Pain Management –

Peggy Mossholder, RN, MSN

Assistant Professor
UNDERTREATMENT
Study outcomes reveal undertreatment
67% of metastatic cancer patients experience pain
50% hospitalized during terminal phase experienced pain (SUPPORT, 1995)
80% of patients in long term care experience pain – only 40-50% are given
analgesics (Ferrell, 1995)
COST OF UNDERTREATMENT
40 million physician visits per year for pain related complaints
Improving pain management costs less than continuing practices that result in inadequate
relief of pain (McCaffery & Pasero, 1999)
Pain is:
An unpleasant sensation caused by noxious stimulation of sensory nerve endings, usually
as a result of disease or injury.
“Whatever the experiencing person says it is, exists whenever they says it is.”
Subjective and highly individualized
Leading cause of disability and is often the reason for seeking health care.
Signals that something is wrong
ACUTE PAIN VS CHRONIC PAIN
Acute Pain
is rapid in onset,
varies in intensity from mild to severe,
Lasts for up to six months
When underlying cause is resolved pain disappears
Chronic Pain
Lasts for six months or longer
Interferes with normal functioning
May be intermittent or persistent
Seems to have no protective purpose
May lead to depression, anger, withdrawal & dependency
Classification of Pain - ORIGIN
Nociceptive
Normal processing of stimuli that damages normal tissue
Somatic
Visceral
Neuropathic
Abnormal processing of sensory input by peripheral or CNS
Damage to PNS or CNS
Indicators
Somatic
Well defined, localized, short duration, throbbing
Cutaneous (skin),
Deep Somatic (bone, muscle, joints)
Visceral
Dull, poorly localized, longer duration
Organ, tumor, obstruction
Neuropathic
Sharp, stabbing, burning, persistent
Related to phantom pain, diabetic neuropathy, damage to nerve tissue

Classification of Pain - Attributes

Radiating
Back  legs
Referred Pain
MI  Lt arm
Phantom Pain
Pain focused on a missing body part
Intractable Pain
Highly resistant to relief

Mechanism of Pain Perception

Pain Physiology - Modulation
The Body’s Analgesia System
Regions of the midbrain are stimulated
 endogenous opioids (enkephalins, dynorphins, beta endorphins) are released
 bind with opiate receptor sites in nerve system
 decrease/block pain impulses and perception.
(often does not function with chronic pain)
The Gate Control Theory
Impulses can be blocked by gate between transmission cells in the dorsal horn of the
spinal cord.
Sensory impulse travel by large A and small C fibers pass thru gate
High A fiber (stimulated by heat, cold, touch) closes gate to the small C fiber
stimulated by pain
Gating mechanisms may be activated by thoughts, feelings, distraction

Reaction / Responses
Pain threshold – amount of stimulation the person needs to feel pain.
Pain tolerance – the maximum amount & duration of pain that a person is willing to
endure
Pain reaction – includes the physiological, behavioral, and affective responses to pain
Physiological Responses
Moderate & Superficial = sympathetic response
Increase resp. rate, dilation of bronchial tubes
Increase heart rate
Pallor & increased BP
Increased blood glucose
Increased output of adrenaline
Diaphoresis
 Muscle tension
Dilated pupils
Decreased gastric motility
Physiological Responses
Severe & Deep = parasympathetic response
Pallor
Rapid, irregular breathing
Nausea & Vomiting
Weakness, exhaustion, fatigue
Fainting, unconsciousness
Prostration
Decreased heart rate, decreased BP
Behavioral Responses
Moving away from the painful stimuli
Clenching the teeth
Holding the painful part
Grimacing
Bending over
Tensing the abdominal muscles
Crying, moaning
Refusing to move
Restlessness
Making frequent requests of the nurse
Affective Responses
Withdrawal
Anxiety, fear
Depression
Anger
Anorexia
Hopelessness
Powerlessness
stoicism

Factors Influencing Pain

Age
Gender
Culture
Meaning
Attention
Environment
Anxiety, fatigue, other stressors
Past pain experiences
Psychological variables
Nursing Assessment
ABCDE
Ask
Believe
Choose
Deliver
Empower
Pain Assessment
Location
Intensity
Quality
Pattern
Precipitating
Factors (precipitating – alleviating)
Associated symptoms
Effects on ADL’s
Coping resources
TOOLS
Pain Scales
Number scale
Visual analog
Color scale
FACES
Behavioral indicators
**Note: Kozier: 1142, 1143, 1144
Nursing Diagnosis
Activity intolerance
r/t unrelieved pain
Ineffective coping strategies
r/t lack of knowledge
Powerlessness
r/t lack of participation in decision making
Anxiety
Fear
Knowledge deficit
Self-care deficit
Treatment Modalities
Pain management interventions can be directed at three points:
Interrupting peripheral transmission of nociception
Modulating pain transmission at the spinal cord level
Altering the perception and integration of nociceptive impulses in the brain
Interrupting Peripheral Transmission of Pain
Often the first step in controlling pain
Application of heat or cryotherapy used alter blood flow and reduce swelling
NSAIDs decrease prostaglandins; many significant SEs including gastrointestinal
bleeding, decreased platelet aggregation, and renal insufficiency
Local anesthetic agents may be used for localized pain
Modulating Pain Transmission at the Spinal Cord
Cutaneous stimulation activates and recruits large sensory fibers that can block the
central progression of nociceptive transmission at the interneurons
Transcutaneous electrical nerve stimulation (TENS)
Massage
Acupuncture
Cryotherapy
Therapeutic touch
Altering the Perception and Integration of Pain
Analgesics work at specific receptor sites located throughout the body but are highly
concentrated in the brain
Opioid analgesics have similar mechanisms of action but very widely in potency
Tolerance is the need for increasing dosages to achieve the same analgesic effect
Dependence is characterized by withdrawal symptoms if treatment is stopped
abruptly
Pharmacologic and Nonpharmacologic Pain Management
Nociceptor activation altered by prostaglandin inhibitors (NSAIDs), heat and cold, and
local anesthetics that block sodium influx through fast channels
Spinal cord transmission can be altered by cutaneous stimulation, intraspinal analgesics,
and dorsal column stimulators
Pain can be altered by systemic analgesics, guided imagery, biofeedback, hypnosis, and
distraction

ANALGESIC GROUPS
Non-opioids
Opioids
Adjuvants

NON-OPIOIDS
Most effective with nociceptive pain
Provide relief for mild pain
Combined with opioid analgesics for both additive analgesic effects or opioid dose-
sparing effects
Examples: acetylsalicylic acid 650 mg every 4 hours, acetaminophen 650 mg Q 4 hr,
ibuprofen 400 mg q 4-6 hr, naproxen 250-500 mg q 12hr, fenoprofen 200 mg q 4-6 h,
indomethacin 25-50mg q 8 hr, ketorolac15-60 mg 4-6 hr, celecoxib 100-200 mg q 12-
24 hr.(arthritis).

OPIOIDS
Provide pain relief primarily through CNS action binding to opioid receptor sites in brain
and spinal cored
Receptor sites include mu, kappa, delta
Pain relief occurs when opioid binds to one or more of these receptors as an agonist
Expect physical dependence – withdrawal will occur when abruptly discontinued or
antagonist (Narcan) is given
Prevent withdrawal by reducing 25%
Tolerance to side effects will occur in few days (other than constipation)
Foundation for analgesia

OPIOID - Options
Codeine
Oxycodone (Percodan)
Propoxyphene (Darvon)
Morphine
Hydromorphone (Dilaudid)
Fentanyl (Duragesic)
Methadone
Levorphanol
Meperidine (Demerol)

OPIOID ROUTES
Oral – preferred
Intramuscular
Subcutaneous
Intravenous – PCA
Transdermal
Rectal
Stomal
Intraspinal

OPIOID SIDE EFFECTS

Constipation
Sedation
Pruritis
Mental Status Changes
Respiratory Depression

EQUIANALGESIA
Refers to doses of various opioid analgesics that provide approximately the same pain
relief
Equianalgesic chart
Provide basis for selecting the appropriate starting dose

BREAKTHROUGH DOSING
Also referred to as “rescue dosing”
Refers to pain that increases above the pain addressed by the ongoing analgesics
Occurs in 2/3 of patients on opioids
Calculated as a range from 1/10 to 1/6 of total daily dose
Adjust when around-the-clock (ATC) dose increases
Provide every 1-2 hours; may take with ATC dose
TITRATION
Titration refers to adjusting the amount or dose of an opioid
Dose increases typically made at the onset or peak effect of analgesic
Goal is to provide smallest dose that provides greatest relief with fewest side effects
Titrate in increments of 25% and up
If pain is moderate, increase by 25-50%

DEFINITIONS
Addiction – a pattern of compulsive drug use characterized by a continued craving for an
opioid and the need to use the opioid for effects other than pain relief (APS,1999)
Pseudoaddiction-the patient who seeks additional medications appropriately or
inappropriately secondary to significant under-treatment of the pain syndrome.
Tolerance – a form of neuroadaptation to the effects of chronically administered opioids,
which is indicated by the need for increasing or more frequent doses of the
medication to achieve the initial effects
Physical Dependence – a physiologic state in which abrupt cessation of the opioid results
in withdrawal syndrome.
MANAGING SPECIAL POPULATIONS
Recovering addict
Geriatrics
Cognitively impaired
Dying
Pain in the Young and Elderly
Young and old often receive inadequate pain management
Inadequate pain treatment in neonates and infants can result in hemodynamic instability,
catabolism, and poor surgical outcomes
Pain perception does not decrease with aging, but communication and expression of pain
may vary
ETHICAL CONSIDERATIONS
Patient’s rights
Principle of Double effect
Advocacy
Unethical use of placebos

References in Lewis, 7th Ed.

Chapter 10, PG 125-149.
Table 10-1: Harm of unrelieved pain
Green Box: pg 127 – Gender differences
Table 10-2: Comparison of Nociceptive and Neuropathic Pain
Table 10-3: Differences of acute vs chronic pain
Table 10-4: Core Principles of pain assessment
Table 10-7/8/9: Drug Therapy
Table 10-10: Nonpharmacologic Therapy
Table 10-11: Hot & Cold Therapy
Table 10-15: Pt/Family Teaching Guide