Sign Up
For the best experience, choose your profession & state.
You are not currently logged in. Please log in to CEUfast to enable the course progress and auto resume features.

Course Library

Pain Assessment and Management: Massachusetts

2 Contact Hours including 2 Pharmacology Hours
This peer reviewed course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Registered Nurse (RN)
This course will be updated or discontinued on or before Saturday, March 25, 2023
Outcomes

≥92% of participants will report an increase in knowledge regarding how to assess and manage pain. This course meets Commonwealth of Massachusetts, Advisory Ruling (AR) 0901: Management of Pain: Chapter 52 of the Acts of 2016, M. G.L. c. 94C, s. 18(e).

Objectives

By the end of this activity, the learner will be able to:

  1. Outline the multidimensional nature of pain.
  2. Illustrate the implications of pain on the patient.
  3. Summarize the assessment and measurement of pain.
  4. Describe the risks of abuse and addiction associated with opioid medications.
  5. Compare and contrast pharmacological and non-pharmacological methods to manage pain.
  6. Compare and contrast the assessment and management of pain in special populations, including infants, children, adults, and geriatric patients.
  7. Categorize the clinical conditions and the management of those conditions that have pain as a major component.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

Last Updated:
CEUfast OwlGet one year unlimited nursing CEUs $39Sign up now
To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Authors:    Raymond Lengel (MSN, FNP-BC, RN) , Maryam Mamou (BSN, RN, CWOCN)

Introduction

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 from damaging behavior or stimuli (Moller, 2014).

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 that "Pain is a more terrible lord of mankind than even death itself" (IASP, 1979).

Multidimensional Nature of Pain

Pain is a significant problem in today's society. Pain carries consequences across a broad range of categories, including ethical, social, economic, and legal arenas. The International Association for the Study of Pain recently updated its definition of pain and defines pain as " An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage"(IASP, 2021). 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 defined as acute pain that refuses to go away, and it can be seen as a disease in its own right (Fillingim et al., 2016).

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 that pain is one of the most common reasons people seek 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. Overall, low back pain costs Brazil 2.2 billion dollars each year, with total health care costs about 460 million dollars. Low back pain results in approximately 20 million missed days of work each year (Carregaro et al., 2020).

Chronic non-malignant pain is defined as pain lasting more than three months and may affect any part of the body (Kennedy et al., 2016). Chronic pain is divided into three broad classes depending on location: localized, regional or widespread. 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. 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 three times as many women as men (van Velzen et al., 2019). Headaches and migraines also have a higher occurrence rate in women than in men; women's annual prevalence rate reaches up to 32% and for men up to 16% (Frederick et al., 2014). This pattern is found not just in the United States but worldwide. Fibromyalgia, osteoarthritis, and irritable bowel syndrome are more prevalent in women than men.

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 may last for a few months. The pain dissipates when the underlying cause has healed. When acute pain lasts longer than 3-6 months, it is then termed chronic. 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, society, 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 made knowledgeable about methods of 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.

Pain Theories

Nerve fibers transmit pain impulses to the brain, where the brain can personalize the pain experience (Wilson, 2020). Pain theories help clinicians understand the pain and help in the guidance of 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.' He believed that the human soul resided in the pineal gland, which was the source of sensations that the individual experienced, including pain (Moayedi & Davis, 2013). The Specificity Theory of Pain suggests that specific pain receptors send out signals to the brain that create pain awareness. According to the theory, pain is an independent sensation with particular peripheral sensory receptors, which act to damage to drive signals through the nervous system to centers in the brain.

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.

A more recent theory is the Gate Control Theory. Pain stimulation is transmitted by small, slow fibers that go into the spinal cord's dorsal horn. The theory states that there is a gate in the spinal cord, which 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.

Types of Pain

  • Acute pain – Pain that has an abrupt onset and offers a warning of a disease process or a threat to the body.
  • Chronic pain – Pain that lasts beyond the usual duration of time that an insult or injury to the body needs to heal. Pain without apparent biologic value that lasted beyond the usual tissue healing time (typically at least three months).
  • Maladaptive pain – Pain that is not useful and is out of proportion to tissue damage. This type of pain tends to last long after tissue healing and is often due to changes in the central nervous system.
  • Adaptive pain – Pain that protects the individual from injury and aids with healing after an injury.
  • Allodynia — Pain from a stimulus that typically does not cause pain.
  • Hyperesthesia – Increased sensitivity to stimulation.
  • Paresthesia — An unusual sensation that is often described as burning or prickling and commonly affects the extremities.
  • Visceral pain – Pain from the viscera mediated by stretch receptors. This pain is commonly described as deep, dull, poorly localized, and cramping.
  • Nociceptive pain – Pain from threatened or real tissue damage to non-neural tissue caused by nociceptors' activation.
  • Neuropathic pain – Pain from an abnormal neural activity from an injury, disease process, or dysfunction of the nervous system.
  • Mononeuropathy - Neuropathy is affecting one nerve.
  • Polyneuropathy – Neuropathy is affecting several nerves.

Pain Anatomy and Physiology

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.

The two major types of physiological pain are somatic pain and visceral pain. Somatic pain occurs when there is an injury to the skin, joints, muscles, or ligaments. It alerts the presence of disease or injury, and it serves an important protective role. Pain-related to stimulation of the peripheral nerves and cranial nerves are also referred to as physiological pain. The brain tissue itself has no pain receptors. However, the dura mater, which is the brain's outer lining and its large arteries, is equipped with pain receptors and can cause physiological pain. Innervation for these pain receptors comes from the trigeminal nerve, cranial nerve V.

Visceral pain arises from the stimulation of 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. It is often difficult for the patient to pinpoint the exact location of the pain, and consequently, it is experienced as referred pain coming from the body surface. For the most part, the viscera's pain receptors are chemoreceptors that respond to different types of chemicals, including those from the inflammatory process's activation. Pain receptors in the viscera can also respond to stretching of the organs 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, changes to the trigeminal nucleus and other brain areas. It is highly complex and difficult to treat. Pathological pain includes central neuropathic pain and the pain in conditions such as fibromyalgia, stroke, and Parkinson's disease.

Primary afferent fibers are involved in transmitting noxious stimuli from the body's periphery to the spinal cord's dorsal horn. The A-delta fibers have a small diameter and are lightly myelinated, and conduct slowly. 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 and respond to multiple stimuli and lead to dull, achy pain.

A-delta and C fibers both react to mechanical stimulation and temperature, hot and cold. Pain receptors innervate the skin surfaces and the joints in the body, but they are not as abundant in the muscles. If the pain signal is strong enough, it transmits through the dorsal horn to the spinothalamic tract and the spinoreticular tract.

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 to the trigeminal nucleus. Modulation refers to how various systems affect pain intensity, and several systems in the spinal cord and brain modulate pain. Endogenous opiates are one way to affect the intensity of pain. Animal studies showed that electrical stimulation of the PAG could reduce 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 (Moller, 2014).

The neurons are involved in the transmission of pain through the release of substances and neurotransmitters. The excitatory substances that contribute 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). Medications are involved in modulating these neurotransmitters to help reduce pain.

The Impact of 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. Up to 52.6 percent of people who have chronic pain suffer from a mood disorder (Pereira et al., 2017). Pain can change the way one thinks and acts leading to behavioral changes. The risk of suicide for those in chronic pain is about twice the general population, and the highest risk is seen in those who suffer from severe chronic headaches.

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. Expression and reporting of pain can vary by culture. Some cultures have a more stoic attitude to pain, while others may express more emotion to pain.

The biopsychosocial model of pain care leads to a significant step in how people with pain were perceived and handled. This holistic approach to pain recognizes the importance of the psychological and social factors that play a role in the patient's subjective pain experience. The biopsychosocial model considers cognitive, emotional, spiritual, and cultural issues unique to the individual and their pain journey. Suffering related to pain is an individual experience. One of the biopsychosocial model's core principles is to give the patient the right to participate in and direct their care (Darnall et al., 2017).

The political arena can strongly influence pain in society. The assessment of pain over the last 20 years 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 adequately assessed and treated with extra caution in preventing medication abuse.

Substance Abuse

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 2016, 48.5 million individuals in the United States misused prescription drugs or used illicit drugs. Sixty-six percent of the 630,000 drug overdose deaths were due to illicit or prescription opioids. The number of opioid overdoses to the emergency department increased by 30 percent from July 2016 to September 2017.
  • According to the Center for Disease Control and Prevention (CDC), 41 people die each day in the United States from an overdose of prescription painkillers (Center for Disease Control, 2020).
  • In 2012, healthcare providers wrote 259 million prescriptions for painkillers (National Center for Injury Prevention and Control, 2014). Two times as many painkiller prescriptions are written in the United States as in Canada.
  • Overdoses from synthetic opioids increased from 3.1 per 100,000 people in 2015 to 6.2 people per 100,000 people in 2016 (Hedegaard et al., 2017).
  • Between 1999 and 2015, drug overdose deaths have tripled (Black et al., 2020).
  • Of U.S. veterans treated in primary care settings, 4.8% reported opioid analgesic misuse (Department of Health and Human Services, 2012).
  • 12.2% of 12th graders reported ever abusing opioids, and 7.9% reported past-year use (Merikangas & McClair, 2012).
  • The number of individuals seeking treatment for non-heroin opioid substance abuse increased from 1.0% in 1995 to 8.7% in 2010 (Department of Health and Human Services, 2012).
  • Research shows that white individuals account for 88% of those who reported non-heroin opioid substance abuse, and the majority of these individuals lived in rural settings.

The Centers for Disease Control and Prevention (CDC) 2016 Guideline for Prescribing Opioids for Chronic Pain (Dowell et al., 2016) 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. 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. Using DSM-IV diagnosis criteria, in 2013, approximately 1.9 million individuals either abused or were dependent on opioid drugs. 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.

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. The CDC recommends using immediate-release opioids at the lowest effective dose, rather than the extended-release form, to treat chronic pain. 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. Continue opioids only if there is sufficient improvement in the patient's pain levels and positive impact on their quality of life that outweigh 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 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.

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.

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. In some states, the law requires the provider to review the PDMP before renewing each opioid prescription.

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 other (diversion), overuse, having multiple prescribers, and concurrent use of alcohol or other illicit substances. Misuse is a necessary but not solely a sufficient criterion for a substance use disorder.

Susceptible individuals are at risk to misuse 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. Physical dependence transpires when there are withdrawal symptoms such as anxiety, tachycardia, hypertension, diaphoresis, a volatile mood, or dysphoria after the substance's rapid discontinuation.

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.

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 in those taking opioids. When prescribing opioids, it is important to determine who is likely to participate in aberrant drug-related behaviors. 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. The prescriber and a specialist should co-manage the patient.

Aberrant behaviors may include abuse, misuse, or addiction. Examples of aberrant drug-related behaviors include:

  • 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

Why Patients do not Report Pain

The reality is that many patients do not report pain or minimize the severity of the pain they are experiencing. There are several reasons for this, 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 have a vital role in these situations as the patient's advocate and navigator through the system's complexity to ensure that pain is appropriately addressed.

Ethics and Pain

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. The management of pain at the end of life is a moral duty for the provider caring for a terminal patient. While opioid use may suppress respiration and may even hasten death, pain treatment is an essential part of care for intractable pain as death nears. The goal of giving pain management is to relieve suffering, not accelerate death. Palliative sedation is used to manage refractory pain at the end of life.

Pain Assessment and Measurement

When and How Should Pain Intensity be Assessed?

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.
  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. It is 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 for them. 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 pain 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 best scales are brief, valid, require minimal training to use, and use behavioral and descriptive pain measures. When selecting a scale, it is important to consider which type of 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 works. 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" equals 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 use
  • 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 location of the pain and may rate the severity of the pain.

Since we have no instrument to objectively measure pain intensity in the same way that a sphygmomanometer measures blood pressure, 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.

pain_chart

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 play an essential role in ensuring that pain is accurately assessed and treated in these vulnerable populations.

Besides current pain intensity, the complete pain assessment includes the following:
1.Location of pain, where does the pain start, and does it spread to other parts of the body?
2.Pain intensity for the worst pain, the best pain gets, and the acceptable level of pain. Satisfactory pain relief is a level of pain that may be noticeable but not bothersome.
3.Character or quality of pain. The words used by the patient to describe pain may enhance the understanding of the etiology of the pain and provide usefulness in selecting interventions to manage it. For example, somatic (musculoskeletal) pain is usually localized and described as dull, achy, and sore. Visceral pain is usually poorly localized and described as a cramping or squeezing pain. Descriptors of burning, shooting, or knife-like are indicative of neuropathic (nerve) pain. (See Table 1)
4.Onset, duration, variations, and pattern (is the pain better or worse at certain times, certain hours?)
5.Alleviating factors – what makes the pain better?
6.Aggravating factors – what makes the pain worse?
7.Impact of pain on quality of life and daily functioning. How does the pain affect sleeping, relationships with others, mood, emotions, and concentration?
Table 1: Types of Pain
Pain TypeDescriptionEtiologyTreatment
Neuropathic
  • Burning
  • Shooting
  • Tingling
  • Numbness
  • Radiating
  • Nerve involvement
  • Tumor
  • Postherpetic neuralgia
  • Diabetic neuropathy
  • Post-stroke pain
  • Antidepressants
  • Anticonvulsants
  • Local anesthetics
  • Opioids
Nociceptive:
  • Visceral (poorly localized)
  • Squeezing
  • Cramping
  • Pressure
  • Distention
  • Deep
  • Tumors occupying the liver
  • Pancreas
  • Spleen
  • Abdominal or thoracic surgery
  • Ascites
  • Non-opioids
  • Acetaminophen
Nociceptive:
  • Somatic (well-localized)
  • Dull
  • Achy
  • Throbbing
  • Sore
  • Bone metastases
  • Musculoskeletal injury
  • Mucositis
  • Skin lesions
  • NSAIDs
  • Opioids
  • Co-analgesics
  • Corticosteroids
  • Local anesthetics
  • Bisphosphonates
  • Radioisotopes

It is also important to document the impact pain has 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 instrumental activities of daily living (IADL), 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 past for 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 assure 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 non-steroidal anti-inflammatory medications can lead to kidney failure in those with chronic kidney disease.

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 an essential factor to ascertain, which could profoundly affect chronic pain treatment. Personal characteristics may have a substantial effect on pain management. Factors that influence 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 out of treatment, and what are the patient's goals? Besides, psychological factors that contribute to the pain should be assessed as this will 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 health care team to determine pain management and functional capacity progress.

The physical exam should include a detailed neurological exam, including the patient's ability to ambulate. 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. Assess 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 an essential part of 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 Tests

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 (which are 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 may be seen in imaging tests that are not the pain source.

An electromyogram (EMG) or nerve condition 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.

Management of Pain

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 health care 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 patients' overall quality of life. One of our most essential roles is listening to our patients, which is especially important for pain patients, particularly in those with chronic pain. These patients often live with intense fear, anxiety, uncertainty about the future, and frequently social isolation and loneliness. The opportunity to tell one's story to someone who is consciously listening is therapeutic in itself.

Educate the patient regarding the plan. Education should include information about medications prescribed, 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 the plan's 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.

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.

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 also physical and psychological therapies. Many caregivers lack knowledge and understanding of non-pharmacological pain treatments and cannot provide patients with the full scope of available pain therapies.

Non-pharmacological Therapy

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 trial of physical therapy or occupational therapy 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 assist in enhancing activities of daily living. With chronic pain, there is a tendency not to move, which leads to deconditioning and further incapacity—deconditioning results in more significant 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 there is of them developing back pain. Physical activity has been shown to improve their overall health significantly for those who have lower back pain. Exercise, especially those performed in water, is beneficial for 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, along with deep breathing and relaxation, is having 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 spasm, joint pathology, or nerve root irritation. Methods of cold application include ice massage, ice bags, and gel packs. Alternating heat and cold may be more effective than the use of 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 the individual becomes aware of their thoughts, feelings, and behaviors and journaling 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 been shown to reduce pain in chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, and back pain. It has also been used successfully as a means to prevent headaches (Moller, 2014).

Relaxation is a state of relative freedom from anxiety and skeletal muscle tension, a quieting or calming 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 the focusing of attention on stimuli other than the pain sensation. The stimuli focused upon can be auditory, visual, or tactile-kinesthetic (hearing, seeing, touching, and moving). By focusing on stimuli other than pain, the pain moves 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 acceptable 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.

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 that it works 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 theory of acupuncture 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 health care 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 signals that provide pain relief. 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.

Teaching Coping Skills

Pain has two parts; first of all, there is the perception of pain, which is related to the strength and characteristics of the pain, and secondly, there is the effect the pain has on the individual. What is its emotional impact, and how is it impacting their quality of life? When healthcare providers perform a pain assessment, it is the strength or intensity of the measured pain, which may not reflect how the pain affects their lives. How pain affects an individual is intimately associated with their ability to cope with the pain (Moller, 2014).

Coping can be defined as what an individual thinks and does in a situation that causes them stress. It is greatly affected by the resources that are available to the person to manage the event. Coping is a crucial part of pain management, especially for those with chronic pain. Nurses need to be aware of the need to assess patients coping patterns as they relate to pain and to be able to discuss necessary coping skills with them.

Catastrophizing is the opposite of coping and is the belief that a situation will continue to worsen and is an essential predictor of pain and pain adjustment, especially in chronic pain. However, recent research has shown an important link between acute pain and pain catastrophizing (Block et al., 2017). The individual experiences heightened levels of worry and fear that have intensified the amount of pain the person feels. Instead of problem-solving, the individual tends to turn away and feel hopeless about their situation. Catastrophizing needs to be something that nurses are watchful for when assessing a patient's pain by listening carefully to how the patient describes their pain and how they perceive its effect on their life now and in the future.

Pharmacologic Interventions

Undertreatment of chronic pain remains a persistent problem, with an estimate of 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 on an as-needed basis for episodic pain or given routinely for chronic pain. The use of 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 medication 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 the medications' 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 the management of nociceptive pain.

Acetaminophen has become the 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 Federal 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 amount of 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 a day. 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 who are on a statin cholesterol medication may need a lower dose of acetaminophen.

Before going to stronger pain medication, clinicians must determine that acetaminophen is dosed correctly. 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 (COX-1) involved in the synthesis of prostaglandins that mediate inflammatory responses 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). The use of topical NSAIDs is 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, corticosteroids, bleeding problems, or a history of gastric ulceration – should not use NSAIDs. For those with compromised gastrointestinal tracts, the use of a proton pump inhibitor reduces the risk of gastric ulceration when NSAIDs are necessary. NSAIDs interact with many antihypertensive medications, aspirin, 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, resulting in a reduction in the glomerular filtration rate. They should be used cautiously in those with renal impairment (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 increased 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.

Antidepressant Use in Pain Management

Antidepressant medications are effective for multiple chronic pain types, including neuropathic pain, fibromyalgia, and pain associated with depression. This next section will look at some of the antidepressants used in the management of pain.

Tricyclic antidepressants (TCA) modify pain by inhibiting the uptake of norepinephrine and serotonin and block multiple channels, including the sodium, adrenergic, cholinergic, and histaminergic channels. Medications in this class include nortriptyline, desipramine, amitriptyline, and imipramine.

Nortriptyline and desipramine (secondary amine tricyclic antidepressants) are preferred agents in this class as they are associated with a better side effect profile. These agents are often used in managing neuropathic pain or in chronic pain management as adjuvant agents.

Tricyclic antidepressants need to be used cautiously in older adults. They have many side effects (constipation, dry mouth, mental status changes, blurred vision, urinary retention, blood pressure change, tachycardia, and heart block). They should be used very cautiously or not at all in those with cardiac or electrocardiographic abnormalities. The analgesic effect is typically noticed in a shorter time and at a lower dose than when treating depression. Some patients will have diminishing side effects as their body adapts to the medications (Tauben & Stacey, 2020).

Most TCAs are often started at 10 mg per day and are then titrated up to 75 mg per day in adults. Older individuals rarely tolerate doses of more than 75-100 mg per day. It may take up to 8 weeks before analgesia is appreciated, but pain relief may be noticed as soon as one week.

Serotonin-norepinephrine reuptake inhibitors are used for neuropathic pain but also treat other types of pain. Duloxetine (Cymbalta®) is indicated for diabetic neuropathy and painful chronic musculoskeletal conditions such as osteoarthritis and chronic low back pain. It is also approved for fibromyalgia. Common side effects include insomnia, drowsiness, dry mouth, fatigue, nausea, and dizziness. Avoid use in those with severe renal insufficiency or hepatic insufficiency. When stopped, it should be tapered slowly due to withdrawal symptoms.

Venlafaxine (Effexor®), another SNRI, is sometimes used for neuropathic pain, but it is unlabeled. Venlafaxine may lead to increased blood pressure. When stopping the medication, it should be tapered slowly to minimize withdrawal symptoms.

Antiepileptic Agents

Gabapentin is approved in adults for post-herpetic neuralgia up to 3600 mg per day in divided doses. Adjust the dose in those with renal disease. It comes in an extended-release form called Gralise. Gabapentin is often used off-label for other neuropathic conditions, including diabetic neuropathy, generalized neuropathic pain, anxiety, and post-operative pain.

Pregabalin (Lyrica®) is approved in adults for fibromyalgia, neuropathic pain (diabetes-related), neuropathic pain in those with spinal cord injury, and post-herpetic neuralgias. Both pregabalin and duloxetine have been given regulatory approval for pain management in neuropathic diabetic pain in the United States, Canada, and Europe (Pop-Busui et al., 2017).

Other Agents

Topical lidocaine is first-line therapy for post-herpetic neuralgia. It is applied to intact skin, and up to three patches are applied for no more than 12 hours in 24 hours.

Muscle relaxants manage acute and chronic pain. Cyclobenzaprine (Flexeril®) was initially classified as a tricyclic antidepressant but was then remade as a muscle relaxer. Side effects are similar between the TCAs and cyclobenzaprine, including sedation, dry mouth, constipation, urinary retention, and mental status changes.

Carisoprodol (Soma®) is another commonly used muscle relaxer but causes dependence. Due to the concerns of dependence, it is not commonly used. The most common side effect of all muscle relaxers is sedation.

Opioids

In recent times opioids therapy has become more commonly used. In the past, it was only used for severe acute pain and cancer pain. A recent position paper from the American Academy of Neurology suggested evidence for adequate short-term pain relief with opioids. However, no good evidence exists for the continuation of pain relief or improved function for extended periods without sustaining serious risk of dependence, overdose, or addiction (Franklin, 2014).

Opioids function by activating opioid receptors that are located in the spinal cord and the brain. The majority of the pain relief related to opioids is due to their actions on the PAG cells and the descending pain pathways. Opioid receptors are molecules located on the surface of cells; opioid substances attach themselves to them and release their effects. There are three different types of opioid receptors found in the brain: Mu, Kappa, and Delta receptors. Mu and Kappa receptors are also found in the spinal cord and mediate pain transmission from the brain's peripheral nervous system. The most important pain receptor in opioid abuse and treatment is the Mu receptor. When opioids activate Mu receptors, the most significant potential for pain relief and addiction is initiated. However, Kappa and Delta receptors also play a role in opioid addiction. Agonists bind with a receptor and activate them; an antagonist is also a substance that binds with a receptor, but it has the opposite effect and blocks the receptor's activation.

Compared to a key that fits in a lock, it does not open it, but it does not allow another key to be inserted. Partial agonists have some of the properties of both antagonists and agonists. They can bind to receptors and activate them, but not to the same intensity as full agonists.

The Role of Naloxone

Naloxone is a drug that is used to reverse an opioid overdose rapidly. It reestablishes normal respiration rates for an individual whose respirations have slowed or stopped due to opioid overdose. Currently, there are three major formulations of naloxone.

  • Injectable naloxone – It is given by paramedics, ER physicians, and other specially trained first responders.
  • Auto-injectable - this is marketed under the trade name of EVZIO®, and it is a prefilled injection device that is injected quickly into the patient's outer thigh. Once it is activated, the device gives verbal instructions on using it, comparable to automated defibrillators.
  • Prepackaged Nasal Spray – NARCAN® is the trade name for a prefilled, needless device that does not need to be assembled and is sprayed into the nostril of a supine patient.

Both EVZIO® and NARCAN® are used for emergencies in the home. Laws regarding naloxone prescription and administration vary from state to state. In Massachusetts, Naloxone or another opioid antagonist may be prescribed and dispensed to an individual at risk for an opiate-related overdose or to a family member, friend, or another person in a position to help a person at risk of experiencing an opiate-related overdose. (Commonwealth of Massachusetts, 2021).

Take precautions when administrating naloxone; regardless of the setting, the patient must be continuously monitored until trained emergency personnel arrive. Once the patient has been transferred to a health professionals’ care, they will require observation for at least another two hours to ensure that respirations do not slow down or stop.

Naloxone is a safe medication. It can sometimes cause withdrawal symptoms that may be unpleasant, but they are not life-threatening, such as headache, alterations in blood pressure, rapid heartbeat, sweating, vomiting, and tremors (FDA, 2020).

Side Effects

Opioid medications are associated with multiple side effects, including constipation, nausea, vomiting, pruritus, abdominal cramping, sedation, and mental status changes. Multiple interventions are available to reduce side effects.

  • Constipation is a frequent issue in those who use opioids. Risk factors for constipation include older age, intra-abdominal pathology, and those who eat a low-fiber diet. Those on opiates should be encouraged to increase fiber intake, drink plenty of fluids, and be encouraged to exercise. Stool softeners (e.g., docusate sodium) and stimulants (e.g., bisacodyl) may be needed to manage constipation. An osmotic laxative such as polyethylene glycol or lactulose may also be considered, which may be added to stools softeners/stimulants for resistant constipation.
  • Antiemetic medication can help treat nausea.
  • Antihistamines can treat pruritus.
  • Opioids are associated with somnolence and other mental status changes. Patients do develop tolerance to these symptoms over weeks. Reducing the dose may lessen the mental status changes. An adjunctive medication may be added to the lower dose of opioid to help manage the pain. Rarely, the use of a stimulant can be used to manage sedation due to opioid use.
  • Respiratory depression may occur, but it is uncommon when the medication is used carefully. Starting low and slowly titrating the dose will reduce the risk of respiratory depression. Problems arise with rapid titration, the addition of another drug that may suppress the respiratory drive (benzodiazepine, alcohol, or a barbiturate), or the patient overdoses. Sedation precedes respiratory depression, so when starting a patient on opioid therapy, encourage them to take the first dose in the office to be monitored or in the presence of a responsible adult who can help monitor the patient. The level of consciousness should be assessed 30-60 minutes after the opioid is given. The next dose should be held. Contact the prescriber immediately if there is a reduced level of consciousness, the patient has hypoxia, or has a respiratory rate of less than 10 per minute.

The most serious risk linked with opioid use is an overdose. Death from overdosing on semi-synthetic opioids occurs every 19 minutes in this country. After car accidents, it is the second major cause of accidental deaths (National Center for Injury Prevention and Control, 2014).

At the end of 2016, the Agency for Healthcare Research and Quality published figures on opioid-related hospital use per State; Massachusetts had the second-highest level of opioid-related inpatient stays per 100,000 of the population with 393.7. Research figures indicate that opioid overdose occurs in all sectors of Massachusetts, rural and urban communities, rich and poor, and among all age groups and ethnicities (Massachusetts Health Policy Commission, 2016).

The Massachusetts Medical Society (Massachusetts Medical Society, 2020) issued their guidelines to voice their support that physicians use "best clinical judgment in patients' treatment." They also supported the adoption of separate guidelines for treating acute and chronic pain, and chronic pain guidelines are used with patients who are on opioid therapy for more than 90-days. The guidelines would not apply to cancer patients, those in hospice and palliative care, and inpatients in hospitals and nursing homes.

The Acute Care Guidelines for Opioid Prescription include the following:

  • Thorough screening of the patient before initiating therapy and will include.
    • Screening for pregnancy.
    • Obtaining and reviewing personal or family histories of a substance abuse disorder.
    • Evaluating the patient's mental status or pertinent behavioral issues.
  • Patients with complex pain issues, mental health conditions, or other serious illnesses should be considered for referral to a specialized pain clinic.
  • The patient's medication profile must be carefully reviewed. Is the patient on benzodiazepines and other medications that can potentiate the danger of opioid use?
  • Patients should be started on a trial of short-acting opioid medication. During this trial period, the patient should be closely monitored for both the positive and negative effects of the medication – is it relieving the pain, and how is it affecting the patient's level of functioning and quality of life? Are there any cognitive side effects or safety issues?
  • Educate patients to keep opioid medication safely, preferably in a locked cabinet, and under no circumstances to share opioid medications with others and properly dispose of unused or expired medications. Most communities have secure drop-off locations for unwanted medications, and many of these are located at the local police stations.

Chronic Pain Guidelines for Opioid Use (Massachusetts Medical Society, 2020):

  • Once a 90-day threshold has been reached, a complete re-evaluation of the patient must be done.
  • The patient is asked to complete an objective pain assessment tool, and the provider does a risk of substance abuse assessment. Baseline urine drug testing may be done.
  • If continued opioid therapy is deemed appropriate, a treatment plan for treatment goals should be put in place and re-evaluated every 60 to 90 days.
  • Female patients should be educated on the risks of opioid use during pregnancy.
  • In consultation with the patient, a treatment agreement should be drawn up and preferably signed by the patient; it then becomes part of the medical record. Treatment agreements include the following:
    • Measurable goals for the reduction of pain.
    • A plan for a reduction in opioid medication that will mirror the decrease inpatient pain, and improved function.
    • Quality of life measurements should also be included in the plan.
    • Circumstances where a patient could get prescriptions from other providers.

All clinicians who work with pain patients must ensure that they know naloxone and how it works in reversing opioid overdose.

Effective treatment for opioid addiction is of paramount importance; research suggests relapse rates as high as 65% to 70% within three months after treatment (Sinha, 2011). It has been found that an individual is at the most significant risk for overdose death after a period of abstinence from opioid use when their tolerance is low, and they again use an opioid of the same strength that they previously used. This phenomenon has been looked at in jail populations, where it was found that during the first two weeks after release, the risk for overdose death is 129 times greater than at any other time in the person's life (Wakeman, 2017). All medicines administered to treat opioid abuse need to be prescribed as part of a comprehensive and individualized care plan that includes counseling and other psychological therapies and social support through active involvement in groups such as Narcotics Anonymous.

Morphine

While there are many opioids, morphine is considered by many as a standard comparator for other drugs. Morphine can be given orally, rectally, intravenously, subcutaneously, or intramuscularly.

Morphine is used for moderate to severe acute pain and chronic serious pain. It comes in multiple formulations. It is dosed at 10-30 mg every 4 hours for acute pain for opioid naïve patients. It is available as a tablet, solution, suppository, and parenteral solution. The immediate-release tablet is dosed 15-30 mg every 4 hours as needed, and the oral solution is dosed 10-20 mg every 4 hours as needed. It can also be given rectally and is often dosed 10-20 mg every 4 hours as needed. Morphine also comes in a controlled release form, a sustained-release form, and an extended-release form.

Longer-acting formulations include:

  • Avinza®: The initial dose for the opioid naïve patient is typically 30 mg a day, and 90 mg and 120 mg are only indicated for use in opioid-tolerant patients. When converting over from immediate-release morphine, the first dose of Avinza may be taken with the last dose of IR formulation. The medication may be adjusted in 15-30 mg increments every 3-4 days. The maximum dose is 1600 mg a day because of the fumaric acid content.
  • Kadian®: It is not indicated for initial opioid analgesia. For non-opioid tolerant patients, 30 mg once a day is recommended. Higher doses are used for opioid-tolerant patients. Titration may be done every 1- 2 days. When converting from other forms of morphine, it may be given once or twice a day.
  • MS Contin® is started at 15 mg every 8-12 hours, with the dosage being adjusted every 1-2 days.

Side effects of morphine are similar to other opioid analgesics and include dry mouth, constipation, bradycardia, hypotension, nausea, drowsiness, dizziness, mental status changes, fever, itching, weakness, hypoxia, and urinary retention.

Morphine should not be used in those with a hypersensitivity to morphine, those with toxin-mediated diarrheal disease, severe/acute asthma, paralytic ileus, or severe respiratory depression. The extended-release form should not be used in those with GI obstruction.

The extended-release forms of morphine are not interchangeable. Changing from one medication to another should be done only by those experienced in how to do this. Extreme caution should be used when using highly concentrated solutions, so overdoses do not occur.

Drug interactions commonly seen with morphine include:

  • Amphetamines may increase the effect of morphine
  • Anticholinergic agents may increase the side effects of morphine (constipation and urinary retention)
  • Antipsychotic agents with morphine may reduce blood pressure
  • Nasal azelastine (Astelin) with morphine enhances the central nervous system (CNS) depression effect
  • Clopidogrel therapeutic efficacy may be reduced with morphine
  • Diuretics side effects may be increased with morphine
  • Hydrocodone enhances CNS depression
  • Hydroxyzine enhances CNS depression
  • MAO Inhibitors enhances the side effects of morphine
  • Selective serotonin reuptake inhibitors with morphine enhance the serotonergic effect and CNS depression
  • Zolpidem enhances the CNS depression

Fentanyl

Fentanyl can be given as an injection, transdermal patch (Duragesic®), an oral transmucosal lozenge (Actiq®), a sublingual tablet (Abstral®), a sublingual spray (Subsys®), a buccal tablet (Fentora®), a buccal film (Onsolis®), and a nasal spray (Lazanda®). The transdermal patch is used in opioid-tolerant patients with moderate to severe pain and is often started at 25 mcg per hour and changed every 72 hours.

Fentanyl can be used for multiple reasons, including premedication for surgery, for general anesthesia, as an adjunct to general and regional anesthesia, and chronic pain management. The transdermal patch is indicated for around-the-clock pain management in those with chronic severe pain. Fentanyl transmucosal and intranasal are indicated for cancer pain.

While no official dosage adjustment is recommended in those with renal or hepatic impairment, those with mild to moderate renal or hepatic impairment should likely have the dose reduced by 50 percent with the patch. The use is not recommended in severe renal or hepatic impairment. Transmucosal and nasal spray have no specific recommendations for dose reduction in renal or hepatic impairment.

Common side effects of fentanyl include dry mouth, edema, bradycardia, dehydration, respiratory depression, shortness of breath, diaphoresis, nausea/vomiting, constipation, application site erythema (patch), weakness, muscle rigidity, mental status changes, headache, sedation, and CNS depression.

As with most opioids, contraindications include hypersensitivity, toxin-mediated diarrheal disease, and paralytic ileus. It should not be used for short-term pain and post-operative pain and should not be used in severe respiratory disease. The transmucosal and nasal forms of fentanyl are typically only used by specialists for opioid-tolerant cancer patients.

The patch form should not be exposed to external heat as this may increase the medication's absorption. Exercising with the patch on has the potential to increase absorption of fentanyl. Besides, patients with a fever may also notice an increase in absorption of the medication. The patch should only be applied to intact skin, and it contains aluminum and must be removed before an MRI.

Like many medications, there are multiple potential interactions. Some more common interactions include:

  • Alcohol may enhance CNS depression
  • Beta-agonists may decrease the serum concentration of fentanyl
  • Amphetamines may enhance the effects of fentanyl
  • Anticholinergic medications along with fentanyl increase the risk of urinary retention and constipation
  • Antipsychotic agents may increase the risk of low blood pressure
  • Azelastine nasal spray may enhance CNS depression
  • Beta-blockers with fentanyl enhance bradycardia
  • Calcium channel blockers may enhance hypotension or bradycardia
  • Hydrocodone may enhance CNS depression
  • Selective serotonin reuptake inhibitors with fentanyl may enhance serotonergic properties
  • Zolpidem effects may be enhanced

Oxycodone

Oxycodone is a schedule II controlled substance and is available in multiple forms.

  • Immediate release (Roxicodone®) is dosed 5-30 mg every 4-6 hours (lower range for opioid-naive patients). There is also an abuse-deterrent tablet (Oxceta) that comes as a 5 mg and 7.5 mg tablet.
  • The controlled release tablet (OxyContin®) is indicated for those who require around-the-clock pain control. It is dosed 10 mg every 12 hours to start and titrated carefully. When changing from immediate release to extended release, start the extended-release at half of the daily dose of oxycodone every 12 hours. When changing from transdermal fentanyl to extended-release oxycodone, substitute 10 mg of extended-release oxycodone every 12 hours for each 25 mcg/hour of fentanyl. The oxycodone should be started 18 hours after the removal of the transdermal fentanyl patch.
  • It also comes as an oral concentrate and oral solution.
  • Oxycodone is often combined with other analgesic agents such as acetaminophen (e.g., Percocet®, Roxicet®, Tylox®), aspirin (e.g., Percodan®, Endodan®, Oxycodan®), and ibuprofen (Combunox®).

Those with a creatinine clearance of less than 60 mL/min should have the dose adjusted down as serum concentration of oxycodone will increase in renal insufficiency. Those with hepatic impairment should have doses reduced; with the extended-release formulation, the starting dose should be lowered one-third to one-half and slowly titrated up to effect.

Side effects include drowsiness, dizziness, itching, constipation, nausea, and vomiting. Less common side effects include dry mouth, headache, abnormal dreaming, blood pressure changes, diaphoresis, weakness, and fever.

Oxycodone is contraindicated in paralytic ileus, significant respiratory depression, hypercarbia, acute or severe bronchial asthma, and GI obstruction.

Caution should be used in those with biliary tract impairment, such as acute pancreatitis, as it may lead to constriction of the sphincter of Oddi. It may lead to an elevation of intracranial pressure (ICP) and should be used carefully for those with intracranial lesions, elevated ICP, or a head injury.

Extended-release tablets may be lodged into the GI tract, including the throat, in those with swallowing issues. It may lead to intestinal obstruction or diverticulitis.

Common drug interactions with oxycodone:

  • Alcohol may enhance CNS depression
  • Amphetamines may increase the effect of oxycodone
  • Anticholinergic agents may increase the side effects of oxycodone (constipation and urinary retention)
  • Antipsychotic agents with oxycodone may reduce blood pressure
  • Nasal azelastine (Astelin) enhances CNS depression
  • Diuretics side effects may be increased with oxycodone
  • Hydrocodone enhances CNS depression
  • Hydroxyzine enhances CNS depression
  • MAO inhibitors enhance the side effects of oxycodone
  • Mirtazapine may enhance CNS depression
  • Rifampin may decrease the serum concentration of oxycodone
  • Selective serotonin reuptake inhibitors with oxycodone enhance the serotonergic effect and CNS depression
  • Zolpidem enhances the CNS depression

Hydrocodone

Hydrocodone, classified as a Schedule II Controlled Substance in October of 2014, is available as a combination pill with non-narcotic analgesic (e.g., Lorcet®, Lortab®, Norco®, and Vicodin®) and by itself in an extended-release form. The combination pill has a short-acting version of hydrocodone and is dosed with 2.5 to 10 mg of hydrocodone every 4-6 hours as needed for moderate to severe pain.

Hydrocodone extended-release (Zohydro® ER) is typically dosed 10 mg every 12 hours in treatment-naive patients. It is used for severe pain requiring around-the-clock dosing of hydrocodone. The dose may be increased every 3-7 days in 10 mg increments.

Those with severe hepatic impairment should start at the lowest dose and titrate up very slowly while monitoring side effects. Caution should be used with renal impairment as plasma concentration may rise.

Side effects include constipation, nausea, vomiting, dry mouth, drowsiness, headache, dizziness, pruritus, and nausea.

Contraindications to hydrocodone include paralytic ileus, severe asthma, severe respiratory depression, and hypercarbia.

Drug interactions:

  • Alcohol may enhance CNS depression
  • Amphetamines may increase the effect of hydrocodone
  • Anticholinergic agents may increase the side effects of hydrocodone (constipation and urinary retention)
  • Nasal azelastine (Astelin®) enhances CNS depression
  • Diuretics side effects may be increased with hydrocodone
  • MAO inhibitors enhance side effects of hydrocodone
  • Selective serotonin reuptake inhibitors with hydrocodone enhance the serotonergic effect and CNS depression
  • Zolpidem enhances the CNS depression

Tramadol

As of August 18, 2014, the DEA placed tramadol into Schedule IV of the Controlled Substance Act. It is indicated for moderate-to-severe pain, and the immediate release form is dosed at 50-100 mg every 4-6 hours for a maximum of 400 mg a day.

Tramadol is also indicated for chronic moderate-to-severe pain. Those who do not need a rapid onset of pain relief and are affected by side effects may be dosed at 25 mg/day and titrated every three days to 50-100 mg every 4-6 hours to a maximum of 400 mg a day.

Tramadol also comes in an extended-release form, ConZip®, and Ultram® ER, which is dosed 100 mg once a day and maybe titrated by 100 mg every five days to a maximum dose of 300 mg a day.

When prescribing tramadol to older adults, use the lower end of the dosage range and titrate slowly. In those over 75 years old, 300 mg a day should not be exceeded, and utilize extreme caution with the extended-release form.

In those with a creatinine clearance less than 30 mL/min, only the immediate release formulation should be used with doses of 25-100 mg split every 12 hours (maximum dose of 200 mg a day). In those with severe liver impairment, the immediate release form should be given at a maximum of 50 mg every 12 hours.

Side effects include flushing, dizziness, constipation, nausea, vomiting, dyspepsia, itching, headache, somnolence, insomnia, and weakness. Less common side effects include orthostatic hypotension, mental status changes, euphoria, rash, hot flashes, diarrhea, dry mouth, anorexia, joint pain, blurred vision, and sweating.

Patients may experience withdrawal symptoms from tramadol, including nausea, diarrhea, anxiety, pain, sweating, tremor, and rigors. Extended tramadol use may lead to dependence, and these medications should be tapered slowly to reduce the risk of withdrawal symptoms.

Tramadol is contraindicated in individuals hypersensitive to the agent and those with severe liver or kidney impairment. The extended-release tablet should not be used with psychotropic drugs, opioids, hypnotics, acute intoxication with alcohol, or centrally acting analgesics, or those with severe respiratory depression, severe asthma, or hypercapnia.

Tramadol has been shown to increase the risk of seizures. This risk is increased in those who take serotonin reuptake inhibitors, tricyclic antidepressants, neuroleptics, other opioids, or other drugs that lower the seizure threshold. The risk may also be increased in those who have seizures or are at risk for seizures, such as those who have a CNS infection, cancer, history of head trauma, or while patients are going through drug or alcohol withdrawal.

Caution should be used in those with respiratory disease as those with significant disease may be at increased risk for respiratory depression.

Drug interactions:

  • Alcohol may enhance CNS depression
  • Amphetamines may increase the effect of tramadol
  • Anticholinergic agents may increase the side effects of tramadol (constipation and urinary retention)
  • Antiemetics may reduce the effects of tramadol
  • Antipsychotics and tramadol may result in reduced blood pressure, increased risk of neuroleptic malignant syndrome, and increased risk of serotonin syndrome
  • Nasal azelastine (Astelin®) enhances CNS depression
  • Carbamazepine with tramadol may enhance CNS depression; tramadol may reduce the therapeutic effect of carbamazepine
  • Cyclobenzaprine and tramadol may increase the risk of seizures or increase the risk of serotonin syndrome
  • Diuretics side effects may be enhanced with tramadol
  • Hydrocodone may enhance CNS depression
  • Hydroxyzine may enhance CNS depression
  • MAO inhibitors with tramadol may increase the risk of seizures or increase the risk of serotonin syndrome
  • Metoclopramide with tramadol may increase side effects of metoclopramide or increase the risk of serotonin syndrome or neuroleptic malignant syndrome
  • Selective serotonin reuptake inhibitors with tramadol may increase the risk of seizures or increase the risk of serotonin syndrome
  • Tricyclic antidepressants with tramadol may increase the risk of seizures or increase the risk of serotonin syndrome
  • Warfarin with tramadol may affect the anticoagulant effect
  • Zolpidem enhances CNS depression

Case Study 1

Ms. L is a 52-year-old female with a history of bilateral knee osteoarthritis; she currently rates the pain as a 7/10 in her right knee and 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 and has been progressively disabled and has stopped exercising because of pain in her knees.

In addition to osteoarthritis, 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 crepitus in both knees and obesity (BMI of 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 tramadol SR 200 mg once a day. The patient was able to function and exercise. Her quality of life was much improved.

Table 3: Oral Opioid - Adult Dosing
DrugInitial dose (TreatmentNaïve)Duration of effect (in hours)Notes
Morphine
Immediate-release10-30 mg every 3-4 hours as needed3-6 
Controlled-released (MS Contin®, Oramorph® SR)15 mg two times a day8-12 
Sustained-release (Kadian®)30 mg one to two times a day12-24 
Extended-release (Avinza®)30 mg once a day24 
Hydromophone
Immediate-release2-4 mg every 3-4 hours as needed3-6 
Extended-release (Exalgo®)8 mg every 24 hours24 
Oxycodone
Immediate-release5-15 mg every 4-6 hours3-6Often combined with acetaminophen or aspirin
Controlled-release (OxyContin®)10 mg two times per day8-12 
Extended-release (with acetaminophen) (Xartemis® XR)15 mg oxycodone with 650 mg acetaminophen every 12 hours8-12 
Hydrocodone
Immediate-release5-10 mg every 6 hours4-8Combined with acetaminophen or ibuprofen
Extended-release (Zohydro® ER)10 mg every 12 hours12 
Fentenyl
Fentanylpatch25 mcg per hour changed every 72 hours48-72 (12 hours after removal)Not for opioid naïve patients, or acute pain; onset 12-24 hours.
Oxymorphone
Immediate-release (Opana®)5-20 mg every 4-6 hours4-6 
Extended-release (OpanaER®)5 mg tow times a day12 
Methadone2.5 mg every 8-12 hoursFirst dose 4-8 hours, up to 48 hours with repeated dosesHigh risk for overdose partly due to the long half-life; prescribed only by a trained prescriber
Tapentadol
Immediate-release (Nucynta®)50-100 mg every 6 hours3-6 
Extended-release (Nucynta® ER)50 mg every 12 hoursunsure 
Tramadol
Immediate-release (tramadol®)50-100mg every 4-6 hours4-6Max dose 400 mg/day
Extended-release (UltramER®, ConZip®)100mg one a dayUnsureMax dose 300 mg/day

Other Medications

Oxymorphone, a schedule II medication, can be given intravenously, subcutaneously, intramuscularly, or orally. The immediate-release tablet (Opana®) is used for acute pain at 5-20 mg every 4-6 hours as needed for opioid naïve patients. For those with chronic severe pain, the extended-release tablet is used (Opana® ER) and is started at 5 mg every 12 hours and maybe titrated up at 5-10 mg increments every 12 hours every three to seven days. Caution should be used in those with a creatinine clearance of less than 50 mL/minute, and the medication should not be used in moderate to severe hepatic impairment.

Hydromorphone can be given orally, rectally, subcutaneously, intramuscularly, or intravenously. The oral medication comes in standard and extended-release forms. The standard form is used for moderate to severe pain and is often dosed 2 to 4 mg every 4-6 hours. The oral liquid is typically dosed 2.5 to 10 mg every 3 to 6 hours. Parental and oral doses are not equivalent. The parenteral dose is five times more potent than the oral dose. The long-acting form (Exalgo®) is used for opioid-tolerant patients who have chronic severe pain. It is dosed 8-64 mg once a day.

Methadone can be given intravenously, subcutaneously, intramuscularly, or orally. The oral dose is started in the opioid naïve patient at 2.5 every 8-12 hours. Methadone is a high-risk drug that leads to overdose. It has a half-life of up to five days and may accumulate in the body. Methadone may also prolong the QT interval leading to cardiac arrhythmias, especially at doses higher than 120 mg a day. Methadone should be used for severe pain that has not been responsive to other agents and only by clinicians with specific training in the use of methadone. Methadone is also used in detoxification.

Tapentadol (Nucynta®, Nucynta® ER) is used for acute moderate to severe pain and started at 50-100 mg every six hours for the immediate-release formulation. The starting dose for the extended-release tablet is 50 mg every 12 hours. For chronic pain, it is typically dosed 50-250 mg two times a day as needed. The maximum dose is 500 mg a day. This medication is not recommended for those with severe liver or renal insufficiency. It is also indicated for diabetic peripheral neuropathy.

Propoxyphene has been taken off the US market as it has been linked with fatal cardiac arrhythmias. Meperidine is not recommended as a first-line agent for chronic pain as it is associated with high rates of central nervous system toxicity. Many narcotics are available in liquid form for pediatric use, including acetaminophen with hydrocodone, morphine, and hydromorphone.

Prevention of Misuse

To prevent prescription drug abuse, the clinician needs to assure:

  • Patients are assessed and reassessed
  • Treatment agreements are used
  • Prescription monitoring occurs
  • Safe prescription methods are practiced

Patients' risks should be assessed, and contraindications should be immediately identified. Contraindications to opioid treatment include those who have erratic follow-up, suffer from current untreated addiction, or have poorly controlled mental illness.

When taking a patient history, document the opioid currently prescribed, its dose, the frequency of use, and duration. It is important to query the state prescription drug monitoring program (PDMP) to confirm the patient’s medication use. Also, it is important to contact past providers to obtain medical records.

Before controlled substances are prescribed, history of illegal substance use, alcohol use, tobacco use, prescription drug use, family history of substance abuse and psychiatric disorders, history of sexual abuse, legal history, behavioral problems, employment history, marital history, social network, and cultural background should be assessed. History of substance abuse does not prohibit treatment with opioids but may necessitate more intensive monitoring or referral to an addiction specialist.

Multiple tools are available to evaluate opioid risk. The Opioid Risk Tool is a tool used in primary care to screen adults for the risk of aberrant behaviors when prescribed opioids for chronic pain. It is a copyrighted tool, encompasses five questions, and takes about one minute to use. It classifies a patient as low, moderate, or high risk to abuse opioids. Those who are high risk have a high likelihood of aberrant drug-related behavior. It is not validated in individuals without pain. The five questions include asking about family and personal history of substance abuse (alcohol, prescription drugs, or illegal drugs), age (risk is 16-45 years old), psychological disease, and preadolescence sexual abuse history. The questions are scored with different points assigned for each question, which is variable between men and women, and the total score is tallied. The patient is placed into low, moderate, or high risk.

Regular follow-up is essential and should occur at a minimum of every three months. When assessing the pain patient, the five A's should be assessed: analgesia, addiction, activities of daily living, adherence, and adverse effects. Part of follow-up should be urine drug testing, which can detect medication adherence and illicit and non-prescription drug use. It is critical that the clinician adequately document any interactions with patients, assessments, and results of testing and treatment plans.

Written treatment agreements, which should be used between prescribers and patients when controlled substances are used, help guide the conversation between patient and prescriber. It discusses expectations, the risks, and the monitoring of the controlled substances. (Table 3).

Table 3: Points Commonly Seen in Opioid Agreements
  • Early refills will generally not be given
  • Patient will not seek controlled substances from another provider
  • Patient will use only one pharmacy
  • Permission for the prescriber to speak freely with other health care providers, pharmacists, and family members regarding opioid use
  • Patient will submit to urine drug test
  • The patient will safeguard the medications
  • Common side effects of the medication will be discussed

Prescription monitoring programs are available in the majority of states, including Massachusetts. They provide an online database that lists all prescriptions of controlled substances dispensed for each patient by pharmacies. Ideally, the prescriber should check the database before prescribing controlled substances. If a patient has an undisclosed prescription for controlled substances, it is prescription drug misuse.

When abuse/misuse is detected, how should the clinician respond? If it is a single, minor deviation, then counseling and more intensive monitoring may be needed. Tapering controlled substances to reduce the risk of withdrawal is appropriate in more severe or persistent misuse cases. When diversion is the cause of misuse, immediate removal of the prescription is likely the best course. If a substance abuse disorder is suspected, a referral to an addiction specialist is recommended.

Pain in Special Populations

Pediatrics

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

It is important to have a standard method to assess pain in neonates. It is difficult to assess pain in neonates and infants because they have limited ability to communicate. In this population, assessment is based on physiological and behavioral factors. Factors that suggest pain in the neonate and infant 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 Neonatal Facial Coding System, 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 those with very low birth weight, on paralytic medications, or those with prolonged pain.

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. It is vital to limit the number of painful procedures performed on young children.

Pain in children is similar to 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. When pain is moderate to severe, providing pain medication around the clock is a reasonable option.

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

Older Adults

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. Those with reduced vision, reduced hearing, or impairments in cognition present a more significant 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 essential to determine the patient's coping techniques. This determination will help the nurse 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, which may extend 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.

Nonverbal Patients

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: (1) facial expressions (e.g., grimacing), (2) verbalizations or vocalizations (e.g., moaning), (3) body movements like tense body posture, (4) changes in interpersonal interactions (e.g., aggression or resisting care), (5) changes in activity patterns (e.g., refusing food or increased wandering), and (6) 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 persists, 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 research 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.

Pain in Pregnancy and Labor

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

Many different pain syndromes are commonly seen in pregnancy. Mechanical back pain due to weight distribution changes is one of the most common types of pain. 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 on the nerves in the carpal tunnel. Symptoms of carpal tunnel syndrome most commonly come on in the third trimester and resolve after pregnancy but may be prolonged by breastfeeding.

Labor is a painful period, and treatment may involve a variety of techniques. The most reliable method to manage pain is with 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 the neonate.

Pain in the Psychiatric Patient

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). The patient with pain and psychiatric disease typically reports more intense pain than the patient without comorbid 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 assure appropriate and adequate treatment of pain. Medications with abuse potential should be used cautiously, as there is a high prevalence of drug use disorders in psychiatric patients. Exercise and cognitive behavioral therapy are important steps in managing pain in the psychiatric patient. Also, monitoring for compliance is an integral part of managing the psychiatric patient who suffers from chronic pain.

Specific Pain Syndromes

Visceral Pain

Many conditions lead to visceral pain. Visceral pain occurs when there is a stimulation of nociceptors of the organs in the abdomen, pelvis, or chest. Visceral pain is diffuse, hard to pinpoint, and often referred 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. The majority of 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 having dark/tarry stools. Common diagnoses that can potentially be life-threatening 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, then that patient should be treated symptomatically. Those individuals over the age of 50 are more likely to have a more serious cause of chronic abdominal pain, and 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. In all women who have the possibility of being pregnant, a pregnancy test should be done. ; 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. For those with chronic pelvic pain, the examination may use a pain map 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, the use of a non-specific treatment may be considered when there is no specific diagnosis.

Sickle Cell Disease

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 of the condition. Acute sickle cell disease pain is secondary to vaso-occlusion and the consequent tissue ischemia and inflammation. Over time chronic pain may result. Assessment of pain is challenging in sickle cell crisis, as there are no objective findings that 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, and dehydration, or alcohol consumption. Pain can affect many parts of the body 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 chronic 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, then 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).

Headache

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 migraine, tension, and cluster headache. 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 they may be bifrontal, bitemporal, or generalized. Tension headaches can be intermittent with a variable duration.

Migraine headaches are classically one-sided (but may generalize) 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 not effective in controlling the pain, the use of 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 for those with severe nausea that accompanies a migraine, a non-oral route is the best option.

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

Neuropathic Pain Conditions

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 dysesthetic 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 is resistant to pharmacotherapy, the use of neuromodulation (deep brain stimulation) and surgery may be considered.

Spinal cord injury (SCI) patients often develop chronic pain that affects the 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, which is thought to be caused by injury 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 on the nearby cord tissue (Eisen & Aminoff, 2019).

Trigeminal neuralgia results in head/facial pain coming from one or more of the 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 there is 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 a gradual sensory loss, numbness, a burning sensation and pain in the feet, 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., control blood sugar in diabetes) and medications to treat the symptoms. Medications used 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, gabapentin take effect, then tapered. If all other options are not sufficient, the use of intrathecal glucocorticoids may be considered.

Back Pain

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 are an essential part of the exam to rule out serious back pain causes and help identify the cause of the back pain. Certain conditions that are more urgent 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 who have 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. When pain is not controlled with NSAIDs, the use of a muscle relaxant may be considered. For those who cannot take a muscle relaxant, the combination of an NSAID and acetaminophen is an option.

The use of opioids and tramadol should be used very 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. One of the most critical aspects in the management of back pain is education. Patients should be educated on the causes of back pain, the expected course, an encouraging prognosis, the value of diagnostic testing, treatment options, and when to contact their healthcare provider.

Table 5: Back Pain Red Flags
  • New bowel or bladder incontinence
  • Saddle anesthesia – loss of sensation in the perineum, buttocks, and inner thighs
  • Severe neurological deficits
  • Weight loss
  • New-onset over age 50 years old or under 18 years-old
  • Progressive motor deficit
  • Night pain or rest pain
  • Fever – concern for infection – recent urinary tract infection or history of intravenous drug use
  • Current or recent cancer diagnosis or significant risk factor for cancer
  • Pain persists beyond six weeks
  • Suspected vertebral fracture

Case Study 2

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 that 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 average, 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 goes to physical therapy and 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 essentially 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.

The use of 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. At times, short-term use of a muscle relaxer may help muscle spasm that often contributes to this type of acute pain. Tramadol is often used in mild acute pain cases, but it should be relegated to a second or third-line option due to its potential abuse. In this case, Chris is also on sertraline, and there is a potential interaction between tramadol and sertraline.

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 low back pain should have exercises to strengthen the low back, stomach, and other core muscles and stretch the low back and legs.

Appropriate health care for back pain will get patients back to normal functioning quickly while minimizing the risk of dangerous treatment options.

Neck Pain

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

Complex regional pain syndrome (CRPS) is broken down into type I and II. It is a disorder of the extremities illustrated by regional pain 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 along with skin atrophy.

The progression of the condition is variable over time. The underlying pathology is not well 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/antagonist (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

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, this can lead to pain and other sensations in the amputated body part (Moller, 2014).

It is essential to rule out other causes of the symptoms, such as infection or a wound on the stump, ischemia, or neuroma, before diagnosing phantom limb pain. The incidence of this condition is variable, and it is hypothesized that not controlling pain before and after the surgery increase 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 blockage (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.

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.

Cancer Pain

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 treatment of pain, nurses working with cancer patients must recognize and routinely assess the patient’s 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 itself, 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, 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 hydromorphone, 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 used, other agents 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 and make 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 parts of the body are involved in radiation treatment (National Cancer Institute, 2021).

Palliative and End of Life Care

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 to allow for a peaceful death with dignity. Morphine is the gold standard for end-of-life pain relief and is the most effective medication for dyspnea treatment. Morphine functions by changing the patient’s awareness of their breathing experience by decreasing the respiratory drive and oxygen intake.

Fibromyalgia

Fibromyalgia (FMS) is a condition 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 usually report that pain is persistently present, 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 all over or feeling as though 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.
  • It is a benign disease, and this should be taught to the patient. 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 in the management of 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 when they are not sufficient, the addition of medication is considered. 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 different symptoms.

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

Rheumatoid Arthritis

Rheumatoid arthritis (RA), a chronic destructive, sometimes deforming disease, attacks the body's collagen, especially in the joints. Rheumatoid arthritis is associated with widespread symptoms such as 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 the care of patients with RA as disease-modifying antirheumatic drugs (DMARD) are complex to use. If therapy is started soon, the patient will experience better outcomes. DMARD therapy is complex and requires much monitoring and 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 get quick control of inflammation until the DMARDs take effect and can be used for pain control.

Osteoarthritis

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 improves the quality of life.

Osteoarthritis is defined as a joint disease with a deterioration of the joint and abnormal bone formation. OA is present when the bones' endings - called cartilage, which generally cushion the bones - no longer do their jobs. The ends of the bones rub together, and the cartilage wears away.

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

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

When non-drug methods do not provide adequate relief, medications are used to treat OA. Acetaminophen is no longer recommended as first-line agents because of safety concerns and lack of efficacy. 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 it provides significant pain relief. Hands should be washed after contact with the substance.

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

Other OA treatment options 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 along with a numbing agent. No more than three injections per year should be given (Leticia Alle Deveza, 2017).

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

Conclusion

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 these conditions, assessing them, and treating them is vital in appropriately managing the pain. In the current health care system, much pain is not even addressed. Many regulatory agencies have implemented guidelines within the health care system to help with addressing the pain epidemic.

The health care team's role is to perform a good initial pain assessment and an on-going assessment of pain. Proper pain management requires a team approach in the evaluation and treatment of 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 health care team also has the responsibility to partner with the patient to manage the pain adequately. Each health care team member has his or her role in the management of pain. Pain management is a significant focus for nurses. If health care team members perform their function and the patient takes an active role in his/her care, the adequate treatment of pain is a very attainable goal.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
OR
Reflect on Practice ImpactDescribe how this course will impact your practice.   (No Test)

References

  • Abdi, S., Shefner, J. M., & Eichler, A. F. (2018). Complex regional pain syndrome in adults: Pathogenesis, clinical manifestations, and diagnosis - UpToDate. UpToDate, 1–18. Visit Source.
  • AGS Panel on Persistent Pain in Older Persons. (2002). The Management of Persistent Pain in Older Persons. Journal of the American Geriatrics Society, 50(S6), 205–224. Visit Source.
  • Ali, A., Arif, A. W., Bhan, C., Kumar, D., Malik, M. B., Sayyed, Z., Akhtar, K. H., & Ahmad, M. Q. (2018). Managing Chronic Pain in the Elderly: An Overview of the Recent Therapeutic Advancements. Cureus, 10(9), e3293. Visit Source.
  • American Chronic Pain Association. (2020). ACPA-Stanford Resource Guide Chronic Pain Management. Visit Source.
  • Barzanji, A., Zareiyan, A., Nezamzadeh, M., & Mazhari, M. S. (2019). Evaluation of observational and behavioral pain assessment tools in nonverbal intubated critically adult patients after open - Heart surgery: A systematic review. Open Access Macedonian Journal of Medical Sciences, 7(3), 446–457. Visit Source.
  • Black, E., Khor, K. E., & Demirkol, A. (2020). Responsible Prescribing of Opioids for Chronic Non-Cancer Pain: A Scoping Review. Pharmacy, 8(3), 150. Visit Source.
  • Block, P. R., Thorn, B. E., Kapoor, S., & White, J. (2017). Pain Catastrophizing, rather than Vital Signs, Associated with Pain Intensity in Patients Presenting to the Emergency Department for Pain. Pain Management Nursing, 18(2), 102–109. Visit Source.
  • Carregaro, R. L., Tottoli, C. R., Rodrigues, D. da S., Bosmans, J. E., da Silva, E. N., & van Tulder, M. (2020). Low back pain should be considered a health and research priority in Brazil: Lost productivity and healthcare costs between 2012 to 2016. PLOS ONE, 15(4). Visit Source.
  • Center for Disease Control. (2020).Overdose Death Maps. Visit Source.
  • Commonwealth of Massachusetts. (2021). General Law - Part I, Title XV, Chapter 94C, Section 19. Visit Source.
  • Dahlhamer, J., Lucas, J., Zelaya, C., Nahin, R., Mackey, S., DeBar, L., Kerns, R., Von Korff, M., Porter, L., & Helmick, C. (2018). Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults — United States, 2016. MMWR. Morbidity and Mortality Weekly Report, 67(36). Visit Source.
  • Darnall, B. D., Carr, D. B., & Schatman, M. E. (2017). Ethics forum: Pain psychology and the biopsychosocial model of pain treatment: Ethical imperatives and social responsibility. In Pain Medicine (United States) (Vol. 18, Issue 8, pp. 1413–1415). Oxford University Press. Visit Source.
  • Department of Health and Human Services. (2012). Substance Use and Military Life DrugFacts | National Institute on Drug Abuse (NIDA). Visit Source.
  • Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain-United States, 2016 Morbidity and Mortality Weekly Report. Centers for Disease Control and Prevention: MMWR Recommendations and Reports, 65(1). Visit Source.
  • Eisen, A., & Aminoff, M. J. (2019). Disorders affecting the spinal cord - UpToDate. Visit Source.
  • FDA. (2020). Information about Naloxone | FDA. FDA. Visit Source.
  • Fillingim, R. B., Loeser, J. D., Baron, R., & Edwards, R. R. (2016). Assessment of Chronic Pain: Domains, Methods, and Mechanisms. In Journal of Pain (Vol. 17, Issue 9, pp. T10–T20). Churchill Livingstone Inc. Visit Source.
  • Franklin, G. M. (2014). Opioids for chronic noncancer pain: A position paper of the American Academy of Neurology. Neurology, 83(14), 1277–1284. Visit Source.
  • Frederick, I. O., Qiu, C., Enquobahrie, D. A., Aurora, S. K., Peterlin, B. L., Gelaye, B., & Williams, M. A. (2014). Lifetime prevalence and correlates of migraine among women in a pacific northwest pregnancy cohort study. Headache, 54(4), 675–685. Visit Source.
  • Garza, I. (2015). Central neuropathic facial pain. 1–10. Visit Source.
  • Hedegaard, M.H., Warner, M, and Miniño, A. M. . (2017). Products - Data Briefs - Number 294 - December 2017. Visit Source.
  • Herr, K., Coyne, P. J., Key, T., Manworren, R., McCaffery, M., Merkel, S., Pelosi-Kelly, J., & Wild, L. (2006). Pain Assessment in the Nonverbal Patient: Position Statement with Clinical Practice Recommendations. Pain Management Nursing, 7(2), 44–52. Visit Source.
  • Hunter, D. J., & Bierma-Zeinstra, S. (2019). Osteoarthritis. In The Lancet (Vol. 393, Issue 10182, pp. 1745–1759). Lancet Publishing Group. Visit Source.
  • IASP. (1979). Definition of pain. Pain, 6, 250. Visit Source.
  • IASP. (2021). IASP Announces Revised Definition of Pain - IASP. Visit Source.
  • Joint Commission. (2017). Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals Official Publication of Joint Commission Requirements New and Revised Standards Related to Pain. In The Official Newsletter of The Joint Commission (Vol. 37, Issue 7). Visit Source.
  • Kennedy, M.-C., Henman, M., & Cousins, G. (2016). General Practitioners and Chronic Non-Malignant Pain Management in Older Patients: A Qualitative Study. Pharmacy, 4(1), 15. Visit Source.
  • Leticia Alle Deveza, M. (2017). Overview of the management of osteoarthritis - UpToDate. UpToDate. Visit Source.
  • Massachusetts Health Policy Commission. (2016). Opioid Use Disorder in Massachusetts: An Analysis of its Impact on the Health Care System, Availability of Pharmacologic Treatment, and Recommendations for Payment and Care Delivery Reform. Visit Source.
  • Massachusetts Medical Society. (2020). Massachusetts Medical Society: Massachusetts Medical Society Opioid Therapy and Physician Communication Guidelines. Visit Source.
  • Merikangas, K. R., & McClair, V. L. (2012). Epidemiology of substance use disorders. In Human Genetics (Vol. 131, Issue 6, pp. 779–789). Hum Genet. Visit Source.
  • Moayedi, M., & Davis, K. D. (2013). Theories of pain: from specificity to gate control. Journal of Neurophysiology, 109(1), 5–12. Visit Source.
  • Moller, A. (2014). Pain: Its anatomy, physiology and treatment (3rd ed.). Moller Publishing.
  • National Cancer Institute. (2021). Cancer Pain (PDQ®)–Health Professional Version - National Cancer Institute. NCI. Visit Source.
  • National Center for Injury Prevention and Control, D. of U. I. P. (2014). Opioid Painkiller Prescribing | VitalSigns | CDC. Visit Source.
  • NIH. (2018). Non-Drug Pain Management: MedlinePlus. Medline. Visit Source.
  • Olek, M., Narayan, R., Frohman, E., & Frohman, T. (2019). Manifestations of multiple sclerosis in adults - UpToDate. Visit Source.
  • Ortega, E. M. (2019). Postherpetic neuralgia - UpToDate. In UpToDate. Visit Source.
  • Osteoarthritis Action Alliance, & Thurston Arthritis Research Center at the University of North Carolina. (2021). OA Prevalence and Burden - Osteoarthritis Action Alliance. OA. Visit Source.
  • Pereira, F. G., França, M. H., Paiva, M. C. A. de, Andrade, L. H., & Viana, M. C. (2017). Prevalence and clinical profile of chronic pain and its association with mental disorders. Revista de Saude Publica, 51, 96. Visit Source.
  • Phillips, J. L., Heneka, N., Hickman, L., Lam, L., & Shaw, T. (2017). Can A Complex Online Intervention Improve Cancer Nurses’ Pain Screening and Assessment Practices? Results from a Multicenter, Pre-post Test Pilot Study. Pain Management Nursing, 18(2), 75–89. Visit Source.
  • Pirschel, C. (2018). Remembering Margo McCaffery’s Contributions to Pain Management | ONS Voice. Visit Source.
  • Pop-Busui, R., Boulton, A. J. M., Feldman, E. L., Bril, V., Freeman, R., Malik, R. A., Sosenko, J. M., & Ziegler, D. (2017). Diabetic neuropathy: A position statement by the American diabetes association. Diabetes Care, 40(1), 136–154. Visit Source.
  • Sinha, R. (2011). New findings on biological factors predicting addiction relapse vulnerability. In Current Psychiatry Reports (Vol. 13, Issue 5, pp. 398–405). NIH Public Access. Visit Source.
  • Renner, J. A. (2014). Managing Patients with Pain, Psychiatric Co-Morbidity and Addiction. Visit Source.
  • Tauben, D. & Stacey, B. (2020). Pharmacologic management of chronic non-cancer pain in adults - UpToDate. UpToDate, 1–39. Visit Source.
  • Van Velzen, G. A. J., Huygen, F. J. P. M., van Kleef, M., van Eijs, F. V., Marinus, J., & van Hilten, J. J. (2019). Sex matters in complex regional pain syndrome. European Journal of Pain (United Kingdom), 23(6), 1108–1116.Visit Source.
  • Vincent, A., Lahr, B. D., Wolfe, F., Clauw, D. J., Whipple, M. O., Oh, T. H., Barton, D. L., & St. Sauver, J. (2013). Prevalence of fibromyalgia: A population-based study in Olmsted County, Minnesota, utilizing the Rochester epidemiology project. Arthritis Care and Research, 65(5), 786–792. Visit Source.
  • Wakeman, S. E. (2017). Why it’s inappropriate not to treat incarcerated patients with opioid agonist therapy. AMA Journal of Ethics, 19(9), 922–930. Visit Source.
  • Welsch, P., Üçeyler, N., Klose, P., Walitt, B., & Häuser, W. (2018). Serotonin and noradrenaline reuptake inhibitors (SNRIs) for fibromyalgia. In Cochrane Database of Systematic Reviews (Vol. 2018, Issue 2). John Wiley and Sons Ltd. Visit Source.
  • Wheeler, S. (2020). Evaluation of low back pain in adults - UpToDate. UptoDate. Visit Source.
  • Wilson, P. R. (2020). Acute Pain Medicine American Academy of Pain Medicine. Pain Medicine, 21(10), 2599–2599. Visit Source.
  • Yoon, E., Babar, A., Choudhary, M., Kutner, M., & Pyrsopoulos, N. (2016). Acetaminophen-induced hepatotoxicity: A comprehensive update. In Journal of Clinical and Translational Hepatology (Vol. 4, Issue 2, pp. 131–142). Xia and He Publishing Inc. Visit Source.