Background

Pain management encompasses various types of pain experiences throughout an individual's life cycle from birth to the end of life. Pain experiences may include acute and chronic pain, pain from a chronic deteriorating condition, or pain as one of many symptoms of the patient receiving palliative care. Pain is not exclusively physiological but also includes spiritual, emotional and psychosocial dimensions. The goal of pain management throughout the life cycle is the same – to address the dimensions of pain and to provide maximum pain relief with minimal side effects.

Review of the literature, anecdotal reports and dialogue with colleagues reveals that the majority of patients do not receive adequate pain management. A wide variety of factors including inaccurate information, myths, rumors, fear and cultural issues contribute to inadequate pain management. For example, a prevailing rumor in the nursing profession is that a nurse can lose his/her nursing license for causing a patient's respiratory depression by frequent administration or by giving high doses of opioids, even though there is no documented evidence to substantiate this fear. The literature shows that adequate assessment in conjunction with opioid titration based on patient response can provide maximum pain relief without adversely affecting respiratory status.

Therefore, it is unwarranted to under-utilize or withhold opioids from a patient who is experiencing pain based on fear of causing respiratory depression. Due to multiple advances in the field of pain management (i.e. pain assessment, pharmacological and non-pharmacological interventions), licensed nurses may have incomplete or inaccurate information about the following variables which contribute to ineffective pain management:

• What is pain and how do patients demonstrate their pain?
• How is pain assessed and managed?
• Is there a difference between psychological dependence, addiction and physical dependence?
• Does aggressive use of opioids cause addiction?
• How does the patient's cultural background effect pain expression and management?

Myths and misinformation also contribute to ineffective pain management. Some common myths include:

• Too much pain medication too frequently constitutes substance abuse, causes addiction, will result in respiratory depression or will hasten death;
• Pain should be treated, not prevented;
• People in pain always report their pain to their health care provider;
• People in pain demonstrate or show that they have pain - pain can be seen in the patient's behavior;
• The level of pain is often exaggerated by the patient;
• Generally a patient cannot be relieved of all pain;
• Some pain is good so that the patient's symptoms are not masked;
• Newborn infants do not have pain; and,
• It is expected that the elderly, especially the frail elderly, always have some pain.

Patient Populations at Risk of Under Management

Because of multiple barriers to adequate pain management, all patients are at risk for under treatment of pain. Since pain is identified and reported primarily through patient self-reporting, difficulty in communicating increases the patient's risk for under-treatment.

Populations identified as being at greater risk include: infants and children, women, the elderly, patients with cognitive dysfunction, patients with emotional or mental illness, patients with chronic pain, patients with neuropathic pain, substance abusers, minority populations, the homeless, and patients with terminal illnesses.

In addition, patients who speak a different language or who are from a cultural tradition different from that of the clinician pose a special challenge. In effect, any patient, regardless of age, is at risk of being under-treated for pain. All populations can be placed at greater risk because of the health care provider's own belief system which may include the previously discussed myths and misinformation. The licensed nurse must become familiar with standards, guidelines and definitions regarding pain and its management in order to effectively advocate for the patient in pain.

Licensed Nurse Role: Knowledge Based Practice

The licensed nurse is responsible and accountable to ensure that a patient receives appropriate evidence-based nursing assessment and intervention which effectively treats the patient's pain and meets the recognized standard of care. In order to advocate for the patient, the licensed nurse must possess the following:

• Knowledge of Self - The practice of nursing includes the knowledge of one's self through assessment of attitudes, values, beliefs, and cultural background and influences that have formed each of us as individuals. These factors affect the nurse when assessing, evaluating, and interpreting the patient's statements, behavior, physical response, and appearance. The greatest barrier to the patient achieving effective pain management may be the nurse's:
1. Individual experiences with pain;
2. Personal use of medications or non-pharmacological methods to manage pain; and,
3. Family's or significant others' history or experience with substances for pain control or mood altering effect.

When the licensed nurse is influenced or constrained by personal factors, the nurse may not assess, evaluate or communicate the patient's pain level effectively or objectively. This can be further compounded if the nurse does not have adequate knowledge regarding pain management and, as a result, can not recognize the need to seek out additional information to assess and manage the patient's pain appropriately. For instance, a nurse who believes or states, “You can tell by looking at the patient if they are in pain” is demonstrating an inadequate knowledge base.

• Knowledge of Pain - Pain is subjective. It is whatever the patient says it is. The nurse utilizes the nursing process in the management of pain. Adequate measurement and management of pain includes knowledge in the following areas:
1. Pain assessment: The nurse utilizes a developmentally appropriate, standardized pain assessment tool which includes: a pain measurement tool which has demonstrated reliability and validity and patient participation, which is essential in the assessment process. For those incapable of self-reporting, standardized pain assessment tools should include behavioral observations with or without physiologic measures.
2. Physiologic signs such as tachycardia, hypertension, diaphoresis and pallor are non-specific to pain and may be an indicator of another, unrelated physiologic problem. For patients in pain, these physiologic signs may be present for a short period of time or not at all. Sole reliance on these physiologic signs to assess pain may be inappropriate.
3. The nurse is knowledgeable regarding the difference in categories of pain (i.e. acute, chronic, breakthrough);
4. The nurse is knowledgeable regarding the most likely potential sources of pain (i.e. neurological, muscular, skeletal, visceral);
5. The nurse assesses the patient's individual pain pattern, including the individual patient's pain experiences, methods of expressing pain, cultural influences, and how the individual manages their pain.

Pharmacologic and Non-Pharmacologic Intervention:

• The nurse is knowledgeable about the pharmacological interventions of opioid, non-opioid, and adjuvant drug therapies (including dosages, side effects, drug interactions, etc.) which are most effective for the most likely source of an individual patient's pain.
• The nurse is knowledgeable that placebos should not be utilized to assess if pain exists or to treat pain.
• The nurse is knowledgeable regarding non-pharmacologic strategies for pain management (i.e. acupuncture, application of hot and cold, massage, breathing techniques, etc.).
• Current pain management standards and guidelines.
• The difference between tolerance, physical and psychological dependence, withdrawal and pseudo addiction.

Knowledge of the Standard of Care - The standard of care is effective ongoing pain assessment and pain management. This includes but is not limited to:

• Acknowledging and accepting the patient's pain;
• Identifying the most likely source of the patient's pain;
• Assessing pain at regular intervals, with each new report of pain or when pain is expected to occur or reoccur. Assessment includes but is not limited to:
• The patient's level of pain utilizing a pain assessment tool;
• Barriers to effective pain management, which may include personal, cultural and Institutional barriers. Sources of these barriers may include but are not limited to patient, family, significant other, physician, nurse and institutional constraints;
• Reporting the patient's level of pain;
• Developing the patient's plan of care that includes an interdisciplinary plan for effective pain management involving the patient, family and significant other;
• Implementing pain management strategies and indicated nursing interventions including:

• Aggressive treatment of side effects (i.e. nausea, vomiting, constipation, pruritus etc),
• Educating the patient, family and significant other(s) regarding,
• Their role in pain management,
• The detrimental effects of unrelieved pain,
• Overcoming barriers to effective pain management,
• The pain management plan and expected outcome of the plan;.

• Evaluating the effectiveness of the strategies and the nursing interventions;
• Documenting and reporting the interventions, patient's response, outcomes; and
• Advocating for the patient and family for effective pain management.

PATIENT ADVOCACY: The nurse's primary commitment is to the health, welfare, comfort and safety of the patient. Self-awareness, knowledge of pain and pain assessment, and knowledge of the standard of care for pain management enhances the nurse's ability to advocate for and assure effective pain management for each patient.

Acute Pain Relief It is well documented that preventive pain control is much more effective than trying to eliminate or reduce pain once it has occurred. While aggressive pain prevention is not always possible, it should be employed whenever the situation allows and should include pre-operative/procedure patient/family teaching. Preventive pain management also includes the use of scheduled pain relief rather than “as needed” (PRN) medications. Often, patients will not request medication until the pain level is too high. It is far easier to get control of pain and keep it at bay, than trying to control it once it has gotten very intense. Scheduling postoperative/procedure pain medication helps to prevent this problem and the patient always has the choice to refuse the medication if they so choose. There are many safe and effective methods of pain management for acute pain. Successful administration depends upon the appropriate action of the Healthcare professional and patient education. Some patients may have had negative experience with acute pain relief in the past and this must be dealt with carefully. Another issue that may affect acute pain relief is a patient's fear of addiction to medications such as opioids. Studies have shown that this fear is unfounded. One study indicated that only 4 individuals out of 11,000 showed addiction one year after taking opioids for acute pain.

Treatment options for acute pain include:

• Acetaminophen - Safe and effective for lesser acute pain. May be purchased over the counter
• NSAIDs - Non-steroidal Anti-inflammatory drugs are safe and effective for relief of most acute pain without opioid side effects, but run the risk of gastric bleeding with long term use
• COX-2 Inhibitors - (Cyclooxygenase-2) celecoxib is very useful for orthopedic surgery, dental surgery, dysmenorrhea and have fewer side effects than NSAIDs with equal efficacy.
• Narcotics and Opioids- meperidine, propoxyphene, codeine, morphine are for moderate and severe pain and the side effects include respiratory depression, nausea, vomiting, constipation, dependence

Good nursing care, such as positioning the patient comfortably, attending to needs promptly, attending to toileting needs, and patient teaching will also add to the comfort level of the patient and are crucial to the success of a pain management plan. Alternative and adjunctive therapies, such as relaxation, massage, hypnosis, acupuncture and acupressure, may also be successfully employed.

Chronic Pain Relief Many of the same pain medications that are effective for acute pain are also useful for chronic pain. There is much overlap and chronic pain medications may also include acetaminophen, NSAIDS, narcotics, and opioids. Additionally, the use of topical preparations may aid in easing joint pain, such as with arthritis or rheumatological disorders. The selection of the drug generally depends on the severity of the pain, other conditions the patient may have, and takes into account any other medications the patient may be taking. The following is a list of other therapies that may be useful for chronic pain sufferers:

• Cognitive Behavior Therapy - This is the use of patient education or other interventions used to assist the patient in coping with factors that may be affecting their pain, such as depression, anxiety, and fear. By weakening the connections between stressful and/or painful situations, the patient can learn to calm the mind and body and therefore change the behavioral response. The cognitive portion helps the patient to change the way certain thinking may affect the way they are feeling. This type of therapy may require a referral to a psychotherapist.
• TENS (Transcutaneous Electrical Nerve Stimulation) - The use of TENS remains a popular option but research is not yet complete. It appears to be much more effective for chronic pain than acute, and necessitates careful implementation, patient instruction, and patience.
• Anticonvulsants - While the exact reason for efficacy is unknown, anticonvulsants have been used for the management of neuropathic pain for decades
• Antidepressants - May be used for analgesia in neuropathic pain, but how it works is not known. Evidence does not show if antidepressants should be favored over anticonvulsants or vice versa.
• Radiotherapy - Aids in pain relief from bone metastasis.
• Muscle relaxants - Particularly useful for chronic low back pain.
• Bed rest - Some studies reveal that bed rest is the cause of adverse effects and is not as highly favored as it once was for herniated disk and sciatica.
• Physical exercise - May be more favored for certain situations, which can bring about the release of endorphins, which help to reduce pain.
• Weight loss - Obesity may aggravate or cause certain conditions and is linked to osteoarthritis of hip and knee.
• Surgery - Usually a last resort in chronic situations.
• Dietary supplements - Omega-3 fatty acids can substitute for NSAIDs Vegetarian Diet can reduce joint inflammation

Methods of Pain Medical Administration Equally as important to the type of medication selected is the route which it is administered. The patient's preferred method of administration should be taken into account whenever possible.

• Oral: Often preferred by patients, is convenient, less expensive and non-invasive
• Parenteral: Intramuscular or intravenous injections provide a more rapid onset of pain relief than when taken orally.
• PCA (Patient Controlled Analgesia): Gives the patient the control by allowing pre-measured medication doses to be infused at the patients command.
• Suppositories: Very useful when GI function is compromised (i.e. nausea/vomiting)
• Intrathecal: The uses of medications delivered into the spinal column have proven effective for patients with severe pain.

Summary Pain management is a major factor in a patient's well-being and satisfaction. Pain management is also a patient's right. As Healthcare professionals, we are required to provide the patient with accurate pain assessment and monitoring, competent and safe administration of medications and other therapies we may be qualified to give, and education about pain and various types of pain relief. Each patient must be treated as an individual, taking into account the specific pain-causing condition, as well as factors which affect the patient's perception of pain, such as emotional state, psychological coping mechanisms, and cultural/social background. Using a multidisciplinary approach will afford the patient the most comprehensive care possible.

DEFINITION OF TERMS

• Pain management: The use of pharmacological and non-pharmacological interventions to control the patient's identified pain. Pain management extends beyond pain relief, encompassing the patient's quality of life, ability to work productively, to enjoy recreation, to function normally in the family and society, and to die with dignity.
• Pain: An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Pain is always subjective and is whatever the person says it is, existing whenever the person says it does. The clinician must accept the patient's report of pain. Categories of pain include but are not limited to:
• Acute Pain: A normal, predicated physiologic response to an adverse clinical, thermal or mechanical stimulus. It is generally time-limited and responsive to opioid and non-opioid therapy. Acute pain responses may vary between patients and between pain episodes within an individual patient. Acute pain episodes may be present in patients with chronic pain.
• Chronic Pain: Malignant or non-malignant pain that exists beyond its expected time frame for healing or where healing may not have occurred. It is persistent pain that is not amenable to routine pain control methods. Chronic pain is often present with no physiologic signs, which may lull the clinician into falsely believing the patient is not in pain. Chronic pain may result in a look of sadness, depression, or fatigue causing the clinician to misinterpret the picture and not identify that the patient may also be experiencing pain. Patients with chronic pain may have episodes of acute pain related to treatment, procedures, disease progression or reoccurrence.
• Breakthrough Pain: An acute exacerbation of pain that breaks through an existing analgesic regime.
• Palliative Care: The active total care of patients focusing on symptom management, of which pain is only one of many symptoms. The goal of palliative care is achievement of the best quality of life for patients, families and significant others by addressing psychological, social and spiritual problems, in addition to controlling the patient's pain and other symptoms.
• Suffering: The state of severe distress associated with events that threaten the well being of the person. Suffering often occurs in the presence of pain, shortness of breath, or other bodily symptoms. Suffering extends beyond the physical domain. For example, a woman awaiting breast biopsy may “suffer” because of anticipated loss of her breast, while after the biopsy the woman may have “pain” from the procedure.
• Tolerance: The process by which the body requires a progressively greater amount of a drug, over time, to achieve the same results. As it relates to pain relief, tolerance is decreasing pain relief over time with the same dosage. Patient can become tolerant to the analgesic effect of opioid therapy, requiring an increase in dose. For many opioids there is no known ceiling to the amount that can be given, meaning that pain relief can increase with an increase in the dose of the opioid. In addition, patients can become tolerant to some adverse effects (respiratory depression, somnolence, and nausea) related to opioid therapy.
• Substance abuse: The use of any chemical substance for other than its medically intended purpose.
• Pseudoaddiction: The pattern of drug-seeking behavior among pain patients because of inadequate management of their pain problem which can be mistaken for addiction.
• Physical dependence: A physical response of the body to a substance characterized by signs of withdrawal if the substance is stopped without tapering, markedly reduced after prolonged use, or if an antagonist is administered. Physical dependence is an expected result of opioid use. Physical dependence, by itself, does not equate with addiction.
• Abstinence (withdrawal) Syndrome: Physical symptoms that can occur after abrupt discontinuation or dose reduction of an opioid or administration of an antagonist. The syndrome is characterized by any or all of the following: anxiety, irritability, chills, hot flashes, salivation, lacrimation, rhinorrhea, diaphoresis, piloerection, nausea, vomiting, abdominal cramps, and insomnia. Withdrawal should be avoided by gradual reduction of dose rather than abrupt discontinuation.
• Addiction: A neurobehavioral disorder characterized by compulsive seeking of mood-altering substances and continued use despite harm. Addiction may also be referred to by terms such as “drug dependence” and “psychological dependence.” Addiction is not the same as physical dependence.
• Opioid: Denotes both natural (codeine, morphine) and synthetic (methadone, fentanyl) drugs whose pharmacologic effects are mediated by specific receptors in the nervous system.
• Non-Opioid: A medication that provides pain relief, but that is not an opiate or a non-steroid anti-inflammatory drugs (NSAIDS), acetaminophen). Synthetic analog of an opiate (i.e.
• Adjuvant Medications: Medications that are used to a) enhance the pain relieving effects of opioids and non-opioids, b) treat concurrent symptoms that exacerbate pain such as utilization of anxiolytics, or c) provide independent analgesia for specific sources of pain (i.e. neurologic pain), such as utilization of tricylic anti-depressants and anti-convulsants.
• Opiate: A drug whose origin is the opium poppy, including codeine and morphine.
• Pain Assessment: The comprehensive evaluation of the patient's pain including but not limited to: location, intensity, duration of the pain; aggravating and relieving factors; effects on activities of daily living, sleep pattern and psychosocial aspects of the patient's life, and effectiveness of current management strategies. Pain assessment includes the use of a standardized pain measurement tool.
• Pain Measurement Tool: The quantitative examination of the intensity of the pain as reported by the patient utilizing a standardized instrument which has demonstrated reliability and validity.
• Titration: Adjustment of medication levels within the dosage and frequency ranges stipulated by the authorized prescriber in accordance with an agency's established protocols, guidelines or policies.
• Evidence-Based Practice: The conscientious and judicious use of current best evidence for making clinical decisions about the care of patients. Evidence may include but is not limited to: research findings, literature, bench-marking data, clinical experts, quality improvement, risk management data, and standards and guidelines.