Pain Management for Michigan Nurses

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By Persis Mary Hamilton, RN, CNS, MS, EdD

LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

• Explain the nature of pain and its definitions, characteristics, types, and sources.
• Recall methods to assess, diagnose, intervene, evaluate, and document pain management.
• Discuss pharmaceutical, complementary, and alternative interventions for pain.

THE NATURE AND EXPERIENCE 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 that we need to do something about it. In a randomized survey of Michigan residents, 28.2% reported they had sought treatment for acute pain and 24.3% for chronic pain (Michigan Department of Community Health, 2009a). 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” (International Association for the Study of Pain, 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 defined pain as “whatever the experiencing person says it is and whenever he says it does” (1979). The American Pain Society 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).

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).

Traditionally, pain was 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 only limited ways to manage it. Recent research shows pain to be a distinct disorder, with physical, emotional, and cognitive components. This view of pain has broadened our understanding of pain and given us new ways to understand its characteristics.

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 an expected healing phase, is non-protective in that it serves no function, and may not have an identifiable cause (Patterson, 2007). When pain goes on more than 6 months, it moves from being a “symptom” to a “condition.” Chronic pain afflicts more than 1 in 5 Americans and is one of the most pervasive and thorny medical conditions in the United States. Such pain is described as nonmalignant (noncancerous), malignant (cancerous), and intractable.

• Nonmalignant, noncancerous chronic pain typically accompanies such conditions as osteoarthritis and peripheral neuropathy. The lack of purpose and uncertainty of duration of such pain may lead to depression, fatigue, insomnia, anorexia, apathy, learned helplessness, and other psychosocial consequences. 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.
• Malignant, cancerous chronic pain may be due to tumor progression, invasive procedures, infection, toxicities of treatment, 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 immediately any new pain in these clients.
• Intractable chronic pain is pain from any cause that is resistant to medical, surgical, and nursing measures. Persistent and ongoing, intractable chronic pain may be psychogenic in nature (Mosby’s Dictionary, 2009).

Sources of Pain

The sources of pain are divided into three main categories: nociceptor, non-nociceptor, and psychogenic.

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 is 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. Lack of evidence, however, does not mean clients are malingering or that they are not suffering.

PHYSIOLOGIC SOURCES OF PAIN

Source: Adapted with permission from Ignatavicius et al., 1999.
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 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, osteoarthritis, 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	Generalized along distribution of damaged nervous 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, trauma, surgery
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

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 and followed by transduction, transmission, perception, and modulation.

TISSUE DAMAGE

When tissue is damaged, there is an immediate release of inflammatory chemicals called excitatory neurotransmitters, such as histamine and bradykinin, a powerful vasodilator. Increased blood in the area causes the injured area to swell, redden, and become tender. The bradykinin stimulates the release of prostaglandins and substance P, a potent neurotransmitter that enhances the movement of impulses across nerve synapses.

TRANSDUCTION AND TRANSMISSION

Transduction occurs as the energy of the stimulus is converted to electrical energy. Transmission of the stimulus takes place when this 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 below) 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.

Neurologic transmission of pain stimuli. (Illustration by Jason McAlexander. © 2005, Wild Iris Medical Education, Inc.)

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 proposed the gate-control theory to explain the relationship between pain and the emotions (1982). 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 (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 and emotions. The gate-control theory helps explain how thoughts and emotions 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 caregivers need to consider.

PHYSIOLOGICAL FACTORS

Age

Age affects the way people respond to pain. It influences both the development and decline of the nervous system. Aging affects the whole body, causing many painful degenerative disorders (such as osteoarthritis), secondary injuries (such as skin abrasions and fractures), and a host of common surgical procedures (such as cataract and hip replacement). Age also affects the way families and caregivers respond to complaints of pain. The following table gives a brief overview of the perception of pain relative to age.

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 behaviors such as crying, grimacing, moving body
Infants, 1 month	Can metabolize analgesics and anesthesia effectively; can recognize caregiver as comforter
Toddlers/Preschoolers	Can describe pain, its location and intensity; respond to pain by crying, anger, 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 an earlier stage of development; seek understanding of reasons for pain
Adolescents	May be slow to acknowledge pain; may consider showing signs of pain a weakness; may regress to earlier stages of development with persistent pain
Adults	Fear of pain may prevent some 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, depression; may not report pain due to fear of expense, possible treatment, 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 patient”

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 may be heightened and their coping skills diminished. Thus, sleep and rest from physical, emotional, and social demands are important measures to manage pain more effectively.

Genetic Makeup

Recent research suggests that sensitivity to and tolerance for pain may a genetically linked trait (Ruda et al., 2000). This finding does not negate the need to manage pain adequately, regardless of inherited traits.

Memory

Memory of painful experiences, especially experiences that occurred as a very young child, may increase sensitivity and decrease tolerance to pain. For example, even young children remember the pain of an immunization at the doctor’s office and henceforth may be afraid to visit the doctor again.

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). In recent years, post-traumatic stress syndrome has been the subject of extensive research, both as to its cause and its treatment (Hamilton, 2008).

Healing

Recent research suggests that unrelieved acute pain slows postoperative wound healing (McGuire, 2006). This evidence is not surprising, given our increasing knowledge of the effect of stress on the human body.

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. Some diseases, such as leprosy, damage peripheral nerves, decrease sensitivity to touch and pain, and render sufferers more vulnerable to injury.

PSYCHOLOGICAL FACTORS

Fear and Anxiety

The relationship between pain and fear is convoluted and complex. Fear tends to increase the perception of pain, and pain increases feelings of fear and anxiety. 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 feelings of helplessness and lack of control. Caregivers need to address both pain and anxiety and use 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 pain or be slow to admit they are suffering. 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 experiencing 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 an individual’s language, religion, or situation, nurses respect every person and strive to alleviate pain and suffering.

STANDARDS AND GUIDELINES FOR PAIN MANAGEMENT

Because pain management is so important to the provision of quality healthcare, many organizations have developed standards by which professional practice is measured. Two such organizations are the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and American Academy of Pediatrics (AAP).

Joint Commission

The Joint Commission is an independent organization that accredits and certifies more than 17,000 healthcare organizations and programs in the United States. It evaluates how well these healthcare providers meet published standards of care, including their management of pain. The federal government accepts Joint Commission–accredited facilities as qualified to participate in Medicare and Medicaid reimbursement programs.

Regarding pain management, the Joint Commission Resources states: “Each and every patient has a right to the assessment and management of pain. Hospitals must develop policies and procedures which address the organization’s expectations of pain management in support of their mission and philosophy of care. Patients and their families also need education regarding their role in pain management. Developing a comprehensive and coordinated pain management program can be made easier by accessing good practices. From policies and procedures for the different types of pain (acute, chronic, etc.) to training assistants (including pre- and post-tests) to assessment tools, good practices can assist your organization to provide a comprehensive approach to pain management that meets the intent of the standards and, at the same time, achieves positive outcomes for patient.” (Joint Commission Resources, Inc., 2009). The JCAHO Standards of Pain Management are listed below.

American Academy of Pediatrics

The American Academy of Pediatrics is a professional organization dedicated to the health, safety, and well-being of infants, children, adolescents, and young adults. As such, its committees develop guidelines, positions, and programs to support the mission of the organization. The AAP guidelines for pain management conclude with the strategies listed below.

PAIN AND THE NURSING PROCESS

The nursing process includes assessment, diagnosis, planning, intervention, and evaluation. To manage pain responsibly, nurses use each step of the nursing process.

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 and maintain confidentiality.

Assessing Pain

Pain is a red flag. It tells us there is a problem somewhere in the body that is crying out for attention. In fact, pain is such an important indicator of health, its assessment has been called the “fifth vital sign,” joining temperature, pulse, respiration, and blood pressure. Even so, until we know more about a specific pain, we cannot fix it. To do this, nurses must gather information from as many sources as possible, especially the primary source, the person in pain. This investigation includes obtaining a comprehensive pain history, making observations of behaviors, performing an appropriate physical examination, and consulting with other healthcare professionals.

PAIN HISTORY

A pain history is obtained from written documents and from interviews with the person in pain, family members, and other caregivers. It asks specific questions about the location, intensity, quality, and history of the pain, as shown in the following box. In some facilities these questions are printed on an assessment form, with space for answers to be recorded beside each question.

BEHAVIORAL OBSERVATIONS

Most people who suffer pain usually show it either by verbal complaint or nonverbal behaviors. The following table lists some typical behaviors nurses may observe when they assess people in pain.

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 need to 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 an appropriate assessment that focuses on the exact nature of the pain. The more specific the diagnosis, the more effective interventions can be. 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 or signs confirmed by objective data. 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 Goal Setting

During the planning stage, nurses synthesize information from many sources and, together with the physician, plan appropriate interventions. The goal of these 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 the best way to achieve a return of function. For the client described above with chronic hip pain, the activity the pain is preventing is mobility.

Planning interventions means working in partnership with clients and physicians 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, such as physical therapists, pharmacists, and physicians.

Goal setting involves the identification of 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 may decide to delay hip replacement surgery and maintain mobility as long as possible with the aid of a cane and analgesics for pain.

Interventions

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. The following table lists some common nonopioid analgesics.

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

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, typically denoted by Greek letters such as mu (μ), kappa (κ), and sigma (σ). 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), 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 central nervous system (CNS), causing such effects as constipation and respiratory depression. The following table lists some common opioid side effects and preventative measures.

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, vomiting	Offer anti-emetic; 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 or lotion; administer antihistamine
Respiratory	Respiratory depression; aggravation of asthma	Monitor respirations closely; administer opioid antagonist such as naloxone hydrochloride (Narcan)

Some medications combine nonopioid with opioid analgesics in one tablet to offer two different levels of pain relief—acting both on peripheral nerve endings at the injury site and at the level of the central nervous system. Acetaminophen with codeine is such a medication.

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 as 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 help overcome tolerance. Even so, drug tolerance is not the only reason drugs become less effective. They may be less effective because there is advancing tissue damage, thus greater 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 μ and σ receptor sites produce euphoria and hallucinations. Thus, 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 further later in 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 inadequate doses spaced too far apart.

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. Caregivers need to remember that these are “helper drugs,” not substitutes for analgesics. Clients in pain still need analgesics. The following table describes some common adjuvant analgesics.

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, prickling, 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	Offsets sedating side effects and enhances analgesic effects of opioids
Steroids	Inflammatory and chronic pain of cancer, malignant spinal cord compression, headaches, and arthritis

Cannabis (Marijuana)

Cannabis is a psychoactive herb derived from the flowers of hemp plants. Although many people associate it with the treatment of pain, it is not currently accepted for any use by the U.S. Drug Enforcement Administration, which lists it as a Schedule 1 drug of the Controlled Substance Act of 1970. Even so, it is marketed as dronabinol (Marinol) and used in the treatment of glaucoma and intractable nausea. All parts of the plant contain various psychoactive substances, including tetrahydrocannabinol (THC), the chemical believed to cause typical psychic effects such as alterations of mood, memory, motor coordination, cognitive ability, and self-perception. Many states, including Michigan, have established medical marijuana programs to regulate the growth, sale, and use of cannabis (Michigan Department of Community Health, 2009).

Placebos

A placebo is a “sugar pill,” an inactive substance prescribed as if it were an effective dose of a medication. 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. Because their purpose is to deceive and strip clients of the right to make informed decisions, legitimate medical practice does not use placebos. Such acts violate the ethical principles of honesty and autonomy. The only exception to this prohibition is when subjects give prior consent for the possible use of placebos in research studies.

World Health Organization Pain Management Ladder

Because of widespread misconceptions about treatment of chronic pain and addiction, in 1990 the World Health Organization (WHO) recommended a three-step pain management ladder based on the intensity of pain.

1. Mild pain (intensity 1–3 on the 0–10 standard): Use nonsteroidal anti-inflammatory drugs and adjuvants. If pain persists, then
2. Mild to moderate pain (intensity 4–6): Use combination medications such as oxycodone and acetaminophen and adjuvants. If pain persists, then
3. Moderate to severe pain (intensity 7–10): Use potent opioids such as morphine, fentanylm methadone, and adjuvants.

To prevent under-treatment of malignant cancer pain, some authorities recommend a different approach. They begin the treatment of malignant cancer 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).

Routes of Administration

Analgesics can be administered by many routes. Each has advantages and disadvantages as well as indications and contraindications. The overriding considerations are effectiveness and safety. The table below lists some of the most common routes for the administration of analgesic drugs.

ANALGESIC DRUG ADMINISTRATION

Route	Indications	Contraindications
Oral (per os = PO)	Preferred route due to lower cost and convenience; may be prepared as powders, capsules, tablets, liquids, or lozenges	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 (IV) bolus	Offers most rapid pain relief (5–15 min) but lasts less than 60 min	Requires IV access; gives only brief pain relief when prolonged relief is needed
Continuous intravenous (IV) infusion	Gives constant opioid blood level when other methods are ineffective	Requires infusion pumps with alarms and close monitoring
Patient-controlled analgesia (PCA)	Allows predetermined IV bolus of analgesic when client desires pain relief	Requires IV access, client cooperation, close supervision; does not give continuous pain relief
Subcutaneous (SC) opioid infusion	Continuous, prolonged parenteral opioids when IV not possible; allows home use	Requires site change every 7 days of 27-gauge butterfly needle; potential 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 analgesic for acute and chronic pain; used 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)	Analgesic for needle sticks, venipuncture, dermatitis, and insect stings	Must be applied 30–60 min in advance of need
Transdermal skin patch	Continuous dose of opioid; allows home use	Costly; when body temperature is over 102°F, absorption is accelerated
Nasal sprays	Alternative to IV, IM, and oral opioid administration; rapid onset of action	Nasal exudates or mucosal swelling may prevent consistent absorption

Principles for the Use of Analgesics

To guide caregivers, the American Pain Society (2005) identifies thirteen principles regarding the use of analgesics to control pain:

1. Individualize the route, dosage, and schedule of analgesics medications.
2. Administer analgesics on a regular basis if pain is present most of the day.
3. Know the dose and time course of several opioid analgesic preparations:
   • Ask client about prior experience with certain drugs.
   • Give preference to long-acting, sustained-release opioids such as OxyContin, which provides up to 12 hours of analgesia; Kadian and Avinza, controlled-release morphine preparations which provide up to 24 hours of pain relief; and transdermal fentanyl, which provides up to 3 days of pain relief.
   • Avoid the adverse effects of emesis by giving anti-emetics.
   • Rotate opioids to compensate for tolerance.
   • Use rapid-onset opioids when necessary.
   • Use concentrated dosage forms when injection volume must be minimized.
4. Give infants and children adequate opioid doses. 
5. Follow clients closely, particularly when beginning or changing analgesics.
6. When changing to a new opioid or a different route, first use equianalgesic doses to estimate the new dose. Then, modify the estimate, based on the clinical situation and the specific drug.
7. Recognize and treat side effects, such as sedation, constipation, nausea, itching, respiratory depression, by doing the following:
   • Change the dose or route of the same drug to maintain constant blood levels.
   • Try different opioids analgesics.
   • Consider multi-drug and multi-modal therapy.
   • Add another drug that counteracts the adverse effects, such as a stimulant for sedation.
   • Use an administration route that minimizes drug concentrations at the site producing the side effect, such as intraspinal instead of oral when appropriate.
8. Do not use meperidine (Demerol) because of neurotoxicity risk or mixed agonist-antagonists (Talwin) because of psychotomimetic effects.
9. Do not use placebos to assess the nature of pain.
10. Monitor for the development of tolerance and treat appropriately. Increased pain may be due to progressive disease, new pathology, skipped doses, or other causes.
11. Expect physical dependence and prevent withdrawal symptoms.
12. Do not diagnose patients as “opioid addicted” solely because of opioid dependence.
13. Be alert to the psychological state of the client.

NONPHARMACOLOGIC INTERVENTIONS

Although there are myriad drugs to relieve pain, all have some risk and cost. Fortunately, there are many nonpharmacologic interventions to reduce pain, 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 a greater sense of control, and are considered holistic nursing practice.

Physical Interventions

Comfort measures such as clean and smooth sheets, soft and 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 well-being of patients.

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 decreases 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.

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, however they may also 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, yoga, and other such interventions may effectively relieve pain. One such exercise involves controlled breathing. A 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 a 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. Distraction, however, 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.

Complementary and Alternative Medicine (CAM)

To relieve their pain, an increasing number of people in the United States are also turning to theories and practices outside the realm of conventional Western medicine. In 1991, the federal government established the Office of Alternative Medicine. In 1998, the agency became the National Center for Complementary and Alternative Medicine (NCCAM), making the center one of 27 institutes and centers of the National Institutes of Health within the Department of Health and Human Services. NCCAM defines CAM as “a group of diverse medical and healthcare systems, practices, and products that are not currently part of conventional medicine” (NCCAM, 2009a).

The mission of NCCAM is to explore “complementary and alternative healing practices in the context of rigorous science…and [to] disseminate authoritative information to the public and professionals” (NCCAM, 2007). In this context, “complementary” describes practices used in conjunction with or to supplement conventional medical treatments, and “alternative” means those that are used independently or in place of conventional medicine. Practitioners of such techniques and practices often use the term holistic because they view health and illness as affecting the whole person—body, mind, and spirit.

The major categories of complementary and alternative medicine are:

• Biologic (herbal mixtures; macrobiotic diets; orthomolecular, such as megadoses of vitamins, magnesium, melatonin, etc.)
• Energy fields (acupuncture, therapeutic touch, pulse fields, Reiki, etc.)
• Manipulative and body-based (chiropractic, lymphatic drainage, reflexology, aromatherapy, deep-muscle massage, shiatsu, etc.)
• Mind-body (biofeedback, hypnosis, art therapy, prayer, etc.) (Diluzio & Spillane 2002)

Biologic. Plants have been used to treat human ailments throughout history. Their therapeutic effects are due to the chemical compounds they contain. Such chemicals may be administered to patients by giving some part of a plant or by extracting or synthesizing the essential chemical. When prepared in a purified form, the dose is more precise than it can be from a plant. Some common active chemicals originally derived from plants are: digitaloid found in the foxglove plant (digitalis), saponins found in sarsaparilla (irritant laxatives), alkaloids found in nightshades (atropine), and alkaloids found in the opium poppy (morphine) (McGuigan & Krug, 1942).

Energy fields. Such healing measures are based on theories about unseen forces in the human body. Acupuncture, for instance, is based on an ancient Chinese theory that two opposing forces, yin and yang, move along meridians in the body. When these forces are out of balance, pain and illness result. There are at least 350 acupuncture points by which energy flows are accessible. The theory posits that by stimulating these points with very fine needles, the energy flow can be rebalanced and pain relieved (Mayo Clinic, 2009; NCCAM, 2009b).

Chiropractic is a healthcare approach that focuses on the relationship between the body’s structure—mainly the spine—and its functioning. Although practitioners may use a variety of treatment approaches, they primarily perform adjustments to the spine or other parts of the body with the goal of correcting alignment problems and supporting the body’s natural ability to heal itself. People seek chiropractic care primarily for pain conditions such as back pain, neck pain, and headache. Side effects and risks depend on the type of chiropractic treatment used. Ongoing research is looking at effects of chiropractic treatment approaches, how they might work, and diseases and conditions for which they may be most helpful. (NCCAM, 2009c.)

Osteopathy is a medical specialty that combines traditional and nontraditional medicine. Practitioners, called doctor of osteopathy (DO), practice traditional, science-based medicine, and are licensed to perform surgery and prescribe drugs. They “take a holistic view of the body as an integrated system and approach prevention, diagnosis, and treatment by way of the musculoskeletal system” (Asher, 2007).

Biofeedback is a method of treating chronic pain and some 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. The machine displays information as visual signals on a monitor. As clients watch the 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 and if so, how much and at what cost in time, treasure, and long-term effects.

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.

Such 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 should be changed. 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, called “point-of-care.” When communicating information about pain, it is important to describe the time and exact nature of an intervention, including details such as an analgesic and dose administered, level of pain before and after the intervention, and any adverse effect that follows, such as respiratory depression. The more specific and timely a report, the more effective the evaluation.

Because pain is a potent motivator for change, people who suffer are vulnerable to all manner of fake gadgets and magical cures. It is the responsibility of healthcare professionals, especially nurses, to give patients accurate information about medications, devices, physical activities, and psychological strategies in clear, understandable ways. Such teaching empowers those who suffer and demonstrates genuine concern, accurate empathy, nonpossessive warmth, and respect.

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