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MEDSURG: CHAPTER 12: PAIN MANAGEMENT:
Terms in this set (71)
- The American Pain Society (APS) (2008) defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage"
- This definition describes pain as a complex phenomenon that can impact a person's psychosocial, emotional, and physical functioning.
- The clinical definition of pain reinforces that pain is a highly personal and subjective experience: "Pain is whatever the experiencing person says it is, existing whenever he says it does"
- •Patient is the most reliable indicator of pain and essential component of pain assessment
Effects Of Pain: (1)
- Pain affects individuals of every age, sex, race, and socioeconomic class
- It is the primary reason people seek health care and one of the most common conditions that nurses treat.
- Unrelieved pain has the potential to affect every system in the body and cause numerous harmful effects, some of which may last a person's lifetime
- Despite many advances in the understanding of the underlying mechanisms of pain and the availability of improved analgesic agents and technology, as well as nonpharmacologic pain management methods, all types of pain continue to be undertreated
Effects Of Pain (2):
•Affects every system
Types Of Pain: Acute Pain:
- Differs from chronic pain primarily in its duration.
- For example, tissue damage as a result of surgery, trauma, or burns produces acute pain, which is expected to have a relatively short duration and resolve with normal healing.
Types Of Pain: Chronic Pain:
- Subcategorized as being of cancer or noncancer origin and can be time limited (e.g., may resolve within months) or persist throughout the course of a person's life.
- Examples of non-cancer pain include peripheral neuropathy from diabetes, back or neck pain after injury, and osteoarthritis pain from joint degeneration.
Types Of Pain: Breakthrough Pain (BTP):
- Some conditions can produce both acute and chronic pain.
- For example, some patients with cancer have continuous chronic pain and also experience acute exacerbations of pain periodically—called breakthrough pain (BTP)—or endure acute pain from repetitive painful procedures during cancer treatment
Classification Of Pain: Nociceptive (Physiologic) Pain:
- Refers to the normal functioning of physiologic systems that leads to the perception of noxious stimuli (tissue injury) as being painful
- This is why nociception is described as "normal" pain transmission.
Classification Of Pain: Neuropathic (Pathophysiologic) Pain:
- Is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the peripheral or central nervous system (CNS) or both
Nociceptive Pain: Transduction: Nociceptors:
- Transduction refers to the processes by which noxious stimuli, such as a surgical incision or burn, activate primary afferent neurons called nociceptors, which are located throughout the body in the skin, subcutaneous tissue, and visceral (organ) and somatic (musculoskeletal) structures
- These neurons have the ability to respond selectively to noxious stimuli generated as a result of tissue damage from mechanical (e.g., incision, tumor growth), thermal (e.g., burn, frostbite), chemical (e.g., toxins, chemotherapy), and infectious sources.
- Noxious stimuli cause the release of a number of excitatory compounds (e.g., serotonin, bradykinin, histamine, substance P, and prostaglandins), which move pain along the pain pathway
Nociceptive Pain Process: Transduction: Prostaglandins:
- Prostaglandins are lipid compounds that initiate inflammatory responses that increase tissue swelling and pain at the site of injury
- They form when the enzyme phospholipase breaks down phospholipids into arachidonic acid.
- In turn, the enzyme cyclo-oxygenase (COX) acts on arachidonic acid to produce prostaglandins
- COX-1 and COX-2 are isoenzymes of COX and play an important role in producing the effects of the nonopioid analgesic agents, which include the nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (Tylenol).
- NSAIDs produce pain relief primarily by blocking the formation of prostaglandins in the periphery
- The nonselective NSAIDs, such as ibuprofen (Motrin, Advil), naproxen (Naprosyn), diclofenac (Voltaren), and ketorolac (Toradol), inhibit both COX-1 and COX-2, and the COX-2 selective NSAIDs, such as celecoxib (Celebrex), inhibit only COX-2.
- Both types of NSAIDs produce anti-inflammation and pain relief through the inhibition of COX-2.
- Acetaminophen is known to be a COX inhibitor that has minimal peripheral effect, is not anti-inflammatory, and can both relieve pain and reduce fever by preventing the formation of prostaglandins in the CNS
- Other analgesic agents work at the site of transduction by affecting the flux of ions.
- For example, sodium channels are closed and inactive at rest but undergo changes in response to nerve membrane depolarization.
- Transient channel opening leads to an influx of sodium that results in nerve conduction
- Local anesthetics reduce nerve conduction by blocking sodium channels.
- Anticonvulsants also produce pain relief by reducing the flux of other ions, such as calcium and potassium
Nociceptive Pain Process: Transmission:
- Transmission is another process involved in nociception.
- Effective transduction generates an action potential that is transmitted along the A-delta (δ) and C fibers
- A-δ fibers are lightly myelinated and faster conducting than the unmyelinated C fibers
- The endings of A-δ fibers detect thermal and mechanical injury, allow relatively quick localization of pain, and are responsible for a rapid reflex withdrawal from the painful stimulus.
- Unmyelinated C fibers are slow impulse conductors and respond to mechanical, thermal, and chemical stimuli.
- They produce poorly localized and often aching or burning pain. A-beta (β) fibers are the largest of the fibers and respond to touch, movement, and vibration but do not normally transmit pain
- Noxious information passes through the dorsal root ganglia and synapses in the dorsal horn of the spinal cord.
- An action potential is generated, and the impulse ascends up to the spinal cord and transmits the information to the brain, where pain is perceived.
- Extensive modulation occurs in the dorsal horn via complex neurochemical mechanisms
- The primary A-δ fibers and C fibers release various transmitters including glutamate, neurokinins, and substance P.
- Glutamate is a key neurotransmitter because it binds to the N-methyl-D-aspartate (NMDA) receptor and promotes pain transmission.
- The drug ketamine, an NMDA receptor antagonist, produces analgesia by preventing glutamate from binding to the NMDA receptor sites.
- Endogenous and exogenous (therapeutically given) opioids bind to opioid receptor sites in the dorsal horn to block substance P and thereby produce analgesia
- The opioid methadone (Dolophine) binds to opioid receptor sites and has NMDA antagonist properties
Nociceptive Pain Process: Perception:
- An additional process involved in nociception is perception.
- Perception is the result of the neural activity associated with transmission of noxious stimuli
- It requires activation of higher brain structures for the occurrence of awareness, emotions, and drives associated with pain
- The physiology of perception of pain continues to be studied but can be targeted by mind-body therapies, such as distraction and imagery, which are based on the belief that brain processes can strongly influence pain perception
Nociceptive Pain Process: Modulation:
- Another process involved in nociception.
- Modulation of the information generated in response to noxious stimuli occurs at every level from the periphery to the cortex and involves many different neurochemicals
- For example, serotonin and norepinephrine are inhibitory neurotransmitters that are released in the spinal cord and the brain stem by the descending (efferent) fibers of the modulatory system.
- Some antidepressants provide pain relief by blocking the body's reuptake (resorption) of serotonin and norepinephrine, extending their availability to fight pain.
- Endogenous opioids are located throughout the peripheral and central nervous systems, and like exogenous opioids, they bind to opioid receptors in the descending system and inhibit pain transmission
- Dual-mechanism analgesic agents, such as tramadol (Ultram) and tapentadol (Nucynta), bind to opioid receptor sites and block the reuptake of serotonin and/or norepinephrine
- Neuropathic pain is sustained by mechanisms that are driven by damage to, or dysfunction of, the peripheral or central nervous system and is the result of abnormal processing of stimuli
- Unlike nociceptive pain, neuropathic pain may occur in the absence of tissue damage and inflammation, even when acute neuropathic pain serves no useful purpose.
- Extensive research is ongoing to better define the peripheral and central mechanisms that initiate and maintain neuropathic pain
Neuropathic Pain: Peripheral Mechanisms:
- At any point from the periphery to the CNS, the potential exists for the development of neuropathic pain.
- Hyperexcitable nerve endings in the periphery can become damaged, leading to abnormal reorganization of the nervous system called neuroplasticity, an underlying mechanism of some neuropathic pain states - Changes in the number and location of ion channels can occur.
- For example, sodium channels abnormally accumulate in injured nociceptors, which can lower the threshold for nerve depolarization and increase response to stimuli, setting off ectopic nerve discharges
- These and many other processes lead to a phenomenon called peripheral sensitization, which is thought to contribute to the maintenance of neuropathic pain.
- Topical local anesthetics, such as lidocaine patch 5% (Lidoderm), produce effects in the tissues right under the site of application by "dampening" neuropathic pain mechanisms in the peripheral nervous system
Neuropathic Pain: Central Mechanisms:
- Central mechanisms also play a role in the establishment of neuropathic pain.
- Central sensitization is defined as abnormal hyperexcitability of central neurons in the spinal cord, which results from complex changes induced by incoming afferent barrages of nociceptors
- Extensive release and binding of excitatory neurotransmitters, such as glutamate, activate the NMDA receptor and cause an increase in intracellular calcium levels into the neuron, resulting in pain.
- Similar to what happens in the peripheral nervous system, an increase in the influx of sodium is thought to lower the threshold for nerve activation, increase response to stimuli, and enlarge the receptive field served by the affected neuron.
- As in the peripheral nervous system, anatomic changes can occur in the CNS.
- For example, injury to a nerve route can lead to reorganization in the dorsal horn of the spinal cord.
- Nerve fibers can invade other locations and create abnormal sensations in the area of the body served by the injured nerve.
- Allodynia, or pain from a normally nonnoxious stimulus (e.g., touch), is one such type of abnormal sensation and a common feature of neuropathic pain.
- In patients with allodynia, the mere weight of clothing or bedsheets on the skin can be excruciatingly painful
Pain Assessment: Self-Report:
- The highly subjective nature of pain causes challenges in assessment and management; however, the patient's self-report is the undisputed standard for assessing the existence and intensity of pain
- Self-report is considered the most reliable measure of the existence and intensity of the patient's pain.
- Accepting and acting on the patient's report of pain are sometimes difficult.
- Because pain cannot be proved, the health care team is vulnerable to inaccurate or untruthful reports of pain.
- Clinicians are entitled to their personal doubts and opinions, but those doubts and opinions cannot be allowed to interfere with appropriate patient care
Pain Assessment: Location Of Pain:
- Ask the patient to state or point to the area(s) of pain on the body.
- Sometimes allowing patients to make marks on a body diagram is helpful in gaining this information.
Pain Assessment: Intensity Of Pain:
- Ask the patient to rate the severity of the pain using a reliable and valid pain assessment tool.
- Various scales translated in several languages have been evaluated and made available for use in clinical practice and for educational practice. The most common include the following:
Pain Assessment: Intensity Of Pain: Numeric Rating Scale (NRS):
- The NRS is most often presented as a horizontal 0- to-10-point scale, with word anchors of "no pain" at one end of the scale, "moderate pain" in the middle of the scale, and "worst possible pain" at the end of the scale.
- It may also be put on a vertical axis, which may be helpful for patients who read from right to left.
Pain Assessment: Intensity Of Pain: Wong-Baker FACES Pain Rating Scale:
- The FACES scale consists of six cartoon faces with word descriptors, ranging from a smiling face on the left for "no pain (or hurt)" to a frowning, tearful face on the right for "worst pain (or hurt)."
- Patients are asked to choose the face that best reflects their pain.
- The faces are most commonly numbered using a 0, 2, 4, 6, 8, 10 metric, although 0 to 5 can also be used. Patients are asked to choose the face that best describes their pain.
- The FACES scale is used in adults and children as young as 3 years
- It is important to appreciate that faces scales are self-report tools; clinicians should not attempt to match a face shown on a scale to the patient's facial expression to determine pain intensity.
- Patients may be able to understand the tool better if it is displayed vertically with no pain as the anchor at the bottom.
Pain Assessment: Intensity Of Pain: Faces Of Pain Scale-Revised (FPS-R):
- The FPS-R has six faces to make it consistent with other scales using the 0 to 10 metric.
- The faces range from a neutral facial expression to one of intense pain and are numbered 0, 2, 4, 6, 8, and 10.
- As with the Wong-Baker FACES scale, patients are asked to choose the face that best reflects their pain.
- Faces scales have been shown to be reliable and valid measures in children as young as 3 years of age; however, the ability to optimally quantify pain (identify a number) is not acquired until approximately 8 years of age
- Some research shows that the FPS-R is preferred by both cognitively intact and impaired older and minority populations
Pain Assessment: Intensity Of Pain: Verbal Descriptor Scale (VDS):
- A VDS uses different words or phrases to describe the intensity of pain, such as "no pain, mild pain, moderate pain, severe pain, very severe pain, and worst possible pain."
- The patient is asked to select the phrase that best describes pain intensity.
Pain Assessment: Intensity Of Pain: Visual Analog Scale (VAS):
- The VAS is a horizontal (sometimes vertical) 10-cm line with word anchors at the extremes, such as "no pain" on one end and "pain as bad as it could be" or "worst possible pain" on the other end.
- Patients are asked to make a mark on the line to indicate intensity of pain, and the length of the mark from "no pain" is measured and recorded in centimeters or millimeters.
- Although often used in research, the VAS is impractical for use in daily clinical practice and rarely used in that setting.
Pain Assessment: Quality:
- Ask the patient to describe how the pain feels.
- Descriptors such as "sharp," "shooting," or "burning" may help identify the presence of neuropathic pain.
Pain Assessment: Onset & Duration:
- Ask the patient when the pain started and whether it is constant or intermittent.
Pain Assessment: Aggravating & Relieving Factors:
- Ask the patient what makes the pain worse and what makes it better.
Pain Assessment: Effect Of Pain On Function/Quality Of Life:
- The effect of pain on the ability to perform recovery activities should be regularly evaluated in the patient with acute pain.
- It is particularly important to ask patients with persistent pain about how pain has affected their lives, what could they do before the pain began that they can no longer do, or what they would like to do but cannot do because of the pain.
Pain Assessment: Comfort-Function (Pain Intensity) Goal:
- For patients with acute pain, identify short-term functional goals and reinforce to the patient that good pain control will more likely lead to successful achievement of the goals.
- For example, surgical patients are told that they will be expected to ambulate or participate in physical therapy postoperatively.
- Patients with chronic pain can be asked to identify their unique functional or quality-of-life goals, such as being able to work or walk the dog.
- Success is measured by progress toward meeting those functional goals
The Hierarchy Of Pain Measure:
- The Hierarchy of Pain Measures is recommended as a framework for assessing pain in nonverbal patients
- The key components of the hierarchy require the nurse to:
(1) Attempt to obtain self-report
(2) Consider underlying pathology or conditions and procedures that might be painful (e.g., surgery)
(3) Observe behaviors
(4) Evaluate physiologic indicators
(5) Conduct an analgesic trial
- Indicated for use in young children.
- Scores are assigned after assessing Facial expression, Leg movement, Activity, Crying, and Consolability, with each of these five categories assigned scores from 0 to 2, yielding a total composite score of 0 to 10.
- Scores of "0" are interpreted as reflecting that the patient is relaxed and comfortable, scores of "1" to "3" are interpreted as consistent with mild discomfort, scores from "4" to "6" are considered consistent with moderate pain, and scores from "7" to "10" are considered consistent with severe discomfort or pain.
Pain Assessment In Advanced Dementia (PAINAD):
- Indicated for use in adults with advanced dementia who are not able to verbalize their needs.
- Patterned after the FLACC, this tool was developed by the U.S. Department of Veterans Affairs for patients who have dementia.
Critical Care Pain Observation Tool (CCPOT):
- Indicated for use in patients in critical care units who cannot self-report pain, whether or not they may be intubated. It is also patterned after the FLACC.
- Achieving optimal pain relief is best viewed on a continuum, with the primary objective being to provide both effective and safe analgesia
- The quality of pain control should be addressed whenever patient care is passed on from one clinician to another, such as at change of shift and transfer from one clinical area to another.
- Optimal pain relief is the responsibility of every member of the health care team and begins with titration of the analgesic agent, followed by continued prompt assessment and analgesic agent administration during the course of care to safely achieve pain intensities that allow patients to meet their functional goals with relative ease.
- Although it may not always be possible to achieve a patient's pain intensity goal within the short time the patient is in an area like the PACU or emergency department, this goal provides direction for ongoing analgesic care.
- Important information to provide during transfer report is the patient's comfort-function goal, how close the patient is to achieving it, what has been done thus far to achieve it (analgesic agents and doses), and how well the patient has tolerated administration of the analgesic agent (adverse effects).
- There is growing interest among both clinicians and researchers in linking pain management to functional goals.
- Pain management interventions should improve and not inhibit progress toward healing and rehabilitation
Pain Management: Responsibility:
- Of all members of healthcare team
Pharmacologic Management of Pain: Multimodal Analgesia:
- Pain is a complex phenomenon involving multiple underlying mechanisms and as such, requires more than one analgesic agent to manage it safely and effectively.
- The recommended approach for the treatment of all types of pain in all age groups is called multimodal analgesia
- A multimodal regimen combines drugs with different underlying mechanisms, which allows lower doses of each of the drugs in the treatment plan, reducing the potential for each to produce adverse effects.
- Furthermore, multimodal analgesia can result in comparable or greater pain relief than can be achieved with any single analgesic agent
Pharmacologic Management of Pain: Routes Of Administration: Oral:
- The oral route is the preferred route of analgesic administration and should be used whenever feasible because it is generally the least expensive, best tolerated, and easiest to administer
- When the oral route is not possible, such as in patients who cannot swallow or are NPO (nothing by mouth) or nauseated, other routes of administration are used.
- For example, patients with cancer pain who are unable to swallow may take analgesic agents by the transdermal, rectal, or subcutaneous route of administration.
Pharmacologic Management of Pain: Routes Of Administration: IV:
- In the immediate postoperative period, the intravenous (IV) route is the first-line route of administration for analgesic delivery, and patients are transitioned to the oral route as tolerated.
Pharmacologic Management of Pain: Routes Of Administration: Rectal:
- The rectal route of analgesic administration is an alternative route when oral or IV analgesic agents are not an option (e.g., for palliative purposes during end-of-life care)
- The rectum allows passive diffusion of medications and absorption into the systemic circulation.
- This route of administration can be less expensive and does not involve the skill and expertise required of the parenteral route of administration.
- Drawbacks are that drug absorption can be unreliable and depends on many factors including rectal tissue health and administrator technique.
- Some patients may be resistant to or fearful of rectal administration.
- The rectal route is contraindicated in patients who are neutropenic or thrombocytopenic because of potential rectal bleeding.
- Diarrhea, perianal abscess or fistula, and abdominoperineal resection are also relative contraindications
Pharmacologic Management of Pain: Routes Of Administration: Topical:
- The topical route of administration is used for both acute and chronic pain.
- For example, the nonopioid diclofenac is available in patch and gel formulations for application directly over painful areas.
- Local anesthetic creams, such as EMLA (eutectic mixture or emulsion of local anesthetics) and L.M.X.4 (lidocaine cream 4%), can be applied directly over the injection site prior to painful needle stick procedures, and the lidocaine patch 5% is often used for well-localized types of neuropathic pain, such as postherpetic neuralgia.
- It is important to distinguish between topical and transdermal drug delivery.
- Although both routes require the drug to cross the stratum corneum to produce analgesia, transdermal drug delivery requires absorption into the systemic circulation to achieve effects; topical agents produce effects in the tissues immediately under the site of application (referred to as targeted peripheral analgesia).
- Compounding pharmacies may be consulted to custom blend analgesics, such as topical morphine or gabapentin (Neurontin), for topical application at the painful site.
Pharmacologic Management of Pain: Routes Of Administration: Intraspinal Analgesia:
- Some of the more invasive methods used to manage pain are accomplished via catheter techniques such as intraspinal analgesia, sometimes referred to as "neuraxial" analgesia.
- Delivery of analgesic agents by the intraspinal routes is accomplished by inserting a needle into the subarachnoid space (for intrathecal [spinal] analgesia) or the epidural space and injecting the analgesic agent, or threading a catheter through the needle and taping it in place temporarily for bolus dosing or continuous administration
- Intrathecal catheters for acute pain management are used most often for providing anesthesia or a single bolus dose of an analgesic agent.
- Implanted intrathecal pumps deliver very small amounts of medication in a constant infusion for treatment of end-of-life pain or persistent pain
- Temporary epidural catheters for acute pain management are removed after 2 to 4 days.
- Epidural analgesia is given by clinician-given bolus, continuous infusion (basal rate), and patient-controlled epidural analgesia (PCEA).
- The most common opioids given intraspinally are morphine, fentanyl, and hydromorphone (Dilaudid).
- These are usually combined with a local anesthetic, most often ropivacaine (Naropin) or bupivacaine (Marcaine), to improve analgesia and produce an opioid dose-sparing effect
Pharmacologic Management of Pain: Routes Of Administration: Perineural Anesthesia:
- A pain management technique that involves the use of an indwelling catheter is the continuous peripheral nerve block (also called perineural anesthesia), whereby an initial local anesthetic block is established and followed by the placement of a catheter or catheters through which an infusion of local anesthetic, usually ropivacaine or bupivacaine, is infused continuously to the targeted site of innervation.
- The effect of local anesthetic is dose dependent: at lower doses, the smaller sensory nerve fibers are affected before the larger motor fibers.
- Patients thus medicated are able to walk but are pain free
Pharmacologic Management Of Pain: Dosing: ATC:
- Two basic principles of providing effective pain management are preventing pain and maintaining a pain intensity that allows the patient to accomplish functional or quality-of-life goals with relative ease
- Accomplishment of these goals may require the mainstay analgesic agent to be given on a scheduled around-the-clock (ATC) basis, rather than PRN (as needed) to maintain stable analgesic blood levels.
- ATC dosing regimens are designed to control pain for patients who report pain being present 12 hours or more during a 24-hour period.
Pharmacologic Management Of Pain: Dosing: PRN:
- PRN dosing of analgesic agents is appropriate for intermittent pain, such as prior to painful procedures and for BTP (pain that "breaks through" the pain being managed by the mainstay analgesic agent), for which supplemental doses of analgesia are provided
Pharmacologic Management Of Pain: Dosing: Patients In Hospital Setting:
- Patients with persistent pain in the hospital setting should be awakened to take their pain medication.
- Awakening postoperative patients with moderate to severe pain to take their pain medication is especially important during the first 24 to 48 hours after surgery to keep pain under control.
- Patients should be told that this helps avoid waking up with severe pain and that if their pain is well controlled, they are likely to go back to sleep quickly.
- The patient can transition gradually to PRN dosing as pain resolves.
- In addition to assessment of the efficacy of the pain intervention, the unintentional effects must be assessed
Patient-Controlled Analgesia (PCA):
- Patient-controlled analgesia (PCA) is an interactive method of pain management that allows patients to treat their pain by self-administering doses of analgesic agents.
- It is used to manage all types of pain by multiple routes of administration, including oral, IV, subcutaneous, epidural, and perineural
-. A PCA infusion device is programmed so that the patient can press a button (pendant) to self-administer a dose of an analgesic agent (PCA dose) at a set time interval (demand or lockout) as needed.
- Patients who use PCAs must be able to understand the relationships between pain, pushing the PCA button or taking the analgesic agent, and pain relief and must be cognitively and physically able to use any equipment that is utilized to administer the therapy.
- The use of a basal rate (continuous infusion) is commonly used for opioid tolerant patients and when PCEA is used. It is sometimes used for patients who are opioid naïve and receiving IV PCA to allow them to manage their pain and rest better. However, it is important to recognize that the patient has no control over the delivery of a continuous infusion.
- Therefore, extreme caution in using basal rates for acute pain management in opioid-naïve individuals is recommended
- Essential to the safe use of a basal rate with PCA is close monitoring by nurses of sedation and respiratory status and prompt decreases in opioid dose (e.g., discontinue basal rate) if increased sedation is detected
- The primary benefit of PCA is that it recognizes that only the patient can feel the pain and only the patient knows how much analgesic will relieve it.
- This reinforces that PCA is for patient use only and that unauthorized activation of the PCA button (PCA by proxy) should be discouraged
- For some patients who are candidates for PCA but unable to use the PCA equipment, the nurse or a capable family member may be authorized to manage the patient's pain using PCA equipment.
- This is referred to as Authorized Agent Controlled Analgesia; guidelines are available for the safe administration of this therapy
Physiologic Basis for Pain Relief Pharmacologic Interventions: Opioid Analgesics:
- Act on the CNS to inhibit activity of ascending nociceptive pathways
Physiologic Basis for Pain Relief Pharmacologic Interventions: NSAIDS:
- Decrease pain by inhibiting cyclo-oxygenase (enzyme involved in production of prostaglandin)
Physiologic Basis for Pain Relief Pharmacologic Interventions: Local Anesthetics:
- Block nerve conduction when applied to nerve fibers
- Analgesic agents are categorized into three main groups:
(1) Non-opioid analgesic agents, which include acetaminophen and NSAIDs
(2) Opioid analgesic agents, which include, among others, morphine, hydromorphone, fentanyl, and oxycodone
(3) Adjuvant analgesic agents (sometimes referred to as coanalgesic agents).
- The adjuvant analgesic agents comprise the largest group and include various agents with unique and widely differing mechanisms of action.
- Examples are local anesthetics, some anticonvulsants, and some antidepressants.
Analgesic Agents: Non-Opioid Analgesic Agents:
- Acetaminophen and NSAIDs comprise the group of nonopioid analgesic agents
- NSAIDs: ibuprofen, naproxen, celecoxib
Analgesic Agents: Opioid Analgesic Agents:
- Although it is often used, the term narcotic is considered obsolete and inaccurate when discussing the use of opioids for pain management, in part because it is a term used loosely by law enforcement and the media to refer to various substances of potential abuse, which include opioids as well as cocaine and other illicit substances.
- Legally, controlled substances classified as narcotics include opioids, cocaine, and others.
- The preferred term is opioid analgesics when discussing these agents in the context of pain management; patients prefer the term pain medications or pain medicine
Analgesic Agents: Opioid Analgesic Agents: Mu Agonist:
Analgesic Agents: Opioid Analgesic Agents: Agonist-Antagonist:
Adjunctive Analgesics: Local Anesthetics:
- Lidocaine patch 5%
- Local anesthetics have a long history of safe and effective use for all types of pain management.
- Local anesthetics are sodium channel blockers that affect the formation and propagation of action potentials.
- They are given by various routes of administration and are generally well tolerated by most individuals
- Injectable and topical local anesthetics are commonly used for procedural pain treatment.
- Local anesthetics are added to opioid analgesic agents and other agents to be given intraspinally for the treatment of both acute and chronic pain.
- They are also infused for continuous peripheral nerve blocks, primarily after surgery.
- The lidocaine patch 5% (Lidoderm) is placed directly over or adjacent to the painful area for absorption into the tissues directly below.
- The drug produces minimal systemic absorption and adverse effects.
- The patch is left in place for 12 hours and then removed for 12 hours (12 hours on, 12 hours off regimen).
- This application process is repeated as needed for continuous analgesia.
- The drug is approved for the neuropathic pain syndrome postherpetic neuralgia; however, research suggests that it is effective and safe for a wide variety of acute and chronic pain conditions
- Allergy to local anesthetics is rare, and adverse effects are dose related. CNS signs of systemic toxicity include ringing in the ears, metallic taste, irritability, and seizures.
- Signs of cardiotoxicity include circumoral tingling and numbness, bradycardia, cardiac dysrhythmias, and CV collapse
Adjunctive Analgesics: Anticonvulsants:
- The anticonvulsants gabapentin (Neurontin) and pregabalin (Lyrica) are first-line analgesic agents for neuropathic pain and are increasingly being added to postoperative pain treatment plans to address the neuropathic component of surgical pain
- Although further research is needed, their addition has been shown to improve analgesia, allow lower doses of other analgesic agents, and help prevent persistent neuropathic postsurgical pain syndromes, such as phantom limb, postthoracotomy, posthernia, and postmastectomy pain
- They are also effective in improving the acute pain associated with burn injuries as well as reducing the potential for subsequent neuropathic pain.
- Analgesic anticonvulsant therapy is initiated with low doses and titration according to patient response.
- Primary adverse effects of anticonvulsants are sedation and dizziness, which are usually transient and most notable during the titration phase of treatment.
Adjunctive Analgesics: Antidepressants: TCAs:
- Their delayed onset of action makes them inappropriate for acute pain treatment.
- Analgesic antidepressant therapy is initiated with low doses and titration according to patient response.
- Primary adverse effects of TCAs are dry mouth, sedation, dizziness, mental clouding, weight gain, and constipation
- Orthostatic hypotension is a potentially serious TCA adverse effect.
- The most serious adverse effect is cardiotoxicity, and patients with significant heart disease are at high risk
Adjunctive Analgesics: Antidepressants: SNRIs:
- Their delayed onset of action makes them inappropriate for acute pain treatment.
- Analgesic antidepressant therapy is initiated with low doses and titration according to patient response.
- Are thought to have a more favorable adverse effect profile and to be better tolerated than the TCAs
- The most common SNRI adverse effects are nausea, headache, sedation, insomnia, weight gain, impaired memory, sweating, and tremors.
Adjunctive Analgesics: Ketamine:
- Is a dissociative anesthetic with dose-dependent analgesic, sedative, and amnestic properties
- As an NMDA antagonist, it blocks the binding of glutamate at the NMDA receptors and thus prevents the transmission of pain to the brain via the ascending pathway
- At high doses, the drug can produce psychomimetic effects (e.g., hallucinations, dreamlike feelings); however, these are minimized when low doses are given - A benefit of the drug is that it does not produce respiratory depression.
- Ketamine is given most often by the IV route but can also be given by the oral, rectal, intranasal, and subcutaneous routes.
- Epidural ketamine is not approved for use in the United States.
- Ketamine has been used for the treatment of persistent neuropathic pain, but its adverse effect profile makes it less favorable than other analgesic agents for long-term therapy.
- It is, however, increasingly used as a third-line analgesic agent for refractory acute pain
Opioid Physical Dependence:
- Is a normal response that occurs with repeated administration of the opioid for 2 or more weeks and cannot be equated with addictive disease.
- It is manifested by the occurrence of withdrawal symptoms when the opioid is suddenly stopped or rapidly reduced or an antagonist such as naloxone is given.
- Withdrawal symptoms may be suppressed by the natural, gradual reduction of the opioid as pain decreases or by gradual, systematic reduction, referred to as tapering.
- Is also a normal response that occurs with regular administration of an opioid and consists of a decrease in one or more effects of the opioid (e.g., decreased analgesia, sedation, or respiratory depression).
- It cannot be equated with addictive disease.
- Tolerance to analgesia usually occurs in the first days to 2 weeks of opioid therapy but is uncommon after that. It may be treated with increases in dose.
- However, disease progression, not tolerance to analgesia, appears to be the reason for most dose escalations.
- Stable pain usually results in stable opioid doses.
- Thus, tolerance poses very few clinical problems.
- With the exception of constipation, tolerance to the opioid adverse effects develops with regular daily dosing of opioids over several days
- (Addictive Disease) is a chronic, relapsing, treatable neurologic disease
-. The development and characteristics of addiction are influenced by genetic, psychosocial, and environmental factors.
- No single cause of addiction, such as taking an opioid for pain relief, has been found.
- It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving to use the opioid for effects other than pain relief.
- This statement reinforces that taking opioids for pain relief is not addiction, no matter how long a person takes opioids or at what doses.
Gerontologic Considerations: Low Dose & Slow:
- Older adults are often sensitive to the effects of the adjuvant analgesic agents that produce sedation and other CNS effects, such as antidepressants and anticonvulsants.
- Therapy should be initiated with low doses, and titration should proceed slowly with systematic assessment of patient response.
- They are sensitive to agents that produce sedation and CNS effects
Gerontologic Considerations: Increased Risk For NSAID-induced & GI Toxicity:
- Older adults are also at increased risk for NSAID-induced GI toxicity.
- The addition of a proton pump inhibitor to NSAID therapy, or opioid analgesic agents rather than an NSAID, is recommended for high-risk patients.
- The American Geriatric Society has proposed that opioids are a safer choice than NSAIDs in many older adults because of the increased risk for NSAID-induced GI adverse effects in that population
- NSAIDs are safest when used for short-term pain flares that may occur during transient worsening in severity of chronic diseases or conditions (e.g., osteoarthritis, fibromyalgia, low back pain)
- Age is considered an important factor to consider when selecting an opioid dose.
Gerontologic Considerations: Acetaminophen:
- Acetaminophen should be used for mild pain.
- It is recommended as first line for musculoskeletal pain (e.g., osteoarthritis) in older adults but is less effective than NSAIDs for chronic inflammatory pain (e.g., rheumatoid arthritis)
- If an NSAID is needed for inflammatory pain, it is recommended that a COX-2 selective NSAID (if not contraindicated by an increased CV risk) or the nonselective NSAID least likely to cause an ulcer should be used.
Gerontologic Considerations: Starting Opioid Dose:
- The starting opioid dose should be reduced by 25% to 50% in adults older than 70 years because they are more sensitive to opioid adverse effects than younger adults; the amount of subsequent doses is based on patient response
- Most individuals use self-management strategies to deal with their health issues and promote well-being.
- Recent national health survey results reveal that American adults spent $14.9 billion on complementary health practices (e.g., acupuncture, chiropractic manipulation, herbal medicines) to treat painful conditions (e.g., back pain, fibromyalgia, arthritis)
- Non-pharmacologic complementary and alternative interventions include using natural products (e.g., herbs or botanicals, vitamins, probiotics) or using mind and body practices (e.g., acupuncture, chiropractic manipulation, massage therapy, yoga, tai chi)
- Non-pharmacologic therapies are usually effective alone for mild to some moderate-intensity pain, and they should complement, but not replace, pharmacologic therapies for more severe pain
- The effectiveness of nonpharmacologic methods can be unpredictable, and although not all will relieve pain, they offer many benefits to patients with pain.
- For example, research suggests that non-pharmacologic methods can facilitate relaxation and reduce anxiety and stress
- Many patients find that the use of non-pharmacologic methods helps them cope better with their pain and feel greater control over the pain experience.
- Several non-pharmacologic methods can be used in the clinical setting to provide comfort and pain relief for all types of pain; however, time is often limited in this setting for implementation of these methods.
- Nurses play an important role in providing them and instructing patients about their use
- Many of the methods are relatively easy for nurses to incorporate into daily clinical practice and may be used individually or in combination with other non-pharmacologic therapies.
Non-Pharmacologic Methods: Natural Products:
Non-Pharmacologic Methods: Mind & Body Practices:
- Chiropractic manipulation
- Massage therapy
- Tai chi
Nursing Process Framework for Pain Management:
•Identify goals for pain management
•Establish nurse-patient relationship, teaching
•Provide physical care
•Manage anxiety related to pain
•Evaluate pain management strategies
Adverse Effects of Analgesic Agents:
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