This course updates the healthcare professional on current assessment and management of pain in the adult population. Special considerations necessary for pain assessment in nonverbal patients are addressed.
After studying the information presented on pain assessment and pain management of the adult patient, you will be able to:
An unpleasant sensation that can range from mild, localized discomfort to agony. Pain has both physical and emotional components. The physical part of pain results from nerve stimulation. Pain may be contained to a discrete area, as in an injury, or it can be more diffuse, as in disorders like fibromyalgia. Pain is mediated by specific nerve fibers that carry the pain impulses to the brain where their conscious appreciation may be modified by many factors (www.Medicine.net.com, 2013).
Patients may experience acute, chronic, or cancer pain.
The prevalence of pain is high. It is estimated that over 75 million Americans suffer with pain. Approximately 50 million Americans have chronic pain and 25 million have acute pain. These numbers make it easy to understand that pain is one of the most common reasons that people seek medical attention.
Pain causes suffering. Unrelieved, it can destroy the quality of life. Persistent pain can impair sleep and appetite, leading to fatigue and nutritional decline. It can delay healing, cause increased stress and anxiety, alter immune function, lead to depression and destroy the will to live. Additionally, current unrelieved acute pain can cause chronic pain at a later date.
The good news is that we have the knowledge and skills to effectively manage most pain. So what is the problem? Why is unrelieved pain still so prevalent?
Knowledge is important. Clinicians as well as patients need to be made knowledgeable about methods of relieving pain. But knowledge alone rarely changes practice. Efforts must go beyond education alone if pain treatment is to improve. Pain needs to be made visible so it will not go unnoticed by clinicians.
Assessment of pain is a critical step in providing good pain management. The American Pain Society initially promoted the phrase "pain as the 5th vital sign" to increase the visibility of pain among healthcare professionals. Vital signs are taken seriously. Practitioners usually do not fail to recognize and take action on an elevated blood pressure, for example. Blood pressure is routinely measured and recorded in the patient´s chart and standard practice holds that elevated blood pressure requires assessment and action. If pain intensity is assessed routinely with the same zeal as the traditional four vital signs (temperature, heart rate, respiratory rate, and blood pressure) and documented with them, pain management would improve. As the "5th vital sign," pain intensity becomes visible and can be used to guide treatment.
Basic pain assessment is simple and must be performed regularly. Action needs to be planned on the basis of patient reports of pain.
It makes no difference whether patients are in the hospital, a long-term care facility, a behavioral health facility, an outpatient clinic or being cared for by a home care agency. No matter where patients are, 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, (4) at regular intervals when vital signs are taken, and (5) at suitable intervals after pharmacologic (45-60 minutes after oral intervention; 15-30 minutes after parenteral intervention) or non-pharmacologic intervention to evaluate the current pain treatment plan.
A "0 to 10" numerical scale is the most widely used measure to assess pain intensity. When using the Numerical Rating Scale (NRS), patients are asked to rate their pain from 0 to 10, with "0" equaling no pain and "10" equaling the worst possible pain they can imagine. Since we have no instrument to objectively measure pain intensity in the same way that blood pressure is measured by a sphygmomanometer, for example, the only valid measure of pain is the patient´s self-report (a subjective measure). Sometimes healthcare providers may believe that 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.
Each institution should select a pain intensity rating that will elicit a full assessment to help formulate the plan of care. Since research suggests that pain at a level of 4 out of 10 is the point at which pain significantly interferes with function, most institutions choose that a full assessment be completed for pain levels of 4 or greater. Besides current pain intensity, the complete pain assessment includes the following:
|Tumors occupying the liver, pancreas, spleen; abdominal or thoracic surgery; ascites||Non-opioids
|Dull, achy, throbbing, sore||Bone metastases, musculoskeletal injury, mucositis, skin lesions|
Once pain is assessed, a pain management plan is formulated. The goal of pain management is to achieve optimal comfort and function with minimal side effects from analgesic therapy. The pain management plan may include treatment of the cause of the pain (if possible), optimal use of analgesic and adjuvant medication, use of non-pharmacologic interventions, and referral for invasive approaches when appropriate.
Opioid analgesics are the cornerstone of pharmacological management for acute pain, especially when the pain is moderate or severe. Other agents such as Non-steroidal anti-inflammatory drugs or NSAIDs may control mild to moderate pain or reduce opioid dose requirements for more severe pain. The intravenous route is the route of choice with acute pain only until oral intake is tolerated. Once oral intake is tolerated, the route should be changed to oral. Intramuscular (IM) administration of medications is never recommended for treatment of any type of pain. Absorption of medication is variable with the IM route and IM injections hurt!
Non -0pioid analgesics include ketamine, an N-methyl-D-aspartate receptor antagonist. Adjuvant analgesics include antiepileptic drugs and antidepressants which are used for the treatment of neuropathic pain.
Medications are the cornerstone of the management of cancer pain because they are effective, relatively low risk, inexpensive, and usually have rapid onset. The following three major classes of medications are used alone or, more commonly, in combination to manage cancer pain: (1) NSAIDs, ASA, and acetaminophen; (2) opioid analgesics and (3) adjuvant or co-analgesic medications. Adjuvant or co-analgesic medications are those medications that are not usually thought of as analgesics but which, when given with known analgesics, have synergistic effects or exhibit analgesic activity of their own. Anticonvulsants (gabapentin, for example) and antidepressants (amitriptyline, for example) are adjuvant medications used to treat neuropathic pain. (Refer to Table 1).
Most cancer pain can be managed using oral medications; however, such things as difficulty in swallowing, gastrointestinal disturbances that make absorption unreliable, and the amount of medication required may necessitate the use of an alternative route of administration.
Over twenty years ago the World Health Organization developed a three-step analgesic ladder which is a simple and effective method for assuring the proper titration of therapy with cancer pain. (Refer to figure 1, A Stepwise Approach to Pain Management.) The steps of the ladder illustrate the process of selecting medications based on pain intensity. Step 1 includes medications that are effective for mild pain, step 2 for moderate pain, and step 3 for severe pain. At each step of the ladder, adjuvant drugs may be combined with analgesics, if indicated. At steps 2 and 3 non-opioids may be combined with opioids for improvement in analgesia. All patients may not enter the ladder at step 1; they should enter at the step of the ladder that corresponds to the intensity of their pain. For example, patients having severe pain should enter the ladder at step 3. While the ladder focuses on a pharmacologic approach to pain management, non-drug modalities for pain control can be used at each step, depending on the patient’s need.
For treatment of any type of pain, the need to change opioid medication may arise if unacceptable side effects develop, if one drug is not providing adequate pain relief in spite of dose escalation, or if the route of administration is changed. Opioids vary in the dose each requires to produce the same amount of analgesia. Also the method of delivery can make a difference. The same amount of drug given by mouth may have a vastly enhanced effect if injected intravenously. Be aware of the differences in changing the route of administration or the opioid medication. Refer to the equianalgesic table (Table 2) to adjust for the differences in the medication or the route of administration to achieve the same results.
|Use this table as a guide only. The following equianalgesic doses are medication and route conversions approximately equal to a single morphine 10 mg parenteral dose. The equianalgesic dose is not the usual starting dose, but just an estimate. Doses and intervals between doses need to be individualized and titrated according to patient response and the clinical situation.|
|Medication||Parenteral Route||Oral Route||Duration (hours)|
|Morphine Sulfate Immediate release||10 mg||30 mg||2-4|
|Morphine Controlled release||N/A||60-90 mg||8 or 12|
|Hydromorphone||1.5 mg||7.5 mg||2-4|
|Oxycodone Immediate release (also in Percocet, Percodan, Tylox, Roxicet)||N/A||20 mg||3-4|
|Oxycodone Controlled release||N/A||60 mg||12|
|Hydrocodone (also in Vicodin, Lortab, Lorcet)||N/A||30 mg||3-4|
|Codeine||120 mg||200 mg||3-4|
Meperidine has purposefully been omitted from this table because its use should be limited. Accumulation of its metabolite, normeperidine, is associated with confusion and seizures. Its use should be considered only for management of acute episodes of pain if the patient has a history of unmanageable adverse reactions to other opioids, for conscious sedation of adults in some circumstances, or for prevention or treatment of rigors and treatment of post-anesthesia shivering. Meperidine should not be used for longer than 48 hours and should not be used for patients with renal insufficiency. Contrary to persistent belief, meperidine has not been shown to have any specific benefit in patients with biliary colic.
Effective pharmacologic management of all types of pain requires that the regimen be individualized. In addition to choosing a suitable medication or medications, optimal doses must be selected. As with acetaminophen and ASA, all NSAIDs have ceiling (maximum) doses that, if exceeded, may precipitate toxicity without improving analgesia. Opioids, however, have no maximum or ceiling dose. Generally, with opioids, the goal is to use the smallest dose that relieves the maximum amount of pain with the fewest side effects. Equally important for effective pharmacologic management of pain, the medication should be given:
A rule of thumb is if the pain is expected to be present 12 or more hours out of the next 24 hours, ATC dosing should be considered. The analgesics should be routinely scheduled to prevent the recurrence of pain. Along with ATC dosing, supplementary analgesia or rescue dose should be available for breakthrough pain (flares of pain or intermittent increases in pain).
All opioid analgesics share common side effects, the most common being constipation, nausea and/or vomiting, sedation and mental clouding, and respiratory depression. Although side effects are usually a less serious problem than the under treatment of pain, they are common enough to warrant discussion. Tolerance to all the side effects, except constipation, develops with time.
Constipation will NOT diminish with time and can become a significant clinical problem if preventive measures are not instituted. Opioids reduce the motility of the intestines. Reduced activity and decreased appetite can make the problem even worse. Constipation can be alleviated by eating foods high in fiber and by drinking eight to ten glasses of water a day (if not contraindicated by other problems). Exercise can help too. When starting on routine opioids, patients need to start on a stool softener/laxative preparation, and they need to be continually re-assessed to make sure the current bowel regimen is working.
When patients complain of nausea and/or vomiting after opioid administration has begun, it is often helpful to administer an antiemetic on a fixed schedule for several days, until tolerance to this side effect develops. At that point, prn dosing is usually adequate. Depending on the antiemetic chosen, patients need to be monitored for the possibility of increased sedation.
Transitory sedation and mental clouding is common when opioid doses are increased, but tolerance usually develops rapidly. Persistent drug-induced sedation is usually best treated by reducing the amount of opioid for each dose and increasing the dosage frequency. This strategy will decrease the peak concentrations in the blood while maintaining the same total dose. CNS stimulants such as caffeine or methylphenidate may be added to increase alertness if the above approach is ineffective in reducing sedation.
Patients receiving long-term opioid therapy usually develop tolerance to the respiratory-depressant effects of these agents. Occasionally, respiratory depression occurs when pain is abruptly relieved and the sedative effects of opioids are no longer opposed by the stimulating effects of pain. In a symptomatic patient, physical stimulation may be enough to prevent significant hypoventilation. When needed, the opioid antagonist naloxone should be administered cautiously to patients who are receiving opioids on a long-term basis. Symptomatic respiratory depression should be treated using a dilute solution of naloxone (0.4 mg in 10 ml of saline), administered as 0.5 ml (0.02 mg) boluses every minute. Naloxone should be given in doses to improve respiratory function, but not to reverse analgesia, since a return to full alertness may be accompanied by a severe withdrawal syndrome as well as a return of pain.
Far more common than acute respiratory depression is sub-acute overdose, in which sedation gradually builds and is followed by a slowing of respiratory rate and then by ventilatory failure. The degree of sedation, rather than the respiratory rate, is a better indicator of impending respiratory depression. This complication is best managed by withholding one or two doses and then reducing the standing dose by 25% of its current level.
Opioids may also occasionally cause other side effects such as urinary retention, pruritus, myoclonus (jerking), seizures, hallucinations, confusion, sexual dysfunction, and sleep disturbances.
In the United States the current climate of change related to opioid use is as follows:
The current climate of change related to prescription drug abuse as noted by the Department of Defense/Veterans Administration is the following:
Another medication used for pain relief is the Medical Marijuana Pill called Dronabinol. Dronabinol contains the active ingredient of marijuana and is being researched. The newest study at Columbia University’s Department of Psychiatry was with assistant professor of clinical neurology, Ziva Cooper. She said “the new findings suggest a marijuana pill can produce analgesic effects far longer without the health risks that come along with smoking. Information on this study was published in the journal Neuropsychopharmacology.
Experts in the current study found that the drug Dronabinol provided a longer-lasting effect in pain sensitivity and was less susceptible to abuse-associated outcomes, compared to marijuana. Dronabinol contains the active ingredient of marijuana - tetrahydrocannabinol (THC) - and has already been approved to treat chemotherapy and AIDS patients with nausea and vomiting.
Dr. John Roberts, an oncologist at the Yale School of Medicine who has studied the effects of marijuana's active ingredient on pain has stated “there might be a role for each form of the drug in pain relief, depending on the users' preferences. For instance, some people with a pain condition may say that they prefer smoking marijuana because it both reduces their pain and gives them a high. However, the issue of whether to allow patients to use potentially addictive drugs (ones they find pleasurable) is a question for public policy”. Medical marijuana is legal in 18 states, and studies have suggested that smoking the drug relieves pain. More research is needed.
Non-pharmacologic techniques of pain management are gaining in popularity. It is estimated that Americans spend $21 billion out of pocket annually on complimentary methods of pain control. Nurses need to know about these approaches to assist patients in making educated decisions. Analgesics are the mainstay of pain relief. However, even with the optimal use of analgesics, pain may be more effectively treated with a combination of analgesic and non-analgesic approaches. For some types of mild pain, non-analgesic approaches alone may provide sufficient relief. However, non-analgesic techniques are a supplement for, but do not replace, pharmacologic interventions for moderate to severe pain.
The basis for the use of 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.
Acupuncture is a neurostimulatory technique that treats pain by the insertion of small, solid needles into the skin at varying depths. Various theories exist to offer explanation of how acupuncture works.
Music Therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional. 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 in in nature. Music therapy currently is considered an established health service similar to occupational or physical therapy. Studies done with those patients who have arthritis demonstrated that music helps to relieve pain and anxiety, induce relaxation, promote healing, enhance mental function, improve communication, promote physical rehabilitation, and reduce stress providing positive changes in both mood and emotional state. Individuals doing music therapy listen to music created under the guidance of an individual specially educated and certified in music therapy.
Jackie, a seventy two year old woman complained of unrelieved chest pain and in the ambulance the EKG showed an elevated ST segment. She was having a myocardial infarction. She was taken to a hospital which did cardiac catherizations (PCI/percutaneous coronary intervention). Three of her coronary vessels were blocked and her vessels were tiny. It was decided she needed open heart surgery. She was to undergo Coronary Artery Bypass Surgery (CABG). Jackie had no tolerance for pain and agreed to listen to music created by the music therapist prior to, during and after surgery.
The surgery was successful and Jackie complained of very little pain. Since she was an actress, the music therapist helped her to choose music she could relate to, dance to and sing to. When she did need pain medication it did not take much. Jackie had always had reactions to medications and was hypersensitive. It did not take a high dose of pain medication to relieve her discomfort.
It is believed that music, like relaxation and guided imagery, can strengthen the right side of the brain, 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 signals that provide pain relief. There are also signals that stimulate the release of neurotransmitters such as endorphins, dynorphins, and enkephalins. Music helps in pain reduction by activating these sensory pathways.
With rare exception, less invasive analgesic approaches should precede invasive approaches. However, if drug therapy, cognitive-behavioral interventions, and/or non-invasive mechanical interventions do not alleviate pain, invasive therapies such as nerve blocks and neurosurgery may be useful.
Since pain is a subjective experience, we measure the existence and intensity of it by the patient’s self-report. Unfortunately, adult patients who have cognitive/expressive deficits or who are intubated, sedated, and/or unconscious may not be able to provide a self-report. Individuals who cannot communicate their pain remain a challenge and are at even 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 for pain assessment and management. Valid and reliable methods to assess pain in nonverbal patients are clearly needed. The American Society for Pain Management recommends the following multifaceted approach for consideration in detecting pain in this population.
The updated 2013 Dublin Business Wire press report in May 2013 related to Pain Therapeutics-drugs, markets and companies stated that the latest concepts of pathomechanisms of pain is to be used as a basis for the management and development of new pharmacotherapies for pain. Tools described in this course are being used for pain management along with brain imaging. Advances in molecular and biological techniques are markedly advancing our understanding of pain and the development of rational and personal therapies for the management of pain.
We all need to strive to ensure that the patient’ rights are not infringed and that all of our patients receive what they have a right to receive – that is appropriate pain assessment and management. The resulting improvements in functional status and quality of life will prevent needless suffering. Nurses are in a key position to make a difference.
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This course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Registered Nurse (RN)
Advance Practice Nurse Pharmacology Credit, CPD: Practice Effectively, Medical Surgical, Michigan Requirements, Pain Management