Interventions for Pain
TERMS
acupressure
acupuncture
adjuvant medications
aromatherapy
around-the-clock dosage schedules
biofeedback
cultural alternatives
distraction
equianalgesic
guided imagery
massage
nonopioid analgesics
nonsteroidal anti-inflammatory drugs (NSAIDs)
opioids
over-the-counter medication
potentiators
prescription medication
PRN
therapeutic touch
touch
transcutaneous electric nerve stimulation (TENS)
QUICK LOOK AT THE CHAPTER AHEAD
Once effective assessment of pain is complete, pain management strategies must be identified to promote optimal pain relief. Some ways to manage the client’s pain may be pharmacological, including analgesics, opioids, and anesthetics. Other options may be physiological, including methods of transcutaneous stimulation, postural changes, or use of acupuncture or acupressure points. Finally, behavioral measures including education, relaxation, guided imagery, or other client choices can be incorporated into the plan. The plan of care may include traditional medical approaches as well as nontraditional, cultural, or religious variables, which may be identified either by the client or caregiver. When designing the plan of care, it is important to include both traditional and nontraditional interventions for optimal relief, rather than take an all-or-none approach. One single intervention rarely provides complete relief for the client. This chapter will provide a review of many of the pain management strategies available, but research continually uncovers new strategies as well as innovative and different ways to utilize old ones.
CASE STUDY
Mrs. L., a 48-year-old woman who is active and in excellent health, has torn her anterior cruciate ligament (ACL) while waterskiing. She now complains of severe pain, which interferes with her usually very active lifestyle. She has used ibuprofen for pain relief with poor success. She states that she has been unable to ride her bike, that kneeling to do her gardening has become impossible, and that even walking has become painful.
On physical examination, her knee is swollen, red, and warm to touch. Because Mrs. L. is in good health and prefers her previous level of activity, ACL repair is planned.
MEDICATION FOR PAIN MANAGEMENTMedication is a commonly used and well-received intervention for pain management. It is used with or without the participation of a healthcare provider. The client or client’s family may choose an over-the-counter medication perceived as appropriate to the client’s symptoms or may choose to use a prescription medication either left over from a previous experience with pain or belonging to someone other than the client. When the client chooses to contact the health-care provider for treatment of pain, he or she often expects medication as an intervention.
Despite the fact that medication is the primary expectation when a client seeks out a healthcare provider for pain management, one single intervention rarely provides complete relief for the client.A wide variety of medications are available for pain management. They include commonly used “pain” medications as well as adjuvant medicines, which moderate factors that can cause or aggravate pain or mediate the activity of the primary medication. Medications that treat the cause of the pain are also instrumental in relieving pain. Medication for specific painful conditions such as angina or neuroleptic pain can be used. Rarely is a single medication successful in alleviating pain unless it is used to treat pain with a very specific causative factor or the pain is quite mild.
The “five rights” for medication administration safety are:
The right drug
The right dose
The right time
The right route
The right client
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Pain is usually classified as mild, moderate, or severe. Severity of pain, along with type and location, are parameters used in initially choosing a medication protocol. Common pain medications include nonopioid analgesics and opioids (narcotics). Nonopioids include acetaminophen, salicylates like aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs) including ibuprofen. These medications, some of which also have antipyretic or anti-inflammatory properties, are chosen to treat mild to moderate pain. With the advent of availability of over-the-counter NSAIDs several years ago (e.g., Motrin, Advil), all three of these types of medications are available to clients for self-treatment of mild to moderate pain.
Dose Schedules
One drawback in the use of these medications is dosage scheduling. They may be prescribed by healthcare professionals or used by clients on an as needed (PRN) basis, not taken until pain is evident or until discomfort is becoming worse. It becomes more of a challenge to alleviate present pain than to prevent recurrence of pain. For this reason, around-the-clock dosage schedules may be more effective for optimal pain relief.
Prevention of pain or of increased severity of pain is a more desirable outcome than treating pain that has already begun or is increasing in severity.Therefore, around-the-clock dosing is significantly more effective for optimal pain relief.
Side Effects and Toxicity
Nonopioids are limited in that they have a ceiling or maximum safe dose beyond which significant toxicity can occur, presenting danger to the client. Each drug has its own specific ceiling and cluster of side effects, which should be known and readily recognized by the healthcare provider who is prescribing their use (Table 3-1). Most medications in these classes are available primarily in oral dose form; however, several are available in suppository form. Several rarely used NSAIDs are available for parenteral administration.
Acetaminophen, aspirin, and NSAIDs are relatively inexpensive, readily available, and do not cause central nervous system (CNS)-related side effects such as bowel or bladder problems, sedation, or respiratory depression. NSAIDs, however, can cause gastrointestinal bleeding because they block prostaglandin synthesis and can interfere with the mucosal barrier of the gastrointestinal tract.
Table 3-1 Dosing Data for Oral NSAIDs | ||||||||||||||||||||||||||||||||||||
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Because renal function depends on prostaglandins, NSAIDS should also be used cautiously in individuals with impaired renal function. Each year there are approximately 107,000 hospitalizations with more
than 16,500 deaths related to side effects of NSAIDs. Individuals at risk for gastrointestinal side effects of NSAIDs may be given cyclooxygenase isoenzyme (COX-2) inhibitors for their analgesic effect. COX-2 inhibitors have a better safety profile than NSAIDs because of their sparing effect on platelet aggregation and on the gastrointestinal tract. Although these COX-2 inhibitors have decreased risk for gastrointestinal bleeding, they too are contraindicated in some client populations. Caution should be taken when considering COX-2 inhibiters for clients who have had allergic reactions to sulfonamides or in clients who have experienced asthma, urticaria, or allergic reactions after taking aspirin or other NSAIDs.
than 16,500 deaths related to side effects of NSAIDs. Individuals at risk for gastrointestinal side effects of NSAIDs may be given cyclooxygenase isoenzyme (COX-2) inhibitors for their analgesic effect. COX-2 inhibitors have a better safety profile than NSAIDs because of their sparing effect on platelet aggregation and on the gastrointestinal tract. Although these COX-2 inhibitors have decreased risk for gastrointestinal bleeding, they too are contraindicated in some client populations. Caution should be taken when considering COX-2 inhibiters for clients who have had allergic reactions to sulfonamides or in clients who have experienced asthma, urticaria, or allergic reactions after taking aspirin or other NSAIDs.
Is there a comprehensive medication history available to plan prescription choices?
Pain is classified as mild, moderate, or severe.Opioids
When pain is moderate to severe, or NSAID or COX-2 inhibitor therapy has failed, the addition of an opioid to the treatment plan is indicated. However, it is important to consider if the failure is related to PRN dosing. Prior to adding an opioid, review the NSAIDs dosage schedule. If PRN dosing was used, it may be possible to have success with NSAIDs administered around-the-clock.
NSAIDs are good potentiators of opioid medication.Opioids work by binding with opioid receptor sites in the central and peripheral nervous systems. Using NSAIDs in combination with opioids usually results in effective pain management with smaller necessary doses of opioids, thereby reducing the risk of CNS side effects associated with opioid use. In addition to CNS side effects, opioids are associated with physical tolerance and psychological dependence. Physical tolerance is unusual in the client with pain using opioids for a short period.
Codeine, oxycodone, morphine, meperidine (Demerol®) and hydrocodone are all opioids commonly used in pain management. Oral forms of codeine, oxycodone, and hydrocodone are often used to treat moderate pain in combination with acetaminophen. Oxycodone and hydrocodone are not available in parenteral formulations, so codeine may be chosen for those clients who cannot tolerate oral medication. Clients often report nausea, vomiting, sedation, and feelings of “disconnectedness” with
these medications. If one of these medications causes unpleasant side effects such as nausea, the client may be able to tolerate one of the other choices. Codeine and the codeine derivatives are frequently prescribed as pain therapy following outpatient invasive procedures, including diagnostics and dental surgery. They are inexpensive and come in combination tablet form with NSAIDs. It is important to be aware of the ceiling dose of the combined NSAID when titrating medication dosages upward for pain relief.
these medications. If one of these medications causes unpleasant side effects such as nausea, the client may be able to tolerate one of the other choices. Codeine and the codeine derivatives are frequently prescribed as pain therapy following outpatient invasive procedures, including diagnostics and dental surgery. They are inexpensive and come in combination tablet form with NSAIDs. It is important to be aware of the ceiling dose of the combined NSAID when titrating medication dosages upward for pain relief.
Nausea or other uncomfortable symptoms are not necessarily cause for discontinuing or changing a medication for pain. If acceptable pain management is possible, try treating the symptom rather than changing medications.Morphine sulfate and hydromorphone (Dilaudid®) are more commonly used for severe pain or after procedures when it is expected that severe pain will occur, such as major surgery. These medications are often administered parenterally, but addition of an NSAID when the client can tolerate oral medication may increase comfort and decrease the need for opioids.
Meperidine is another medication used after procedures, but it is not recommended in elders or in clients with renal dysfunction. If meperidine is given parenterally, it should only be used for 48 hours because of the risk of meperidine toxicity. When meperidine is prescribed, doses should be adequate to provide good pain relief and given frequently enough. It is often prescribed in inadequate doses with no consideration for its very short serum half-life.
Never use meperidine in patients with renal dysfunction, or patients at high risk for renal dysfunction, such as diabetics.Morphine sulfate is the “gold standard” for opioid pain relief. It is against this standard that dosing and efficacy are measured and equianalgesic tables are constructed. It is available in oral, parenteral, and rectal preparations, as well as in immediate-release and extended-release oral forms. Clients using morphine may experience nausea and vomiting, which usually resolves within 24 hours of the first dose and is responsive to conventional antiemetic therapy. Itching is another unpleasant side effect described by a small percentage of clients who use morphine. Inability to provide comfort from these side effects requires consideration of a different opioid for pain relief.
In addition to sedation and respiratory depression, opioids can cause constipation, which can have a significantly negative impact on quality of life. Baseline bowel assessment should be done, with continued assessment for regular bowel activity during opioid use. Addition of extra fluids and extra fiber to the diet or a bulk laxative with adequate fluid intake should be instituted when the client can tolerate it.
Efficacy of opioid use depends on assessment or evaluation for pain relief, as well as the presence of medication side effects. Poor relief in the absence of side effects indicates the need for increased doses of the opioid. Other medications that enhance the activity of the opioid or reduce factors that cause or exacerbate pain should also be considered for use. These are called adjuvant medications—drugs used in addition to the already prescribed therapy. Use of adjuvant medications does not preclude continuing to use NSAIDs previously incorporated into the opioid regimen.
Untreated constipation related to opioid use will increase a client’s level of discomfort.Potentiators of opioids include benzodiazepines and phenothiazines. Anti-anxiety medications such as diazepam (Valium®) or lorazepam (Ativan®) promote relaxation, may reduce muscular tension, and reduce anxiety. Lorazepam and antihistamines also act as antiemetics, reducing nausea and vomiting. Diphenhydramine (Benadryl®), a common antihistamine, when used with morphine can help to relieve nausea and itching. Steroids reduce inflammation. It is important to consider undesirable side effects, such as increased sedation, which may be enhanced by the adjuvant medications.
Finally, certain medications are specific to certain pain syndromes. Neuroleptic or nerve pain is poorly relieved with traditional doses of opioids, and the pain is often too severe to respond solely to anti-inflammatory therapy. Phantom pain following amputation or pain from nerve compression by tumor or fracture are two good examples of this type of pain. Tricyclic antidepressants and anticonvulsant medications are very useful in relieving this type of pain. However, it has been demonstrated that larger-than-usual doses of opioids, particularly morphine, effectively relieve this type of pain. In place of large doses of morphine, some practitioners consider the use of methadone, which is highly effective but has greater risk of multiple side effects.
Methadone has been used in treatment of opioid addiction but is currently being used in treatment of severe pain. It is a drug that, with
repeated dosing, has high affinity for the mu receptors and demonstrates greater efficacy than other opioid drugs. For this reason, it is a very good choice for treating pain, such as neuroleptic pain, at lower doses than morphine. Severe toxicities may not become evident until several days of methadone therapy, so great care should be taken when starting methadone as medication for pain management.
repeated dosing, has high affinity for the mu receptors and demonstrates greater efficacy than other opioid drugs. For this reason, it is a very good choice for treating pain, such as neuroleptic pain, at lower doses than morphine. Severe toxicities may not become evident until several days of methadone therapy, so great care should be taken when starting methadone as medication for pain management.
Cardiac anginal pain, which occurs as the result of inadequate oxygen to the myocardium, responds to morphine partly because the sedating effect reduces cardiac metabolism, simultaneously reducing the oxygen deficit. Vasodilators are successfully used to relieve anginal pain, both cardiac and elsewhere in the body, by increasing circulation and oxygen delivery to the affected area. Local anesthetic agents are used topically or subcutaneously for local pain control.
Routes of Administration
Choice and administration of medications include considering the “five rights” in client-focused safety: the right drug, the right dose, the right time, the right route, and the right client. Choosing an appropriate route for medication administration takes into consideration many factors. Oral medication is commonly the easiest and most cost-effective route of choice. It is appropriate when the client can safely swallow and tolerate oral intake.
Whenever possible, choose the oral route—easy, cost effective, and well received by clients and family.When oral administration is not an option, relatively less invasive routes include sublingual, rectal, and transcutaneous. Choices among these routes are dictated by the availability of medication for that particular route, as well as client-specific issues.
Injectable administration is a relatively more invasive or traumatic choice. Clients may have fears or preconceptions about receiving injections. There is a small chance of infection, especially with poor technique. Although small, the risk for infection is greater than with previously described administration choices. Subcutaneous injection allows for delivery and absorption of small volumes of fluid; intramuscular injection will accommodate larger volumes, but
still no more than 2.5 cc. Absorption and delivery of medication to central circulation is slower and less reliable with subcutaneous injection. Poor peripheral circulation and loss of subcutaneous tissue further decrease the efficacy of medication delivery with subcutaneous injection.
still no more than 2.5 cc. Absorption and delivery of medication to central circulation is slower and less reliable with subcutaneous injection. Poor peripheral circulation and loss of subcutaneous tissue further decrease the efficacy of medication delivery with subcutaneous injection.
Clients and families can be taught to administer subcutaneous injections, but only if they are willing.
Subcutaneous injections require smaller, finer needles for injection, resulting in minimal pain and trauma.
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