Pain Assessment and Management – Advance Practice Nurse Pharmacology Credit
The purpose of this course is to provide a comprehensive overview of pain assessment and pain management.
By the completion of this activity, the learner will be able to:
- Outline the multidimensional nature of pain
- Discuss the implications of pain for the patient
- Define acute, chronic, nociceptive and visceral pain
- Describe the assessment and measurement of pain
- Explain drug abuse, dependence, tolerance and addiction
- Compare and contrast pharmacological and non-pharmacological methods to manage pain
- List five strategies for the management of pain
- Compare and contrast the assessment and management of pain in special populations including: infants, children, adults and geriatric patients
- Discuss the management of clinical conditions that have pain as a major component
Pain is a subjective experience, and the context in which it happens influences both how the pain is experienced, and its meaning to the individual. Defining and quantifying pain has never been easy. As part of the human experience, pain has been described from the earliest times. Prehistoric man related pain and pain relief to the acceptance or anger of the gods. Early Greek histories describe pain in the context of injuries received during battles; the Greek physician Hippocrates was the first to regard pain as a symptom, a sensory experience that could be explained by the patient to the practitioner. In the Middle Ages Leonardo da Vinci wrote that:1 “the chief good is wisdom, the chief evil is body pain.”
In 1842, a physician in the state of Georgia, Dr. Crawford Williamson Long was the first doctor to use ether as a general anesthetic while performing surgery to remove a tumor from the neck of a patient.1 The issue of pain during childbirth was hotly debated, with many in the medical profession supporting the tenet that experiencing pain during delivery was a religious principle. However, in 1853 the British Monarch, Queen Victoria was given chloroform during childbirth and for her next delivery in 1855. She described the experience of giving birth with the addition of anesthesia as: “soothing, quieting and delightful beyond measure.” This positive affirmation from Queen Victoria was an important first step in changing the prevailing views about pain relief during childbirth.2
What is pain?
The French physician, Dr. Albert Schweitzer, proclaimed in 1931 that, “Pain is a more terrible lord of mankind than even death itself.” (Partners for Understanding Pain 2016) However, from a positive viewpoint pain is an important diagnostic marker of injury or disease, and is significant in formulating a diagnosis.3
Nerve stimulation leads to the physical component of pain. Pain results from an injury and may be confined to a discrete area, or it can be generalized in conditions such as fibromyalgia. Nerve fibers transmit pain impulses to the brain where the brain can personalize the pain experience.4
Two definitions of pain that have changed how those involved in healthcare view pain are the definition from The International Association for the Study of Pain which states that: pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage.” The second is Margo McCaffery’s landmark definition that describes pain as: “whatever the experiencing person says it is, existing whenever and wherever the person say it does.”
Patients may experience acute, chronic, or cancer pain. Acute pain follows injury to the body and generally disappears as healing takes place. There is an identifiable pathology that accounts for the pain. It may arise from operative procedures or tissue trauma associated with an inflammatory process. It may be associated with objective physical signs such as increased heart rate, increased blood pressure, and pallor (autonomic nervous system activity); making patients “look” like they are in pain.
Chronic non-malignant pain is pain that lasts for an extended period of time. There may or may not be known active pathology to account for the suffering that the individual is experiencing. Chronic pain, in contrast to acute pain, is rarely accompanied by signs of autonomic nervous system activity. Chronic pain is not defined as acute pain that refuses to go away, and it can be seen as a disease in its own right.5 Australia has been one of the first countries to recognize pain as a disease entity, and several other countries are set to follow suit.2
Cancer pain may be acute, chronic, or intermittent. It usually has a definable cause, which is typically related to tumor recurrence or treatment.
Multidimensional Nature of Pain
Pain is a major problem in today’s society. Pain carries with it consequences across a broad range of categories including ethical, social, economic and legal arenas.
In 2011, a conservative estimate put those suffering from chronic pain at least 100 million adults in this country. This figure does not include children with chronic pain conditions. Research shows that greater than 1.5 billion people worldwide suffer from chronic pain and that between 3- 4.5% of the world population is affected by neuropathic pain.6
These numbers make it easy to understand that pain is one of the most common reasons that people seek medical attention.
Persistent pain is often associated with anxiety, depression, functional impairment, sleep disturbances, disability, and impairment in activities of daily living. Health economists from Johns Hopkins University have put the total annual cost of chronic pain to be as high as $635 billion yearly in the United States, which exceeds the annual costs for cancer, heart disease, and diabetes. The pervasiveness of pain has a huge impact on commerce, a report by the Institute of Medicine demonstrated that lost productivity in 2010 cost between $297.4 billion to 335.5 billion.6
Chronic non-malignant pain is defined as pain lasting more than three months and may affect any part of the body. Chronic pain can be divided into three broad classes depending on location, these are, localized, regional or widespread.2 A 2012 worldwide systematic review of the prevalence of low back pain indicated that it is a main source of chronic pain globally with the highest rates occurring in women between the ages of 40 years and 80 years.2
Chronic Pain and Gender
A consistent finding is that chronic pain occurs more frequently in women than in men. Complex Regional Pain Syndrome (CRPS) is found to have over a three times higher incidence in women than in men. Headaches and migraines also have a higher occurrence rate in women than in men, the annual prevalence rate for women reaches up to 33% and for men up to 16%. This pattern is found not just in the USA but worldwide. Fibromyalgia, osteoarthritis and irritable bowel syndrome are also found in consistently higher rates in women.5
Acute pain typically has an abrupt onset and is often described as sharp. It is often caused by events such as a broken bone, surgery, childbirth, dental pain or burns. Acute pain may last a short period of time or may last for a few months. The pain dissipates when the underlying cause has healed. When acute pain lasts longer than 3-6 months, it is then termed chronic. It is possible that acute pain that is not treated properly may lead to chronic pain.
Multiple barriers to effective pain management exist. These include many individual, family, healthcare provider, society and political barriers.
The good news is that we have the knowledge and skills to manage most pain effectively. So, what is the problem? Why is unrelieved pain still so prevalent?
Knowledge is important. Clinicians, as well as patients, need to be made knowledgeable about methods of assessing and managing pain. Knowledge alone rarely changes practice. Efforts must go beyond education alone if pain treatment is to improve. Pain needs to be made visible so it will not go unnoticed by clinicians.
Pain theories help clinicians understand pain and help in the guidance of the treatment of pain. The first theory of pain was formulated by the French philosopher Rene Descartes in the 17th Century and was titled the ‘Specificity Theory.’ He believed that the human soul resided in the pineal gland, and that was the source of sensations that the individual experienced including pain.2 The Specificity Theory of Pain suggests that certain pain receptors send out signals to the brain that creates the awareness of pain. According to the theory, pain is an independent sensation with particular peripheral sensory receptors, which act in response to damage to drive signals through the nervous system to centers in the brain.
Other theories that came to light in the 1900’s include the Pattern Theory, Central Summation Theory, the Fourth Theory of Pain and the Sensory Interaction Theory.
A more recent theory is the Gate Control Theory. Pain stimulation is transmitted by small, slow fibers that go into the dorsal horn of the spinal cord. The theory states that there is a gate in the spinal cord which controls sensory information through the spinal cord. When there is more pain stimulation, the gate blocking is less effective. When there is a lot of activity in the pain fibers, the gates open. When there is stimulation of the A-beta fibers, which provide stimulus for mild irritation such as lightly touching the skin (massage), the gates may be closed. The gates being closed inhibits the perception of pain.
In addition, messages that descend from the brain – such as those in anxiety states or extreme excitement – can affect opening or closing of the gates.
The Biopsychosocial Model of Pain suggests that pain involves not just physiological factors but also psychological and social factors. It suggests that family and culture influence the perception of pain and the individual’s response to pain.
Types of pain
- Acute pain – Pain that has an abrupt onset and offers a warning of a disease process or a threat to the body.
- Chronic pain – Pain that lasts beyond the usual duration of time that an insult or injury to the body needs to heal. Pain without apparent biologic value that has lasted beyond the usual tissue healing time (typically at least three months).
- Maladaptive pain – Pain that is not useful and is out of proportion to tissue damage. This type of pain tends to last long after tissue healing and is often due to changes in the central nervous system.
- Adaptive pain – Pain that protects the individual from injury and aids with healing after an injury.
- Allodynia — Pain from a stimulus that typically does not cause pain.
- Hyperesthesia – Increased sensitivity to stimulation.
- Paresthesia— An unusual sensation that is often described as burning or prickling and commonly affects the extremities.
- Visceral pain – Pain from the viscera mediated by stretch receptors. This pain is commonly described as deep, dull, poorly localized and cramping.
- Nociceptive pain – Pain from threatened or real tissue damage to non-neural tissue that is caused by the activation of nociceptors.
- Neuropathic pain – Pain from abnormal neural activity from an injury, disease process or dysfunction of the nervous system.
- Mononeuropathy – Neuropathy affecting one nerve.
- Polyneuropathy – Neuropathy affecting several nerves.
Pain Anatomy and Physiology
Anatomy and physiology are key factors in understanding pain. A primary function of the central nervous system is to deliver information about actual or potential threats or injury.2 Stimulation of pain receptors (nociceptors) results in physiological pain. It is also referred to as receptor or nociceptor pain. The two major types of physiological pain are somatic pain and visceral pain. Somatic pain occurs when there is injury to the skin, joint, muscles and ligaments, and by the inflammatory response, and because it alerts to presence of disease or injury, it serves an important protective role. Pain related to stimulation of the peripheral nerves and the cranial nerves also referred to as physiological pain. The brain tissue itself has no pain receptors. However, the dura mater, which is the outer lining of the brain and its large arteries are equipped with pain receptors and can cause physiological pain. Innervation for these pain receptors comes from the trigeminal nerve, cranial nerve V.3
Visceral pain arises from the stimulation of pain receptors in the internal organs such as the heart, the intestines, the lungs, the liver and the pancreas, and it is less specific than somatic pain. This vague pain may be due to the fact that the number of cells in the spinal cord receiving signals from the internal organs are less than those that get responses for the superficial body locations. It is often difficult for the patient to pinpoint the exact location of the pain, and it is frequently experienced as referred pain coming from the body surface. For the most part, pain receptors in the viscera are chemoreceptors that respond to different types of chemicals including those from the activation of the inflammatory process. Pain receptors in the viscera can also respond to stretching of the organs and organ ischemia.3
Primary afferent fibers are involved in the transmission of pain. A delta and C fibers transmit noxious stimuli from the body’s periphery to the dorsal horn of the spinal cord. The A delta fibers have a small diameter and are lightly myelinated and conduct slowly. They transmit rapid, sharp pain, and give precise information regarding the anatomical location of the pain. C fibers are small and unmyelinated fibers that conduct slowly and respond to multiple stimuli and lead to dull, achy pain. A delta and C fibers both react to mechanical stimulation and temperature, hot and cold. The skin surfaces and the joints in the body are well supplied with pain receptors, but they are not as abundant in the muscles.3 If the pain signal is strong enough, it transmits through the dorsal horn to the spinothalamic tract and the spinoreticular tract. Head pain is processed by the trigeminal nucleus before it reaches the brain. These are the ascending tracts to the cerebral cortex where the stimulus is recognized as pain. The Periaqueductal Grey (PAG) is an area of the midbrain, and it plays a major role in processing pain, particularly in the modulation of pain signals that are transmitted back to the dorsal horn of the spinal cord and to the trigeminal nucleus. Animal studies showed that electrical stimulation of the PAG had the ability to reduce pain. When the pain is identified in the cerebral cortex, it descends back to the periphery. Descending pathways for path begin in many areas of the brain and travel to cells in the dorsal horn of the spinal cord and the cells in the trigeminal nucleus. Descending pathways are usually parallel to the ascending pathways. It has been found that the vagus nerve provides an additional route for sensory and pain information to the brain, especially from the viscera and the head to some degree.3
The neurons are involved in the transmission of pain through the release of substances and neurotransmitters. The excitatory substances that contribute to pain include substance P, glutamate, prostaglandins and nitrous oxide. Inhibitory neurotransmitters inhibit, or partially, the transmission of pain. Common inhibitory neurotransmitters include glycine, serotonin, norepinephrine, acetylcholine, and gamma-aminobutyric acid (GABA). Medications are involved in modulating these neurotransmitters to help reduce pain.
Neuropathic or pathological pain is the result of changes in the central nervous system in either the brain or the spinal cord. It is regarded as one of the most difficult forms of pain to successfully treat. An integrative approach that utilizes both pharmacological and non-pharmacological treatments provide the best outcomes in the pathological pain relief.3
The Impact of Pain
Pain affects multiple aspects of life. Pain can lead to physiological changes and potentially to physical illness. It has the potential to lead to cognitive changes as many patients with chronic pain suffer from depression and anxiety. Studies suggest that at least 20% of those who suffer from chronic pain also have a serious mood disorder.5 Pain can change the way one thinks and acts leading to behavioral changes. The risk of suicide for those who are in chronic pain is approximately twice that of the general population, and the utmost risk is found among those who suffer from severe chronic headaches.5
Pain has the potential to affect an individual’s social life. Chronic pain may limit the patient’s desire to interact in social settings. Social consequences of unrelieved pain may include isolation, inability or reduced desire to go to work and an overall reduced quality of life. Expression and reporting of pain can vary by culture. Some cultures have a more stoic attitude to pain, while others may express more emotion to pain.
The biopsychosocial model of pain care leads to a major step forward in how people with pain were perceived and managed. This holistic approach to pain recognizes the importance of the psychological and social factors that play a role in the patient’s subjective experience of pain. The biopsychosocial model takes into account cognitive, emotional, spiritual and cultural issues that are unique to the individual and his or her journey with pain. Suffering related to pain is an individual experience. One of the core principles of the biopsychosocial model is to give the patient the right to participate in and direct their own care.2
The political arena can strongly influence pain in society. The assessment of pain over the last 20 years has focused on eliminating and reducing pain at all costs. This attitude has contributed to the opioid epidemic and many problems for society. In recent years, politicians have been implementing laws to help assure that pain is adequately assessed and treated with extra caution being placed on the prevention of medication abuse. It is important to recognize the importance of an individual’s ability to cope with pain, and since coping is a skill that is learned, it is essential for healthcare providers to recognize the importance of teaching this essential skill to patients or refer them to appropriate source for learning coping techniques.3
Many regulatory issues surround pain management. Pain management will be optimized when regulatory barriers are limited. The Institute of Medicine (2011) is calling for laws to be reviewed that have the potential to prevent optimal pain management. It is a challenging venture as regulations and law must be set up to manage pain optimally, but also to deter the abuse, diversion and illegal use of controlled substances.7
Society, including regulations set in the political arena, must change to help assure that the negative effects of pain and the treatment of pain do not lead to further problems in society. Substance abuse/misuse and drug diversion are major problems associated with pain management.
Substance abuse issues are a real concern in the management of pain.
Opioid misuse and abuse is a major public health problem, and it affects 34.2 million Americans over the age of 12.8 According to the Center for Disease Control, in the United States, 46 people die each day from an overdose of prescription painkillers. In 2012, healthcare providers wrote 259 million prescriptions for painkillers. Two times as many painkiller prescriptions are written in the United States as in Canada.9
Misuse prevalence is variable. Of individuals over the age of twelve, 4.6 percent reported non-medical opioid use within the last year.
Abuse of prescription medications, especially opioids, is higher in those who service in the armed forces than in the civilian population. In 2008, 11% of service members admitted abusing prescribed drugs, mostly opioids. Multiple deployments and injuries sustained on active duty are cited as some of the causes. The number of prescriptions for pain relief medications written by military doctors between the years 2001 and 2009 quadrupled. In 2008, the number of suicides among military personnel exceeded that of the civilian population, and in 2010, a report from the Army Suicide Preventions Task Force found that prescription drugs were implicated in close to one-third of military suicides in 2009. In an attempt to reverse the misuse of prescription drugs, the Army has instigated changes that incorporate the period of prescriptions for opioids to 6 months. Studies also indicate an increasing use of opioids by veterans. In 2010, over 43,000 patients were treated in VA facilities for opioid abuse, and this does not take into account the number of veterans who do not seek out treatment.10 12.2 percent of 12th graders reported abusing opioid, and 7.9 percent reported past-year use.11
The number of people who sought treatment for non-heroin opioid substance abuse increased from 1.0 percent in 1995 to 8.7 percent in 2010.12 Research also shows that white individuals account for 88 percent of those who reported non-heroin opioid substance abuse, and the majority of these individuals lived in a rural setting. Those who live in rural settings account for 10.6 percent of cases and urban individuals accounting for 4.0 percent of non-heroin opioid abuse individuals who sought treatment.12
Of the overdose deaths from opioid analgesia, thirty percent also involved benzodiazepines. In 2007, the total cost of prescription opioid abuse to the US economy was placed at $55.7 billion. Lost work productivity accounted for $25 billion of that amount, healthcare costs were around $25 billion, and the criminal justice cost was close to $5 billion.13
Opioids have the potential to provide analgesia and improve function. These benefits must be weighed against the potential risks including misuse, addiction, physical dependence, tolerance, overdose, abuse by others, drug-to-drug and drug-to-disease interactions.
The Centers for Disease Control and Prevention (CDC) 2016 Guideline for Prescribing Opioids for Chronic Pain reiterate the need for adequate pain control, and the challenges that are involved, particularly in the area of chronic pain control. It recommends that providers utilize the “full range of therapeutic options” in the treatment of chronic pain. The report goes on to state that it is hard to quantify the number of individuals who could benefit from long-term use of opioid medications. Looking at the serious consequences of opioid use, the report states that between the years 1999 and 2014 more than 165,000 people died from opioid overdoses. Using DSM-IV diagnosis criteria, in 2013 approximately 1.9 million individuals either abused or were dependent on opioid drugs. Research has found practices that have contributed to the opioid overdose epidemic, the most important of which are prescribing high doses of opioids, overlapping opioid and benzodiazepine prescriptions, and the use of extended-release opioids for acute pain.
The CDC guidelines make recommendations in three areas of opioid use:
- Determining when to start or continue opioid medications in the treatment of chronic pain.
- Selection, dosage, duration of therapy, follow-up and medication discontinuation.
- Assessment of risk factors, and tackling the harmful consequences that can occur with opioid use.
When treating chronic pain, the guideline recommends that non-pharmacologic therapies and non-opioid medications are the first line treatment. The CDC recommends the use of immediate-release opioids at the lowest effective dose, rather than the extended release form of the treatment of chronic pain. Prior to starting opioid therapy for the treatment of chronic pain clinicians are advised to the establish goals with the patient that involve realistic outcomes for pain relief and improved activity. Opioids should only be continued if there is sufficient improvement in the patient’s pain levels and positive impact on their quality of life that outweigh the possible negative side effects of opioid use. After one to four weeks of opioid therapy, the provider needs to reassess the patient, and for continued opioid therapy, evaluations for benefits and risks of opioid therapy need to be done at least every three months. When opioids are discontinued, a reduction of 10% of the medication dose per week is recommended to alleviate the symptoms of opioid withdrawal.
Areas of risk for opioid use include patients with sleep apnea, pregnancy, patients with renal or hepatic insufficiency, those older than 65 years, people with mental health disorders, patients with substance abuse disorders, and individuals with a previous nonfatal overdose.
The CDC guidelines also note the importance of the clinician using State Prescription Drug Monitoring Program (PDMP) data to verify whether or not the patient is getting opioid medications or dangerous medication combinations that place them at a high risk for overdose. In some states, the law requires the provider to review the PDMP before renewing each opioid prescription.14
Prescription drug misuse is the use of prescription medication in a method or intent inconsistent of how it was prescribed. Prescription drug misuse includes using a medication to get high, selling or sharing it with other (diversion), overuse, having multiple prescribers, and concurrent use of alcohol or other illicit substances. Misuse is a necessary but not solely a sufficient criterion for a substance use disorder.
Susceptible individuals are at risk to misuse medications that stimulate the reward center of the brain which may include opioid analgesics, stimulants, benzodiazepines or tranquilizers.
Drug abuse is when drugs are not used medically or socially appropriately. Controlled substances may lead to dependence, either physical or psychological. Physical dependence transpires when there are withdrawal symptoms such as anxiety, tachycardia, hypertension, diaphoresis, a volatile mood, or dysphoria after the rapid discontinuation of the substance. Psychological dependence is the perceived need for the substance. It makes the person feel as though they cannot function if they do not have the substance. Psychological dependence often kicks in after physical dependence wears off, and it typically lasts much longer than physical dependence and is a strong contributing factor to relapse.
Addiction is psychological dependence and extreme behavior patterns associated with the drug. At this point, there is typically a loss of control regarding drug use. The drug is continued despite serious medical and/or social consequences. Tolerance, increasing doses of the medication needed to produce an equivalent effect, is typically seen by the time addiction is present. Physical dependence can occur without addiction. Individuals who take chronic pain medication may be dependent on the medication, but not addicted.
Addiction is a major concern in those taking opioids. When opioids are prescribed, it is important to determine who is likely to participate in aberrant drug-related behaviors. Deviant use may occur in those with major depression, psychotropic medication use, younger age or those with a family or personal history of drug or alcohol misuse.15 Those at high risk for addiction should likely be managed in concert with a specialist.16
Aberrant behaviors may include abuse, misuse or addiction. Examples of aberrant drug-related behaviors include:
- Requests for early refills,
- Not taking medications as prescribed,
- Failure to keep appointments,
- Visits in distress,
- Frequent reports of lost medication,
- Using multiple prescribers,
- Positive urine drug test for illicit substances,
- Altering prescriptions,
- Resistance to referrals,
- Resistance to providing prior medical records,
- Resistance to change in therapy,
- Increasing the dose without telling the prescriber,
- Requests for specific drugs.
Why Patients don’t report pain
The reality is that many patients do not report pain or minimize the severity of the pain they are experiencing. There are several reasons for this including poor communication between patients and healthcare providers. There are increased levels of anxiety for those who are admitted to an acute care facility, seeing several different providers, not being quite sure who to report their pain too, and the sense of helpless in finding themselves in a hospital gown and a strange environment. Nurses have a vital role in these situations as the patient’s advocate and navigator through the complexity of the system to ensure that pain is properly addressed.
Policies Related to Pain Control
The Joint Commission (JC) recognizes that pain control is an important part of quality health care. They acknowledge that pain is considered the fifth vital sign and should be assessed with other vital signs. According to the JC, patients have the right to assessment and treatment of pain. Other beliefs of the JC include:
- Patients should be educated about pain.
- Providers must be competent in the assessment and treatment of pain.
- Pain should not interfere with function.17
Ethics and Pain
However, pain is not well managed, and several factors play into the mishandling of pain. Most importantly is the reality that many doctors know very little about pain and pain management; it is not a topic that is dealt with extensively in medical schools –or in nursing education programs. This lack of education means that patients in pain see health care providers that are ill-equipped to understand and treat them. Added to this is the fact that very little is spent on pain research. In 2012, only around 1% of the National Institutes of Health (NIH) budget was devoted to pain research.5
Pain and its management are surrounded by multiple ethical issues. Healthcare providers should attempt to minimize pain and suffering while maintaining a balance between adequate pain management and minimizing harm from the treatment of pain.
Ethical issues surround end of life care. The management of pain at the end of life is a moral duty for the provider caring for a terminal patient. While opioid use may suppress respirations, and may even hasten death, the treatment of pain is an important part of care for intractable pain as death nears. The goal of giving pain management is to relieve suffering, not accelerate death. The use of palliative sedation may be considered to manage refractory pain at the end of life.
Pain Assessment and Measurement
When and how should pain intensity be assessed?
Basic pain assessment is simple and must regularly be performed. Action needs to be planned on the basis of the patient’s report of pain. It makes no difference whether patients are in the hospital, a long-term care facility, a behavioral health facility, an outpatient clinic or being cared for by a home care agency. No matter where patients are, the intensity of pain should be assessed and documented:
- during the initial evaluation of the patient,
- after any known pain-producing,
- with each new report of pain,
- at regular intervals when vital signs are taken, and
- at suitable intervals after pharmacologic (45-60 minutes after oral intervention; 15-30 minutes after parenteral intervention) or non-pharmacologic intervention to evaluate the current pain treatment plan.
Pain threshold refers to the minimal level at which an individual senses pain as a harmful stimulus. It is the level at which the patient first states that what they are feeling is painful, and as such, varies greatly from patient to patient. Pain tolerance refers to the degree of pain a person can tolerate before it becomes unbearable for them. Pain tolerance not only differs from patient to patient but can also vary for the same individual depending on numerous factors including time, setting and stimulus. Healthcare providers must resist the temptation to make comparisons between the pain threshold and pain tolerance of patients, especially those who have had similar procedures.
Measuring the severity of pain is often done on scales. Pain scales are meant to compare the intensity of the patient’s pain at different points in time, not to compare one person’s pain to another. The use of pain scales assists the healthcare provider to determine the effectiveness of pain treatment.
The best scales are those that are brief, valid, require minimal training to use, and use both behavioral and descriptive measures of pain. When selecting a scale, it is important to consider which type of scale would work best for the individual patient. Patient education regarding pain assessment is also important. For example, prior to a surgical procedure, the nurse needs to discuss with the patient how their pain will be assessed after the surgery and demonstrate to them how the Numbering Rating Scale and the Wong-Baker FACES Pain Rating Scale works; allow the patient to choose which scale will work better for them.2
A “0 to 10” numerical scale is the most widely used measure to assess pain intensity. When using the Numerical Rating Scale (NRS), patients are asked to rate their pain from 0 to 10, with “0” equaling no pain and “10” equaling the worst possible pain they can imagine.
Another scale allows the patient to rate their pain as, “no pain, mild pain, moderate pain, severe pain, or unbearable pain.” Pain maps can be used for those who have a difficult time speaking. In a pain map, there is a front and rear view of the body on a piece of paper, and the patient draws on the location of the pain and may rate the severity of the pain.
Since we have no instrument to objectively measure pain intensity in the same way that blood pressure is measured by a sphygmomanometer, for example, the only valid measure of pain is the patient´s self-report (a subjective measure). Sometimes healthcare providers may believe that they are the best judges of a person´s pain; however, many studies demonstrate that healthcare providers either over or underestimate a patient´s pain.
For patients who are NOT cognitively impaired but who cannot respond verbally and/or rate their pain numerically, faces scales with happy faces representing no pain (0) and progressively sadder faces representing increasing pain intensity may be used. The patient is asked to choose the face that best depicts how they are feeling.
Besides current pain intensity, the complete pain assessment includes the following:
- Location of pain, where does the pain start, and does it spread to other parts of the body?
- Pain intensity for the worst pain, the best pain gets, and the acceptable level of pain. Satisfactory pain relief is a level of pain that may be noticeable, but not bothersome.
- Character or quality of pain. The words used by the patient to describe pain may enhance the understanding of the etiology of the pain and provide usefulness in selecting interventions to manage it. For example, somatic, (musculoskeletal) pain is usually localized and described as dull, achy and sore. Visceral pain is usually poorly localized and described as cramping or squeezing. Descriptors of burning, shooting, or knife-like are indicative of neuropathic (nerve) pain. (Refer to Table 1.)
- Onset, duration, variations and pattern (is the pain better or worse at certain times, certain hours?)
- Alleviating factors – what makes the pain better?
- Aggravating factors – what makes the pain worse?
- Impact of pain on quality of life and daily functioning. How long has the pain affected sleeping, relationships with others, mood, emotions, concentration, for examples?
It is also important to document the impact pain has on quality of life. Key questions to ask include:
- Does pain affect sleep?
- Does the pain lead to mood alterations?
- Does the pain lead to reduced energy?
- Does the pain reduce the patient’s ability to participate in activities and socializing?
- Does the pain affect relationships?
- Does the pain limit or affect activity or exercise?
- Is the patient able to participate in activities of daily living such as bathing, dressing, feeding, toileting, or brushing their teeth?
- Does the pain impact instrumental activities of daily living (IADL), such as the use of the telephone, doing the laundry, handling of medications or ability to handle the finances? This is less important in the nursing home setting as many of the IADL are impaired at baseline which is the reason there was nursing home placement.
Understanding how pain was treated in the past for the patient will help the clinician treat the current pain. A review of past medical records will help the pain management team evaluate the condition. Reviewing all previous history, diagnostic testing, treatment options and the efficacy of those treatment options will help the team make an accurate diagnosis and manage pain appropriately. Certain treatment modalities, including specific medications, are often more effective in one individual when compared to another based on individual genetic variations.
Having a full understanding of all medical and surgical conditions can be very helpful in assuring proper pain management. Chronic disease may have a strong impact on the management of pain. Chronic kidney disease, for example, can affect the way that drugs are excreted. The use of non-steroidal anti-inflammatory medications can lead to kidney failure in those with chronic kidney disease.
A mental health evaluation can help the clinician understand the best way to manage pain. Mood or cognitive disorders can affect the way the pain is managed. If mental illness is not appropriately identified and managed, chronic pain will likely never be adequately managed. A history of drug abuse is an important factor to ascertain, as this could profoundly affect how chronic pain is treated.
Personal characteristics may have a strong effect on pain management. Factors that influence pain include race, age, culture, religion, sex and/or language.
Review of the patient’s perception of the pain is important. Why does the patient believe they have persistent pain? Does the patient feel there was adequate workup done on their condition? What does the patient expect out of treatment and what are the patient’s goals? In addition, psychological factors that contribute to the pain should be assessed; this will help assess the patient’s expectations. It is important for patients to have realistic expectations about pain management.
A complete physical exam is an essential part of the management of pain. It is important to have a baseline examination, so subsequent evaluations will allow the health care team to determine progress in pain management and functional capacity.
The physical exam should include a detailed neurological exam including the patient’s ability to ambulate. While exams may include general observations, exams may be focused according to the presenting condition. Observing hygiene, posture, dress and appearance is important. Those with severe pain will often have poor hygiene, unkempt dress and appear to be in pain. Observe for any splinting, which may suggest a painful part of the body. Assessing skin and joints for redness, swelling or deformities helps determine the location and etiology of pain. An abdominal exam for any tenderness or distention should be done. In addition, checking joints for range of motion is an important part of the physical exam in chronic pain. The exam should include an evaluation of functional capacity, strength, endurance and any pain-related limitations.
Ongoing monitoring for the efficacy and effectiveness of the implemented plan is important. Utilizing similar assessment tools, the healthcare provider can document the effectiveness of the pain management plan on the patient, which will include any improvement in quality of life.
Diagnostic testing can be helpful in evaluating painful conditions. It is important to realize that an abnormal diagnostic test does not confirm the source of the pain. Blood tests can be helpful in some conditions to determine or monitor certain causes of pain. For example, an elevated C-reactive protein or an erythrocyte sedimentation rate may be seen in those with polymyalgia rheumatica, infection or rheumatoid arthritis (which are all conditions that may cause pain).
Imaging may be necessary for some situation of chronic pain. X-rays, computed tomography and magnetic resonance imaging can help define the etiology of the pain. Caution must be utilized when using imaging as many abnormalities may be seen in imaging tests that are not the source of the pain.
An electromyogram (EMG) or nerve condition studies are often done to assess the cause of pain. The EMG measures electrical activity of the muscle and can help find damaged muscle, nerves or neuromuscular abnormalities such as a herniated disc or myasthenia gravis. The nerve conduction study measures the ability of the nerves to send electrical signals and can help diagnose carpal tunnel syndromeor other neuropathies.
Management of Pain
Goals of pain management are not necessarily complete pain relief. They may include a reduction in the amount of pain, improved quality of life, improved physical and psychological functioning, improved ability to work, improved ability to function in society and a reduction in health care utilizations.
A pain management plan is more than just a prescription for pain medication. In addition to pharmacotherapy, it should include psychological and physical modalities to manage pain. It should be modified when interventions are not effective. Successful treatment of chronic pain is more than a prescription for medication it requires the input of an interdisciplinary healthcare team, and a holistic approach to care with the goal of improving the patient’s overall quality of life. As nurses, one of our most important roles is to listen to our patients, and this is especially important for patients in pain particularly chronic pain. These patients often live with intense fear, anxiety, uncertainty about the future, and frequently social isolation and loneliness. The opportunity to be able to tell ones’ story to someone who is consciously listening is therapeutic in itself.2
The patient should be provided education regarding the plan. It should include information about medications prescribed, other treatment options and methods to contact the pain management team.
When developing a treatment plan, there are many considerations, including the type of pain. In addition, the effect the pain has on lifestyle including psychological, social and biological components of life should be considered.
Many factors affect the success of the treatment plan. Issues related to the patient, such as their ability to understand and apply the management plan, will help determine the success of the plan. The patient’s willingness to implement the whole plan can have a profound effect on the success of the plan. If a patient is willing to take a pill but is not willing to work on non-pharmacologic interventions (such as physical therapy or weight loss), then the plan will lose its effectiveness.
Referral to a pain management specialist may be indicated for those who have debilitating symptoms, those that need increased doses of pain medications, those who are non-responsive to treatments, or those with symptoms at multiple sites.
Caregiver or healthcare provider issues often affect the pain management plan. Many caregivers and healthcare providers do not have an accurate comprehension of the patient’s pain and may hold false beliefs regarding pain management. Caregivers and healthcare providers may be inhibited by fear of side effects from medications or concerns of drug addiction so may withhold giving medication to those who are in pain. In addition, caregivers/healthcare providers and patients may have discordant goals.
Controlled substances should be prescribed for a legitimate medical purpose with a careful consideration of the patient’s safety, goals of therapy and efficacy of the treatment. Treatment of pain should include pharmacotherapy but also physical and psychological therapies.
Numerous non-pharmacologic therapies are used in the management of pain. These may include a combination of physical and psychological techniques. Methods used other than medications include:
- physical therapy,
- ultrasound therapy,
- heat/cold application,
- chiropractic manipulation,
- relaxation therapy,
- transcutaneous electrical nerve stimulation (TENS),
- music therapy,
- spinal cord stimulation,
- deep brain stimulation, and
- radiofrequency ablation of nerve tissue.
For those with pain, a trial of physical therapy and/or occupational therapy can be helpful. With the help of a physical therapist, the use of exercises targeting a specific type of pathology can be helpful in the management of pain. Occupational therapists can be helpful in recommending devices that can assist in enhancing activities of daily living. With chronic pain, there is a tendency not to move which leads to deconditioning, and further incapacity results in greater pain with any form of movement. Maintaining muscle mass prevents this downward spiral. It has also been proven that the more an individual participates in exercise, the less probability there is of them developing back pain. For those who have lower back pain, physical activity has been shown to produce a considerable improvement in their overall health. Exercise, especially those performed in water are beneficial for patients with arthritis pain, and aerobic exercise has proven to very effective in decreasing pain connected with fibromyalgia.5
Yoga and Pilates have also become popular alternative treatments, especially for back pain. However, some yoga poses can be a potential cause of injury especially those that involve overstretching of the neck. Tai’ Chi which is another Chinese practice involving slow, gentle movements, along with deep breathing and relaxation is having positive effects on pain relief for several conditions including fibromyalgia, arthritis, and low back pain.5
Massage is soothing and relaxing, both physically and mentally. Massage may decrease pain by relaxing muscle tension and increasing capillary circulation, thereby improving general circulation.
Vibration is a form of electric massage. When vibration is applied lightly, it may have a soothing effect similar to massage. Vibration applied with moderate pressure may relieve pain by causing numbness, paresthesia, and/or anesthesia of the area stimulated.
Heat and cold therapies can assist in the management of pain. Heat reduces inflammation and promotes relaxation. It can be in the form of hot tub baths, heating pads, or heat packs. Cold is often more effective in relieving pain than heat. The application of cold reduces muscle spasms secondary to underlying skeletal muscle spasm, joint pathology, or nerve root irritation. Methods of cold application include ice massage, ice bags, and gel packs. Alternating heat and cold may be more effective than the use of either one alone.
Multiple psychological techniques can aid in reducing pain. The basis for the use of these methods is that thought influences feelings, and if thought (and behaviors) can be changed, so can feelings and even sensations, such as pain. Cognitive-behavioral methods require the patient’s active participation. Cognitive behavioral therapy (CBT) has proven to be an effective coping skill for those with chronic pain. CBT emphasizes the present moment, where the individual becomes aware of their thoughts, feelings and behaviors, and journaling these perceptions. CBT helps to decrease the emotional distress associated with chronic pain, by focusing on how one perceives pain and adjusts to it. CBT has been shown to decrease pain in chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, and back pain. It has also been used successfully as a means to prevent headache.5
Relaxation is a state of relative freedom from both anxiety and skeletal muscle tension, a quieting or calming of the mind and muscles. Although relaxation is a learned technique, it can be achieved quickly in a motivated patient.
Imagery/Visualization involves mentally creating a picture by using one’s imagination. This may be a focus on a close person, a place of enjoyment, a past event, or anything that is thought to bring pleasure. Since the mind is occupied, the pain is reduced in focus.
Distraction from pain is the focusing of attention on stimuli other than the pain sensation. The stimuli focused upon can be auditory, visual, or tactile-kinesthetic (hearing, seeing, touching, and moving). By focusing attention and concentration on stimuli other than pain, pain is placed on the periphery of awareness. Distraction does not make the pain go away, nor does the effectiveness of the use of distraction indicate the absence of pain. Music and humor are extremely effective means of distraction.
Transcutaneous Electrical Nerve Stimulation (TENS) provides low voltage electricity to the body via electrodes placed on the skin. TENS may help with acute or chronic pain. Electrical stimulation of sensory nerves helps block pain signals going to the brain. TENS is not to be used for patients with pacemakers, electrical implants, cardiac arrhythmias, problems with circulation, and during pregnancy.2
Biofeedback is a technique to harness the mind’s power to allow the patient to be more aware of the sensations in the body. The exact mechanism that it works is unclear, but it promotes relaxation and helps reduce pain.18
Acupuncture is a neurostimulation technique that treats pain by the insertion of small, solid needles into the skin at varying depths. Various theories exist to offer an explanation of how acupuncture works. The Chinese theory of acupuncture is that it allows the release of blocked energy in the body. In Chinese medicine, this energy source is known as Qi, and its ability to flow freely through the body is related to overall well-being.5
Music therapy may be used to treat pain. Music therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional. This individual has to complete an approved music therapy program. Research in music therapy supports its effectiveness in a wide variety of health care and educational settings.
Music therapists use music to facilitate changes that are non-musical in nature. Individuals doing music therapy listen to music created under the guidance of a specially educated and certified professional in music therapy.
It is believed that music, like relaxation and guided imagery, can strengthen the right side of the brain, which controls the body’s healing processes. The theory of music therapy’s effect on chronic pain deals with how pain signals travel through the body. When the brain senses injury to the body, pain signals begin in the somatosensory cortex and the hypothalamus and work their way through the “pain pathway,” ultimately sending signals that provide pain relief. There are also signals that stimulate the release of neurotransmitters such as endorphins, dynorphins, and enkephalins. Music helps in pain reduction by activating these sensory pathways.
Different surgical interventions or procedures can be used in the pain management plan. Procedures may include injections, spinal cord stimulation, deep brain stimulation, neural ablative techniques, and surgical interventions. These are potential options for those in whom other methods have not controlled the pain.
Teaching Coping Skills
Pain can be seen as having two parts, first of all, there is the perception of pain, which is related to the strength and characteristics of the pain, and secondly, there is the effect the pain has on the individual. What is its emotional impact, and how is it impacting their quality of life? When healthcare providers perform a pain assessment, it is the strength or intensity of the pain that is measured, which may not reflect how the pain is affecting the life of the person. What has been determined is that how pain affects an individual is intimately associated with their ability to cope with pain.3
Coping can be defined as what an individual thinks and does in a situation that causes them stress. It is greatly affected by the resources that are available to the person to manage the event.2 Coping is a crucial part of pain management especially for those with chronic pain. Nurses need to be aware of the need to assess patients coping patterns as they relate to pain, and to be able to discuss basic coping skills with them and be aware of resources where patients can be referred to learn positive coping techniques.
Catastrophizing can be seen as the opposite of coping and is the belief that a situation will continue to get worse. The individual experiences heightened levels of worry and fear that have been shown to intensify the amount of pain the person feels (Moller 2014). Rather than looking for solutions to the problem, the individual tends to turn away from it and has a sense of hopelessness about their situation. Catastrophizing needs to be something that nurses are watchful for when assessing a patient’s pain by listening carefully to how the patient describes their pain and how they perceive its effect on their life now and in the future.
Under treatment of chronic pain remains a persistent problem, with an estimate of approximately 30% of those who suffer from chronic pain receiving less than adequate treatment.5 Pain medication decreases (modulate) pain by altering transmission at various points of the pain pathways.3
Analgesic agents are often given orally as this is convenient and allows a relatively steady blood concentration of the drug. Pain medication may be administered on an as-needed basis for episodic pain, or it may be given routinely for chronic pain. The use of routine, around-the-clock medication sustains a steady state in the blood and offers better pain relief for those with persistent pain. When deciding on what medication to use, side effects must be taken into consideration.
Classes of medications include non-opioid analgesic agents, antidepressants, muscle relaxants, antiepileptic medications, topical agents and opioids. Some get effective relief from one medication, but some get better pain relief from a combination of medications that work on different pathways. Unfortunately, research is sparse on combination medication in the management of pain.
Considering all co-morbidities is an important step in the management of pain. When a patient is afflicted with chronic pain and depression, some medications may help effectively manage both conditions (for example, duloxetine is approved to treat chronic musculoskeletal pain, including discomfort from osteoarthritis and chronic lower back pain in addition to depression). It is also important to establish the pathophysiology of the pain syndrome, evaluate the medication list, and consider the side effects of the medications being prescribed.
The clinician should distinguish between neuropathic pain and nociceptive pain. The etiology of neuropathic pain must be established and if the etiology is reversible, manage the underlying problem. For example, if a medication (e. g., metronidazole, nitrofurantoin, isoniazid, or many cancer agents) is the etiology of the neuropathy – stop that medication.
Medications used in the treatment of neuropathic pain include calcium channel alpha 2-delta ligands (gabapentin and pregabalin), tricyclic antidepressants, serotonin-norepinephrine uptake inhibitors (SNRIs), the lidocaine patch and narcotic analgesics.
Nociceptive pain is typically treated with non-narcotic and opioid analgesia. Common causes of nociceptive pain include arthritis and chronic low back pain. Acetaminophen is often used as a first-line agent in the management of nociceptive pain.
Acetaminophen has become the chief cause of acute liver failure. According to government statistics, there are close to 30,000 hospital admissions annually associated with acetaminophen overdose. Patients must be warned that alcohol and acetaminophen is a particularly dangerous mixture, and alcohol consumption needs to be avoided when taking this medication. In January 2011, the Federal Drug Administration (FDA) requested drug manufacturers to limit the amount of acetaminophen in combined products to 325 milligrams per dose. The FDA also required that labels carry a ‘black-box’ warning highlighting the fact that acetaminophen can result in severe liver damage.5
Acetaminophen is not an anti-inflammatory agent but is a very common over the counter medication used for the management of pain. Acetaminophen is commonly administered with opioid medications to reduce the amount of opioid medication needed to manage the pain. There is some evidence of renal toxicity with long-term use of high-dose acetaminophen over the years.
Acetaminophen is dosed 325 to 650 mg every four hours or 500-1000 mg every 6 hours, not to exceed 3000 to 4000 mg a day. In the pediatric population, acetaminophen is dosed at 10-15 mg/kg/dose every 4-6 hours with a maximum of 75 mg/kg/day, but no more than 4000 mg a day. The dose should be reduced in those with hepatic insufficiency or alcohol abuse. Absolute contraindication to acetaminophen is liver failure while relative contraindications include chronic alcohol abuse or hepatic insufficiency. Those who are on a statin cholesterol medication may need a lower dose of acetaminophen.
Before going to a stronger pain medication, it is important that clinicians determine that acetaminophen is given in the proper dose. The use of up to 1000 mg per dose (in adults) may be necessary to provide relief.
NSAIDs are used as alternative options to acetaminophen and are indicated for mild to moderate pain, while some are indicated for severe pain. Like acetaminophen, they act synergistically with opioids. Because they act as an anti-inflammatory agent, they are often used for arthritis, strains, sprains, bursitis and tendonitis. The most frequently used NSAIDs are acetylsalicylic acid (Aspirin), ibuprofen (Advil, Motrin), naproxen (Aleve) and diclofenac (Voltaren). NSAIDs are believed to work by inhibiting the production of the enzymes cyclooxygenase 2 (COX-2) and (COX-1) that are involved in the synthesis of prostaglandins that mediate inflammatory responses and also cause pain. COX-1 is involved in the protection of the stomach lining, and one of the most frequently cited side effects of NSAIDs is stomach bleeding.3
NSAIDs are associated with more side effects and are potentially more problematic, especially in older adults. In older adults, the American Geriatric Society guidelines recommend that persistent pain due to osteoarthritis not be primarily managed with non-steroidal anti-inflammatory agents. The use of topical NSAIDs is a good option for those with localized pain.
Absolute contraindications to NSAIDs include an active peptic ulcer, chronic kidney disease or heart failure. Relative contraindications include a history of peptic ulcer disease, Helicobacter pylori infection, hypertension, or concomitant use of selective serotonin receptor inhibitors or corticosteroids.
Other side effects of NSAIDs include renal insults, adverse cardiovascular effects, headaches, constipation and mental status changes. Gastrointestinal effects may include gastric ulceration and dyspepsia. Taking the medication with food or antacids may reduce the risk of dyspepsia. Those at high risk of gastric ulceration – older age, on corticosteroids, bleeding problems, or a history of gastric ulceration – should likely not use NSAIDs. The use of a proton pump inhibitor reduces the risk of gastric ulceration with the use of NSAIDs. NSAIDs have the potential to interact with many antihypertensive medications, aspirin, selective serotonin reuptake inhibitors, corticosteroids and warfarin.
NSAIDs have the potential to cause nephrotoxicity. NSAIDs inhibit prostaglandin synthesis which leads to vasoconstriction of the afferent arteriole in the kidney, resulting in a reduction in the glomerular filtration rate. NSAIDs should be used cautiously in those with renal impairment.
NSAIDs have the potential to lead to cardiovascular complications and have been implicated in increasing the risk of myocardial infarctions, especially in patients who take high doses over a prolonged period of time. For those with high cardiovascular risk, the use of NSAIDs should be limited.
They should also be avoided in those with thrombocytopenia (low platelet count). Patients receiving warfarin or heparin should not receive NSAIDs. NSAIDs have been shown to impede thrombocyte aggregation, which can increase the risk of bleeding.3
Antidepressant use in Pain Management
Antidepressant medications are effective for multiple types of chronic pain. They have shown effectiveness in neuropathic pain, fibromyalgia and pain associated with depression. This next section will look at some of the antidepressants used in the management of pain.
Tricyclic antidepressants (TCA) modify pain by inhibiting the uptake of norepinephrine and serotonin and block multiple channels including the sodium, adrenergic, cholinergic and histaminergic channels. Medications in this class include nortriptyline, desipramine, amitriptyline and imipramine.
Nortriptyline and desipramine (secondary amine tricyclic antidepressants) are preferred agents in this class as they are associated with a better side effect profile. These agents are often used in the management of neuropathic pain, but can also be used in chronic pain management as adjuvant agents.
Tricyclic antidepressants need to be used cautiously in older adults as they have many side effects (constipation, dry mouth, mental status changes, blurred vision, urinary retention, blood pressure change, tachycardia, and heart block). They should be used very cautiously or not at all in those with cardiac or electrocardiographic abnormalities. The analgesic effect is typically noticed in a shorter period of time and at a lower dose than when treating for depression. Some patients will have a diminishing of side effects as their body adapts to the medications.
In adults, most TCAs are often started at 10 mg per day and is then titrated up to 75 mg per day. Older individuals rarely tolerate doses more than 75-100 mg per day. It may take up to 8 weeks before analgesia is appreciated, but pain relief may be noticed as soon as one week.
Serotonin-norepinephrine reuptake inhibitors are used for neuropathic pain but can be used for other types of pain. Duloxetine (Cymbalta) is indicated for diabetic neuropathy and painful chronic musculoskeletal conditions such as osteoarthritis and chronic low back pain. It is also approved for fibromyalgia. Common side effects include insomnia, drowsiness, dry mouth, fatigue, nausea and dizziness.
It should not be used in those with severe renal insufficiency or hepatic insufficiency. When stopped, it should be tapered slowly due to withdrawal symptoms.
Venlafaxine (Effexor), another SNRI, is sometimes used for neuropathic pain, but it is an unlabeled use. Venlafaxine may lead to increased blood pressure. When the medications stopped, it should be tapered slowly to minimize withdrawal symptoms.
Gabapentin is approved in adults for post-herpetic neuralgia up to 3600 mg per day in divided doses. Dosage adjustment is needed in those with renal disease. It comes in an extended release form called Gralise. Gabapentin is often used off-label for other neuropathic conditions including diabetic neuropathy, generalized neuropathic pain, anxiety, and post-operative pain.
Pregabalin (Lyrica) can be used in adults for fibromyalgia, neuropathic pain (diabetes related), neuropathic pain in those with spinal cord injury and post-herpetic neuralgia. Both Pregabalin and duloxetine have been given regulatory approval for pain management in neuropathic diabetic pain in the United States, Canada and Europe.19
Topical lidocaine is used as first-line therapy for post-herpetic neuralgia. It must be applied to intact skin, and up to three patches may be applied for no more than 12 hours in a 24-hour period.
Muscle relaxants can be used in the management of acute and chronic pain. Cyclobenzaprine (Flexeril) was initially classified as a tricyclic antidepressant but was then remade as a muscle relaxer. Side effects are similar between the TCAs and the cyclobenzaprine including sedation, dry mouth, constipation, urinary retention and mental status changes.
Carisoprodol (Soma) is another commonly used muscle relaxer that has been increasingly linked to dependence. Due to the concerns of dependence, this medication is less commonly used. The most common side effect of all muscle relaxers is sedation.
In recent times, opioids therapy has become more commonly used; in the past, it was only used for severe acute pain and cancer pain. Approximately 8 million Americans with chronic pain are being treated with opioids.5 A recent position paper from the American Academy of Neurology suggested that there is evidence for good short-term pain relief with opioids, but no good evidence exists for continuation of pain relief or improved function for extended periods of time without sustaining serious risk of dependence, overdose, or addiction.20 Opioids function by activating opioid receptors that are located in the spinal cord and brain. The majority of the pain relief related to opioids is as a result of their actions on the cells in the PAG and the descending pain pathways.
Opioid medications are associated with multiple side effects including constipation, nausea, vomiting, pruritus, abdominal cramping, sedation, and mental status changes. Multiple interventions are available to reduce side effects.
Constipation is a frequent issue in those who use opioids. Risk factors for constipation include older age, those with intra-abdominal pathology and those who eat a low-fiber diet. Those on opiates should be encouraged to increase fiber intake, drink plenty of fluids and be encouraged to exercise. Stool softeners (e.g., docusate sodium) and stimulants (e.g., bisacodyl) may be needed to manage constipation. An osmotic laxative such as polyethylene glycol or lactulose may also be considered, which may be added to stools softeners/stimulants for resistant constipation.
Antiemetic medication can help treat nausea.
Antihistamines can treat pruritus.
Opioids are associated with somnolence and other mental status changes. Patients do develop tolerance to these symptoms over weeks. Reducing the dose may lessen the mental status changes. An adjunctive medication may be added to the lower dose of opioid to help manage the pain. Rarely, the use of a stimulant can be used to manage the sedation due to opioid use.
Respiratory depression may occur, but it is uncommon when the medication is used carefully. Starting low and slowly titrating the dose will reduce the risk of respiratory depression. Problems arise with rapid titration, the addition of another drug that may suppress the respiratory drive (benzodiazepine, alcohol or a barbiturate) or the patient overdoses. Sedation precedes respiratory depression, so when starting a patient on opioid therapy encourage them to take the first dose in the office to be monitored or in the presence of a responsible adult who can help monitor the patient. The level of consciousness should be assessed 30-60 minutes after the opioid is given. The next dose should be held and immediately contact the prescriber if there is a reduced level of consciousness, has hypoxia or has a respiratory rate less than 10 per minute.21 Tolerance and addiction are two serious concerns with opioid use. Tolerance refers to the fact that over a period time the amount of the drug taken must be increased to achieve the same amount of pain relief. Tolerance has become a problem with the long-term use of opioids and results from desensitization and down-regulation of opioid receptors in the body.
Addiction refers to the fact that withdrawal symptoms occur if the drug is stopped. Different opioids have different levels of risk for causing addiction, i.e. morphine, which is a naturally occurring opioid is highly addictive and produces a sense of euphoria. Synthetic opioids result in little or no feelings of euphoria and have less risk of causing addiction. Use of opioids over a prolonged period of time can have negative consequences for pain control – central sensitization caused by opioids can result in increased pain sensitivity known as hyperalgesia.3
The most serious risk linked with opioid use is overdose.5 Death from overdosing on semi-synthetic opioids occurs every 19 minutes in this country, and after car accidents, it is the second major cause of accidental deaths
While there are many opioids, morphine is considered by many as a standard comparator for other drugs. Morphine can be given orally, rectally, intravenously, subcutaneously or intramuscularly.
Morphine is used for moderate to severe acute pain and chronic serious pain. It comes in multiple formulations. For acute pain, it is dosed at 10-30 mg every 4 hours for those who are opioid naïve. It is available as tablet, solution, suppository and parenteral solution. The immediate release tablet is dosed 15-30 mg every 4 hours as needed and the oral solution is dosed 10-20 mg every 4 hours as needed. It can also be given rectally and is often dosed 10-20 mg every 4 hours as needed. Morphine also comes in a controlled release form, a sustained release form and an extended release form.
Longer-acting formulations include Avinza, Kadian, and MS Contin.
Side effects of morphine are similar to other opioid analgesics and include dry mouth, constipation, bradycardia, hypotension, nausea, drowsiness, dizziness, mental status changes, fever, itching, weakness, hypoxia and urinary retention.
Morphine should not be used in those with a hypersensitivity to morphine, those with toxin-mediated diarrheal disease, those with severe/acute asthma, paralytic ileus or severe respiratory depression. The extended release form should not be used in those with GI obstruction.
The extended release forms of morphine are not interchangeable. Changing from one medication to another should be done only by those experienced in how to do this. Extreme caution should be used when using highly concentrated solution, so overdoses do not occur.
Drug interactions commonly seen with morphine include:
- Amphetamines may increase the effect of morphine
- Anticholinergic agents may increase the side effects of morphine (constipation and urinary retention)
- Antipsychotic agents with morphine may reduce blood pressure
- Nasal azelastine (Astelin) with morphine enhances the central nervous system (CNS) depression effect
- Clopidogrel therapeutic efficacy may be reduced with morphine
- Diuretics side effects may be increased with morphine
- Hydrocodone enhances CNS depression
- Hydroxyzine enhances CNS depression
- MAO Inhibitors enhances side effects of morphine
- Selective serotonin reuptake inhibitors with morphine enhance the serotonergic effect and CNS depression
- Zolpidem enhances the CNS depression
Morphine is pregnancy category C. It does enter breast milk, and it is not recommended in those who are breastfeeding.
Fentanyl is a very strong synthetic opioid. It is 100 times more powerful than morphine and can be given as an injection, transdermal patch (Duragesic), an oral transmucosal lozenge (Actiq), a sublingual tablet (Abstral), a sublingual spray (Subsys), a buccal tablet (Fentora), a buccal film (Onsolis) and a nasal spray (Lazanda). The transdermal patch is used in opioid tolerant patients with moderate to severe pain and is often started at 25 mcg per hour and changed every 72 hours.
Fentanyl can be used for multiple reasons including premedication for surgery, for general anesthesia, as an adjunct to general and regional anesthesia, and chronic pain management. The transdermal patch is indicated for around the clock pain management in those with chronic severe pain. Fentanyl transmucosal and intranasal is indicated for cancer pain.
While no official dosage adjustment is recommended in those with renal or hepatic impairment, those with mild to moderate renal or hepatic impairment should likely have the dose reduced by 50 percent with the patch, and use is not recommended in severe renal or hepatic impairment. Transmucosal and nasal spray have no specific recommendations for dose reduction in renal or hepatic impairment.
Common side effects of fentanyl include dry mouth, edema, bradycardia, dehydration, respiratory depression, shortness of breath, diaphoresis, nausea/vomiting, constipation, application site erythema (patch), weakness, muscle rigidity, mental status changes, headache, sedation, and CNS depression.
As with most opioids, contraindications includes hypersensitivity, toxin-mediated diarrheal disease, and paralytic ileus. It should not be used for short-term pain, post-operative pain and should not be used for those who have a severe respiratory disease. The transmucosal and nasal form of fentanyl are typically only used by specialists for opioid-tolerant cancer patients.
The patch form should not be exposed to external heat as this may increase absorption of the medication. Exercising with the patch on has the potential to increase absorption of fentanyl. In addition, patients with a fever may also notice an increase in absorption of the medication. The patch should only be applied to intact skin; it contains aluminum and must be removed prior to an MRI.
Like many medications, there are multiple potential interactions. Some more common interactions include:
- Alcohol may enhance CNS depression
- Beta-agonists may decrease the serum concentration of fentanyl
- Amphetamines may enhance the effects of fentanyl
- Anticholinergic medications along with fentanyl increase the risk of urinary retention and constipation
- Antipsychotic agents may increase the risk of low blood pressure
- Azelastine nasal spray may enhance CNS depression
- Beta-blockers with fentanyl enhance bradycardia
- Calcium channel blockers may enhance hypotension or bradycardia
- Hydrocodone may enhance CNS depression
- Selective serotonin reuptake inhibitors with fentanyl may enhance serotonergic properties
- Zolpidem effects may be enhanced
Fentanyl is pregnancy category C. It does enter the breast milk and is not recommended in the breastfeeding mother.
Oxycodone is a schedule II controlled substance and is available in multiple forms.
- Immediate release (Roxicodone) is dosed 5-30 mg every 4-6 hours (lower range for opioid-naive patients). There is also an abuse deterrent tablet (Oxceta) that comes as a 5 mg and 7.5 mg tablet.
- The controlled release tablet (OxyContin) is indicated for those who require around the clock pain control. It is dosed 10 mg every 12 hours to start and titrated carefully.
Oxycodone is often combined with other analgesic agents such as acetaminophen (e.g., Percocet, Roxicet, Tylox), aspirin (e.g., Percodan, Endodan, Oxycodan) and ibuprofen (Combunox).
Those with a creatinine clearance less than 60 mL/min should have the dose adjusted down as serum concentration of oxycodone will increase in renal insufficiency. Those with hepatic impairment should have doses reduced; with the extended release formulation, the starting dose should be lowered one-third to one-half and slowly titrated up to affect.
Side effects include drowsiness, dizziness, itching, constipation, nausea and vomiting. Less common side effects include dry mouth, headache, abnormal dreaming, blood pressure changes, diaphoresis, weakness and fever.
Oxycodone is contraindicated in those with paralytic ileus, significant respiratory depression, hypercarbia, acute or severe bronchial asthma, and GI obstruction.
Caution should be used in those with biliary tract impairment such as acute pancreatitis as it may lead to constriction of the sphincter of Oddi. It may lead to an elevation of intracranial pressure (ICP) and should be used carefully in those with intracranial lesions, elevated ICP or a head injury.
Extended-release tablets may be lodged in the GI tract including the throat in those with swallowing issues. It may also lead to intestinal obstruction or diverticulitis.
Common drug interactions with oxycodone:
- Alcohol may enhance CNS depression
- Amphetamines may increase the effect of oxycodone
- Anticholinergic agents may increase the side effects of oxycodone (constipation and urinary retention)
- Antipsychotic agents with oxycodone may reduce blood pressure
- Nasal azelastine (Astelin) enhances CNS depression
- Diuretics side effects may be increased with oxycodone
- Hydrocodone enhances CNS depression
- Hydroxyzine enhances CNS depression
- MAO inhibitors enhance side effects of oxycodone
- Mirtazapine may enhance CNS depression
- Rifampin may decrease the serum concentration of oxycodone
- Selective serotonin reuptake inhibitors with oxycodone enhance the serotonergic effect and CNS depression
- Zolpidem enhances the CNS depression
Oxycodone is pregnancy category B and D if used for an extended period of time or near term. It does enter breast milk and is not recommended in those who are breastfeeding.
Hydrocodone, which was classified as a Schedule II Controlled Substance in October of 2014, is available as a combination pill with non-narcotic analgesia (e.g., Lorcet, Lortab, Norco and Vicodin) and by its self in an extended release form. The combination pill has a short acting version of hydrocodone and is dosed 2.5 to 10 mg of hydrocodone every 4-6 hours as needed for moderate to severe pain.
Hydrocodone extended-release (Zohydro ER) is typically dosed 10 mg every 12 hours in treatment-naive patients. It is used for severe pain requiring around the clock dosing of hydrocodone. The dose may be increased every 3-7 days in 10 mg increments.
Those with severe hepatic impairment should start at the lowest dose and titrate up very slowly while monitoring for side effects. Caution should be used with renal impairment as plasma concentration may rise.
Side effects include constipation, nausea, vomiting, dry mouth, drowsiness, headache, dizziness, pruritus and nausea.
Contraindications to hydrocodone include paralytic ileus, severe asthma, severe respiratory depression and hypercarbia.
- Alcohol may enhance CNS depression
- Amphetamines may increase the effect of hydrocodone
- Anticholinergic agents may increase the side effects of hydrocodone (constipation and urinary retention)
- Nasal azelastine (Astelin) enhance the CNS depression
- Diuretics side effects may be increased with hydrocodone
- MAO inhibitors enhance side effects of hydrocodone
- Selective serotonin reuptake inhibitors with hydrocodone enhance the serotonergic effect and CNS depression
- Zolpidem enhances the CNS depression
- Hydrocodone is pregnancy category C. The extended release form minimally enters the breast milk and should be used with caution in breastfeeding and the combination pill has been shown to enter breast milk and its use is not recommended.
As of August 18, 2014, the DEA placed tramadol into a Schedule IV of the Controlled Substance Act. It is indicated for moderate-to-severe pain, and the immediate release form is dosed at 50-100 mg every 4-6 hours for a maximum of 400 mg a day.
Tramadol is also indicated for chronic moderate-to-severe pain.
Tramadol also comes in an extended release form, ConZip and Ultram ER.
When prescribing tramadol to older adults, use the lower end of the dosage range and titrate slowly. In those over 75 years old, 300 mg a day should not be exceeded and utilize extreme caution with the extended release form.
In those with a creatinine clearance less than 30 mL/min, only the immediate release formulation should be used with doses of 25-100 mg split every 12 hours (maximum dose of 200 mg a day). In those with severe liver impairment, the immediate release form should be given to a maximum of 50 mg every 12 hours.
Side effects include flushing, dizziness, constipation, nausea, vomiting, dyspepsia, itching, headache, somnolence, insomnia and weakness. Less common side effects include orthostatic hypotension, mental status changes, euphoria, rash, hot flashes, diarrhea, dry mouth, anorexia, joint pain, blurred vision and sweating.
Patients may experience withdrawal symptoms from tramadol that may include nausea, diarrhea, anxiety, pain, sweating, tremor and rigors. Extended use of tramadol may lead to dependence, and these medications should be tapered slowly to reduce the risk of withdrawal symptoms.
Tramadol is contraindicated in those who are hypersensitive to the agent and those with severe liver or kidney impairment. The extended-release tablet should not be used with psychotropic drugs, opioids, hypnotics, acute intoxication with alcohol or centrally acting analgesics and the extended release capsule formulation should not be used in those with severe respiratory depression, severe asthma or hypercapnia.
Tramadol has been shown to increase the risk of seizures. This risk is increased in those who take serotonin reuptake inhibitors, tricyclic antidepressants, neuroleptics, other opioids, or other drugs that lower the seizure threshold. The risk may also be increased in those who have seizures or are at risk for seizures such as those who have a CNS infection, cancer, history of head trauma or while patients are going through drug or alcohol withdrawal.
Caution should be used in those with respiratory disease as those with significant disease may be at increased risk for respiratory depression.
- Alcohol may enhance CNS depression
- Amphetamines may increase the effect of tramadol
- Anticholinergic agents may increase the side effects of tramadol (constipation and urinary retention)
- Antiemetics may reduce the effects of tramadol
- Antipsychotics and tramadol may result in reduced blood pressure, increased risk of neuroleptic malignant syndrome and increased risk of serotonin syndrome
- Nasal azelastine (Astelin) enhances CNS depression
- Carbamazepine with tramadol may enhance CNS depression; tramadol may reduce the therapeutic effect of carbamazepine
- Cyclobenzaprine and tramadol may increase the risk of seizures or increase the risk of serotonin syndrome
- Diuretics side effects may be enhanced with tramadol
- Hydrocodone may enhance CNS depression
- Hydroxyzine may enhance CNS depression
- MAO inhibitors with tramadol may increase the risk of seizures or increase the risk of serotonin syndrome
- Metoclopramide with tramadol may increase side effects of metoclopramide or increase the risk of serotonin syndrome or neuroleptic malignant syndrome
- Selective serotonin reuptake inhibitors with tramadol may increase the risk of seizures or increase the risk of serotonin syndrome
- Tricyclic antidepressants with tramadol may increase the risk of seizures or increase the risk of serotonin syndrome
- Warfarin with tramadol may affect the anticoagulant effect
- Zolpidem enhances CNS depression
- Tramadol is pregnancy category C. It enters the breast milk and is not recommended in lactating women
Oxymorphone, a schedule II medication, can be given intravenously, subcutaneously, intramuscularly or orally. Oxymorphone is pregnancy category C, and it is unclear if it is excreted in breast milk and should, therefore, be used cautiously.
Hydromorphone can be given orally, rectally, subcutaneously, intramuscularly or intravenously. Hydromorphone is pregnancy category C and is excreted in breast milk. It is not recommended for lactating women.
Methadone can be given intravenously, subcutaneously, intramuscularly or orally. Methadone is a high-risk drug to lead to overdose. It has a half-life of up to five days and may accumulate in the body. Methadone may also prolong the QT interval leading to cardiac arrhythmias especially at doses higher than 120 mg a day. Methadone should be used for severe pain that has not been responsive to other agents and only by clinicians with specific training in the use of methadone. Methadone is also used in detoxification.
Tapentadol (Nucynta, Nucynta ER) is used for acute moderate to severe pain. This medication is not recommended for those with severe liver or renal insufficiency. It is also indicated for diabetic peripheral neuropathy.
Meperidine is not recommended as a first-line agent for chronic pain as it is associated with high rates of central nervous system toxicity.
Oxymorphone, a schedule II medication, can be given intravenously, subcutaneously, intramuscularly or orally. For acute pain, the immediate-release tablet (Opana) is used at 5-20 mg every 4-6 hours as needed for opioid naïve patients. For those with chronic severe pain, the extended release tablet is used (Opana® ER) and is started at 5 mg every 12 hours and may be titrated up at 5-10 mg increments every 12 hours every three to seven days.
Opioid Dosing in Pediatrics
Many narcotics are available in liquid form for pediatric use. Acetaminophen with hydrocodone is available as an elixir. Acetaminophen with oxycodone and oxycodone alone are also available in liquid form. The dose is based on the oxycodone and is dosed at 0.05 to 0.15 mg/kg/dose every 4-6 hours to a maximum of 5 mg per dose. Morphine is available as an immediate release formulation and is dosed at 0.2 to 0.5 mg/kg every 4-6 hours to a maximum of 30 mg per dose. Hydromorphone is dosed at 0.05 mg/kg
The Controlled Substance Act
The Controlled Substance Act divided drugs and other substances into five schedules, which is updated annually at http://www.deadiversion.usdoj.gov/21cfr/cifr/2108cfrt.htm.
Schedule I controlled substances have no accepted medical use in the United States; it includes heroin and lysergic acid diethylamide (LSD).
Schedule II and IIN substances may potentially be abused and may lead to severe physical or psychological dependence. Schedule II narcotics include oxycodone (OxyContin, Percocet), hydrocodone (Vicodin, Zohydro ER), Fentanyl (Sublimaze, Duragesic), methadone (Dolophine), hydromorphone (Dilaudid), morphine, opium, and codeine.
Schedule III or IIINsubstances have less abuse potential than those substances that are Schedule I or II. They are high risk for psychological dependence and low to moderate risk of physical dependence. Examples of medications in this class include buprenorphine (Suboxone) and products that have less than 90 milligrams of codeine per dosage unit such as Tylenol with codeine. Schedule IIIN include anabolic steroids such as Depo-Testosterone and ketamine.
Schedule IV controlled substances have a lower potential for abuse when compared to Schedule III controlled substances. Examples of this class include benzodiazepines, midazolam (Versed), tramadol (Ultram) and carisoprodol (Soma).
Schedule V controlled substances have a low abuse potential relative to Schedule IV and include cough preparations that contain less than 200 milligrams of codeine per 100 milliliters or per 100 grams such as Robitussin AC.
Most controlled substances alter mood, feeling or thought due to their effect on the central nervous system. Medications likely to produce euphoria are more likely to be abused, but medications may be abused to aid in sleep, reduce pain, reduce anxiety, reduce depression and improve energy.
When opioid therapy is prescribed, it is important to have a record of the discussion between the patient and provider. The documentation must include the diagnosis being treated and the medication that will be used to manage the diagnosis. In addition, the goals of therapy along with the anticipative results should be documented. Any alternative or additional therapies should be discussed. When discussing the medications, it is important to document significant adverse reactions, risk for addiction or withdrawal, and medication interactions.
Prevention of Misuse
To prevent prescription drug abuse, the clinician needs to assure:
- Patients are assessed and reassessed
- Treatment agreements are used
- Prescription monitoring occurs
- Safe prescription methods are practiced
Patients risk should be assessed and contraindications should be immediately identified. Contraindications to opioid treatment include those who have erratic follow-up, suffer from current untreated addiction or have poorly controlled mental illness.22 Patients should not be prescribed an opioid medication alone for pain control a non-opioid analgesia should also be included, particularly acetaminophen which functions centrally as an opioid sparing medication.2
When taking a patient history, document the opioid currently prescribed, its dose, the frequency of use and the duration of use. It is important to query the State Prescription Drug Monitoring Program (PDMP) to confirm the patient’s report of prescription use. In addition, it is important to contact past providers to obtain medical records.
Before controlled substances are prescribed, history of illegal substances use, alcohol use, tobacco use, prescription drugs use, family history of substance abuse and psychiatric disorders, history of sexual abuse, legal history, behavioral problems, employment history, marital history, social network and cultural background should be assessed. History of substance abuse does not prohibit treatment with opioids but may necessitate more intensive monitoring or referral to an addiction specialist.
Multiple tools are available to evaluate for opioid risk. The Opioid Risk Tool is a tool that is used in primary care to screen adults for the risk of aberrant behaviors when they are prescribed opioids for chronic pain. It is a copyrighted tool, encompasses five questions and takes about one minute to use. It classifies a patient as low, moderate or high risk to abuse opioids. Those who are high risk have a high likelihood of aberrant drug-related behavior. It is not validated in the individuals without pain. The five questions include asking about family and personal history of substance abuse (alcohol, prescription drugs or illegal drugs), age (risk is 16-45 years old), psychological disease and a history of preadolescence sexual abuse. The questions are scored with different points assigned to each question which is variable between men and women, and the total score is tallied. The patient is placed into low, moderate or high risk.
Regular follow-up is important and should occur at a minimum of every three months. When assessing the pain patient, the five A’s should be assessed: analgesia, addiction, activities of daily living, adherence and adverse effects. Part of follow-up should be urine drug testing which can be used to detect medication adherence as well as illicit and non-prescription drug use. It is critical that the clinician adequately documents any and all interactions with patients, assessments, results of testing and treatment plans.
Written treatment agreements, which should be used between prescribers and patients when controlled substances are used, help guide the conversation between patient and prescriber. It discusses expectations, the risks and the monitoring that will occur to limit the complications of controlled substances (Table 4).
Prescription monitoring programs are available in the majority of states, including Oregon. They provide an online database which lists all prescriptions of controlled substances dispensed to each patient by pharmacies. Ideally, the prescriber should check the database before prescribing controlled substances. If a patient has an undisclosed prescription for controlled substances, it is prescription drug misuse.
When abuse/misuse is detected how should the clinician respond? If it is a single, minor deviation, then counseling along with more intensive monitoring may be all that is needed. Tapering controlled substance to reduce the risk of withdrawal is appropriate in more severe or persistent cases of misuse. When diversion is the cause of misuse, immediate removal of the prescription is likely the best course. If a substance abuse disorder is suspected, a referral to an addiction specialist is recommended.
Marijuana use is still a controversial issue and is regarded by many as an addictive and dangerous substance leading to serious illegal drug use. But all indications point to marijuana being a safe substance when used in a medically controlled way. Unlike opioids, it does not cause respiratory depression, and studies have shown that it can reduce chronic pain by greater than 30%, which is comparable to the results achieve with opioids. It appears to be most effective with neuropathic pain, pain related to multiple sclerosis and fibromyalgia. The most common side-effect noted with the use of medical marijuana is dizziness. 5 The two active constituents of marijuana are Tetrahydrocannabinol (THC) and cannabidiol (CBD). Studies indicate that CBD provides good results in controlling pain, especially neuropathic pain. Research proposes that marijuana affects pain by its interaction with pain receptors located in the frontal region of the brain and the limbic area.3
Pain in Special Populations
One of the terrible fallacies that existed up until the recent past, including the 1980s, was that pediatric patients did not experience pain. The hypothesis was that babies, in particular, premature babies, had nervous systems that were too immature to allow them to feel pain.5 However, the reality is neonates feel pain like any other patient. Untreated or pain not treated appropriately may lead to long-term effects including altered sensitivity to pain.23
It is important to have a standard method to assess pain in neonates. It is difficult to assess pain in neonates and infants because they have limited ability to communicate. In this population, assessment is based on physiological and behavioral factors. Factors that suggest pain in the neonate and infant include vital signs, oxygen saturation, skin color, crying pattern, facial expressions, muscle tone and consolability. Scales for pain in neonates used in the neonatal intensive care unit include Neonatal Facial Coding System, Neonatal Infant Pain Scale and the Neonatal Pain Agitation and Sedation Scale. No tools are universally accepted to assess pain in infants and children. In neonates, pain assessment tools have a difficult time detecting pain in those with a very low birth weight, on paralytic medications or those that have prolonged pain.23
Due to the difficulty in finding and quantifying pain in the neonate and young child, pain management should include an attempt to reduce or prevent pain in the face of potentially painful situations. It is important to limit the number of painful procedures performed on young children.
Pain in children is similar to adults. The source of the pain, along with its location and severity should be ascertained. In older children, self-reporting is a reasonable technique to assess pain. For those too young to understand self-reporting, the use of scales such as the facial expression scale can be used. With the help of a caregiver, observing the child for verbal responses, motor responses or facial expressions will help the clinician determine the degree of pain in a non-verbal child.
Pain management in children should work to control, lower or prevent the pain. Pain management techniques are based on the severity, type, duration and source of pain. Non-pharmacological measures to control pain include physical/occupational therapy and cognitive/behavioral therapy.
Pharmacological agents may also be considered. When prescribing pharmacological agents for neonates and infants, there needs to be extra thought of immature body systems involved, and the increased risk of drug-induced toxicity due to decreased rates of hepatic metabolism and renal excretion.2 Mild pain can be managed with NSAIDs or acetaminophen. When pain is not responsive to these medications, the use of stronger medications including opioids are considered. Regular assessment of pain control during treatment will help assure proper pain management. When pain is moderate to severe, providing pain medication around the clock is a reasonable option.
Adjunctive therapy can be used in children including medications to manage co-morbid depression and anxiety. The use of anticonvulsants for neuropathic pain may also be considered.
Age does not cause pain, but many conditions that cause pain are more common in older adults. The national Health and Aging Trends Study conducted in 2011 showed that the incidence of troublesome pain among those 65 years and older was 52.9%, and almost 75% of older adults identified several pain sites. Among the most prevalent pain sites in older adults are the joints, typically the hips, and knees, as well as back pain. Osteoporosis is also a common cause of both acute and chronic pain in the older population and is associated with both spinal and hip fractures. Falls are a major concern, and it is estimated that one in three adults over the age of 65 years sustain a fall annually.2 Those with reduced vision, reduced hearing or impairments in cognition present a bigger challenge in the assessment of pain.
In individuals who are cognitively intact, self-report of pain is the most reliable method to assess pain.24 For those who have cognitive impairment, simple questions and basic screening tools can often reliably identify pain. Long-term care residents are often afflicted with some degree of cognitive impairment. Residents of long-term care facilities may present with behavioral changes or some physical change as the presentation of pain.
Older adults may not report pain as readily as younger adults. Some older adults believe that pain is part of aging and therefore do not bother to discuss it with the health care team. When assessing the older adult, it is important to determine their perception of pain. Some patients perceive severe pain as a sign of a serious illness or loss of independence, or they may believe this is just a consequence of aging.
When evaluating the older adult, it is important to have an accurate medication history including herbal medication and dietary supplements. Patients should also be asked about alcohol use, drug use and tobacco use.
It is also important to determine the patient’s coping techniques as this will help the nurse understand how the patient functions and to help them deal with the pain in the most effective way. Many older adults use prayer and hope to assist in coping with pain.
Goals should be set for the patient to determine an acceptable level of pain to allow the patient to have a satisfactory quality of life. Closely monitoring for adverse drug reactions is an important part of the management of chronic pain as many medications have many side effects. A balance should be sought between quality of life and side effects/risks of the treatment.
Older adults have some physiological changes that affect the way medications are used. There is slowing of the gastrointestinal transit time which may extend the effects of continuous release medications. Changes in gastric pH may affect absorption of some medications. Chronic liver changes may lead to changes in drug metabolism. Chronic renal insufficiency is common in older adults and may lead to a reduced clearance of medications.
Pain is often an ignored symptom of Parkinson’s disease; however, studies show that pain can be present for around 40% of individuals affected with Parkinson’s disease and that it can also be the first presenting symptom of the disease. Pain experienced with Parkinson’s disease may be central pain or musculoskeletal pain due to poor posture.3
The cognitive decline that occurs with Alzheimer’s disease may mask pain, and in advance stages of the disease, the patient is unable to express his or her pain experience. Even though pain can be difficult to assess in dementia patients, it’s estimated that at least 50% of those affected with dementia routinely experience pain. The most common types of pain that occur with dementia are often related to the musculoskeletal system, with osteoarthritis being a frequent finding in this population. Research has indicated that patients with Alzheimer’s disease experience the same pain sensitivity as those without the condition. Research has also shown that there is insufficient pain control for Alzheimer’s patients.3
Since pain is a subjective experience, we measure the existence and intensity of it by the patient’s self-report. Unfortunately, adult patients who have cognitive/expressive deficits or who are intubated, sedated, and/or unconscious may not be able to provide a self-report. Individuals who cannot communicate their pain remain a challenge and are at even greater risk for inadequate pain control. When patients cannot self-report, other measures need to be used to detect pain. Even if they cannot speak for themselves, these patients have the right to pain assessment and management. Valid and reliable methods to assess pain in nonverbal patients are clearly needed. The American Society for Pain Management recommends the following multifaceted approach for consideration in detecting pain in this population.25
- Use the Hierarchy of Importance of Measures of Pain Intensity for Nonverbal Patients
- Self-report of pain is the most reliable way to assess pain.
- Although self-report may be possible with mild to moderate cognitive impairment, as dementia progresses, the ability to self-report decreases and eventually becomes impossible. However, even if patients cannot communicate the experience of pain, they still experience pain sensation.
- Obtaining a report of pain from a critically ill patient may be hampered by such conditions as delirium, decreased level of consciousness, presence of an endotracheal tube, sedatives, and neuromuscular blocking agents, for example. In these situations, the patient’s ability to self-report may wax and wane; therefore, serial assessment of the ability to self-report should be conducted.
- Search for Potential Causes of Pain.
- Assume pain is present and intervene with common problems or procedures known to cause pain (e.g., surgery, wound care, positioning), even in the absence of behavioral indicators of pain.
- Rule out or treat other problems that may cause discomfort (e.g., infection, constipation, urinary retention)
- Consider chronic pain causes that may have been present before (e.g. history of arthritis or low back pain).
- Observe patient behaviors – a valid approach only when self-report is absent. The American Geriatrics Society identifies the following six main types of pain behaviors: (1) facial expressions (grimacing, e.g.), (2) verbalizations or vocalizations (moaning, e.g.), (3) body movements like tense body posture, (4) changes in interpersonal interactions (aggression or resisting care, e.g.), (5) changes in activity patterns (refusing food or increased wandering, e.g.), and (6) mental status changes like crying or increased confusion.
- Encourage proxy pain rating by family members or caregivers who know the patient when patients are unable to provide self-reports of pain. Inquire about behaviors that may indicate pain or whether preexisting conditions that may cause pain, such as arthritis, are present.
- Attempt an analgesic trial with procedures or conditions that are likely to cause pain or when pain behaviors continue after attention to basic needs and comfort measures. Make appropriate adjustments such as increases in dose or addition of other analgesics if behaviors indicative of pain persists, or additional potentially painful procedures occur.
- Self-report of pain is the most reliable way to assess pain.
- Establish a Procedure for Pain Assessment
- When patients are unable to self-report pain, other less reliable measures must be used to identify its existence. These assessment measures (described above) form a hierarchy, arranged in order of probable importance. Health care facilities should institute a procedure for the use of this hierarchy of assessment techniques as a template for the initial assessment and treatment procedure.
- Use Behavioral Pain Assessment Tools, as Appropriate
- The number of studies addressing assessment of pain in nonverbal adults who cannot provide a self-report has increased recently. Further study is required, though, to demonstrate their reliability, validity, and usefulness in the clinical setting. When utilizing behavioral pain assessment tools, one must keep in mind the following considerations:
- Scores obtained when utilizing behavioral pain assessment tools are NOT equivalent to self-reported intensity ratings and should never be documented as such. Only self-reported intensity ratings may be documented as the “5th Vital Sign”.
- Pain behaviors may not indicate pain, but another source of distress, such as emotional distress.
- It is best to observe a patient during care activities when pain behavior is more likely, rather than at rest.
- Behavioral assessment tools may be helpful to identify the presence of pain. They also can be used to evaluate attempts to relieve pain by observing for a decrease in pain behaviors following intervention.
- At least 14 behavioral assessment tools have been developed to assess for pain in nonverbal patients with dementia. These tools are in varying stages of development and validation. When selecting a tool, choose one that has been researched for reliability and validity in a similar clinical setting. Behavioral assessment tools for the cognitively impaired are of two types: pain behavior scales and pain behavior checklists.
- Pain behavior scales are scored by identifying the degree of observed behavior. This score is not the same as a pain intensity score. An example of a pain behavior scale is the Pain Assessment in Advance Dementia Scale (PAINAD). It evaluates and scores five categories of behavior: breathing, negative vocalization, facialexpression, body language, and controllability. Each category may receive a score ranging from 0 to 2. Any positive score may indicate that pain is present and the score can be used to evaluate intervention, but cannot be interpreted to mean pain intensity. For a pain behavior scale to be used, the patient needs to be able to respond in all categories of behavior. For example, the PAINAD should not be used with a patient who is a quadriplegic, since body language could not be scored.
- Behavior checklists differ from pain behavior scales. They do not evaluate the degree of observed behavior, but just its presence or absence, and do not require a patient to demonstrate all of the behaviors specified. An example of a pain behavior checklist is the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC). This checklist evaluates 60 behaviors such as restlessness, agitation, decreased activity, and appetite changes. The total number of behaviors that a pain exhibits cannot be equated with a pain intensity score. A patient who scores 5 out of 60 behaviors does not necessarily have less pain than a patient who scores 10 out of 60. In an individual patient, though, a change in the total number of behaviors may suggest more or less pain and can be used to evaluate response to interventions.
- Tools developed to assess pain with mechanically ventilated and/or unconscious patients are fewer in number. One such tool – the Adult Nonverbal Pain Scale (NVPS) – was patterned after the Faces, Legs, Activity, Cry, Consolability Observation Tool (FLACC) used to assess pain in infants and children. When tools are adapted, and used in different settings, they need to be tested for reliability and validity in the new patient population. The NVPS was tested in the burn trauma unit at Strong Memorial Hospital, Rochester, New York. After initial testing, further revision was made to include a respiratory component with ventilator compliance. This revised scale, which scores the categories of facial expression, activity, guarding, physiology (vital signs), and compliance with ventilator, is currently being implemented in several health-care institutions while undergoing further testing.
- Minimize Emphasis on Physiologic Indicators
Research does not support the use of vital sign changes for identifying pain. The absence of an increase in blood pressure, respiratory rate, or heart rate does not indicate absence of pain.
- Reassess and Document
Just as with patients who self-report pain, reassessment of pain with non-verbal patients’ needs to occur after intervention and regularly over time. Reassessment should occur utilizing the same initial behavioral pain assessment tool and observing for changes in those behaviors with effective treatment.2
- The number of studies addressing assessment of pain in nonverbal adults who cannot provide a self-report has increased recently. Further study is required, though, to demonstrate their reliability, validity, and usefulness in the clinical setting. When utilizing behavioral pain assessment tools, one must keep in mind the following considerations:
Pain in Pregnancy and Labor
Pregnancy is associated with many changes that have the potential to cause pain such as changing body shape, increasing weight, hormonal shifts and joint laxity. Acetaminophen is thought to be a safe option for pain control throughout pregnancy. NSAIDs should not be used in late pregnancy. NSAIDs have the potential to lead to premature closing of the ductus arteriosus if used in the third trimester.
Many different pain syndromes are commonly seen in pregnancy. Mechanical back pain due to weight distribution changes is one of the most common types of pain. Pain in the pubic symphysis is common and can be managed with position changes and the use of pelvic support devices. Leg cramps may be prevented and treated with calf stretching. Carpal tunnel syndrome is often seen during pregnancy and is likely related to fluid retention which causes compression on the nerves in the carpal tunnel. Symptoms of carpal tunnel syndrome most commonly come on in the third trimester and resolve after pregnancy, but may be prolonged by breastfeeding.
Labor is a painful period and treatment may involve a variety of techniques. The most reliable method to manage pain is with epidural and spinal analgesic techniques. The use of opioids induces sedation and thereby contributes to pain control. Unfortunately, opioids act systemically, and some effect may be transferred to the fetus leading to respiratory depression in the neonate.
Pain in the Psychiatric Patient
Psychiatric disorders are up to three times higher in those with chronic pain when compared to the general population. Depression, anxiety and post-traumatic stress disorder are the most prevalent psychiatric disorders in patients with chronic pain.26 The patient with pain and psychiatric disease typically reports more intense pain than the patient without co-morbid mental illness.
Chronic pain management has multiple challenges in psychiatric patients. Optimizing treatment of the underlying psychiatric illness is an important step in order to achieve an optimal reduction in pain. It is also important to screen and treat for any substance abuse or substance-induced disorder as this will help assure appropriate and adequate treatment of pain. Medications with abuse potential should be used cautiously, as there is a high prevalence of drug use disorders in psychiatric patients. The use of exercise and cognitive behavioral therapy is an important step in the management of pain in the psychiatric patient. In addition, monitoring for compliance is an important part of the management of the psychiatric patient who suffers from chronic pain.
Specific Pain Syndrome
Many conditions lead to visceral pain. Visceral pain occurs when there is stimulation of nociceptors of the organs in the abdomen, pelvis or chest. Visceral pain is diffuse, hard to pinpoint and often referred to a remote structure. Visceral structures are aggravated by ischemia, inflammation and stretch.
Chest pain can occur from many different etiologies. There are a few life-threatening situations that must be considered including myocardial infarction, pulmonary embolism, aortic dissection, tension pneumothorax and esophageal rupture. The majority of chest pain is not life threatening, and selected causes include chest wall pain (costochondritis, muscle strain), panic attacks, pneumonia, pleurisy, myocarditis, gastroesophageal reflux disease and pericarditis.
Abdominal pain is a common problem, and most cases are not life threatening. Like chest pain, it is important to rule out serious causes of abdominal pain immediately. Serious causes of abdominal pain are suggested by unstable vital signs, high fever, an inability to pass gas or have a bowel movement, vomiting blood or having dark/tarry stools. Common diagnoses that are potentially life-threatening include acute bowel obstruction, acute mesenteric ischemia, bowel perforation, ulcer, acute myocardial infarction and ectopic pregnancy. Other causes of abdominal pain include appendicitis, gallbladder disease, diverticulitis, constipation, kidney stones, lactose intolerance and inflammatory bowel disease.
Many patients have chronic abdominal pain, and many of these cases are benign – functional dyspepsia or irritable bowel syndrome. If no organic disease is found, then that patient should be treated symptomatically. Those individuals over the age of 50 are more likely to have a more serious cause of chronic abdominal pain, and functional abdominal pain should be thought of only after more serious causes have been ruled out.
Pelvic pain is a common problem in women and may represent a urologic, gynecologic, gastrointestinal, musculoskeletal, metabolic or vascular issue. Acute pelvic pain may be of visceral or somatic origin. In all women who have the possibility of being pregnant, a pregnancy test should be done. Other testing to rule out other causes of pelvic pain includes a complete blood count, sedimentation rate, chlamydia/gonorrhea testing, a serum hCG level and a urinalysis.
Diagnostic testing may include a pelvic ultrasound to rule out a mass or ectopic pregnancy, or a laparoscopy can help determine if endometriosis is present. Features that suggest a serious cause of pelvic pain include peritoneal signs, brisk vaginal bleeding, high fever or unstable vital signs.
There are many potential causes of chronic pelvic pain. Diagnosing and treating chronic pelvic pain can be challenging. Determining the exact cause of the abdominal pain may include the use of extensive laboratory evaluation, imaging modalities and at times exploratory surgery. For those with chronic pelvic pain, the examination may use a pain map to identify tender areas and see if physical exam tender areas match the pain map. Ideally, the clinician should attempt to treat the underlying cause of the pelvic pain, but the use of non-specific treatment may be considered when there is no specific diagnosis.
Sickle Cell Disease
Sickle cell crisis is a vaso-occlusive phenomenon leading to pain associated with blood cell destruction and subsequent anemia. While not the only feature of sickle cell disease, pain is a major component of the condition. Acute sickle cell disease pain is secondary to vaso-occlusion and the consequent tissue ischemia and inflammation. Over time chronic pain may result. Assessment of pain is challenging in sickle cell crisis as there are no objective findings that definitively confirm a crisis or the degree of pain.
An acute painful episode can be precipitated by multiple events such as stress, infection, weather conditions, dehydration or alcohol consumption. Pain can affect many parts of the body such as the chest, back, extremities or abdomen. Many times the pain is associated with fever, elevated breathing rate, hypertension, nausea and vomiting.
Treatment of pain in chronic disease can be challenging to manage. If mild pain is present and the patient is not on chronic opioid therapy, pain management should be started with non-opioid therapy moving to opioids when pain becomes more severe. Individuals who are on chronic opioids will require additional opioids for breakthrough pain. When treated in the emergency room, the use of intravenous morphine, hydromorphone or fentanyl can be used. If pain cannot be relieved with 2 doses, then admitting the patient to the hospital for pain management may be necessary. Many patients with sickle cell disease have chronic pain that is managed with long-acting opioids.27
Headaches are a frequent cause of recurrent pain and one of the most common diagnoses seen in health care. There are multiple types of headaches including migraine, tension, and cluster headache. Tension headache is the most common. It is important for the healthcare provider to understand red flags that suggest a serious cause of a headache. When a serious cause of a headache is suspected, urgent evaluation is necessary and may include the use of brain imaging to rule out an underlying secondary cause of a headache. Signs/symptoms that suggest a more serious cause of headache include:
- New onset headache, especially in those over age 40
- Worst headache of your life
- A headache with an accompanied neurologic sign or symptom – e.g., confusion, stiff neck, seizure, focal neurologic sign (e.g., one-sided weakness), impaired alertness
- Headaches that awaken the patient from sleep
- Fever and stiff neck
- Pregnancy – may suggest pre-Eclampsia
- History of cancer
- History of HIV or immune compromise
- Headache made worse by cough, exertion or the Valsalva maneuver
- History of recent head trauma
- Illicit drug use
- Progressive headache
Tension headaches may occur every day and have a variable presentation. Typically, they are described are pressure, tightness or aching. They may feel like a band around the head, and they may be bifrontal or bitemporal or generalized. Tension headaches can be intermittent with a variable duration or constant
Migraine headaches are classically one sided (but may generalize), are pounding or throbbing. Patients with migraines often have co-existent nausea/vomiting and/or photophobia.
An acute migraine can be managed with multiple agents. The use of acetaminophen or NSAIDs may be considered. When simple analgesics are not effective in the management of the pain, the use of migraine-specific agents (triptans or dihydroergotamine) may be considered. These agents are available in oral, rectal and injectable formulations. Oral agents are preferred by many patients, but for those with severe nausea that accompanies a migraine, a non-oral route is the best option. First line prophylactic agents for migraines include propranolol, amitriptyline, topiramate and valproic acid. Pain medication for headaches should be taken in such a way that the pain disappears, many times patients take less than the require amount, or they don’t take medication until the pain has reached an intolerable level which can result in poorly controlled prolonged periods of pain.3
Neuropathic Pain Conditions
Many conditions lead to neuropathic pain including multiple sclerosis, post-stroke pain, spinal cord injury, traumatic brain injury, syringomyelia, trigeminal neuralgia, peripheral neuropathy and post-herpetic neuralgia. Chronic neuropathic pain can be difficult to treat and result in a great deal of patient suffering.3
Multiple sclerosis (MS) is commonly associated with pain. It is estimated that 43 percent of MS patients have at least one painful symptom.28 Common painful symptoms include dysesthetic pain, back pain, spasms, Lhermitte sign, visceral pain and trigeminal neuralgia.
Central post-stroke pain is experienced as unilateral head/facial pain that starts within six months of a stroke. It affects up to 8 percent of stroke victims.29 The pain is typically persistent but may come and go. The severity of the pain may be variable, and stress often exacerbates the pain.
Treatment of central post-stroke pain include benzodiazepines; anticonvulsants such as gabapentin, pregabalin, lamotrigine or carbamazepine; baclofen; antidepressants such as amitriptyline or a SSRIs; and clonidine. When pain is resistant to pharmacotherapy, the use of neuromodulation (deep brain stimulation) and surgery may be considered.
Spinal cord injury (SCI) patients often develop chronic pain after spinal cord injury that affects the quality of life. Pain is often poorly localized and neuropathic in nature (e.g., burning, stabbing). The pain can be evoked or spontaneous. Pain can be at-level pain (pain at the level of the SCI) that is caused by injury to the nerve roots and dorsal gray matter causing pain at the level of the injury. Pain can also be below the level of the SCI which is thought to be caused by injury to the spinothalamic tractsand/orthalamic deafferentation.
Pain may be managed with antidepressants (e.g., tricyclic antidepressants), antiepileptics (e.g., gabapentin, lamotrigine or valproate), and standard analgesic medications (opiates). When medications are not effective, the use of invasive treatments is considered. These may include deep brain stimulation, cordotomy or motor cortex stimulation.
Syringomyelia is a delayed progressive intramedullary cystic degeneration that affects a small number or patients after spinal cord injury. It is thought to occur from scarring and subsequent obstruction of cerebral spinal fluid flow and altered tissue compliance leading to extension of the central canal which presses on the nearby cord tissue.30
Trigeminal neuralgia results in head/facial pain coming from one or more of the branches of the trigeminal nerve. Classically the pain is unilateral, brief, stabbing and/or lancinating that is sudden in onset.
Imaging, typically with an MRI, is sometimes done to distinguish primary from secondary trigeminal neuralgia. Primary disease has no identifiable lesion causing the symptoms. Secondary causes of trigeminal neuralgia include acoustic neuromas, multiple sclerosis, cerebral aneurysms and trigeminal neuromas. Secondary disease is more common if there is bilateral involvement; it occurs at a younger age; or if there is associated sensory loss.
Conditions that may mimic trigeminal neuralgia include dental pain, multiple sclerosis, herpes zoster or atypical headaches.
Treatment for the pain of trigeminal neuralgia includes carbamazepine and oxcarbazepine. For those who are intolerant or non-responsive to these agents, baclofen or lamotrigine can be used. Surgical options are sometimes tried for refractory cases.
Peripheral neuropathy can come from many etiologies including diabetes, cancer, alcohol and HIV. Peripheral neuropathy typically presents with distal sensory loss, weakness, numbness and/or burning. The presentation may be variable.
Neuropathy due to diabetes is one of the more common types of neuropathies. They typically result in symptoms that begin in the lower extremities. Sensory symptoms are seen first; followed by motor symptoms. Patients complain of a gradual sensory loss, numbness, a burning sensation and pain in the feet, and mild gait abnormalities. Overtime weakness may develop and a “stocking and glove” distribution of sensory loss may occur. Physical exam findings depend on which nerve fibers are involved.
Treatment of neuropathies includes treating the underlying disease (e.g., control blood sugar in diabetes) and medications to treat the symptoms. Medications used to manage the pain of neuropathy include tricyclic antidepressants, duloxetine, gabapentin, pregabalin, carbamazepine, topiramate, tramadol and NSAIDs.
Post-herpetic neuralgia is pain that presents after a herpes zoster infection, which is caused by the varicella zoster virus. Certain groups are at higher risk to develop pain after a herpes zoster infection. These include older individuals, those who had higher levels of acute pain during the acute infection and those with a more severe rash.31
Herpes zoster is an infection that starts with a sharp, burning, stabbing pain that follows a dermatome. A rash will be seen a few days later along the same dermatome. Commonly affected dermatomes include the thoracic, cervical and trigeminal nerves. After the rash abates, some individuals develop pain along the same dermatome that persists longer than four months. Pain may persist for years or even throughout life. Allodynia is often seen in those with post-herpetic neuralgia.
Post-herpetic neuralgia is commonly treated with tricyclic antidepressants, pregabalin and gabapentin. Topical capsaicin or lidocaine can be used. Opioids are sometimes used but should be used cautiously. They are considered second or third line options and are sometimes used while the TCAs, pregabalin, gabapentin take effect, then tapered. If all other options are not effective, the use of intrathecal glucocorticoids may be considered.
Chronic low back pain is the fifth most frequent cause of a visit to see a physician.5 Most cases of back pain are non-specific and will improve within a few weeks with conservative treatment, but some people develop chronic pain. Those more likely to develop chronic back pain include those with functional impairment, poor health, psychiatric co-morbid conditions, maladaptive pain coping behaviors and non-organic signs – such as pain in the low back when pressing directly on top of the head.32 Non-invasive treatments are recommended as the safest and most appropriate approach to the resolution of back pain.5 Less than one percent of patients with back pain have a serious cause of back pain, and less than ten percent have specific etiologies.32 When back pain is present, it is important to rule out any serious pathologies. Serious pathologies are suggested by certain red flags (See Table 5)
A complete history and physical exam is an important part of the exam to rule out serious causes of back pain and help identify the cause of the back pain.
Certain conditions that are more urgent require immediate imaging with an MRI and referral, including those who have any red flags. Those who have not improved after 4-6 weeks of conservative therapy may be considered for imaging. Patients who have conditions that may benefit from surgery or epidural injections should have imaging. Other conditions that are helped by imaging include osteoarthritis and ankylosing spondylitis.
Back pain should not be treated with bed rest, but modifying activity slightly to account for the pain is appropriate. Oral analgesics should be used short-term to provide pain control. Re-evaluation should occur at four weeks to assure improvement, evaluate for any needed testing and reevaluate the need for pain medications.
Initial oral agents should include NSAIDs for 2-4 weeks. Those with an allergy or contraindication to NSAIDs may consider acetaminophen. When pain is not controlled with NSAIDs the use of a muscle relaxant may be considered. For those who cannot take a muscle relaxant, the combination of an NSAID and acetaminophen is an option.
The use of opioids and tramadol should be used very judiciously in acute low back pain and only in those who are not getting pain control from other agents or contraindications to those other agents.
Physical therapy can be used for acute low back pain but is more often used for chronic low back pain. One of the most important aspects in the management of back pain is education. Patients should be educated on the causes of back pain, the expected course of back pain, its encouraging prognosis, the value of diagnostic testing, treatment options and when to contact their healthcare provider.
Neck pain can occur from multiple pathologies including trauma, muscle strain or disc pain. The majority of cases of neck pain will resolve within three weeks. Initial treatments are conservative including oral analgesics (acetaminophen or NSAIDs for mild or moderate pain; short-term opioids for severe pain), posture modification and exercise.
Chronic neck pain has multiple treatment options. The use of a long-term cervical collar is not recommended. The use of a cervical collar to manage severe pain for less than three hours a day for at a maximum of 2 weeks may be considered. Physical therapy and home exercises should be used.
Pharmacological options for chronic pain include: acetaminophen; NSAIDs; a low-dose antidepressant, especially in those who have pain that interrupts sleep; a muscle relaxant may be considered for those with muscle spasm; and rarely opioids.
Other options for pain management include trigger point injections, cervical medial branch blocks, TENS units, and radiofrequency neurotomy. Surgical evaluation may be considered in those with myelopathy or neurological symptoms associated with radiculopathy.
Complex Regional Pain Syndrome
Complex region pain syndrome (CRPS) is broken down into type I and II. It is a disorder of the extremities illustrated by regional pain that is inconsistent in degree or time to the expected pain. The pain is localized around a certain territory.
The primary clinical manifestation is pain that is typically described as stinging, burning or tearing and is exacerbated by movement, temperature variation, stress or any contact. In addition, some individuals have allodynia or hyperalgesia. The patient may also notice differences in skin color or temperature. The affected side may be more edematous or sweat more when compared to the other side. Limb movement is typically impaired by pain, edema or contractures. The patient with CRPS may also have unilateral variations in hair or nail growth along with skin atrophy.
The progression of the condition is variable over time. The underlying pathology is not well understood but may include inflammation and changes in pain perception in the central nervous system.
CRPS I is the more common type and is diagnosed when the typical symptoms are present and there is no evidence of a peripheral nerve injury. CRPS II is less common and is present when there is evidence of a peripheral nerve injury.
CRPS is more commonly seen in women. It is often associated with some acute event that starts the syndrome. An example of an event may include trauma such as a broken bone or a crush injury. The diagnosis is made on clinical exam after other conditions are ruled out.
Treatment of CPRS should involve a multidisciplinary approach including physical and occupational therapy, physiological interventions and pharmacotherapy. Pharmacologic options include NSAIDs, tricyclic antidepressants, gabapentin, or topical treatments (lidocaine or capsaicin). Other less common options include calcitonin, glucocorticoids, alpha-adrenergic agonists/antagonist (e.g., prazosin, clonidine), ketamine, and opioids. Multiple interventional approaches may be considered including regional sympathetic nerve blocks, trigger/tenderpoint injections and spinal cord stimulation
Phantom Limb Pain
Phantom limb pain is aching, burning or shock-like pain where an amputated limb used to be, and is related to the perception of self. Sensory input from various parts of the body forms a ‘body map’ in the brain. When a limb is amputated, that map still exists in the brain leading to the feeling of pain and other sensations in the amputated body part.3 It is important to rule out other cause of the symptoms, such as infection or wound on the stump, ischemia or neuroma, before diagnosing phantom limb pain. The incidence of this condition is variable, and it is hypothesized that not controlling pain before and after the surgery increase the risk of phantom limb pain. It has been shown that stopping pain transmission in the spinal cord for 72 hours prior to the amputation surgery by using lumbar epidural blockage (LEB) has a positive long-term effect in preventing amputation pain. Also, aggressively managing pain immediately after surgery reduces the risk of developing phantom limb pain.3Multiple agents are helpful in the management of phantom limb pain including acetaminophen, NSAIDs, TCAs, and gabapentin. In addition to medication, non-pharmacologic methods to manage pain include TENS units, mirror therapy (which helps resolve the visual-proprioceptive disconnect), biofeedback and occasionally surgical interventions.
Pain is very prevalent in cancer. It is present in up to one-half of patients when first diagnosed with cancer and according to some estimates up to 100 percent of people with advanced cancer.33 Fear of uncontrolled pain is one of the most prevalent findings among cancer patients. Research shows that around 70% of cancer patients have severe pain at some point during the disease process.2
Pain in cancer can be acute or chronic. Acute pain is seen during interventions such as surgery, tissue injury or radiation therapy. Acute pain can also be felt secondary to the cancer itself such as an obstructed bowel, a perforated bile duct, bleeding from a liver cancer or a pathological fracture. Chronic pain during cancer is typically related to the tumor itself or as a complication of treatment.
Neuropathic pain is also seen in cancer patients. Neuropathic pain in cancer can arise from the tumor pressing on a nerve or nerve plexus. In addition, neuropathic pain can be a result of the treatment as many chemotherapeutic agents or radiation therapy have the potential to cause nerve injury. Many conditions that result in neuropathic pain – such as herpes zoster, post-herpetic neuralgia – are relatively common in cancer patients.
‘Breakthrough’ pain is a debilitating, and often difficult to control occurrence for cancer patients. It can be defined as acute, severe pain that has a rapid and unpredictable onset.2 It requires analgesia that has a rapid onset and necessitates re-evaluation of the patient’s pain management regime.
Management of cancer pain is typically aggressive. The use of opioids is common in chronic cancer pain, and doses should be titrated to find effective pain control. Agents commonly used include hydromorphone, morphine, oxycodone and hydromorphone. These agents are preferably given orally or transdermally. Dosing is commonly started with short-acting agents, but for those with chronic pain switching over to a long-acting formulation is preferred with the continued use of short-acting agents for break-through pain. The dose for breakthrough pain is typically about 10 percent of the basal daily opioid dose. Individuals who need rapid titration do well with the use of opioids given via infusion by the IV or SC route.
While morphine is traditionally a common agent that is used, other agents have a good effect in certain situations. For those with swallowing difficulty or poor ability to absorb from the GI tract, the use of fentanyl can be used. Hydromorphone or fentanyl is recommended for those with renal insufficiency. Bone pain is another serious debilitating issue for many cancer patients to cope with, either as a primary lesion or as metastatic bone pain. Bisphosphonates, medications that are used to decrease the loss of bone mass are being used along with analgesic drugs to help alleviate bone pain in cancer patients.2
While looking at cancer pain, it is also important to exam pain related to the treatment of cancer, chemotherapy pain. Several chemotherapy agents can cause neuropathic pain, including Paclitaxel, Cisplatin, and vinca alkaloids, for example, vincristine and vinblastine.5
Palliative and End of Life Care
Palliative and End of Life Care have become two distinct terms. The population of palliative care patients has expanded to include those who are not necessarily close to death but are suffering from chronic conditions that require symptom control and pain management.
End of Life Care requires skilled pain management to allow for a peaceful death with dignity. Morphine is the gold standard for end of life pain relief and is the most effective medication for the treatment of dyspnea. Morphine functions by changing the patient’s awareness of their breathing experience by decreasing the respiratory drive, and the intake of oxygen.2
Fibromyalgia (FMS) is a condition characterized by chronic widespread musculoskeletal pain. Patients also complain of fatigue, sleep disturbances, psychiatric symptoms, cognitive disturbances and multiple other somatic complaints. The etiology and pathophysiology are unclear.
In FMS, pain is typically diffuse and persistent. It is often described as stiffness, deep aching, soreness, burning or throbbing. Patients typically report that pain is persistently present, but the intensity may vary. Poor sleep, excessive stress, and/or exposure to cold may exacerbate the pain. Generally, pain is worse in the morning and improves throughout the day. Pain commonly affects the neck, shoulders, back, arms, legs and chest wall.
Fibromyalgia is more common in women and has been shown to be six times more common when compared to men. The prevalence is about 2-3 percent in the United States. It is the most common cause of generalized musculoskeletal pain in females aged 20 to 55.34
Patients with FMS often complain of hurting all over or feeling as though they have the flu. It is diagnosed in those with chronic pain and no hint of muscle inflammation.
Differential diagnosis of FMS includes osteoarthritis, autoimmune disease, rheumatoid arthritis, systemic lupus erythematosus, hypothyroidism, inflammatory myopathy, systemic inflammatory arthropathies, spondyloarthritis, ankylosing spondylitis, myositis and polymyalgia rheumatic.
Education is a critical step in the treatment of FMS. The condition must be explained to the patient including treatment approaches. Key aspects of patient education include:
- Symptoms will vary over time – fatigue and pain typically persist.
- It is a benign disease, and this should be taught to the patient. The patient must understand that the disease will not deform the patient, lead to a cosmetic issue or become life-threatening.
- Emotional or physical stress may increase symptoms. The patient should be taught stress-reduction and relaxation techniques to help in the management of the condition.
- While infection may be a precipitating factor, it is not a persistent infection that causes the symptoms.
- Neurohormonal abnormalities may account for fatigue, pain, mood disturbance and sleep disturbance.
- Exercise should be encouraged but may increase pain – especially early in an exercise program.
- Other non-pharmacological methods to manage FMS include supervised physical therapy, cognitive behavioral therapy, biofeedback, tai chi or yoga.
Medications are often used in the management of FMS. Typically, non-pharmacological methods are used first and when they are not effective the addition of medication is considered. Commonly used medications include low dose tricyclic antidepressants, selective serotonin reuptake inhibitors, pregabalin, duloxetine, cyclobenzaprine and milnacipran. When utilizing medications, the dose should be started low and built up gradually.
Amitriptyline, milnacipran and duloxetine are fist line agents for fibromyalgia, but most patients do not find significant improvement (some improvement was noted with sleep and pain, but fatigue and quality of life were only minimally improved) on these medications and many have significant side effects.35
When first line agents do not work, a combination of medications can be tried. For example, the use of duloxetine in the morning and a tricyclic antidepressant before bed is one such combination. Combinations of medications work through different mechanisms of action and focus on different symptoms.
At times the addition of analgesics or anti-inflammatory medication can be tried. The use of acetaminophen, NSAIDs or tramadol may be considered to target pain when more traditional FMS agents do not work. Generally, opioids should be avoided in FMS.
Rheumatoid arthritis (RA), a chronic destructive, sometimes deforming disease, attacks the collagen in the body, especially in the joints. Rheumatoid arthritis is associated with widespread symptoms such as fatigue, fever, poor appetite, nerve damage and increased size of the spleen and lymph nodes. RA can irreversibly damage joints. Therefore, early diagnosis and treatment to control inflammation can improve outcomes of the disease.
Treatment options include psychosocial care, patient education, therapy and pharmacologic treatment. A rheumatologist should be involved in the care of patients with RA as disease-modifying antirheumatic drugs (DMARD) are complex to use. If therapy is started soon, the patient will experience better outcomes. DMARD therapy is complex and requires a lot of monitoring. For this reason, DMARD is beyond the scope of this article.
The use of NSAIDs and glucocorticoids are also used in the management of RA. They can be used as bridging therapy to get quick control of inflammation until the DMARDs take effect and can be used for pain control.
Osteoarthritis is the most prevalent joint condition globally, and is one of the leading sources of pain and disability in older adults.2
Arthritis affects twenty percent of adults and costs more than $128 billion annually in the United States. As the population ages, the burden of OA will increase.36 Managing arthritis improves mobility, decreases falls, decreases death rates and improves quality of life.
Osteoarthritis is defined as a joint disease with deterioration of the joint and abnormal bone formation. OA is present when the endings of the bones – called cartilage, which normally cushion the bones – no longer do their jobs. The ends of the bones rub together, and the cartilage wears away.
Treatment of osteoarthritis focuses on pain control and maintaining function. In the near future, there may be treatments available to reverse or even cure the disease process, but at present symptom control is the only option. Treatment focuses on medications and non-medication means to control the pain and minimize disability.
Non-drug treatment is first line management as it bypasses the negative effects drugs have on the body. Non-drug treatments include exercise, nutrition, physical and occupational therapy, heat and cold treatments, ultrasound, weight loss, magnets and patient education.
When non-drug methods do not provide adequate relief, medications are used to treat OA. Acetaminophen, primarily due to its lack of negative side effects when compared to non-steroidal anti-inflammatory medications, is recommended as fist line treatment for OA.37 Acetaminophen is more likely to be beneficial if the arthritis is not inflammatory.
Topical NSAIDs may be used especially if the disease is localized to one area. Topical agents are associated with a significantly less adverse event profile than systemic agents. In the United States, diclofenac sodium topical gel and diclofenac sodium topical solution are available for the management of osteoarthritis.
Other topical agents can provide significant relief for patients with OA. Capsaicin (Zostrix) decreases the neurotransmitter called substance P, which is involved in the transmission of pain. Capsaicin is applied three to four times a day. It takes Capsaicin a few weeks before it provides significant pain relief. Hands should be washed after contact with the substance.
Another topical agent sometimes used for the treatment of localized pain is the lidoderm patch. The patch is not approved by the Food and Drug Administration for use in OA but is often used. It is a small patch applied to the skin around the painful joint wore for no more than 12 hours a day.
Other options include tramadol, codeine, hydrocodone, hydromorphone, oxycodone, fentanyl, and morphine.
Intra-articular steroid injections can be used for painful joints. This injection involves placing a needle directly into the arthritic joint and injecting a steroid along with a numbing agent. No more than three injections per year should be given.38
When medical treatment fails, surgery is the next option. Surgical options include arthroscopy, osteotomy, total joint arthroplasty, or joint fusion.
Pain is a disagreeable sensory and emotional experience connected with actual or potential tissue damage or explained in terms of such damage. Many conditions have the potential to cause pain. Understanding these conditions, how to assess them and how to treat them are a vital part of adequately managing the pain. In the current health care system, much pain is not even addressed. Many regulatory agencies have implemented guidelines within the health care system to help with addressing the pain epidemic.
In February 2013, a report issued by the United Nations stated that certain types of abuse in healthcare settings “may cross a threshold of mistreatment that is tantamount to torture or cruel, inhuman or degrading treatment or punishment.” In particular, the United Nations report emphasized that countries drug control laws should recognize the “indispensable nature of narcotic and psychotropic drugs for the relief of pain and suffering,” and governments should appraise national laws, “to guarantee adequate availability of those medicines for legitimate medical uses” 5
It is the role of the health care team to perform a good initial pain assessment and an on-going assessment of pain. Proper pain management requires a team approach in the assessment and treatment of pain. Many options are available for the management of pain including non-pharmacological options, non-opioid medications, opioid medications, and adjunctive medications. Opioid analgesics, while very good at managing pain, have led to many social and legal problems including overuse and diversion.
The health care team also has the responsibility to partner with the patient to properly manage the pain. Each health care team member has their role in the management of pain. If health care team members perform their role and the patient takes an active role in his/her care, the adequate treatment of pain is a very attainable goal.