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Michigan: Pain and Symptom Management

Persis Mary Hamilton, RN, CNS, MS, EdD

Susan Walters Schmid, BA, MA, PhD (candidate)

Also available: Pain and Its Management
for nurses, PTs/OTs, and EMT/paramedics in other states

This course meets the continuing education requirement for coursework in pain and symptom management for nurses in Michigan.

Wild Iris Medical Education is an approved provider (#PA-54) of continuing nursing education by the Washington State Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Our courses fulfill continuing nursing education requirements in all 50 states.
Nurse practitioners may apply these contact hours to pharmacy continuing education and prescriptive authorization.

In the early 1990s, a number of studies highlighted the need to address pain and symptom management policies in healthcare institutions throughout the United States. Michigan established its first interdisciplinary advisory committee on pain in 1994. Comprising representatives from eighteen healthcare boards, the committee was asked to create legislative mandates in the areas of public and professional education, and public policy (MDCIS, 2002).

In the Pain and Policy Studies Group's 2007 report card for nationwide state pain policies, Michigan was one of only four states to receive an "A" grade, reflecting its success in establishing a balanced approach to statewide pain policy (PPSG, 2007). Other indications of change include an increase in the number of Michigan physicians (MDs and DOs) who are licensed to prescribe Schedule II medications; yet there is still room for improvement in pain and symptom management for Michigan's citizens (Lewandowski, 2007).

The Pain and Symptom Management Advisory Committee was established in 1999 under the occupational regulation sections of the Michigan Public Health Code, P.A. 421 of 1998. The committee encouraged the development of a pain and symptom management website, recommended that hospitals create guidelines for required coursework in pain and symptom management, and directed pharmacies to share information and stock adequate amounts of Schedule II medications (MDCH, 2003). The Michigan Department of Community Health now maintains a comprehensive pain and symptom management website with material for both patients/caregivers and healthcare providers (see Resources).

In recent years many Michigan boards, including the Board of Nursing, have adopted comprehensive pain and symptom management guidelines, in recognition of healthcare professionals' need for up-to-date information about pharmacologic and nonpharmacologic modalities. Controlled substances received special consideration, and the boards have emphasized the need for healthcare practitioners to (1) improve their knowledge of opioid analgesics for the treatment of pain, (2) understand opioid addiction and recognize that fear of addiction should not be a barrier to pain management, and (3) understand that they will not be sanctioned or investigated for using controlled substances for the treatment of pain medications (MDCH, 2003).

To address these concerns, the Michigan Board of Nursing established the following nursing principles of pain management:

• All persons who are experiencing pain have the right to have their pain relieved to the greatest extent.
• A person's self-report of pain is the optimal standard upon which all pain management interventions are based.
• A comprehensive nursing assessment includes the subjective description of pain, objective data, and the identified need for psychosocial/spiritual support.
• Fear of addiction to opioids and other pain medications should not be a barrier to pain management. Nurses recognize and apply the following concepts in the provision of care:
• Tolerance and physical dependence are consequences of sustained use of opioid analgesics and are not synonymous with addiction.
• Pseudo-addiction is a pattern of drug-seeking behavior by persons with pain who are fearful of receiving inadequate pain management. These behaviors may be mistaken for addiction.
• Continuity of care within and across healthcare settings is essential to effective pain management.
• Persons with a history of substance abuse have the right to adequate pain relief, even if opioids must be used. Such persons may require specialized care, treatment and a referral to an appropriate healthcare professional.
• An interdisciplinary approach to pain management is optimal.
• Pain management continues even if the person becomes unresponsive (Michigan Board of Nursing, n.d.).

THE NATURE OF PAIN

Pain is a universal human experience and the most common reason people seek medical care. Pain tells us something is wrong in the structure or function of our body and we need to do something about it. Because pain is such a strong motivator for action, it is considered one of the body's most important protective mechanisms.

Definitions of Pain

The International Association for the Study of Pain defined pain as "an unpleasant, subjective, sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (1979)." Pain, however, is much more than a physical sensation caused by a single entity. It is subjective and highly individual, a complex mechanism with physical, emotional, and cognitive components.

Pain cannot be objectively measured in the same way as, for example, the chemical content of urine or the oxygen content level of blood. Only the person who is suffering knows how the experience feels. For these reasons, McCaffery (1979) defined pain as "whatever the experiencing person says it is and whenever he says it does." The American Pain Society (2005) goes further by stating that it is "not the responsibility of clients to prove they are in pain; it is the nurse's responsibility to accept the client's report of pain (2005)."

Comfort: The Absence of Pain

Pain alters the quality of life more than any other health-related problem. It interferes with sleep, mobility, nutrition, thought, sexual activity, emotional well-being, creativity, and self-actualization. Surprisingly, even though pain is such an important obstacle to comfort, it is one of the least understood, most under-treated and oft-discounted problems of healthcare providers and their clients. For this reason, some nurses add "comfort" to Maslow's hierarchy of basic human needs (1968). The American Pain Society goes further, declaring the relief of pain a "basic human right (2005)" and the American Bar Association called it a "basic legal right (2000)."

Characteristics of Pain

Traditionally, pain has been considered merely a physical symptom of illness or injury, a simple stimulus-response mechanism. Though the historic role of nurses has been to relieve pain and suffering, there has been little understanding of the complexity of pain and there have been only limited ways to manage it. Recent research shows pain to be a distinct disorder, with physical, emotional, and cognitive components. This view has broadened our understanding of pain and given us new ways to understand its characteristics, as described in Box 1-1.

Types of Pain

Pain is classified as acute and chronic. Acute pain has an identifiable cause and occurs soon after an injury to tissues in the body, such as bone, skin, or muscle. Acute pain is protective in that it motivates a person to take action. Its onset may be sudden or slow and its intensity may vary from mild to severe. Acute pain is temporary and subsides as healing takes place. Severe acute pain activates the sympathetic nervous system, causing diaphoresis, increased respiratory and pulse rates, and elevated blood pressure.

Chronic pain lasts beyond the expected healing phase, is nonprotective in that it serves no purpose, and may not have an identifiable cause (Patterson, 2007). When pain lasts more than three months it crosses from a "symptom" to a "condition." It is described as nonmalignant (noncancerous) and malignant (cancerous). Nonmalignant, noncancerous chronic pain typically accompanies such conditions as osteoarthritis and peripheral neuropathy. The lack of purpose, and uncertainty of duration, of chronic pain may lead to depression, fatigue, insomnia, anorexia, apathy, and learned helplessness. If it is severe, chronic pain—like prolonged stress—activates the parasympathetic nervous system, resulting in muscle tension, decreased heart rate and blood pressure, and failure of body defenses. Chronic pain is one of the most pervasive and intractable medical conditions in the United States, afflicting more than 1 in 5 Americans.

Malignant, cancerous chronic pain may be due to tumor progression, invasive procedures, toxicities of treatment, infection, and physical limitations. Such pain may be felt at the tumor site or some distance from it. Since clients with cancer may experience both chronic and acute pain, caregivers need to investigate any new pain in these clients immediately.

Sources of Pain

The sources of pain are divided into three main categories: nociceptor, non-nociceptor, and psychogenic, as shown in Table 1-1, below.

Nociceptor pain results when tissue damage produces a pain-producing stimulus that sends an electrical impulse across a pain receptor (nociceptor) by way of a nerve fiber to the central nervous system. Nociceptor pain in further divided into visceral and somatic pain. Visceral pain results from stimulation of nociceptors in the abdominal cavity, and thorax. Somatic pain is divided into deep somatic and cutaneous pain. Deep somatic pain arises from bones, tendons, nerves, and blood vessels. Cutaneous pain originates in the skin or subcutaneous tissue. Some body tissues, such as the brain and lung, have no nociceptors and some tissues have many.

Non-nociceptor (neuropathic) pain is caused by direct injury to structures of the nervous system.

Psychogenic pain is pain for which there is little or no physical evidence of organic disease or identified injury to tissues in the body. However, lack of evidence does not mean the client is not suffering or is malingering.

TABLE 1-1

PHYSIOLOGIC SOURCES OF PAIN

Nociceptor: visceral
Physiologic structures	Organs and linings of body cavities
Mechanism	Activation of nociceptors
Characteristics	Poorly localized, diffuse, deep, cramping or splitting
Sources of acute pain	Chest tubes, abdominal tube drains, bladder and intestinal distention
Sources of chronic pain syndromes	Pancreatitis, liver metastases, colitis
Nociceptor: somatic
Physiologic structures	Cutaneous: skin and sub-cutaneous tissues Deep somatic: blood, muscle, blood vessels, connective tissue
Mechanism	Activation of nociceptors
Characteristics	Well-localized, constant and achy
Sources of acute pain	Incisional pain, insertion sites of tubes and drains, wound complications, orthopedic procedures, skeletal muscle spasms
Sources of chronic pain syndromes	Bony metastases, osteo- and rheumatoid arthritis, low-back pain, peripheral vascular disease
Non-nociceptor: neuropathic
Physiologic structures	Nerve fibers, spinal cord, and central nervous system
Mechanism	Non-nociceptive injury to nervous system structures
Characteristics	Non-nociceptive injury to nervous system structures
Sources of acute pain	Poorly localized: shooting, burning, fiery, shock-like, sharp, painful numbness
Sources of chronic pain syndromes	Nervous tissue injury due to diabetes, HIV, chemotherapy, neuropathies, postherpetic neuralgia
Psychogenic
Physiologic structures	No organic structures
Mechanism	Emotional
Characteristics	Variable, often numerous
Sources of acute pain	Nonorganic
Sources of chronic pain syndromes	Nonorganic psychological factors
Source: Adapted with permission from Ignatavicius et al., 1999.

PHYSIOLOGY OF PAIN

Though a person is not consciously aware of the process, the experience of pain involves a complex sequence of biochemical and electrical events or processes beginning with tissue damage, followed by transduction, transmission, perception, and modulation. See Figure 1-1.

Figure 1-1    Neurological transmission of pain stimuli. Illustration by Jason McAlexander. Copyright © Wild Iris Medical Education.

Tissue Damage

Typically, when tissue damage occurs it releases inflammatory chemicals, called excitatory neurotransmitters, such as histamine and bradykinin, a powerful vasodilator. These substances cause the injured area to swell, redden, and become tender. Bradykinin also stimulates the release of prostaglandins and substance P, a potent neurotransmitter that enhances the movement of impulses across nerve synapses.

Transduction

Transduction occurs as the energy of the stimulus is converted to electrical energy.

Transmission

Transmission of the stimulus takes place when energy crosses into a nociceptor at the end of an afferent nerve fiber. Two types of peripheral nerve fibers conduct painful stimuli: the fast, myelinated A-delta fibers and the very small, slow, unmyelinated C-fibers. A-fibers send sharp, distinct sensations that localize the source of the pain and detect its intensity. C-fibers relay impulses that are poorly localized, burning, and persistent. For example, after burning a finger, a person initially feels a sharp localized pain as a result of A-fiber transmission. Within a few seconds the pain becomes more diffuse and widespread, as a result of C-fiber transmission. Pain stimuli travel quickly to the substantia gelatinosa in the dorsal horn of the spinal cord where the "gating" mechanism (discussed later) occurs. Pain impulses then cross over to the opposite side of the spinal cord and ascend to the higher centers in the brain via the spinothalamic tracts and on to the thalamus and higher centers of the brain, including the reticular formation, limbic system, and somatosensory cortex.

Perception

When pain stimuli reach the cerebral cortex, the brain interprets the signal, processes information from experiences, knowledge, and cultural associations, and perceives pain. Thus, perception is the awareness of pain. The somatosensory cortex identifies the location and intensity of pain, and the associated cortex determines how an individual interprets its meaning.

Modulation

Once the brain perceives the pain, the body releases neuromodulators, such as endogenous opioids (endorphins and enkephalins), serotonin, norepinephrine, and gamma aminobutyric acid. These chemicals hinder the transmission of pain and help produce an analgesic, pain-relieving effect. This inhibition of the pain impulse is called modulation. The descending paths of the efferent fibers extend from the cortex down to the spinal cord and may influence pain impulses at the level of the spinal cord.

Gate-Control Theory

Melzack and Wall (1982) proposed the gate-control theory to explain the relationship between pain and the emotions. According to the theory, a gating mechanism occurs when a pain impulse travels to the substantia gelatinosa in the dorsal horn of the spinal cord. There, trigger cells (T-cells) influence the transmission of pain impulses. When their activity is inhibited, the gate closes and impulses are less likely to be transmitted to the brain. This mechanism is controlled by descending nerve fibers from the thalamus and cerebral cortex, areas of the brain that regulate thought, beliefs, and emotions. The gate-control theory helps explain how the thoughts and emotions of a person modify the perception of pain and why interventions such as imagery and distraction help relieve it.

FACTORS THAT INFLUENCE PAIN

The perception of pain is influenced by physiologic, psychological, and cultural factors, all of which must be considered by caregivers of persons in pain.

Physiologic Factors

Age affects the way people respond to pain. It influences both the development and decline of the nervous system. Aging affects the whole body, exposing the older adult to painful degenerative disorders such as osteoarthritis, painful secondary injuries such as skin abrasions and fractures, and painful surgical procedures such as cataract and hip replacement. Age also affects the way nurses and families respond to a complaint of pain. For example, a nurse may be more sympathetic toward a toddler than an adolescent or a young adult. Table 1–2 gives a brief overview of the perception of pain relative to age.

TABLE 1-2

AGE AND THE PERCEPTION OF PAIN

Age	Pain perception
Pre-term infants	Have anatomical and functional ability to process pain by mid to late gestation; seem to have greater sensitivity to pain than term infants or children
Newborn infants	Response to pain is inborn and does not require prior learning; respond to pain with behavioral cues: facial, crying, body movement
Infants 1 month	Infants can metabolize analgesics and anesthesia effectively; can increasingly recognize caregiver as comforter
Toddlers / Preschoolers	Can describe pain, its location and intensity; respond to pain by crying, anger, and sadness; may consider pain a punishment; may hold someone accountable for pain and remember experiences in a certain location such as a clinic
School-age children	May try to be brave when facing a painful procedure; may regress to earlier stage of development; seek to understand reasons for pain
Adolescents	May be slow to acknowledge pain; may consider showing signs of pain a weakness; with persistent pain may regress to earlier stages of development
Adults	Fear of pain may prevent some adults from seeking care; may believe admission of pain is a weakness and inappropriate for age or sex; may consider pain a punishment for moral failure
Older adults	May have decreased sensations or perceptions of pain; may consider pain an inevitable part of aging; chronic pain may produce anorexia, lethargy, and depression; may not report pain due to fear of expense , possible treatment, and dependency; often describe pain in nonmedical terms such as "hurt" or "ache"; may fear addiction to analgesics; may not want to bother nurses or be a "bad client"

FATIGUE

Fatigue decreases coping abilities and heightens the perception of pain. When people are exhausted from physical activity, stress, and lack of sleep, their perception of pain is heightened. Thus, rest from physical, emotional, and social demands as well as sleep are important measures that reduce pain.

GENETIC MAKEUP

Recent research suggests that sensitivity to and tolerance for pain may a genetically linked trait (Ruda et al., 2000). This factor does not negate the need for adequate pain management of all clients.

MEMORY

Memory of painful experiences, especially experiences that occur when a child was very young, may increase sensitivity and decrease tolerance to pain. This may be due to anticipation and fear of a specific painful event, such as repeated immunization injections. Sensitivity to pain is increased when there is nonspecific memory of a painful event, such as newborn circumcision without anesthesia. Fortunately, modern medicine no longer condones such draconian practices.

STRESS RESPONSE

Research has shown that "severe, unrelieved pain can cause an overwhelming stress response in both pre-term and full term infants which can lead to serious complications and even death (Pasero, 2004).

NEUROLOGIC FUNCTION

Any factor that interrupts or interferes with normal pain transmission affects the awareness and response of clients to pain and places them at risk for injury. Analgesics, sedatives, and alcohol depress the functioning of the central nervous system and some diseases (such as leprosy, or Hansen's disease) damage peripheral nerves, decrease sensitivity to touch and pain, and render affected individuals more vulnerable to injury.

Psychological Factors

FEAR AND ANXIETY

The relationship between pain and anxiety is complex and difficult to manage. Fear tends to increase the perception of pain and pain increases feelings of fear. This connection occurs in the brain because painful stimuli activate portions of the limbic system believed to control emotional reactions. People who are seriously injured or critically ill often experience both pain and heightened levels of anxiety due to their helplessness and lack of control. Nurses need to address both pain and anxiety, using all appropriate measures to relieve suffering.

COPING

People manage pain and other stressors of life in different ways. Some see themselves as self-sufficient, internally controlled, and independent. As a result, they may deny or be slow to admit they are in pain. Others see themselves as insufficient, externally controlled, and dependent on others to treat their pain. Self-sufficient, internally controlled people may do better with patient-controlled analgesia (PCA), whereas dependent, externally controlled individuals may prefer nurse-administered analgesia. No matter what the coping style, it is the responsibility of caregivers to relieve pain.

Cultural Factors

Cultural beliefs and values affect the way people respond to pain. As children they learn what is and what is not acceptable behavior when in pain. In some cultures, any expression of pain is considered cowardly and shameful. In others, noisy demonstrations of pain are expected and acceptable. The meaning of pain itself may be markedly different in different cultures. Some ethnic groups see pain as a punishment for wrongdoing. Others see pain as a test of faith, and still others view pain as a challenge to be overcome. Recent immigrants to America are more likely to view pain from their cultural roots. Regardless of language, religion, or situation, nurses respect every individual and strive to alleviate pain and suffering.

STANDARDS AND GUIDELINES FOR PAIN MANAGEMENT

Because the pain is so important to the provision of healthcare today, many organizations have developed standards by which those who provide healthcare can measure their practice. Two such organizations are the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, Box 1–2) and American Academy of Pediatrics (AAP, Box 1–3). These standards indicate how seriously these national organizations view the reduction of pain and provision of comfort for people of all ages.

The nursing process includes assessment, diagnosis, planning, intervention, and evaluation. All are involved as the nurse addresses pain management.

ASSESSING PAIN

Pain is a red flag, telling us there is a problem somewhere in the body that needs fixing. In fact, it is such an important indicator of health, pain assessment has been called the "fifth vital sign," joining temperature, pulse, respiration, and blood pressure. However, until we know more about the pain, we cannot fix the problem. To do this, like detectives solving a murder mystery, nurses gather information from as many sources as possible, especially the primary source, the person in pain. The investigation includes a comprehensive pain history, behavioral observations, appropriate physical examination, and consultation with other healthcare professionals.

History

The pain history can be obtained from written documents and from interviews with persons in pain, parents, and/or caregivers. The pain history asks specific questions about the location, intensity, quality, and history of the pain, as shown in Box 2–1. In some facilities these questions are printed on an assessment form, with space for answers to be recorded beside each question.

BEHAVIORAL OBSERVATIONS

People who suffer pain usually show it, either by verbal complaint or nonverbal behaviors. Table 2–1 lists some typical nonverbal behaviors nurses may observe when they assess people are in pain.

TABLE 2-1

NONVERBAL BEHAVIORS INDICATING PAIN

Facial expressions	Vocalizations	Body movement	Social interaction
Clenched teeth Wrinkled forehead Biting lips Scowling Closing eyes tightly Widely opened eyes or mouth	Crying Moaning Gasping Groaning Grunting	Restlessness Protective body movement Muscle tension Immobility Pacing Rhythmic movement	Silence Withdrawal Reduced attention span Focus on pain relief measures

PHYSICAL EXAMINATION

When clients complain of pain or show it by their behavior, nurses immediately take action to find the cause. Assessment is most effective if the pain history interview and behavioral observations are conducted at the same time as the physical examination. For example, if a client complains of acute pain on the sole of a foot, the nurse visually examines the foot for unusual signs, observes the person for behavioral cues of pain, and asks about the onset, intensity, quality, and pattern of the pain and what makes it worse or better. If the cause is not identified immediately, the nurse refers the client for further assessment.

DIAGNOSING PAIN

An accurate diagnosis depends on a appropriate assessment, focusing on the exact nature of the pain. The more specific the diagnosis, the more effective the intervention to alleviate the pain and minimize complications. The North American Nursing Diagnosis Association (NANDA) has identified two primary diagnoses for pain: acute and chronic. A complete nursing diagnosis, however, goes further. After identifying whether the pain is acute or chronic, it adds, "related to" the medical diagnosis. For example, "chronic pain related to osteoarthritis of the left hip." Then, it adds, "manifested by" and lists the various symptoms experienced by the client. Thus, a complete diagnosis might be "chronic pain, related to osteoarthritis, manifested by stabbing pain in the left hip with weight-bearing." The advantage of clear, specific information is that it leads to more effective interventions. In this case, an appropriate intervention might be an assistive devise such as a cane or walker and referral to an orthopedic surgeon for further evaluation.

PLANNING AND IMPLEMENTING INTERVENTIONS

During the planning stage, nurses synthesize information from many sources and plan appropriate interventions. The goal of interventions is to relieve pain and facilitate the highest possible level of functioning. Practically speaking, this means identifying what activity the pain is preventing and what level of pain is permissible for return of function. For the client described above who had chronic hip pain, the activity the pain is preventing is mobility.

Planning interventions means setting goals and collaborating with clients and other healthcare professionals to provide specific measures to manage the pain. These interventions may be independent or collaborative. Independent nursing actions fall within the scope of nursing practice and include controlling the environment, giving emotional support, and providing comfort. Collaborative nursing actions involve cooperative interventions with other members of the healthcare team.

Goal setting involves identifying attainable objectives and reasonable priorities. Because every person is different, the nurse discusses various alternatives with the client and together they set priorities. For example, after consulting an orthopedic surgeon, the person with osteoarthritis decides to delay hip replacement surgery and maintain mobility as long as possible, using analgesics for pain and a cane for safer mobility.

Basic to every strategy for managing pain is showing respect for the validity of a client's experience of pain. To communicate respect, nurses:

• Acknowledge pain and take action to manage it.
• Give accurate information, to reduce anxiety and facilitate relief of pain.
• Reduce environmental stressors that add to the experience of pain.
• Encourage disclosure of feelings and fears.
• Provide privacy.

Pharmacologic Interventions

There are two primary groups of pain medications: nonopioids and opioids. A third group of drugs called adjuvants or co-analgesics, address symptoms that often accompany pain, such as insomnia, anxiety, muscle spasm, anorexia, and depression.

NONOPIOID ANALGESICS

Nonopioid analgesics relieve pain by acting on peripheral nerve endings at the injury site to decrease the level of inflammatory mediators. This group of analgesics includes drugs such as acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) such as acetylsalicylic acid (aspirin) and ibuprofen (Motrin). The specific actions and dosages of these analgesics vary. Generally speaking, however, they have analgesic, antipyretic, and anti-inflammatory effects and are useful for mild to moderate pain.

With the exception of acetaminophen, most nonopioids are potent anti-inflammatory agents. These drugs are especially effective when the primary cause of pain is inflammation, as occurs in rheumatoid arthritis and bone cancer. When tissue is damaged, a series of biochemical events leads to the release of prostaglandin, which causes edema, inflammation, and pain. Two isoenzymes, cyclo-oxygenase-1 (COX-1) and cyclo-oxygenase-2 (COX-2) play an important part in this biochemical process. Drugs that inhibit their action, especially that of COX-2, reduce prostaglandin production and the inflammation it creates. However, these drugs must be used with caution because the safety of long-term use has not been verified. Table 2–2 lists some common nonopioid analgesics.

TABLE 2-2

COMMON NONOPIOID ANALGESICS

Drug	Adult dose	Considerations
Acetaminophen (Tylenol)	650–975 mg q 4 hr	Used for headaches, osteoarthritis; lacks peripheral anti-inflammatory activity of NSAIDs
Aspirin	650–975 mg q 4 hr	Used for headaches, osteoarthritis, general pain; antipyretic; inhibits platelet aggregation, causing bleeding
Ibuprofen (Motrin)	400 mg q 4–6 hr	Used for osteoarthritis; antipyretic; multiple brand names; available as liquid
Indomethacin (Indocin)	150–200 mg/day	Used for gout; anti-inflammatory; anti-rheumatic
Naproxen (Naprosyn)	500 mg initial dose, then 250 mg q 6–8 hr	Used for gout, headaches; anti-inflammatory; anti-rheumatic; available in liquid preparation

While nonopioid analgesics relieve pain by acting on peripheral nerve endings at the injury site, opioids work at the level of the central nervous system, decreasing the perception of pain. Thus, nonopioids work in an entirely different way than opioids. Some medications combine nonopioid with opioid analgesics to offer two different levels of pain relief in one tablet. Acetaminophen and codeine is such a medication.

OPIOID ANALGESICS

Opioid (narcotic, CNS-acting) analgesics are derivatives of opium and include such drugs as morphine, codeine, and methadone. These drugs modify the perception of pain and provide a sense of euphoria by binding to specific opiate receptors throughout the central nervous system. Opiate receptors have various names—Greek letters mu (μ), sigma (σ), kappa (κ). Many of the characteristics of particular opioids relate to the receptor to which they bind. For example, morphine binds to μ receptors and follow μ receptor control.

Opioid analgesics are classified as full agonists, partial agonists, and mixed agonist-antagonists. Full agonists bind to μ receptor sites, block pain impulses, and produce maximum pain control, an "agonist effect." Full agonists include such drugs as morphine (Kadian, Avinza, Rylomine intranasal), meperidine (Demerol), fentanyl (Duragesic patch, Fentanyl oralets), propoxyphene (Darvon), oxycodone hydrochloride (OxyContin) and hydromorphine (Dilaudid).

Partial agonists produce a lesser response than full agonists and include such drugs as buprenorphine (Buprenex) and nalbuphine (Nubain). Mixed agonist-antagonist analgesics include such drugs as pentazocine hydrochloride (Talwin), and butorphanol tartrate (Stadol). An antagonist is a drug that competes with opioid receptor sites. Naloxone hydrochloride (Narcan) is such a drug. It is used for opioid overdoses and physical dependency.

The primary action of opioids (narcotics) is to alleviate moderate-to-severe pain. Many of the unwanted effects of this class of drugs are related to their actions on systems of the body other than the CNS, causing such effects as constipation and respiratory depression. Table 2–3 shows common opioid side effects and preventative measures.

TABLE 2-3

OPIOID ADVERSE EFFECTS AND PREVENTIVE MEASURES

Body system	Adverse side effects	Preventative measures
Cardiovascular	Hypotension, palpitations, flushing	Monitor blood pressure and heart rate
CNS	Sedation, disorientation, euphoria, dysphoria, light-headedness, lower seizure threshold, tremors	Inform client that tolerance may develop over 3–5 days; administer stimulants as needed
Gastrointestinal	Constipation, nausea and vomiting	Offer anti-emetic or change analgesic; increase fluid and fiber intake; increase exercise; administer laxatives
Genitourinary	Urinary retention	Catheterize as needed; administer opioid antagonist
Integumentary	Itching, rash, wheal formation	Apply cool packs, lotion, etc.; administer antihistamine
Respiratory	Respiratory depression; aggravation of asthma	Monitor respirations closely; administer opioid antagonist such as naloxone hydrochloride (Narcan)

DRUG TOLERANCE AND DEPENDENCE

Drug tolerance is a physiologic condition in which humans require larger and larger doses of drugs to provide the same effect provided by the original dose. The first sign of tolerance is a decrease in the duration of the analgesic effect. This condition is followed by a decrease in total analgesic effect. Decreasing the time between doses or increasing the dosage may helps overcome tolerance. Even so, drug tolerance is not the only reason drugs become less effective. They may become less effective because the there is advancing tissue damage and greater resulting pain.

Pseudotolerance is the need to increase opioid dosage for reasons other than the physical adaptation of continuous use. These other needs include drug-to-drug interaction, drug-to-food interaction, increased physical activity, psychological dependence (addiction), and changes in opioid formulation.

Physical dependence is a physiologic adaptation of tissues to the drug. If a person who is physically dependent on opioids abruptly stops using them, withdrawal symptoms occur. These symptoms result from an autonomic nervous system response, and may include excessive yawning, nausea and vomiting, hypertension, tachycardia, muscle twitching, diaphoresis, delirium, and convulsions. When opioid analgesics are to be discontinued, physical withdrawal symptoms can be reduced or eliminated by a slow reduction of dose.

Psychological dependence (addiction) is the compulsive use of a substance characterized by a continuous craving for a drug's nonanalgesic emotional effects. Opioids (narcotics) with an affinity for both mu and sigma receptor sites produce euphoria and hallucinations. These drugs are the most frequently abused opioids. When people take opioids to relieve pain, tolerance and physical dependence may occur, but addiction will not necessarily follow. Psychological dependence is far more complex and involves emotional, social, and cultural issues. Pain management in clients with addictive disease is discussed in Part 5 of this course.

Pseudoaddiction is a term used to describe people who, because of severe, unrelieved pain, focus on finding relief. As a consequence, they seem preoccupied with obtaining opioids. This preoccupation is not truly "drug-seeking" but "relief-seeking." Their quest for opioids is directly related to inadequate pain relief caused by an inappropriate opioid or an inadequate dose spaced too far apart.

Because of widespread misconceptions about treatment of chronic pain and addiction, in 1990 the World Health Organization (WHO) recommended the following three-step approach when a client complains of pain.

Step 1: Use nonsteroidal anti-inflammatory drugs and adjuvants. If pain persists,

Step 2: Use weak opioids and adjuvants. If pain persists,

Step 3: Use strong opioids and adjuvants.

To prevent undertreatment of malignant cancer pain, some authorities recommend a different approach. They begin the treatment of malignant pain with strong opioids, providing immediate relief, then slowly reduce the type and dosage until pain relief is achieved at the lower level (Jackson & Stanford, 2003).

ADJUVANT ANALGESICS

Adjuvant analgesics (co-analgesics) are drugs that were developed for uses other than pain, but have been found to enhance the effects of analgesics. Nurses need to remember that these are "helper drugs," not substitutes for analgesics. Clients in pain still need analgesics. Table 2–4 lists some common adjuvant analgesics.

TABLE 2-4

COMMON ADJUVANT (CO-ANALGESIC) DRUGS

Class of adjuvant drugs	Indications and primary effects
Antidepressants: Tricyclics and serotonin, reuptake inhibitors	Burning, neuropathic pain, improves sleep, enhances mood and analgesic effects
Anti-epileptic drugs	Neuralgic and neuropathic pain (sharp, shooting pain)
Antispasmodic	Reflex sympathetic dystrophy syndrome
Anxiolytic drugs: Benzodiazepines, buspirone, venlafaxine	Anxiety and sedation
Botulinum toxin	Migraine headache
Lidocaine	Neuralgic pain and diabetic neuropathic pain
Psychostimulants	Offset sedating side effects and enhances analgesic effects of opioids
Steroids	Inflammatory and chronic pain of cancer, malignant cord compression, headaches, and arthritis

PLACEBOS

A placebo is a "sugar pill" with no active ingredients. Even so, research has found that placebos produce hoped-for results in 30% to 50% of the people who take them (Thompson, 2000). This so-called placebo effect has been exploited for centuries by hucksters and charlatans who sell tonics, treatments, and gadgets to people in pain. Legitimate medical practice does not use placebos, because their purpose is to deceive and strip individuals of the right to make informed decisions. Such acts violate the ethical principles of honesty and autonomy. The only exception to this prohibition is made in research studies, when subjects give prior consent for the possible use of placebos.

ROUTES OF ADMINISTRATION

Analgesics can be administered by many routes. Each has advantages and disadvantages, indications and contraindications. The overriding considerations are effectiveness and safety. Table 2–5 lists some of the most common routes for the administration of analgesic drugs.

TABLE 2-5

ROUTES OF ANALGESIC DRUG ADMINISTRATION

Route	Indications	Contraindications
Oral (per os = PO )	Preferred route due to lower cost and convenience; multiple preparations: liquids, tablets, powders, lozenges, capsules	Gastrointestinal irritation; inability to swallow; need for more potent analgesic
Rectal (R)	Inability to take oral drugs; can be self-administered; longer duration than oral	Anal or rectal lesions, diarrhea, thrombocytopenia
Intramuscular (IM)	Acute, short-term pain relief	Need for prolonged pain relief; absorption may be poor; possible muscle or nerve damage; costly
Intravenous bolus (IV)	Offers most rapid pain relief (5–15 min) but lasts less than 60 min	Requires IV access; need for prolonged pain relief; brief duration
Continuous intravenous infusion (IV)	Gives constant opioid blood level when other methods ineffective	Requires infusion pumps with alarms and close monitoring
Client controlled analgesia (PCA)	Allows predetermined IV bolus of opioid when client desires pain relief	Requires IV access, client cooperation, close supervision; does not give continuous pain relief
Subcutaneous opioid infusion (SC)	Continuous, prolonged parenteral opioids when IV not possible; allows home use	Requires site change every 7 days of 27-gauge butterfly needle; possible site irritation
Intraspinal (neuraxial), intrathecal, epidural, subarachnoid, intraventricular	Labor contractions; also intractable pain when client cannot tolerate systemic opioids by other routes	Requires expert insertion of catheter into intended space; attached to infusion pump or implanted reservoir; high risk for infection or dislodgment
Regional nerve blocks	Continuous or single dose control of acute and chronic pain for trauma, burns, and labor	Requires expert insertion of catheter to specific nerve root; attached to infusion pump or implanted reservoir; high risk for infection or dislodgment
Topical (cream-laden anesthetic)	Venipuncture and needle-stick	Must be applied 30–60 min in advance of need
Transdermal	Continuous dose of opioid via skin patch for those who cannot tolerate other analgesic regimens; allows home use	Body temperature over 102°F accelerates absorption; costly

Nonpharmacologic Interventions

Although there are a myriad of drugs to relieve pain, all have some risk and cost. Fortunately, there are many nonpharmacologic interventions to give pain relief, especially when used in conjunction with pharmacologic measures. Described as physical and cognitive-behavioral interventions, many of these approaches are noninvasive, low-risk, inexpensive, easily performed and taught, and within the scope of nursing practice. Physical interventions give comfort, increase mobility, and alter physiologic responses. Cognitive-behavioral interventions alter the perception of pain, reduce fear, give clients a greater sense of control, and are considered holistic nursing practice.

PHYSICAL INTERVENTIONS

Comfort measures such as clean, smooth sheets, soft, supportive pillows, warm blankets, and a soothing environment have been used by nurses throughout history to relieve pain and suffering. These measures may be difficult to provide in the noisy, mechanized healthcare facilities of today. Nonetheless, they are important to the mental and physical health of clients.

Position change and movement are well-known pain-relieving interventions. Moving the body, even a small amount, relieves muscle spasm and provides a degree of pain relief. So important is movement of the body to health, an entire profession has developed specializing in physical therapy. However, nurses need not wait for a specialist to offer these important pain-relieving interventions.

Massage relieves muscle spasm, improves circulation, and provides cutaneous stimulation. While there are many different massage techniques, they all involve rubbing the skin in various patterns and degrees of pressure. Once considered an expected part of basic nursing care, backrubs offer an important noninvasive way to relieve pain and provide comfort.

Applications of hot and cold are effective pain-relieving measures when used appropriately. Heat decreases muscle spasm and increases blood flow to an area. Cold decrease blood flow, edema, and inflammation and may decrease muscle spasm and pain. Many devices are available to provide hot and cold, including electric heating pads, patches, and ice packs. Soaks and baths relieve muscle spasm and are an important means of providing comfort.

Acupuncture is an invasive procedure that involves insertion of needles at various points in the body to relieve pain. It is based on an ancient Chinese theory that two opposing forces, yin and yang, move along meridians in the body. When they are out of balance, pain and illness result. There are about a thousand acupuncture points along these meridians, each of which correspond roughly to hypersensitive areas in muscle and connective tissue. The theory posits that pain is relieved when the correct point is stimulated or prolonged pressure is applied. Acupuncture may also release endorphins and stimulate large nerve fibers to "close the gate" in the spinal cord to pain impulses.

Transcutaneous electrical nerve stimulation (TENS) provides a continuous, mild electric current via 2 to 4 electrodes placed on the skin near a painful site. The stimulator is a small, battery operated devise worn by the client. Experienced as a tingling sensation, TENS works by stimulating large nerve fibers to close the "gate" in the spinal cord. It also may stimulate endorphin production. TENS may be used for acute postoperative pain or for chronic conditions, such as low back pain, phantom limb pain, and neuralgia.

Surgical interventions may be recommended when severe pain persists despite medical treatment. If pain is due to a known condition, such as osteoarthritis of a joint, joint replacement surgery may be offered. When specific interventions are not available and conservative measures do not relieve pain, surgical interruption of pain pathways may be undertaken.

Rhizotomy and cordotomy are two such procedures. In a rhizotomy the surgeon destroys dorsal posterior nerve roots as they enter the spinal cord, either by delivering neurolytic chemicals, heat, or extreme cold by way of a catheter or by performing a laminectomy, isolating the nerve roots, and directly destroying the nerve. A chordotomy is more extensive than a rhizotomy, involving resection of the spinothalamic tract. Both procedures cause permanent loss of pain and thermal sensations and may cause paralysis due to motor nerve damage.

COGNITIVE-BEHAVIORAL INTERVENTIONS

Relaxation exercises are useful ways to reduce anxiety, decrease muscle tension, and lower blood pressure and heart rate. They induce a state of altered consciousness and give individuals a sense of control and peace of mind. Meditation, Zen, yoga, and other such interventions may effectively relieve pain. One such exercise involves controlled breathing. The coach speaks in a calm, clear voice, suggesting the subject begin by breathing slowly and diaphragmatically, allowing the abdomen to rise slowly and the chest to expand fully. Then, the coach suggests the subject locate an area of muscle tension, contract the muscles in that area and then relax them. As the subject relaxes, pain perception and anxiety diminish.

Guided imagery is similar to relaxation exercises in that the coach leads subjects in a calm, clear voice, often beginning with a relaxation exercise. The coach then suggests subjects imagine themselves in some peaceful place where they experience various sensory pleasures such as the warmth of the sun, the sound of ocean waves, and the smell of salt water. The purpose of the exercise is to provide an experience of relaxation and relief from stress and pain.

Distraction diverts the attention of individuals away from painful stimuli. When people focus on something that gives pleasure, they are less likely to feel acute pain. This phenomenon occurs because the reticular activating system briefly inhibits the awareness of pain. Distraction works best for short acute pain, such as a needle stick. Such things as listening to music, watching an intense scene on television, or describing something of special interest may temporarily distract a person from pain. However, it is important to remember that distraction does not work for chronic, long-term pain.

Biofeedback is a method of treating chronic pain and other stress-related conditions. It uses an electric device to gather information about physical responses and report them back to clients. The information goes to the biofeedback machine by way of electrode sensors placed on the person's skin. It is displayed as visual signals on a monitor. As clients watch these signals, they learn to control their responses.

EVALUATING THE EFFECTIVENESS OF INTERVENTIONS

Evaluation is one of the most critical phases of the nursing process. It tells us the degree to which an intervention achieved an expected outcome. If the expected outcome is pain reduction, evaluation tells us if the intervention did, in fact, reduce pain.

To find out, we gather data from the best source of information, the client, or the second-best source, the client's caregivers. To be of value, the information must address the aspects of pain that were noted before the intervention, including the location, intensity, quality, and duration of the pain. In addition, nurses gather data about adverse effects of an intervention, such as an allergic reaction, hypotension, or respiratory depression.

This feedback is essential if we are to revise the plan of care effectively. A positive evaluation means that an intervention was successful and probably should be continued. A negative evaluation means that an intervention was not satisfactory and change needs to be made. Hence the adage "Negative feedback makes for change."

COMMUNICATING, DOCUMENTING, AND TEACHING

Communication about pain and the response of clients to interventions is facilitated by accurate and thorough documentation. This communication needs to be conveyed from nurse to nurse, shift to shift, and nurse to other responsible healthcare providers. Various tools have been devised to facilitate this communication, including pain flow sheets, running diaries, and bedside computer charting (known as "point-of-care" charting). When communicating information about pain, it is important accurately to describe the time and exact nature of an intervention, including the analgesic and dosage administered, level of pain before and after the intervention, and adverse effects, such as respiratory depression. The more specific and timely the report, the more effective the evaluation.

Because pain is a potent motivator for change, people who suffer are open to suggestions. They deserve accurate information about the many interventions now available. It is the responsibility of healthcare professionals, especially nurses, to give patients information about new pain-relieving devices, medication, physical activities, and psychological strategies in clear, understandable ways. By doing so, caregivers demonstrate respect, accurate empathy, nonpossessive warmth, and genuine concern.

Posted April 3, 2008

Expires April 1, 2010

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