Pain Assessment and Management: Massachusetts

Pain is a universal experience. It can be the result of a single trauma or the symptom of many diseases. Although pain is seen as an adverse occurrence, in many instances, it is beneficial, a warning signal that the body needs care and protection.

Pain is a subjective experience, and the context in which it happens influences both how the pain is experienced and its meaning to the individual. Defining and quantifying pain has never been easy. As part of the human experience, pain has been described from the earliest times. The prehistoric person related pain and pain relief to the acceptance or anger of the gods. The French physician Dr. Albert Schweitzer proclaimed in 1931, "Pain is a more terrible lord of mankind than even death itself" (AZ Quotes, n.d.).

Pain is a significant problem in today's society. Pain carries consequences across various categories, including ethical, social, economic, and legal arenas. The International Association for the Study of Pain defines pain as "An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage" (International Association for the Study of Pain [IASP], 2020). Margo McCaffery's landmark definition describes pain as: "whatever the experiencing person says it is, existing whenever and wherever the person says it does" (Pirschel, 2018). Chronic pain is not acute pain that refuses to go away, and it can be seen as a disease in its own right.

It is estimated that 20.4 percent of adults in the United States suffer from chronic pain, and eight percent of adults have high-impact pain (Dahlhamer et al., 2018). These numbers make it easy to understand why pain is one of the most popular reasons people pursue medical attention.

Persistent pain is often associated with anxiety, depression, functional impairment, sleep disturbances, disability, and impairment in activities of daily living. Low back pain is a common cause of chronic pain. Low back pain costs Brazil 2.2 billion dollars annually, with total health care costs of about 460 million dollars. Low back pain results in millions of missed work days yearly (Carregaro et al., 2020). Persistent pain is a significant cause of morbidity and is associated with significant costs.

Chronic non-malignant pain is defined as pain lasting more than three months and may affect any part of the body (Dydyk & Conermann, 2024). Chronic pain is multifaceted and presents in many ways. Incorrectly treated, acute pain can convert to chronic pain, and in many instances of chronic pain, the cause is unknown (National Institute of Neurological Disorders and Stroke, 2025). Chronic pain can also have a psychological impact that results in anxiety, depression, or the manifestation of somatization disorders. Treatment of chronic pain requires a patient-centered approach to enhance patients' well-being and improve their overall quality of life.

A consistent finding is that chronic pain occurs more frequently in women than in men. Complex Regional Pain Syndrome (CRPS) presents in three times as many women as men (van Velzen et al., 2019). It is estimated that global migraine prevalence is 14–15 percent, and it explains five percent of the time of those who live with a disability (Steiner & Stovner, 2023). Despite their higher prevalence of chronic pain, women’s pain complaints are sometimes dismissed or underestimated, leading to delayed diagnoses and treatment (Samulowitz et al., 2018).

Acute pain typically has an abrupt onset and is often described as sharp. It is often caused by events such as a broken bone, surgery, childbirth, dental pain, or burns. Acute pain may last a short period or a few months. The pain dissipates when the underlying cause has healed. When acute pain lasts longer than 3-6 months, it is termed chronic (Dydyk & Conermann, 2024). Acute pain that is not appropriately treated may lead to chronic pain.

Multiple barriers to effective pain management exist. These include many individual, family, healthcare provider, societal, and political barriers. The good news is that we have the knowledge and skills to manage most pain effectively. So, what is the problem? Why is unrelieved pain still so prevalent?

Knowledge is important. Clinicians and patients need to be knowledgeable about assessing and managing pain. 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.

Nerve fibers transmit pain impulses to the brain, where the brain can personalize the pain experience. Pain theories help clinicians understand the pain and help guide the treatment of pain. One of the first theories of pain was formulated by the French philosopher Rene Descartes in the 17th Century and was titled the 'Specificity Theory' (Moayedi & Davis, 2013).

Descartes believed that the human soul resided in the pineal gland, the source of sensations the individual experienced, including pain. The Specificity Theory of Pain suggests that specific pain receptors send signals to the brain that create pain awareness. According to the theory, pain is an independent sensation with particular peripheral sensory receptors, which drive signals through the nervous system to centers in the brain (Moayedi & Davis, 2013).

Other theories that came to light in the 1900s include the Pattern Theory, Central Summation Theory, the Fourth Theory of Pain, and the Sensory Interaction Theory.

Another theory is the Gate Control Theory (Moayedi & Davis, 2013). Pain stimulation is transmitted by small, slow fibers that go into the spinal cord's dorsal horn. The theory states that a gate in the spinal cord controls sensory information through the cord. When there is more pain stimulation, the gate blocking is less effective, and the gates remain open. When stimulation of the A-beta fibers occurs, such as lightly touching the skin, the gates may be closed, thus inhibiting pain perception. Also, messages that descend from the brain – such as those in anxiety states or extreme excitement – can affect the gates' opening or closing.

The Neuromatrix Theory of Pain (Melzack, 1999) offers a comprehensive framework for understanding pain as a multifaceted and individualized experience. Unlike earlier models, such as the Gate Control Theory, which emphasizes the role of sensory input in pain, the Neuromatrix Theory highlights the central nervous system's active role in generating pain.

According to this theory, pain arises from a "neuromatrix," a widespread network of neurons in the brain that integrates sensory, cognitive, and emotional information. The neuromatrix processes inputs from multiple sources, including sensory signals from the body, psychological states (e.g., stress, anxiety), memories of past experiences, and genetic predispositions. This integrated activity produces the "pain neurosignature," a unique pattern of neural activity that underpins the subjective experience of pain.

• Acute pain – Pain that has an abrupt onset and warns of a disease process or a threat to the body (National Institute of Neurological Disorders and Stroke, 2025).
• Chronic pain – Pain that lasts beyond the usual duration that an insult or injury to the body needs to heal. Pain without apparent biological value that lasted beyond the usual tissue healing time (typically at least three months) (Dydyk & Conermann, 2024).
• Maladaptive pain – Pain that is not useful and is out of proportion to tissue damage. This type of pain lasts long after tissue healing and is often due to changes in the central nervous system (Walters, 2019).
• Allodynia — Pain from a stimulus that typically does not cause pain (National Institute of Neurological Disorders and Stroke, 2025).
• Hyperesthesia – Increased sensitivity to stimulation (National Institute of Neurological Disorders and Stroke, 2025).
• Paresthesia — An unusual sensation often described as burning or prickling and commonly affects the extremities (Hammi & Yeung, 2022).
• Visceral pain – Pain from the viscera mediated by stretch receptors. This pain is commonly described as deep, dull, poorly localized, and cramping (Grundy et al., 2019).
• Nociceptive pain – Pain from threatened or real tissue damage to non-neural tissue caused by nociceptor activation (National Institute of Neurological Disorders and Stroke, 2025).
• Neuropathic pain – Pain from an abnormal neural activity from an injury, disease process, or nervous system dysfunction (National Institute of Neurological Disorders and Stroke, 2025).
• Mononeuropathy - Neuropathy that affects one nerve (Hammi & Yeung, 2022).
• Polyneuropathy – Neuropathy that affects several nerves (Hammi & Yeung, 2022).

Anatomy and physiology are key factors in understanding pain. The central nervous system's primary function is to deliver information about actual or potential threats or injuries. Stimulation of pain receptors (nociceptors) results in physiological pain (Armstrong & Herr, 2023).

Two major types of physiological pain are somatic pain and visceral pain. Somatic pain originates from the skin, muscles, bones, joints, or connective tissues (Armstrong & Herr, 2023). Depending on the structures involved, it is categorized as superficial or deep. Superficial somatic pain arises from the skin or mucous membranes and is often sharp or burning, such as a cut or a minor burn. Deep somatic pain originates from muscles, bones, tendons, or ligaments and is typically described as aching, throbbing, or dull, such as pain from a sprain or a bone fracture (Armstrong & Herr, 2023).

Somatic pain is transmitted by nociceptors, which detect injury or inflammation and send signals to the brain through the peripheral and central nervous systems. This type of pain is usually well-localized, allowing individuals to pinpoint the affected area.

Somatic pain serves a protective function, alerting the body to injury and promoting behaviors that facilitate healing, such as resting the affected area. It is distinct from visceral or neuropathic pain.

Visceral pain arises from stimulating pain receptors in the internal organs such as the heart, intestines, lungs, liver, and pancreas. It is less specific than somatic pain. The number of cells in the spinal cord receiving signals from the internal organs is less than those that get responses for the superficial body locations (Robinson & Gebhart, 2008). It is often difficult for the patient to pinpoint the exact location of the pain; consequently, it is often experienced as referred pain coming from the body surface. Visceral pain receptors include chemoreceptors, but they are not limited to them. Instead, visceral pain is detected by various specialized nociceptors in the walls of internal organs, which respond to different stimuli. The viscera's pain chemoreceptors respond to different chemicals, including those from activating the inflammatory process. Pain receptors in the viscera can also respond to stretching of the organs, temperature, and organ ischemia.

Pathological pain is caused not by stimulation of pain receptors but by damage to the central nervous system itself, including changes in the spinal cord's neural pathways, the trigeminal nucleus, and other brain areas. It is highly complex and difficult to treat. Pathological pain includes central neuropathic pain and pain in diseases including CRPS, fibromyalgia syndrome (FMS), and irritable bowel syndrome (Dydyk & Givler, 2023)

Primary afferent fibers transmit noxious stimuli from the body's periphery to the spinal cord's dorsal horn. The A-delta fibers have a small diameter, are lightly myelinated, and conduct pain signals relatively quickly. They transmit rapid, sharp pain and give precise information regarding the anatomical location of the pain. C fibers are small and unmyelinated fibers that conduct slowly, respond to multiple stimuli, and lead to dull, achy pain (Anwar, 2016).

The Periaqueductal Gray (PAG) is an area of the midbrain, and it plays a major role in processing pain, particularly in the modulation of pain signals transmitted back to the dorsal horn of the spinal cord and the trigeminal nucleus (Mokhtar & Singh, 2023). Modulation describes how numerous systems affect pain intensity, and several spinal cord and brain systems modulate pain. Endogenous opiates are one way to affect the intensity of pain. When the pain is identified in the cerebral cortex, it descends back to the periphery. Descending pathways for pain begin in many brain areas and travel to cells in the spinal cord's dorsal horn and the trigeminal nucleus cells and are usually parallel to the ascending pathways. The vagus nerve provides an additional route for sensory and pain information to the brain, especially from the viscera (Kenny & Bordoni, 2022).

The neurons transmit pain by releasing substances and neurotransmitters (Teleanu et al., 2022). The excitatory substances contributing to pain include substance P, glutamate, prostaglandins, and nitrous oxide. Inhibitory neurotransmitters inhibit, or partially inhibit, the transmission of pain. Common inhibitory neurotransmitters include glycine, serotonin, norepinephrine, acetylcholine, and gamma-aminobutyric acid (GABA) (Teleanu et al., 2022). Certain medications are involved in modulating these neurotransmitters to help reduce pain.

Pain affects multiple aspects of life. Pain can lead to physiological changes and potentially to physical illness. It may lead to cognitive changes, as many patients with chronic pain suffer from depression and anxiety. In primary care clinics, up to 46 percent of people with chronic pain also suffer from depression (Meda et al., 2022). Pain can change how one thinks and acts, leading to behavioral changes.

Pain has the potential to affect an individual's social life. Chronic pain may limit the patient's desire to interact in social settings. Social consequences of unrelieved pain may include isolation, inability or reduced desire to go to work, and overall reduced quality of life (Ashton-James et al., 2022). Expression and reporting of pain can vary by culture. Some cultures have a more stoic attitude to pain, while others may express more emotion.

The biopsychosocial model of pain care leads to a significant step in how people with pain are perceived and handled. This holistic approach to pain acknowledges the importance of the psychological and social factors that play a role in the patient's subjective pain experience and considers cognitive, emotional, spiritual, and cultural issues unique to the individual and their pain journey (Borrell-Carrió et al., 2004). Suffering related to pain is an individual experience. One of the biopsychosocial model's core principles is permitting patients to take part in and direct their care (Borrell-Carrió et al., 2004).

The political arena can greatly affect pain in society. Previously, pain management has focused on eliminating and reducing pain at all costs. This attitude has contributed to the opioid epidemic and many problems for society. In recent years, politicians have been implementing laws to ensure that pain is sufficiently assessed and treated with extra caution in stopping medication abuse and addiction.

Substance abuse issues are a real concern in the management of pain. Inappropriate prescriptions of pain medications have the potential to increase patient's chances of medication abuse. Below are some statistics regarding the current state of substance abuse.

• In 2020, 40.3 million Americans had a substance use disorder, and only 6.5 percent received treatment (National Institute of Drug Abuse, 2023).
• Black, American Indians, and Native Alaskans had the largest number of fatal overdoses (National Institute of Drug Abuse, 2023).
• The number of annual opioid overdose deaths is more than six times higher than it was in 1999 (Federal Communications Commission, n.d.).
• In 2022, nearly 108,000 drug overdose deaths occurred in the United States, with approximately 82,000 (about 76%) involving opioids (Centers for Disease Control and Prevention [CDC], 2024).

The CDC 2022 Guideline for Prescribing Opioids for Chronic Pain (Dowell et al., 2022) reiterates the need for adequate pain control and the challenges involved, particularly in chronic pain control. It recommends that providers utilize the "full range of therapeutic options" to treat chronic pain (Dowell et al., 2022). The report states that it is hard to quantify the number of individuals who could benefit from long-term use of opioid medications.

The report states that between 1999 and 2014, more than 165,000 people died from opioid overdoses (Dowell et al., 2022). Research has found practices that have contributed to the opioid overdose epidemic, the most important of which are prescribing high doses of opioids, overlapping opioid and benzodiazepine prescriptions, and the use of extended-release opioids for acute pain (Dowell et al., 2022).

The CDC guidelines make recommendations in three areas of opioid use:

• Determining when to start or continue opioid medications in the treatment of chronic pain
• Selection, dosage, duration of therapy, follow-up, and medication discontinuation
• Assessment of risk factors and tackling the harmful consequences that can occur with opioid use

The guideline recommends that non-pharmacologic therapies and non-opioid medications are the first-line treatment when treating chronic pain (Dowell et al., 2022). The CDC recommends using immediate-release opioids at the lowest effective dose, rather than the extended-release form, to treat acute pain (Dowell et al., 2022).

Before starting opioid therapy to treat chronic pain, clinicians must establish goals with the patient that involve realistic outcomes for pain relief and improved activity (Dowell et al., 2022). Continue opioids only if there is sufficient improvement in the patient's pain levels and a positive impact on their quality of life that outweighs the possible adverse side effects of opioid use. After one to four weeks of opioid therapy, the provider needs to reassess the patient. Continued opioid therapy evaluations for the benefits and risks of opioid therapy need to be done at least every three months. When discontinuing opioids, a reduction of 10% of the medication dose per week should alleviate the symptoms of opioid withdrawal.

Extra caution should be implemented in some groups of patients. Areas of risk for opioid use include patients with sleep apnea, pregnancy, patients with renal or hepatic insufficiency, those older than 65, people with mental health disorders, patients with substance abuse disorders, and individuals with a previous non-fatal overdose (Dowell et al., 2022).

The CDC guidelines also note the clinician's importance of using state Prescription Drug Monitoring Program (PDMP) data to verify whether or not the patient is getting opioid medications or dangerous medication combinations that place them at high risk for overdose (Dowell et al., 2022).

Prescription drug misuse is the use of prescription medication in a method or intent inconsistent with how it was prescribed. Misuse includes using medication to get high, selling or sharing it with others (diversion), overuse, having multiple prescribers, and concurrent use of alcohol or other illicit substances. Misuse is a necessary criterion, but solely sufficient, for a substance use disorder (American Psychiatric Association, 2022).

Susceptible individuals are at risk of misusing medications that stimulate the brain's reward center, including opioid analgesics, stimulants, benzodiazepines, or tranquilizers. Drug abuse is when drugs are not used medically or socially appropriately. Controlled substances may lead to dependence, either physical or psychological, or both. Physical dependence transpires when there are withdrawal symptoms such as anxiety, elevated heart rate, hypertension, sweating, an unstable mood, or dysphoria after the substance is stopped (Szalavitz et al., 2021).

Psychological dependence is the perceived need for the substance. It makes the person feel as though they cannot function if they do not have the substance. Psychological dependence often kicks in after physical dependence wears off. It typically lasts much longer than physical dependence and often is a substantial contributing factor to relapse (Wyoming Legislature, n.d; Szalavitz et al., 2021).

The National Institute on Drug Abuse provides multiple definitions for substance use/abuse-related terms (Wyoming Legislature, n.d.). Addiction is psychological dependence and extreme behavior patterns associated with the drug. At this point, there is typically a loss of control regarding drug use. The drug is continued despite severe medical and social consequences. Tolerance, increasing doses of the medication needed to produce an equivalent effect, is typically seen by the time addiction is present. Physical dependence can occur without addiction. Individuals who take chronic pain medication may be dependent on the medication but not addicted.

Addiction is a major concern for those taking opioids. When prescribing opioids, it is important to determine who is likely to participate in aberrant drug-related behaviors. Inappropriate use may occur in those with major depression, psychotropic medication use, younger age, or those with a family or personal history of drug or alcohol misuse (Dowell et al., 2022; Webster, 2017).

Aberrant behaviors may include abuse, misuse, or addiction. Examples of aberrant drug-related behaviors include (Dowell et al., 2022; Maumus et al., 2020):

• Requests for early refills
• Not taking medications as prescribed
• Failure to keep appointments
• Visits in distress
• Frequent reports of lost medication
• Using multiple prescribers
• Positive urine drug test for illicit substances
• Altering prescriptions
• Resistance to referrals
• Resistance to providing prior medical records
• Resistance to change in therapy
• Increasing the dose without telling the prescriber
• Requests for specific drugs

The reality is that many patients do not report pain or minimize the severity of the pain they are experiencing. There are several reasons, including poor communication between patients and healthcare providers. There are increased anxiety levels for those admitted to an acute care facility, seeing several different providers, not being entirely sure whom to report their pain to, and the sense of helplessness in finding themselves in a hospital gown and a strange environment. Nurses are vital as the patient's advocate and navigator through the system's complexity to ensure that pain is appropriately addressed.

Multiple ethical issues surround pain and its management. Healthcare providers should attempt to minimize pain and suffering while maintaining a balance between adequate pain management and minimizing harm from pain treatment.

Ethical issues surround end-of-life care. Pain management at the end of life is a moral duty for the healthcare professional caring for a terminal patient. While opioid use may suppress respiration and may even accelerate death, pain treatment is a necessary part of care for intractable pain as death approaches. The goal of pain management is to ease suffering, not accelerate death. Palliative sedation is used to manage refractory pain at the end of life.

The Joint Commission (2022) emphasizes the value of efficient pain assessment and management across healthcare settings. Organizations are responsible for guaranteeing that suitable screening and assessment tools are accessible and used appropriately. These tools must be evidence-based and designed for the patient's age, condition, and understanding capacity.

A 'screening' evaluates the potential presence of a problem. An 'assessment' gathers more specified information through data collection, observation, and physical exam. Pain assessment tools should be evidence-based and include an evaluation of pain intensity, location, quality, and associated symptoms (The Joint Commission, 2022).

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

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

Pain threshold refers to the minimal level at which an individual senses pain as a harmful stimulus (Lalouni et al., 2021). It is the level at which the patient first states that what they are feeling is painful, which 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 (Fillingim, 2017). 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 intensity of the patient's pain at different time points, not to compare one person's pain to another. The use of pain scales assists the healthcare provider in determining the effectiveness of pain treatment.

The most effective pain assessment scales are concise, valid, require minimal training, and incorporate both behavioral and descriptive pain measures (Herr et al., 2011). When selecting a scale, it is essential to consider the individual needs of the patient to ensure accurate pain assessment (Pasero & McCaffery, 2011). Additionally, patient education regarding pain assessment plays a critical role in effective pain management.

A "0 to 10" numerical scale is a widely used measure to assess pain intensity (Nugent et al., 2021). 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 (Quinlan-Colwell et al., 2022).

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" (Quinlan-Colwell et al., 2022). 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 (Quinlan-Colwell et al., 2022):

• 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" (Haefeli & Elfering, 2006). 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 location of the pain and may rate the severity of the pain.

Since we have no instrument to measure pain intensity, like a sphygmomanometer measures blood pressure objectively, self-report is used as a valid measure of pain. Sometimes, healthcare providers think they are the best judges of a person's pain; however, they often either over or underestimate a patient's pain.

Pain Scale

For patients who are NOT cognitively impaired but cannot respond verbally to rate their pain numerically, face scales with happy faces representing no pain (0) and progressively sadder faces representing increasing pain intensity may be used. 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- or over-treatment. Nurses must ensure that pain is accurately assessed and treated in these vulnerable populations (Table 1).

Pain assessment should include documentation of its impact on a patient’s quality of life. Key questions to consider include (Australian Pain Society, n.d., Haefeli & Elfering, 2006; Wahezi et al., 2022):

• Does pain restrict physical activity or exercise?
• Does pain impact sleep?
• Do you need assistance or mobility aids because of your pain?
• Has your pain limited your ability to work or perform household tasks?
• Are there any hobbies or activities you have stopped because of pain?
• Can you perform essential daily living activities such as bathing, dressing, feeding, toileting, or brushing your teeth?
• Does your pain affect your mood or cause feelings of anxiety, stress, or depression?
• Does pain lower energy levels?
• Does pain limit participation in activities and social interactions?
• Does pain impact personal relationships?
• Does pain interfere with instrumental activities of daily living (IADLs), such as using the telephone, doing laundry, managing medications, or handling finances?

Understanding how pain was treated in the past for the patient will help the clinician treat the current pain. Reviewing 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 differences.

Understanding all medical and surgical conditions can help ensure proper pain management. A chronic disease may have a substantial impact on the management of pain. Chronic kidney disease, for example, reduces medication excretion. The use of NSAIDs can lead to kidney failure in those with chronic kidney disease (Baker & Perazella, 2020).

Many factors contribute to chronic pain. A mental health evaluation can help the clinician understand the best way to manage pain. Mood or cognitive disorders can impact the way the pain is treated. Chronic pain cannot be adequately managed in those with unidentified and untreated mental illness. A history of drug abuse is an essential factor 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 that 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 will often have poor hygiene, unkempt dress, and appear to be in pain. Observe for any splinting, which may suggest a painful part of the body. Assessing skin and joints for redness, swelling, or deformities helps determine the location and etiology of the 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 evaluate functional capacity, strength, endurance, and pain-related limitations (Haefeli & Elfering, 2006; Wahezi et al., 2022).

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 improvements in the quality of life.

The goals of pain management are not necessarily complete pain relief. They may include a reduction in pain, improved quality of life, improved physical and psychological functioning, improved ability to work, improved ability to function in society, and reduced healthcare utilization.

A pain management plan is more than just a prescription for pain medication. In addition to pharmacotherapy, it should include psychological and physical modalities to manage pain. It should be modified when interventions are not sufficient. Successful treatment of chronic pain requires an interdisciplinary healthcare team's input and a holistic approach to care to improve the patient's overall quality of life. One of our most essential roles is listening to our patients, which is especially important for pain patients, particularly those with chronic pain. These patients frequently suffer from intense fear, anxiety, insecurity about the future, social isolation, and loneliness. The opportunity to tell one's story to someone consciously listening is therapeutic.

Educate the patient regarding the plan. Education should include information about prescribed medications, other treatment options, and methods to contact the pain management team.

When developing a treatment plan, there are many considerations. Consider the type of pain and its effect on lifestyle, including psychological, social, and biological components. Many factors affect the success of the treatment plan. Issues related to the patient, such as their ability to understand and apply the management plan, will help determine its success. The patient's willingness to implement the whole plan can profoundly affect the success of the plan. If a patient is willing to take a pill but is unwilling to work on non-pharmacologic interventions (such as physical therapy or weight loss), the plan will lose its effectiveness.

Caregiver or healthcare provider issues often affect the pain management plan. Many caregivers and healthcare providers do not accurately comprehend the patient's pain and may hold false beliefs regarding pain management. Caregivers and healthcare providers may be inhibited by fear of side effects from medications or concerns of drug addiction; therefore, they may withhold medication to those in pain. Also, caregivers/healthcare providers and patients may have conflicting goals.

Controlled substances should be prescribed for a legitimate medical purpose with careful consideration of the patient's safety, therapy goals, and efficacy. Not only should the treatment of pain include pharmacotherapy, but physical and psychological therapies should also be used. Many caregivers lack knowledge and understanding of non-pharmacological pain treatments and cannot provide patients with the full scope of available pain therapies. Referral to a pain management specialist may be indicated for those who have debilitating symptoms, those who need increased doses of pain medications, those who are non-responsive to treatments, or those with symptoms at multiple sites.

Ms. L is a 52-year-old female with a history of bilateral knee OA; she currently rates the pain as a 7/10 in her right knee and a 6/10 in her left knee. She takes celecoxib 200 mg twice a day and uses 1000 mg of acetaminophen for breakthrough pain three times a day. She has taken the same medications over the last six months, but over the last month, she has not been getting adequate relief from her pain, has been progressively disabled, and has stopped exercising because of pain in her knees.

In addition to OA, she has a past medical history of hypertension, dyslipidemia, depression, and obesity. She has a past surgical history of an inguinal hernia repair as a child and is currently on simvastatin, lisinopril, celecoxib, and acetaminophen. She has no known allergies.

She has no history of alcohol, drug, or substance abuse. She has a strong family network, including a supportive husband of 25 years and two sons who live within twenty miles of her home. She has a history of depression but is currently not depressed.

The physical exam exhibits bilateral knee crepitus and obesity (body mass index [BMI] 35). She is unable to extend the right knee due to pain.

An X-ray demonstrates moderate arthritic changes in both knees. The patient is unwilling to consider surgery on her knees.

The prescriber offers tramadol immediate-release 25 mg in the morning, titrated every three days in 25 mg increments to 25 mg three times a day. Pain control was still not adequate, and the dose was then increased by 25 mg every three days to 50 mg every 8 hours.

Pain control was significantly improved, and then the patient was given extended-release tramadol 200 mg once a day. The patient was able to function and exercise. Her quality of life was much improved.

Chris is a 44-year-old secretary who presents to her primary care provider with back pain for the last three weeks. The pain started after she lifted a heavy box at work. Her self-management regime included bed rest and taking acetaminophen alternating with ibuprofen for the last three weeks. She reports that the pain is not getting any better. The pain is described as aching and diffuse along her lower back. She says the pain worsens with walking and prolonged standing or sitting and is relieved when lying down. She reports that the pain radiates into her right buttock but not down the leg.

Chris is generally healthy. The only medication that she takes regularly is sertraline for depression. She has never had any surgeries and has no allergies to medications.

On physical exam, her vitals are stable, and she appears comfortable. She walks with a slight limp. The exam shows diffuse tenderness across her lumbar spine. There is no deformity, the straight leg raise is negative, the sensation is intact to the lower extremities, and her exam's remaining aspects show no focal neurological finding. Recent labs demonstrated a normal blood count and normal liver and renal function.

Her primary care physician recommends that she go to physical therapy, prescribes diclofenac 50 mg three times a day for three weeks, and encourages her to use acetaminophen for breakthrough pain.

At the three-week follow-up, Chris is doing better. Her primary care physician recommends continued home exercises as recommended by the physical therapist and, as needed, acetaminophen for pain; the NSAID is stopped at this time as there is likely limited inflammation contributing to the pain.

This case is typical of back pain; it resolved within six weeks. The pain was caused by an acute injury with muscle spasms causing referral of pain into the buttock. Radicular pain was not present. Radicular pain would be present if there were inflammation, compression, or injury to a spinal nerve root.

Imaging is not indicated in this case because there were no red flags. Typically, this type of back pain responds to simple analgesics; the use of opioids is not necessary. Acetaminophen is preferred for analgesia because of its relatively safe profile. The use of an NSAID may be needed because of its anti-inflammatory effect. Sometimes, short-term use of a muscle relaxer may help muscle spasms, which often contributes to this type of acute pain. 

The goal is to minimize disability and return Chris to her baseline function as soon as possible. Relative rest may be appropriate, but prolonged bed rest will contribute to deconditioning and stiffness and prolong recovery. The patient with acute lower back pain should have exercises to strengthen the lower back, stomach, and other core muscles and stretch the lower back and legs. Appropriate healthcare for back pain will get patients back to normal functioning quickly while minimizing the risk of dangerous treatment options.

Opioid antagonists and overdose prevention treatments are critical tools in combating opioid overdoses, which have become a major public health crisis. Opioid antagonists are medications that bind to opioid receptors in the brain but do not activate them, thus blocking the effects of opioids like heroin, morphine, and prescription painkillers. The primary opioid antagonist used in overdose prevention is naloxone (brand names include Narcan® and Evzio®).

• Naloxone: Quickly reverses opioid overdoses by displacing opioids from their receptors in the brain. It can be administered through an injection or nasal spray.
• Naltrexone: Another opioid antagonist, but it is used for longer-term treatment of opioid addiction rather than for immediate overdose reversal.

In addition to naloxone, overdose prevention efforts focus on harm reduction strategies and long-term treatment for opioid use disorder (OUD).

Prevention methods include:

• Naloxone distribution: Ensuring that naloxone is widely available, particularly to individuals at risk of opioid overdose, their families, and first responders.
• Medication-assisted treatment (MAT): Use of medications such as buprenorphine and methadone, combined with counseling and behavioral therapies, to help patients reduce or quit opioid use.
• Education on safe opioid use: Educating patients about the risks of opioids, safe storage, and proper disposal of unused medications.

Patients might be counseled on opioid antagonists and overdose prevention treatments in several key scenarios. Individuals with high-risk opioid use are the first groups of patients who may benefit. Patients prescribed opioids for chronic pain management may be advised on naloxone use if they have a history of substance use disorder or if they are prescribed high doses. People who use opioids recreationally, particularly those using street drugs (e.g., heroin or fentanyl), should be educated on naloxone and overdose risks.

Other groups that should be considered include family and caregivers of opioid users, patients in recovery, and those being discharged from medical care. Family members or caregivers of individuals at risk for opioid overdose are often provided with naloxone and trained on how to administer it in case of an emergency. Individuals undergoing treatment for OUD or who have a history of opioid addiction might be encouraged to have naloxone available to prevent accidental overdose relapses.

They may also be advised on long-term treatments like MAT, including access to buprenorphine, methadone, or naltrexone. Patients leaving the hospital after being treated for an opioid overdose are typically given naloxone and information on how to access further care, including overdose prevention services. Discharged patients may also be directed to local harm reduction programs, needle exchange programs, and outpatient treatment for addiction management.

Buprenorphine is a medication commonly used as part of MAT for OUD. It helps individuals reduce or quit the use of opioids such as heroin, prescription painkillers, and other opioid substances. Buprenorphine is effective because it addresses both the physical and psychological components of opioid addiction.

Buprenorphine is a partial opioid agonist. It activates opioid receptors in the brain, but not to the same degree as full agonists like heroin or prescription opioids. Buprenorphine reduces cravings and withdrawal symptoms without producing the intense "high" associated with opioid abuse (Kumar et al., 2024). The "ceiling effect" of buprenorphine limits its potential for misuse, as higher doses do not produce greater effects beyond a certain point.

Formulations of buprenorphine include oral and injectable formulations. Suboxone® is a combination of buprenorphine and naloxone (the latter helps deter misuse by causing withdrawal symptoms if the medication is injected). Subutex® contains only buprenorphine and is often used in specific cases such as pregnancy or individuals with naloxone sensitivities. Buprenorphine extended-release injections provide long-acting options that help reduce the burden of daily dosing.

The benefits of buprenorphine in MAT include reducing opioid cravings, minimizing withdrawal symptoms, improving retention in treatment, and lowering the risk of overdose. It reduces opioid cravings by stimulating opioid receptors, making it easier for patients to avoid relapse. It minimizes withdrawal symptoms by alleviating the uncomfortable and often painful withdrawal symptoms, which are a significant barrier to recovery. Buprenorphine improves retention by improving engagement in treatment, which increases the chances of long-term recovery. Lastly, the partial agonist property of buprenorphine lowers the risk of overdose compared to full opioid agonists.

Buprenorphine has nuances in administration and supervision. The induction phase is typically introduced when the patient is in mild-to-moderate withdrawal from opioids to avoid triggering more severe withdrawal symptoms. In the stabilization phase, the patient’s dose is adjusted to reduce withdrawal and cravings without causing sedation or intoxication. In the maintenance phase, the optimal dose is established, and patients can remain on buprenorphine for months or even years, depending on individual needs and recovery progress. Buprenorphine can be prescribed by trained healthcare providers in an office-based setting, offering more flexibility than other treatments like methadone, which must be administered in specialized clinics.

Buprenorphine is most effective when combined with behavioral therapy and counseling. A complete methodology addresses the psychological, social, and environmental factors contributing to opioid addiction. CBT, contingency management, and motivational interviewing are some therapeutic methods used alongside MAT to improve outcomes.

Buprenorphine is associated with risks, including diversion/misuse, side effects, and risk in pregnancy. While buprenorphine has a lower potential for abuse, there is still some risk, particularly if not taken as prescribed. This is why formulations like Suboxone® (with naloxone) are preferred for outpatient treatment. Common side effects include constipation, headache, nausea, and insomnia (Kumar et al., 2024). Rarely, patients may experience respiratory depression if combined with other CNS depressants.

Pain is a disagreeable sensory and emotional experience connected with actual or potential tissue damage or explained in terms of such damage. Many conditions have the potential to cause pain. Understanding, assessing, and treating these conditions is vital in appropriately managing the pain. In the current healthcare system, many aspects of pain are not even addressed. Many regulatory agencies have implemented guidelines within the healthcare system to help address the pain epidemic.

The healthcare team's role is to perform a good initial and ongoing pain assessment. Proper pain management requires a team approach to evaluate and treat pain. Many options are available to manage pain, including non-pharmacological options, non-opioid medications, opioid medications, and adjunctive medications. Opioid analgesics, while very good at managing pain, have led to many social and legal problems, including overuse and diversion.

The healthcare team is also responsible for partnering with the patient to manage the pain adequately. Each healthcare team member has a role in the management of pain. Pain management is a significant focus for nurses. If healthcare team members perform their function and the patient takes an active role in their care, adequately treating pain is a very attainable goal.

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