the body is related to overall well-being (NIH, 2018).

Music therapy treats pain. Music therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a credentialed professional's therapeutic relationship. This individual has to complete an approved music therapy program. Research in music therapy supports its effectiveness in a wide variety of healthcare and educational settings.

Music therapists use music to facilitate changes that are non-musical. Individuals doing music therapy listen to music created under the guidance of a specially educated and certified professional in music therapy.

Like relaxation and guided imagery, music can strengthen the brain's right side, which controls the body's healing processes. The theory of music therapy's effect on chronic pain deals with how pain signals travel through the body. When the brain senses injury to the body, pain signals begin in the somatosensory cortex and the hypothalamus and work their way through the "pain pathway," ultimately sending pain relief signals. Some signals stimulate the release of neurotransmitters such as endorphins, dynorphins, and enkephalins. Music helps in pain reduction by activating these sensory pathways.

Different surgical interventions or procedures can be used in the pain management plan. Procedures may include injections, spinal cord stimulation, deep brain stimulation, neural ablative techniques, and surgical interventions. These are potential options for those in whom other methods have not controlled the pain.

Undertreatment of chronic pain remains a persistent problem, with approximately 30% of those who suffer from chronic pain receiving less than adequate treatment. Pain medication decreases pain by altering transmission at various points of the pain pathways (American Chronic Pain Association, 2020).

Prescribing oral analgesic agents is convenient and allows a relatively steady blood concentration of the drug. Pain medication may be administered as needed for episodic pain or given routinely for chronic pain. Routine, around-the-clock medication sustains a steady state in the blood and offers better pain relief for those with persistent pain. Consider side effects when deciding which drug to use.

Medication classes include non-opioid analgesic agents, antidepressants, muscle relaxants, antiepileptic medications, topical agents, and opioids. Some get adequate relief from one medication, but some get better pain relief from a combination of medications that work on different pathways. Unfortunately, research is sparse on combination medication in the management of pain.

Considering all co-morbidities is an essential step in the management of pain. For example, when a patient suffers from chronic pain and depression, some medications may help effectively manage both conditions (for example, duloxetine is approved to treat chronic musculoskeletal pain, including discomfort from osteoarthritis and chronic lower back pain in addition to depression). It is also essential to establish the pain syndrome's pathophysiology, evaluate the medication list, and consider its side effects.

The clinician should distinguish between neuropathic pain and nociceptive pain. Establish the etiology of neuropathic pain and, if the etiology is reversible, manage the underlying problem. For example, if a medication (e.g., metronidazole, nitrofurantoin, isoniazid, or many cancer agents) is the cause of the neuropathy, stop that medication.

Medications used in treating neuropathic pain include calcium channels alpha 2-delta ligands (gabapentin and pregabalin), tricyclic antidepressants, serotonin-norepinephrine uptake inhibitors (SNRIs), the lidocaine patch, and narcotic analgesics.

Treat nociceptive pain with non-narcotic and opioid analgesia. Common causes of nociceptive pain include arthritis and chronic low back pain. Acetaminophen is often used as a first-line agent in managing nociceptive pain.

Acetaminophen has become a chief cause of acute liver failure. According to government statistics, there are close to 30,000 hospital admissions annually associated with acetaminophen overdose (Yoon et al., 2016). Patients must be warned that alcohol and acetaminophen are a hazardous mixture, and alcohol consumption should be avoided when taking this medication. In January 2011, the Food and Drug Administration (FDA) requested drug manufacturers to limit acetaminophen in combined products to 325 milligrams per dose. The FDA also required that labels carry a 'black-box' warning, highlighting that acetaminophen can result in severe liver damage.

Acetaminophen is not an anti-inflammatory agent but is a very common over-the-counter medication used to manage pain. Acetaminophen is commonly administered with opioid medications to reduce the opioid medication needed to manage the pain.

Acetaminophen is dosed 325 to 650 mg every four hours or 500-1000 mg every 6 hours, not to exceed 3000 to 4000 mg a day. In the pediatric population, acetaminophen is dosed at 10-15 mg/kg/dose every 4-6 hours, with a maximum of 75 mg/kg/day, but no more than 4000 mg daily. Reduce the dose in those with hepatic insufficiency or alcohol abuse. Absolute contraindication to acetaminophen is liver failure, while relative contraindications include chronic alcohol abuse or hepatic insufficiency. Those on a statin cholesterol medication may need a lower dose of acetaminophen.

Before taking stronger pain medication, clinicians must determine that acetaminophen is properly dosed. The use of up to 1000 mg per dose (in adults) may be necessary to provide relief.

Non-steroidal anti-inflammatory drugs (NSAIDs) are used as alternative options to acetaminophen and are indicated for mild to moderate pain, and some manage severe pain. Like acetaminophen, they act synergistically with opioids.

Because they act as an anti-inflammatory agent, they are often used for arthritis, strains, sprains, bursitis, and tendonitis. Frequently used NSAIDs are acetylsalicylic acid (Aspirin, which is the oldest known NSAID), ibuprofen (Advil®, Motrin®), naproxen (Aleve®), and diclofenac (Voltaren®). NSAIDs inhibit the production of the enzymes cyclooxygenase 2 (COX-2) and cyclooxygenase 1 (COX-1) involved in the synthesis of prostaglandins that mediate inflammatory responses and also cause pain. COX-1 is involved in protecting the stomach lining from the damaging effects of acid, and one of the most frequently cited side effects of NSAIDs is stomach bleeding. Do not use aspirin in children under 17 because of the danger of Reye's Syndrome.

NSAIDs are associated with more side effects and are potentially more problematic, especially in older adults. In older adults, the American Geriatric Society guidelines recommend that persistent pain due to osteoarthritis not be primarily managed with non-steroidal anti-inflammatory agents (Ali et al., 2018). Topical NSAIDs are a good option for those with localized pain.

Absolute contraindications to NSAIDs include an active peptic ulcer, chronic kidney disease, or heart failure. Relative contraindications include a history of peptic ulcer disease, Helicobacter pylori infection, hypertension, or concomitant use of selective serotonin receptor inhibitors or corticosteroids.

NSAIDs' side effects include renal insults, adverse cardiovascular effects, headaches, constipation, and mental status changes. Gastrointestinal effects may include gastric ulceration and dyspepsia. Taking the medication with food or antacids may reduce the risk of dyspepsia. Those at high risk of gastric ulceration – older age, taking corticosteroids, bleeding problems, or a history of gastric ulceration – should not use NSAIDs. For those with compromised gastrointestinal tracts, using a proton pump inhibitor reduces the risk of gastric ulceration when NSAIDs are necessary. NSAIDs interact with many antihypertensive medications, selective serotonin reuptake inhibitors, corticosteroids, and warfarin.

NSAIDs have the potential to cause nephrotoxicity. They inhibit prostaglandin synthesis, which leads to vasoconstriction of the afferent arteriole in the kidney, thus reducing the glomerular filtration rate. They should be used cautiously in renal impairment patients (Ali et al., 2018).

NSAIDs lead to cardiovascular complications and increase the risk of myocardial infarctions, especially in patients who take high doses over a prolonged period. For those with high cardiovascular risk, their use should be limited.

Do not use NSAIDs in those with thrombocytopenia (low platelet count). Patients receiving warfarin or heparin should not receive NSAIDs. NSAIDs impede thrombocyte aggregation, which can increase the risk of bleeding.

Neonates feel pain like any other patient. Untreated pain or pain not treated appropriately may lead to long-term effects, including altered sensitivity to pain (Mathews, 2011).

It is important to have a standard method to assess pain in neonates. Assessing pain in neonates and infants is difficult because they cannot communicate. In this population, assessment is based on physiological and behavioral factors. Factors that suggest pain in neonates and infants include vital signs, oxygen saturation, skin color, crying pattern, facial expressions, muscle tone, and consolability. Scales for neonates' pain in the neonatal intensive care unit include the Neonatal Facial Coding System, the Neonatal Infant Pain Scale, and the Neonatal Pain Agitation and Sedation Scale. No tools are universally accepted to assess pain in infants and children. In neonates, pain assessment tools have difficulty detecting pain in patients with very low birth weight, paralytic medications, or prolonged pain (Mathews, 2011).

Due to the difficulty in finding and quantifying pain in the neonate and young child, pain management should include an attempt to reduce or prevent pain in the face of potentially painful situations. Limiting the number of painful procedures performed on young children is important.

Pain in children is similar to that of adults. The source of the pain, along with its location and severity, should be ascertained. In older children, self-reporting is a useful technique to assess pain. For those too young to understand self-reporting, scales such as the facial expression scale can be used. With the help of a caregiver, observing the child for verbal responses, motor responses, or facial expressions will help the clinician determine the degree of pain in a non-verbal child.

Pain management in children should work to control, lower, or prevent the pain. Pain management techniques are based on the severity, type, duration, and source of pain. Non-pharmacological measures to control pain include physical/occupational therapy and cognitive/behavioral therapy.

Pharmacological agents may also be considered. Mild pain can be managed with NSAIDs or acetaminophen; when pain is not responsive to these medications, stronger medications, including opioids, are considered. Regular assessment of pain control during treatment will help assure proper pain management. Providing pain medication around the clock is a reasonable option when pain is moderate to severe.

Adjunctive therapy can be used in children, including medications to manage co-morbid depression and anxiety. The use of anticonvulsants for neuropathic pain may also be considered.

Age does not cause pain, but many conditions that cause pain are more common in older adults. In general, older adults are undertreated regarding their pain partly because they have problems communicating pain (Feldt et al., 1998). Those with reduced vision, reduced hearing, or impairments in cognition present a bigger challenge in assessing pain.

In cognitively intact individuals, self-report of pain is the most reliable method to assess pain (AGS Panel on Persistent Pain in Older Persons, 2002). For those who have a cognitive impairment, simple questions and basic screening tools can often reliably identify pain. Long-term care residents are often afflicted with some degree of cognitive impairment. Residents of long-term care facilities may present with behavioral changes or physical changes as a presentation of pain.

Older adults may not report pain as readily as younger adults. Some older adults believe that pain is part of aging and therefore do not bother to discuss it with the health care team. When assessing older adults, it is important to determine their perception of pain. Some patients perceive severe pain as a sign of a serious illness or loss of independence, or they may believe this is just a consequence of aging.

When evaluating the older adult, it is important to have an accurate medication history, including herbal medicines and dietary supplements. Patients should also be asked about alcohol use, drug use, and tobacco use.

It is also important to determine the patient’s coping techniques. This determination will help the clinician understand how the patient functions and help them deal with the pain effectively. Many older adults use prayer and hope to assist in coping with pain.

Goals should be set for the patient to determine an acceptable level of pain to have a satisfactory life quality. Closely monitoring for adverse drug reactions is an important part of managing chronic pain, as pain medications have many side effects. A balance should be sought between the quality of life and the side effects/risks of the treatment.

Older adults have some physiological changes that affect the way medications are used. There is a slowing of the gastrointestinal transit time, extending the effects of continuous release medications. Changes in gastric pH may affect the absorption of some medications. Chronic liver changes may lead to changes in drug metabolism. Chronic renal insufficiency is common in older adults and may lead to reduced clearance of medications.

Since pain is a subjective experience, we measure the existence and intensity by the patient’s self-report. Unfortunately, adult patients who have cognitive/expressive deficits or who are intubated, sedated, and unconscious may not be able to provide a self-report. Individuals who cannot communicate their pain remain a challenge and are at greater risk for inadequate pain control.

When patients cannot self-report, other measures need to be used to detect pain. Even if they cannot speak for themselves, these patients have the right to pain assessment and management. Valid and reliable methods to assess pain in nonverbal patients are needed. The American Society for Pain Management recommends the following multifaceted approach to detect pain in this population (Herr et al., 2006).

• Use the Hierarchy of Importance of Measures of Pain Intensity for Nonverbal Patients:
  • Self-report of pain is the most reliable way to assess pain.
    • Although self-report may be possible with mild to moderate cognitive impairment, as dementia progresses, the ability to self-report decreases and eventually becomes impossible. However, even if patients cannot communicate the experience of pain, they still experience pain sensation.
    • Obtaining a report of pain from a critically ill patient may be hampered by such conditions as delirium, decreased level of consciousness, presence of an endotracheal tube, sedatives, and neuromuscular blocking agents, for example. In these situations, the patient’s ability to self-report may wax and wane; therefore, serial assessment of the ability to self-report should be conducted.
  • Search for Potential Causes of Pain.
    • Assume pain is present and intervene with common problems or procedures known to cause pain (e.g., surgery, wound care, positioning), even in the absence of behavioral indicators of pain.
    • Rule out or treat other problems that may cause discomfort (e.g., infection, constipation, urinary retention).
    • Consider chronic pain causes that may have been present before (e.g., history of arthritis or low back pain).
  • Observe patient behaviors – a good approach only when self-report is absent.
    • The American Geriatrics Society (Herr et al., 2006) identifies the following six main types of pain behaviors:
      • facial expressions (e.g., grimacing)
      • verbalizations or vocalizations (e.g., moaning)
      • body movements like tense body posture
      • changes in interpersonal interactions (e.g., aggression or resisting care)
      • changes in activity patterns (e.g., refusing food or increased wandering), and
      • mental status changes like crying or increased confusion
  • Encourage proxy pain rating by family members or caregivers who know the patient when they cannot provide self-reports of pain. Inquire about behaviors that may indicate pain or whether preexisting conditions may cause pain, such as arthritis, are present.
  • Attempt an analgesic trial with procedures or conditions that are likely to cause pain or when pain behaviors continue after attention to basic needs and comfort measures. Make appropriate adjustments such as increases in dose or addition of other analgesics if behaviors indicative of pain persist or additional potentially painful procedures occur.
    • Establish a Procedure for Pain Assessment
      • When patients cannot self-report pain, other less reliable measures must be used to identify its existence. These assessment measures (described above) form a hierarchy arranged in order of probable importance. Health care facilities should institute a procedure for using this hierarchy of assessment techniques as a template for the initial assessment and treatment procedure.
  • Use Behavioral Pain Assessment Tools, as Appropriate
    • The number of studies addressing pain assessment in nonverbal adults who cannot provide a self-report has increased recently. However, further study must demonstrate their reliability, validity, and usefulness in the clinical setting. When utilizing behavioral pain assessment tools, one must keep in mind the following considerations:
      • Scores obtained when utilizing behavioral pain assessment tools are NOT equivalent to self-reported intensity ratings and should never be documented. Only self-reported intensity ratings may be documented as the “5th Vital Sign”.
      • Pain behaviors may not indicate pain, but another source of distress, such as emotional distress.
      • It is best to observe a patient during care activities when pain behavior is more likely, rather than at rest.
      • Behavioral assessment tools may be helpful to identify the presence of pain. They can also evaluate attempts to relieve pain by observing a decrease in pain behaviors following an intervention.
        • At least 14 behavioral assessment tools have been developed to assess for pain in nonverbal patients with dementia. These tools are in varying stages of development and validation. When selecting a tool, choose one researched for reliability and validity in a similar clinical setting. Behavioral assessment tools for the cognitively impaired are of two types: pain behavior scales and pain behavior checklists.
      • Pain behavior scales are scored by identifying the degree of observed behavior. This score is not the same as a pain intensity score. An example of a pain behavior scale is the Pain Assessment in Advanced Dementia Scale (PAINAD). It evaluates and scores five behavior categories: breathing, negative vocalization, facial expression, body language, and consolability. Each category may receive a score ranging from 0 to 2. Any positive score may indicate that pain is present, and the score can be used to evaluate the intervention but cannot be interpreted to mean pain intensity. For a pain behavior scale to be used, the patient needs to respond in all behavior categories. For example, the PAINAD should not be used with a patient who has quadriplegia since body language could not be scored.
      • Behavior checklists differ from pain behavior scales. They do not evaluate the degree of observed behavior, but just its presence or absence, and do not require a patient to demonstrate all of the behaviors specified. An example of a pain behavior checklist is the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC). This checklist evaluates 60 behaviors such as restlessness, agitation, decreased activity, and appetite changes. The total number of behaviors that a patient exhibits cannot be equated with a pain intensity score. A patient who scores 5 out of 60 behaviors does not necessarily have less pain than a patient who scores 10 out of 60. In an individual patient, though, a change in the total number of behaviors may suggest more or less pain and can be used to evaluate response to interventions.
        • Tools developed to assess pain with mechanically ventilated and unconscious patients are fewer in number. One such tool – the Adult Nonverbal Pain Scale (NVPS) – was patterned after the Faces, Legs, Activity, Cry, Consolability Observation Tool (FLACC) - is used to assess pain in infants and children. When tools are adapted and used in different settings, they need to be tested for reliability and validity in the new patient population. The NVPS was tested in the burn trauma unit at Strong Memorial Hospital, Rochester, New York. After initial testing, a further revision was made to include a respiratory component with ventilator compliance. This revised scale, which scores the categories of facial expression, activity, guarding, physiology (vital signs), and compliance with the ventilator, is currently being implemented in several healthcare institutions while undergoing further testing (Barzanji et al., 2019).
        • Minimize Emphasis on Physiologic Indicators. Research does not support the use of vital sign changes for identifying pain. The absence of increased blood pressure, respiratory rate, or heart rate does not indicate an absence of pain.
        • Reassess and Document. Just as with patients who self-report pain, reassessment of pain with non-verbal patients needs to occur after the intervention and regularly over time. Reassessment should occur utilizing the same initial behavioral pain assessment tool and observing changes in those behaviors with effective treatment.

Pregnancy is associated with many changes that can cause pain, such as changing body shape, increasing weight, hormonal shifts, and joint laxity. Acetaminophen is considered a safe option for pain control throughout pregnancy (Thiele et al., 2013). NSAIDs should not be used in late pregnancy. If used in the third trimester, NSAIDs can lead to premature closing of the ductus arteriosus.

Many different pain syndromes are commonly seen in pregnancy. Mechanical back pain due to weight distribution changes is one of the most common types. Pain in the pubic symphysis is common and can be managed with position changes and pelvic support devices. Leg cramps may be prevented and treated with calf stretching. Carpal tunnel syndrome is often seen during pregnancy and is likely related to fluid retention, which causes compression of the nerves in the carpal tunnel. Symptoms of carpal tunnel syndrome most commonly occur in the third trimester and resolve after pregnancy but may be prolonged by breastfeeding.

Labor is a painful period, and treatment may involve various techniques. The most reliable pain management method is epidural and spinal analgesia techniques. The use of opioids induces sedation and thereby contributes to pain control. Unfortunately, opioids act systemically, and some effects may be transferred to the fetus, leading to respiratory depression in neonates.

Psychiatric disorders are three times higher in those with chronic pain than the general population. Depression, anxiety, and post-traumatic stress disorder are the most prevalent psychiatric disorders in patients with chronic pain (Renner, 2014). Patients with pain and psychiatric disease typically report more intense pain than those without co-morbid mental illness.

Chronic pain management has multiple challenges in psychiatric patients. Optimizing treatment of the underlying psychiatric illness is an important step to achieve an optimal reduction in pain. It is also important to screen and treat for any substance abuse or substance-induced disorder. This screening will help ensure appropriate and adequate treatment of pain. Medications with potential abuse should be used cautiously, as psychiatric patients have a high prevalence of drug use disorders. Exercise and cognitive behavioral therapy are important steps in managing pain in the psychiatric patient. Also, monitoring for compliance is an important part of managing a psychiatric patient who suffers from chronic pain.

Many conditions lead to visceral pain. Visceral pain occurs when there is stimulation of nociceptors of the organs in the abdomen, pelvis, or chest. Visceral pain is diffuse, hard to pinpoint, and often referred to from a remote structure. Visceral structures are aggravated by ischemia, inflammation, and stretch.

Chest pain can occur from many different etiologies. A few life-threatening situations must be considered, including myocardial infarction, pulmonary embolism, aortic dissection, tension pneumothorax, and esophageal rupture. Most chest pain is not life-threatening, and selected causes include chest wall pain (costochondritis, muscle strain), panic attacks, pneumonia, pleurisy, myocarditis, gastroesophageal reflux disease, and pericarditis.

Abdominal pain is a common problem, and most cases are not life-threatening. Like chest pain, it is essential to rule out serious causes of abdominal pain immediately. Severe causes of abdominal pain are suggested by unstable vital signs, high fever, an inability to pass gas or have a bowel movement, vomiting blood, or dark/tarry stools. Common potentially life-threatening diagnoses include acute bowel obstruction, acute mesenteric ischemia, bowel perforation, ulcer, acute myocardial infarction, and ectopic pregnancy. Other causes of abdominal pain include appendicitis, gallbladder disease, diverticulitis, constipation, kidney stones, lactose intolerance, and inflammatory bowel disease.

Many patients have chronic abdominal pain, and many of these cases are benign – functional dyspepsia or irritable bowel syndrome. If no organic disease is found, that patient should be treated symptomatically. Individuals over 50 are more likely to have a more serious cause of chronic abdominal pain. Functional abdominal pain should be made only after more serious causes have been ruled out.

Pelvic pain is a common problem in women and may represent a urologic, gynecologic, gastrointestinal, musculoskeletal, metabolic, or vascular issue. Acute pelvic pain may be of visceral or somatic origin. A pregnancy test should be done for all women who have the possibility of being pregnant. Other testing to rule out other pelvic pain causes includes a complete blood count, sedimentation rate, chlamydia/gonorrhea testing, a serum HCG level, and a urinalysis.

Diagnostic testing may include a pelvic ultrasound to rule out a mass or ectopic pregnancy, or laparoscopy can help determine if endometriosis is present. Features that suggest a severe pelvic pain cause include peritoneal signs, brisk vaginal bleeding, high fever, or unstable vital signs.

There are many potential causes of chronic pelvic pain. Diagnosing and treating chronic pelvic pain can be challenging. Determining the exact cause of the abdominal pain may include extensive laboratory evaluation, imaging modalities, and exploratory surgery. The examination may use a pain map for chronic pelvic pain and identify tender areas to see if physical exam tender areas match the pain map. Ideally, the clinician should attempt to treat the underlying cause of the pelvic pain. Still, a non-specific treatment may be considered without a specific diagnosis.

Sickle cell crisis is a vaso-occlusive phenomenon leading to pain associated with blood cell destruction and subsequent anemia. While not the only feature of sickle cell disease, pain is a significant component. Acute sickle cell disease pain is secondary to vaso-occlusion, tissue ischemia, and inflammation. Over time, chronic pain may result. Pain assessment is challenging in sickle cell crisis, as no objective findings definitively confirm a crisis or the degree of pain.

An acute painful episode can be precipitated by multiple events such as stress, infection, weather conditions, dehydration, or alcohol consumption. Pain can affect many body parts, such as the chest, back, extremities, or abdomen, and may be associated with fever, elevated breathing rate, hypertension, nausea, and vomiting.

Treatment of pain in chronic disease can be challenging to manage. If mild pain is present and the patient is not on regular opioid therapy, pain management should be started with non-opioid therapy and move to opioids when the pain becomes more severe. Individuals who are on chronic opioids will require additional opioids for breakthrough pain. When treated in the emergency room, intravenous morphine, hydromorphone, or fentanyl can be used. If pain cannot be relieved with two doses, admitting the patient to the hospital for pain management may be necessary. Many patients with sickle cell disease have chronic pain managed with long-acting opioids (Dowell et al., 2016).

Headaches are a frequent cause of recurrent pain and one of the most common diagnoses seen in health care. There are multiple types of headaches, including migraines, tension, and cluster headaches. Tension headache is the most common. The healthcare provider needs to understand red flags that suggest a severe cause of a headache. When a severe cause of a headache is suspected, urgent evaluation is necessary and may include brain imaging to rule out an underlying secondary cause of a headache. Signs/symptoms that suggest a more severe cause of headache include:

• New-onset headache, especially in those over age 40
• Worst headache ever experienced
• A headache with an accompanied neurologic sign or symptom – e.g., confusion, stiff neck, seizure, focal neurologic sign (e.g., one-sided weakness), impaired alertness
• Headaches that awaken the patient from sleep
• Fever and stiff neck
• Pregnancy – may suggest pre-eclampsia
• History of cancer
• History of HIV or immune compromise
• Headache made worse by cough, exertion, or the Valsalva maneuver
• History of recent head trauma
• Illicit drug use
• Progressive headache

Tension headaches may occur every day and have a variable presentation. Typically, they are described as pressure, tightness, or aching. They may feel like a band around the head and be bifrontal, bitemporal, or generalized. Tension headaches can be intermittent with a variable duration.

Migraine headaches are classically one-sided (but may be generalized) and are described as pounding or throbbing. Patients with migraines often have co-existent nausea/vomiting and photophobia.

An acute migraine can be managed with multiple agents. The use of acetaminophen or NSAIDs may be considered. When simple analgesics are ineffective in managing pain, migraine-specific agents (triptans or dihydroergotamine) may be considered. These agents are available in oral, rectal, and injectable formulations. Many patients prefer oral agents, but a non-oral route is the best option for those with severe nausea that accompanies a migraine.

First-line prophylactic migraine agents include propranolol, amitriptyline, topiramate, and valproic acid.

Many conditions lead to neuropathic pain, including multiple sclerosis, post-stroke pain, spinal cord injury, traumatic brain injury, syringomyelia, trigeminal neuralgia, peripheral neuropathy, and post-herpetic neuralgia.

Multiple sclerosis (MS) is commonly associated with pain. It is estimated that 43 percent of MS patients have at least one painful symptom (Olek et al., 2019). Common painful symptoms include dysesthesia pain, back pain, spasms, Lhermitte sign, visceral pain, and trigeminal neuralgia.

Central post-stroke pain is experienced as unilateral head/facial pain that starts within six months of a stroke. It affects up to 8 percent of stroke victims (Garza, 2015). The pain is typically persistent but may come and go. The severity of the pain may be variable, and stress often exacerbates the pain.

Treatment of central post-stroke pain includes benzodiazepines; anticonvulsants such as gabapentin, pregabalin, lamotrigine, or carbamazepine; baclofen; antidepressants such as amitriptyline or an SSRI; and clonidine. When pain resists pharmacotherapy, neuromodulation (deep brain stimulation) and surgery may be considered.

Spinal cord injury (SCI) patients often develop chronic pain that affects their quality of life. Pain is often poorly localized and neuropathic (e.g., burning, stabbing). The pain can be evoked or spontaneous. Pain can be at-level pain caused by injury to the nerve roots and dorsal gray matter causing pain at the injury level. Pain can also be below the SCI level caused by damage to the spinothalamic tracts and thalamic deafferentation.

Pain may be managed with antidepressants (e.g., tricyclic antidepressants), antiepileptics (e.g., gabapentin, lamotrigine, or valproate), and standard analgesic medications. When medications are not effective, the use of invasive treatments is considered. These may include deep brain stimulation, cordotomy, or motor cortex stimulation.

Syringomyelia is a delayed progressive intramedullary cystic degeneration that affects a small number of patients after spinal cord injury. It is thought to occur from scarring and subsequent obstruction of cerebral spinal fluid flow and altered tissue compliance, leading to an extension of the central canal, which presses the nearby cord tissue (Eisen & Aminoff, 2019).

Trigeminal neuralgia results in head/facial pain from one or more trigeminal nerve branches. Classically, the pain is unilateral, brief, stabbing, and lancinating that is sudden in onset.

Imaging, typically with an MRI, is sometimes done to distinguish primary from secondary trigeminal neuralgia. The primary disease has no identifiable lesion causing the symptoms. Secondary causes of trigeminal neuralgia include acoustic neuromas, multiple sclerosis, cerebral aneurysms, and trigeminal neuromas. The secondary disease is more common if bilateral involvement occurs at a younger age or associated sensory loss. Conditions that may mimic trigeminal neuralgia include dental pain, multiple sclerosis, herpes zoster, or atypical headaches.

Treatment for the pain of trigeminal neuralgia includes carbamazepine and oxcarbazepine. For those who are intolerant or non-responsive to these agents, baclofen or lamotrigine can be used. Surgical options are sometimes tried for refractory cases.

Peripheral neuropathy can come from many etiologies, including diabetes, cancer, alcohol, and HIV, and typically presents with distal sensory loss, weakness, numbness, and burning. The presentation may be variable.

Neuropathy due to diabetes is one of the more common types of neuropathies. It typically results in symptoms that begin in the lower extremities. Sensory symptoms are seen first, followed by motor symptoms. Patients complain of gradual sensory loss, numbness, burning sensation, foot pain, and mild gait abnormalities. Over time, weakness may develop, and a "stocking and glove" distribution of sensory loss may occur. Physical exam findings depend on which nerve fibers are involved.

Treatment of neuropathies includes treating the underlying disease (e.g., controlling blood sugar in diabetes) and medications to treat the symptoms. Medications to manage neuropathy pain include tricyclic antidepressants, duloxetine, gabapentin, pregabalin, carbamazepine, topiramate, tramadol, and NSAIDs.

Post-herpetic neuralgia is pain that presents after a herpes zoster infection caused by the varicella-zoster virus. Certain groups are at higher risk of developing pain after a herpes zoster infection. These include older individuals, those with higher acute pain levels during the acute infection, and those with a more severe rash (Ortega, 2019).

Herpes zoster is an infection that starts with a sharp, burning, stabbing pain that follows a dermatome. A rash will be seen a few days later along the same dermatome. Commonly affected dermatomes include the thoracic, cervical, and trigeminal nerves. After the rash abates, some individuals develop pain along the same dermatome that persists longer than four months. Pain may persist for years or even throughout life. Allodynia is often seen in those with post-herpetic neuralgia.

Post-herpetic neuralgia is commonly treated with tricyclic antidepressants, pregabalin, and gabapentin. Topical capsaicin or lidocaine can be used. Opioids are sometimes used but should be used cautiously. They are considered second or third-line options and are sometimes used while the TCAs, pregabalin, and gabapentin take effect, then tapered. If all other options are not sufficient, the use of intrathecal glucocorticoids may be considered.

Most back pain cases are non-specific and will improve within a few weeks with conservative treatment, but some develop chronic pain. Those more likely to develop chronic back pain include functional impairment, poor health, comorbid psychiatric conditions, maladaptive pain-coping behaviors, and non-organic signs – such as pain in the low back when pressing directly on top of the head (Wheeler, 2020). Less than one percent of patients with back pain have a serious cause of back pain, and less than ten percent have specific etiologies (Wheeler, 2020). When back pain is present, it is essential to rule out any severe pathologies. Certain red flags suggest serious pathologies (See Table 5).

A complete history and physical exam is an essential part of the workup to rule out serious back pain causes and help identify the cause of the back pain. Certain more urgent conditions require immediate imaging with an MRI and referral, including those with red flags. Those who have not improved after 4-6 weeks of conservative therapy may be considered for imaging. Patients with conditions that may benefit from surgery or epidural injections should have imaging. Other conditions that are helped by imaging include osteoarthritis and ankylosing spondylitis.

Back pain should not be treated with bed rest, but modifying activity slightly to account for the pain is appropriate. Oral analgesics should be used short-term to provide pain control. Re-evaluation should occur at four weeks to ensure improvement, evaluate for any needed testing, and reevaluate the need for pain medications.

Initial oral agents should include NSAIDs for 2-4 weeks. Those with an allergy or contraindication to NSAIDs may consider acetaminophen. A muscle relaxant may be considered when pain is not controlled with NSAIDs. For those who cannot take a muscle relaxant, an NSAID and acetaminophen combination is an option.

The use of opioids and tramadol should be used judiciously in acute low back pain and only in those who are not getting pain control from other agents or contraindications to those other agents.

Physical therapy can be used for acute low back pain but is more often used for chronic low back pain. Education is one of the most critical aspects of managing back pain. Patients should be educated on the causes of back pain, the expected course, its encouraging prognosis, the value of diagnostic testing, treatment options, and when to contact their healthcare provider.

Neck pain can occur from multiple pathologies, including trauma, muscle strain, or disc pain. The majority of cases of neck pain will resolve within three weeks. Initial treatments are conservative, including oral analgesics (acetaminophen or NSAIDs for mild or moderate pain; short-term opioids for severe pain), posture modification, and exercise.

Chronic neck pain has multiple treatment options. The use of a long-term cervical collar is not recommended. The use of a cervical collar to manage severe pain for less than three hours a day for a maximum of 2 weeks may be considered. Physical therapy and home exercises should be used.

Pharmacological options for chronic pain include acetaminophen; NSAIDs, a low-dose antidepressant, especially in those who have pain that interrupts sleep; a muscle relaxant may be considered for those with muscle spasms; and rarely opioids.

Other pain management options include trigger point injections, cervical medial branch blocks, TENS units, and radiofrequency neurotomy. A surgical evaluation may be considered in those with myelopathy or neurological symptoms associated with radiculopathy.

Complex regional pain syndrome (CRPS) is categorized into types I and II. It is a disorder of the extremities illustrated by regional pain that is inconsistent in degree or time to the expected pain. The pain is localized around a specific territory.

The primary clinical manifestation is pain typically described as stinging, burning, or tearing and is exacerbated by movement, temperature variation, stress, or any contact. Also, some individuals have allodynia or hyperalgesia. The patient may also notice differences in skin color or temperature. The affected side may be more edematous or sweat more when compared to the other side. Limb movement is typically impaired by pain, edema, or contractures. The patient with CRPS may also have unilateral variations in hair or nail growth and skin atrophy.

The progression of the condition is variable over time. The underlying pathology is poorly understood but may include inflammation and pain perception changes in the central nervous system (Abdi et al., 2018).

CRPS I is the more common type and is diagnosed when the typical symptoms are present and there is no evidence of a peripheral nerve injury. CRPS II is less common and is present when there is evidence of a peripheral nerve injury (Abdi et al., 2018).

CRPS is more commonly seen in women. It is often associated with some acute event that starts the syndrome. Examples of trauma may include a broken bone or a crush injury. The diagnosis is made on clinical exam after other conditions are ruled out.

Treatment of CPRS should involve a multidisciplinary approach, including physical and occupational therapy, physiological interventions, and pharmacotherapy. Pharmacologic options include NSAIDs, tricyclic antidepressants, gabapentin, or topical treatments (lidocaine or capsaicin). Other less common options include calcitonin, glucocorticoids, alpha-adrenergic agonists/antagonists (e.g., prazosin, clonidine), ketamine, and opioids. Multiple interventional approaches may be considered, including regional sympathetic nerve blocks, trigger/tender point injections, and spinal cord stimulation.

Phantom limb pain is aching, burning, or shock-like pain where an amputated limb used to be and is related to the perception of self. Sensory input from various parts of the body forms a ‘body map’ in the brain, and when a limb is amputated, that map still exists in the brain. Because the body map still exists, pain and other sensations in the amputated body part (Moller, 2014).

Before diagnosing phantom limb pain, it is essential to rule out other causes of the symptoms, such as infection or a wound on the stump, ischemia, or neuroma. The incidence of this condition is variable, and it is hypothesized that not controlling pain before and after the surgery increases the risk of phantom limb pain. It has been shown that stopping pain transmission in the spinal cord for 72 hours before the amputation surgery using lumbar epidural block (LEB) has a positive long-term effect in preventing amputation pain. Also, aggressively managing pain immediately after surgery reduces the risk of developing phantom limb pain (McGreevy et al., 2011).

Multiple agents help manage phantom limb pain, including acetaminophen, NSAIDs, TCAs, and gabapentin. In addition to medication, non-pharmacologic methods to manage pain include TENS units, mirror therapy (which helps resolve the visual-proprioceptive disconnect), biofeedback, and occasionally surgical interventions.

Pain is very prevalent in cancer. According to some estimates, it is present in up to one-half of patients when first diagnosed with cancer and, according to some estimates, up to 80 percent of people with advanced cancer (National Cancer Institute, 2021). Fear of uncontrolled pain is one of the most prevalent findings among cancer patients. Nurses play an essential role in improving outcomes for cancer patients. To ensure appropriate pain treatment, nurses working with cancer patients must recognize and routinely assess their pain and communicate their findings to other care team members (Phillips et al., 2017).

Pain in cancer can be acute or chronic. Acute pain is seen during interventions such as surgery, tissue injury, or radiation therapy. Acute pain can also be felt secondary to cancer, such as an obstructed bowel, a perforated bile duct, bleeding from liver cancer, or a pathological fracture. Chronic pain during cancer is typically related to the tumor itself or as a complication of treatment.

Neuropathic pain is also seen in cancer patients. Neuropathic pain in cancer can arise from the tumor pressing on a nerve or nerve plexus. Also, neuropathic pain can result from the treatment, as many chemotherapeutic agents or radiation therapy can cause nerve injury. Many conditions that result in neuropathic pain - such as herpes zoster and post-herpetic neuralgia - are relatively common in cancer patients.

Management of cancer pain is typically aggressive. The use of opioids is common in chronic cancer pain, and doses should be titrated to find effective pain control. Agents commonly used include morphine, oxycodone, and hydromorphone. These agents are preferably given orally or transdermally.

Dosing is commonly started with short-acting agents, but those with chronic pain switching over to a long-acting formulation are preferred with the continued use of short-acting agents for breakthrough pain. The dose for breakthrough pain is typically about 10 percent of the basal daily opioid dose. Individuals who need rapid titration do well-using opioids given via infusion by the IV or SC route.

While morphine is traditionally a common agent, others have a good effect in certain situations. For those with swallowing difficulty or poor ability to absorb from the GI tract, fentanyl can be used. Hydromorphone or fentanyl is recommended for those with renal insufficiency.

While evaluating cancer pain, it is also important to consider pain related to cancer treatment, including chemotherapy pain. Several chemotherapy agents can cause neuropathic pain.

Chemotherapy can also result in the development of mouth sores, stomatitis, or mucositis. These sores cause pain in the patient’s mouth and throat, making eating, drinking, and even talking painful.

Radiation therapy for cancer patients can cause skin burns and injury to the patient’s throat, intestines, and bladder. The patient may complain of pain if these body parts are involved in radiation treatment (National Cancer, 2021).

Palliative and End of Life Care have become two distinct terms. The population of palliative care patients has expanded to include those who are not necessarily close to death but are suffering from chronic conditions that require symptom control and pain management.

End-of-life care requires skilled pain management for a dignified, peaceful death. Morphine is the gold standard for end-of-life pain relief and is the most effective medication for dyspnea treatment. Morphine changes the patient’s awareness of their breathing experience by decreasing the respiratory drive and oxygen intake.

Fibromyalgia (FMS) is characterized by chronic, widespread musculoskeletal pain. Patients also complain of fatigue, sleep disturbances, psychiatric symptoms, cognitive disturbances, and multiple other somatic complaints. The etiology and pathophysiology are unclear.

In FMS, pain is typically diffuse and persistent. It is often described as stiffness, deep aching, soreness, burning, or throbbing. Patients typically report persistently present pain, but the intensity may vary. Poor sleep, excessive stress, and exposure to cold may exacerbate the pain. Generally, pain is worse in the morning and improves throughout the day. Pain commonly affects the neck, shoulders, back, arms, legs, and chest wall.

Fibromyalgia is six times more common in women when compared to men. The prevalence is about 2-3 percent in the United States. It is the most common cause of generalized musculoskeletal pain in females aged 20 to 55 (Vincent et al., 2013).

Patients with FMS often complain of hurting or feeling like they have the flu. It is diagnosed in those with chronic pain and no markers of muscle inflammation.

Differential diagnosis of FMS includes osteoarthritis, autoimmune disease, rheumatoid arthritis, systemic lupus erythematosus, hypothyroidism, inflammatory myopathy, systemic inflammatory arthropathies, spondyloarthritis, Ankylosing spondylitis, myositis, and polymyalgia rheumatica.

Education is a critical step in the treatment of FMS. The condition must be explained to the patient, including treatment approaches. Key aspects of patient education include:

• Sleep hygiene.
• Symptoms will vary over time – fatigue and pain typically persist.
• The patient must understand that the disease will not deform the patient, lead to a cosmetic issue, or become life-threatening.
• Emotional or physical stress may increase symptoms. The patient should be taught stress-reduction and relaxation techniques to help manage the condition.
• While infection may be a precipitating factor, it is not a persistent infection that causes the symptoms.
• Neurohormonal abnormalities may account for fatigue, pain, mood disturbance, and sleep disturbance.
• Exercise should be encouraged but may increase pain – especially early in an exercise program.
• Other non-pharmacological methods to manage FMS include supervised physical therapy, cognitive behavioral therapy, biofeedback, tai chi, or yoga.

Medications are often used in the management of FMS. Typically, non-pharmacological methods are used first, and medication is considered when they are ineffective. Commonly used medications include low-dose tricyclic antidepressants, selective serotonin reuptake inhibitors, pregabalin, duloxetine, cyclobenzaprine, and milnacipran. When utilizing medications, the dose should be started low and built up gradually.

Amitriptyline, milnacipran, and duloxetine are first-line agents for fibromyalgia. However, most patients do not find significant improvement (some improvement was noted with sleep and pain, but fatigue and quality of life were only minimally improved) on these medications, and many have significant side effects (Welsch et al., 2018).

When first-line agents do not work, a combination of medications can be tried. For example, duloxetine in the morning and a tricyclic antidepressant before bed is one such combination. Combinations of medications work through different mechanisms of action and focus on other symptoms.

At times, the addition of analgesics or anti-inflammatory medication can be tried. Using acetaminophen, NSAIDs, or tramadol may target pain when more traditional FMS agents do not work. Generally, opioids should be avoided in FMS.

Rheumatoid arthritis (RA), a chronic, destructive, sometimes deforming disease, attacks the body's collagen, especially in the joints. Rheumatoid arthritis is associated with widespread fatigue, fever, poor appetite, nerve damage, and increased size of the spleen and lymph nodes. RA can irreversibly damage joints; therefore, early diagnosis and treatment to control inflammation can improve the disease's outcomes.

Treatment options include psychosocial care, patient education, therapy, and pharmacologic treatment. A rheumatologist should be involved in caring for patients with RA as disease-modifying antirheumatic drugs (DMARDs) are complex to use. If therapy is started soon, the patient will experience better outcomes. DMARD therapy is complex, requires much monitoring, and is beyond the scope of this article.

The use of NSAIDs and glucocorticoids is also used in the management of RA. They can be used as bridging therapy to quickly control inflammation until the DMARDs take effect and can be used for pain control.

Osteoarthritis is the most prevalent joint condition globally and is one of the leading sources of pain and disability in older adults (Hunter & Bierma-Zeinstra, 2019).

Arthritis affects twenty percent of adults and costs more than $136 billion annually in the United States (Osteoarthritis Action Alliance & Thurston Arthritis Research Center at the University of North Carolina, 2021). As the population ages, the burden of OA will increase. Managing arthritis improves mobility, decreases falls, decreases death rates, and enhances the quality of life.

Osteoarthritis is defined as a joint disease with deterioration of the joint and abnormal bone formation. OA is present when the cartilage, which usually cushions the bones - no longer functions. The ends of the bones rub together, and the cartilage wears away.

Treatment of osteoarthritis focuses on pain control and maintaining function. Shortly, treatments may be available to reverse or even cure the disease process, but symptom control is currently the only option. Treatment focuses on medications, and non-medication means controlling pain and minimizing disability.

Non-drug treatment is first-line management as it bypasses drugs' adverse effects on the body. Non-drug treatments include exercise, nutrition, physical and occupational therapy, heat and cold treatments, ultrasound, weight loss, magnets, and patient education.

Medications are used to treat OA when non-drug methods do not provide adequate relief. Because of safety concerns and lack of efficacy, Acetaminophen is no longer recommended as a first-line agent. Non-steroidal anti-inflammatory agents are now recommended ahead of acetaminophen (Hunter & Bierma-Zeinstra, 2019).

Topical NSAIDs may be used, especially if the disease is localized to one area. Topical agents are associated with a significantly less adverse event profile than systemic agents. In the United States, diclofenac sodium topical gel and diclofenac sodium topical solution can manage osteoarthritis.

Other topical agents can provide significant relief for patients with OA. Capsaicin (Zostrix®) decreases the neurotransmitter called substance P, which is involved in transmitting pain. Capsaicin is applied three to four times a day and takes a few weeks before providing significant pain relief. Hands should be washed after contact with the substance.

Another topical agent sometimes used to treat localized pain is the lidocaine patch. The lidocaine patch is not approved by the Food and Drug Administration for OA but is often used. A small patch applied to the skin around the painful joint is worn for no more than 12 hours a day.

Other options for OA treatment include tramadol, codeine, hydrocodone, hydromorphone, oxycodone, fentanyl, and morphine.

Intra-articular steroid injections can be used for painful joints, which involves placing a needle directly into the arthritic joint and injecting a steroid and a numbing agent. No more than three injections per year should be given (Deveza, 2017).

When medical treatment fails, surgery is the next option. Surgical options include arthroscopy, osteotomy, total joint arthroplasty, or joint fusion.