Lewis: Medical-Surgical Nursing, 10th Edition

Chapter 8

Pain

KEY POINTS

MAGNITUDE OF PAIN PROBLEM

Pain is a complex, multidimensional experience that can cause suffering and
decreased quality of life.
Millions of people suffer from pain, with a staggering effect on physical and
psychosocial function and significant financial impact.
Inadequate pain management occurs across care settings and patient populations.
Untreated pain can result in physical and psychosocial dysfunction, impaired recovery
from acute illness and surgery, immunosuppression, and sleep disturbances.
The reasons for under management may be:
Insufficient knowledge and skills to assess and manage pain.
Unwillingness of providers to believe patients reports of pain.
Inadequate reassessments resulting in failure to readjust treatments.
Inaccurate and inadequate information regarding addiction, tolerance,
respiratory depression, and other side effects of opioids.
Fear that aggressive pain management may hasten or cause death.

DEFINITIONS AND DIMENSIONS OF PAIN

Pain is defined as whatever the person experiencing the pain says it is, existing
whenever the person says it does.
Pain is a complex, multidimensional experience, with physiologic, affective,
cognitive, behavioral, and sociocultural dimensions, that occurs in many patients and in
all settings.
The emotional distress of untreated pain can cause suffering, which is the state of
severe distress associated with events that threaten the intactness of the person.

Pain Mechanisms
Nociception is the physiologic process by which information about tissue damage
is communicated from the peripheral to the central nervous system (CNS). Nociception
involves transduction, transmission, perception, and modulation:
Transduction is the conversion of a mechanical, thermal, or chemical
stimulus into a neuronal action potential.
Transmission is the movement of pain impulses from the site of
transduction to the brain. Increased sensitivity and hyperexcitability of neurons in
the CNS is called central sensitization.
The first-order neuron extends the entire distance from the periphery to
the dorsal horn of the spinal cord with no synapses.
 The neurons in the spinal cord that project to the thalamus are called
second-order neurons.
o From the dorsal horn, nociceptive stimuli are communicated to the third-
order neuron, primarily in the thalamus.
o Peripheral sensitization refers to increased susceptibility to nociceptor
activation due to injury, inflammation, and/or disease.
o Perception occurs when pain is recognized, defined, and assigned meaning
by the individual experiencing the pain. The brain is necessary for pain
perception.
o Modulation involves the activation of descending neurochemical pathways
that exert inhibitory or facilitatory effects on the transmission of pain.
o Dermatomes are areas on the skin that are innervated primarily by a single
spinal cord segment.

CLASSIFICATION OF PAIN
Pain is most commonly categorized as nociceptive or neuropathic based on
underlying pathology or as acute or chronic.
Nociceptive pain is caused by damage to somatic or visceral tissue, which
activates peripheral nociceptors. It is further classified as somatic or visceral.
Somatic pain is characterized as deep, aching, sharp, or throbbing that is
well localized and arises from bone, joint, muscle, skin, or connective tissue.
Visceral pain is often poorly localized and described as deep aching,
cramping, pressure, or referred and resulting from stimuli such as stretch,
compression, or ischemia of the hollow or solid internal organs or organ
coverings.
Neuropathic pain is caused by damage to peripheral nerves or CNS that results in
the abnormal processing of stimuli. Patients typically describe neuropathic pain as a
numbing, burning, shooting, stabbing, shock-like, or itchy sensation. There may be
associated areas of decreased sensation (numbness) and/or areas of hypersensitivity.
A type of neuropathic pain is complex regional pain syndrome (CRPS). Typical
features include dramatic changes in the color and temperature of the skin over the
affected limb or body part, accompanied by intense burning pain, skin sensitivity,
sweating, and swelling.
Acute pain and chronic pain are different as reflected in their cause, course,
manifestations, and treatment.
Normally, acute pain diminishes over time as healing occurs.
Chronic pain lasts for longer periods, often defined as longer than 3
months or past the time when an expected acute pain or acute injury should
subside.

PAIN ASSESSMENT
The goals of a nursing pain assessment are to describe the patients
multidimensional pain experience for the purpose of identifying and implementing
 appropriate pain management techniques and to identify the patients goal for therapy and
resources for self-management.
A comprehensive assessment of pain includes describing the onset, duration,
characteristics, pattern, location, intensity, quality, and associated symptoms such as
anxiety and depression. The patients beliefs, expectations, and goals for pain
management are also assessed.
Pain scales are useful tools to help the patient communicate pain intensity. A
variety of scales are available based on developmental needs and cognitive function.
Ongoing documentation of findings along with reassessments is key to providing
optimal pain management.
Breakthrough pain (BTP) is transient, moderate to severe pain that occurs in
patients whose baseline persistent pain is otherwise mild to moderate and fairly well
controlled.
Patient and family beliefs, attitudes, and expectations influence responses to pain
and pain treatment.

PAIN TREATMENT
Drug Therapy for Pain
Pain medications generally are divided into three categories: nonopioids, opioids,
and adjuvant (coanalgesic) drugs.
Mild pain often can be relieved using nonopioids alone.
Moderate to severe pain usually requires an opioid.
Neuropathic pain often requires adjuvant drug therapy alone or in
combination with an opioid or another class of analgesics. Treatment is typically
augmented with adjuvant therapies including tricyclic antidepressants, antiseizure
drugs, and 2-adrenergic agonists.
Nonopioids are often used in conjunction with opioids because they reduce the
amount of opioid needed for pain relief. This phenomenon is called the opioid-sparing
effect.
Multimodal analgesia employs the use of two or more classes of analgesic agents
to take advantage of the various mechanisms of action.

Nonopioids
Nonopioids are characterized by an analgesic ceiling, lack of ability to produce
tolerance or dependence, and availability without a prescription.
An analgesic ceiling means that increasing the dose beyond an upper limit
provides no greater analgesia.
Nonopioid pain medications include acetaminophen, aspirin, and NSAIDs.
NSAIDs are associated with a number of side effects including bleeding
tendencies, gastrointestinal (GI) ulcers and bleeding, and renal and CNS dysfunction.

Opioids
 Opioids are the strongest analgesics available. Opioids produce their pain-
relieving effects by binding to receptors in the CNS, inhibiting the transmission of
nociceptive input from the periphery to the CNS.
Common side effects of opioids include constipation, nausea, vomiting, sedation,
respiratory depression, and pruritus.
Concerns about sedation and respiratory depression are two of the most common
fears associated with opioids.
Sedation is usually seen in opioid-naive patients in the treatment of acute pain.
Patients at most risk for respiratory depression and renal insufficiency include
those who are opioid naive, are elderly, have underlying lung or renal disease, have
a history of sleep apnea, or are receiving other CNS depressants.
Patient-controlled analgesia (PCA) or demand analgesia is a method that allows
the patient to self-administer preset doses of an analgesic within a prescribed time period
using activation of an infusion pump.
Patient-controlled epidural analgesia (PCEA) is an electronically controlled
infusion pump that delivers the medication by an epidural route.

Adjuvant Analgesic Therapy

Adjuvant analgesic medications are used alone or in conjunction with opioid and
nonopioid analgesics. They include antidepressants, antiseizure drugs, -adrenergic
agonists, and corticosteroids.
Tricyclic antidepressants enhance the descending inhibitory system and are
effective for a variety of pain syndromes, especially neuropathic pain syndromes.
Antiseizure drugs affect peripheral nerves and the CNS and are effective for
neuropathic pain and preventative treatment of migraine headaches.
Clonidine (Catapres) and tizanidine (Zanaflex) are the most widely used 2-
adrenergic agonists and may be used for chronic headache and neuropathic pain.
Corticosteroids, including dexamethasone, prednisone, and methylprednisolone
(Medrol), are used for management of acute and chronic cancer pain, pain resulting from
spinal cord compression, and inflammatory joint pain syndromes.
Ketamine (Ketalar) is an NMDA receptor antagonist that is potentially useful for
blocking mechanisms that lead to or sustain central sensitization.

Administration
Appropriate analgesic scheduling focuses on prevention or control of pain rather
than the provision of analgesics only after the patients pain has become severe.
Analgesic titration is dose adjustment based on assessment of the adequacy of the
analgesic effect versus the side effects produced.
The term equianalgesic dose refers to a dose of one analgesic that is
approximately equivalent in pain-relieving effects compared with another analgesic.
Opioids and other analgesic agents can be delivered via numerous routes,
allowing flexibility in achieving pain control.
Oral administration is the route of first choice when the patient has a
functioning GI tract.
 Transmucosal and buccal medications are absorbed more directly into
systemic circulation, which would exempt them from the first-pass effect.
Transdermal fentanyl (Duragesic) diffuses across the skin to form a depot
of drug in the subcutaneous fat from where it is then absorbed into the systemic
circulation.
Intranasal administration allows delivery of medication to highly vascular
mucosa and avoids the first-pass effect. An example is butorphanol (Stadol).
Rectal preparations are useful when a patient cannot take medications
orally.
IV administration is the best route when immediate analgesia and rapid
titration are necessary.
Intraspinal (epidural or intrathecal) administered analgesics are highly
potent because they are delivered close to the receptors in the spinal cord dorsal
horn.
Topical administration delivers the drug through the skin to local tissue
with reduced absorption into the bloodstream and low risk of systemic side
effects. Examples are topical NSAIDs and aspirin creams.

Interventional Therapies
Interventional nerve therapies include regional anesthesia, neuroablative
interventions, and neuroaugmentation.
Regional anesthesia includes nerve blocks and epidural or intrathecal infusions.
Neuroablative interventions involve cutting or destroying nerves and are
performed for severe pain that is unresponsive to all other therapies.
Neuroaugmentation involves electrical stimulation of the brain and the spinal
cord.

Non-Drug Therapies
Non-drug therapies include physical or cognitive behavioral strategies. Physical
methods include superficial and deep massage, exercise, transcutaneous electrical nerve
stimulation (TENS), acupuncture, and thermal treatment. Cognitive-behavioral
techniques alter the affective, cognitive, and behavioral components of pain and include
distraction, hypnosis, and relaxation techniques such as guided imagery, meditation, and
progressive muscle relaxation.
TENS involves the delivery of an electric current through electrodes applied to
the skin surface over the painful region, at trigger points, or over a peripheral nerve.
Trigger point is a circumscribed hypersensitive area within a tight band of muscle.
It is caused by acute or chronic muscle strain and can often be felt as a tight knot under
the skin.
Acupuncture is a technique of Traditional Chinese Medicine in which very thin
needles are inserted into the body at designated points to reduce musculoskeletal pain,
repetitive strain disorders, myofascial pain syndrome, postsurgical pain, postherpetic
neuralgia, peripheral neuropathic pain, and headaches.
 Thermal therapies are the application of moist or dry heat or cold to the skin.

NURSING AND INTERPROFESSIONAL MANAGEMENT: PAIN

In your role as a nurse, provide input into the comprehensive assessment and
reassessment of pain. Help in the planning and implementation of pain treatment
including education, advocacy, and support of the patient and family.
Your beliefs and attitudes may hinder appropriate pain management.

Challenges to Effective Pain Management

Tolerance occurs with chronic exposure to a variety of drugs. It is characterized
by the need for an increased opioid dose to maintain the same degree of analgesia.
Physical dependence is an expected physiologic response to ongoing exposure to
pharmacologic agents, manifested by a withdrawal syndrome that occurs when blood
levels of the drug are abruptly decreased.
Addiction is a complex neurobiologic condition characterized by loss of control,
craving, and compulsive use of a drug that may be associated with aberrant behaviors and
harm arising from a drive to obtain and take substances for reasons other than the
prescribed therapeutic value.
There is no evidence that providing opioid analgesia to substance-abusing patients
worsens their addictive disease. In fact, the stress of unrelieved pain may contribute to
relapse in the recovering patient or increased drug use in the patient who is actively using
or abusing drugs.
Pseudoaddiction occurs when patients exhibit behaviors commonly associated
with addiction (frequent requests for analgesic refills and/or higher doses), but the
behaviors resolve with adequate pain treatment.

INSTITUTIONALIZING PAIN EDUCATION AND MANAGEMENT

Under regulatory standards, health care facilities are required to recognize the
patients right to appropriate assessment and management of pain and provide education
to HCPs, patients, and their families regarding pain management.

ETHICAL ISSUES IN PAIN MANAGEMENT

A common concern is that providing sufficient opioids to relieve pain will
precipitate the death of a terminally ill person.
The use of placebos in clinical practice to assess or treat pain outside of the
situation of informed consent in research studies is unethical.

GERONTOLOGIC CONSIDERATIONS: PAIN

Persistent pain is a common problem in older adults and is often associated with
significant physical disability and psychosocial problems.
Treatment of pain in the older adult is complicated by changes in drug
pharmacokinetics (absorption, distribution, metabolism, and excretion) and increased
risk for adverse events because of the potential for higher blood levels and drug-to-drug
interactions.
 HCPs should titrate drugs slowly and monitor carefully for side effects in the
older patient.
The use of NSAIDs in the older adult is associated with a high frequency
of serious GI bleeding.
Cognitive impairment and ataxia can be exacerbated when analgesics such
as opioids, antidepressants, benzodiazepines, and antiseizure drugs are used.

MANAGING PAIN IN SPECIAL POPULATIONS

In those who are unable to self-report, behavioral and physiologic changes may be
useful in the assessment of pain. A variety of behavioral pain assessment scales are
available for patients who are cognitively impaired.
Assessing and treating pain in persons with current, or a history of, drug and
alcohol abuse is challenging, particularly when therapy involves medications that may,
themselves, be abused (e.g., opioids). Opioids may be used effectively and safely in
patients with substance dependence when indicated for pain control.