CHAPTER 46: PAIN MANAGEMENT

Pain

- Margo McCaffery - “ Pain is whatever the person says it is and exists whenever he says it does”

- an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of
such damage

IASP - International Association for the Study of Pain

Three Aspects:

- Pain is a physical and emotional experience, not all in the body or all in the mind

- it is in response to actual or potential tissue damage, so laboratory or radiographic reports may not be abnormal despite the
real pain

- pain is described in terms of such damage (e.g. neuropathic pain)

Pain management - alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the client

Types of Pain:

- may be described in terms of location, duration, intensity

Location:

- radiate - spread or extend to other areas

- referred - appear to arise in different areas to other parts of the body

- visceral - pain arising from organs or hollow viscera; is often referred to perceived in an area remote from the organ causing
the pain

Common sites of referred pain from various body organs:

Duration:

- acute - lasts only through expected recovery

period

- chronic - persistent pain; prolonged, recurring,

lasts 3 months or more, interferes with body
functioning

- cancer pain - malignant pain; result from direct

effects of the disease and its treatment
Difference between acute and chronic:

Intensity - most practitioners classify intensity of pain by a standard scale (0-10)

- 1-3 - mild pain

- 4-6 - moderate pain

- 7-10 - severe pain

Etiology:

Nociceptive pain - experienced when an intact, properly functioning nervous system sends signal that tissues are damaged,
requiring attention and proper care

Somatic pain - originates in the skin, muscled, bone or connective tissue

Visceral pain - activation or pain receptors in the organs or hollow viscera

Neuropathic pain - damaged or malfunctioning nerves due to illness

- typically chronic; described as burning, electric shock, tingling, dull and aching

- episodes of sharp, shooting pain can also be experienced

Peripheral neuropathic pain - phantom limb pain, carpal tunnel syndrome

- follows damage or sensitization of peripheral nerves

Central neuropathic pain - spinal cord injury, post-stroke pain, multiple sclerosis

- results from malfunctioning of nerves in CNS

Sympathetically maintained pain - abnormal connections between pain fibers and the sympathetic nervous system

Concepts associated with pain:

- pain threshold - least amount of stimuli that is needed for a person to label a sensation as pain

- pain tolerance - maximum amount of pain stimuli that a person is willing to withstand without seeking relief

- hyperalgesia and hyperpathia - used interchangeably to mean heightened response to painful stimuli

- allodynia - nonpainful stimuli that produces pain (light touch, contact with linen, water or wind)

- dysesthesia - mimics pathology of central neuropathic pain disorder

- sensitization - increased sensitivity

- wind-up - progressive increase in excitability and sensitivity of spinal cord neurons, leading to persistent, increased pain

Physiology of Pain:

Nociception - the peripheral nervous system includes specialized primary sensory neurons that detect mechanical, thermal, or
chemical conditions associated with potential tissue damage

- When these nociceptors are activated, signals are transduced and transmitted to the spine and brain where the signals
are modified before they are ultimately understood and then “felt”

- the physiological process related to pain perception

Four physiological processes:

- transduction

- transmission

- perception

- modulation

Transduction - specialized pain receptors can be excited by mechanical, thermal, or chemical stimuli

Transmission - second process of nociception; includes three segments

- first segment - pain impulses travel from peripheral nerve fibers to spinal cord

- second segment - transmission of pain signal though ascending pathway in the spinal cord to the brain

- third segment - transmission of transformation to the brain where pain perception occurs
Perception - client becomes conscious of the pain

Modulation - descending system

- neurons in the brain sends signal back down to the dorsal horn of the spinal cord

- these descending fibers release substances such as endogenous opioids, serotonin, and norepinephrine, which

can inhibit or reduce the ascending painful impulses in the dorsal horn

Physiology of pain reception:

Gate control theory - small diameter (A-delta or C-fibers) peripheral nerve fibers carry noxious stimuli signals to the dorsal horn,
where these signals are modified when they are exposed to the substantia glatinosa which may be imbalanced in the excitatory
or inhibitory direction

Response to pain - sympathetic nervous system responds, resulting in the fight or flight response, with noticeable increase in
pulse and blood pressure

Wind up phenomenon - resulted of repeated pain signals that cause stronger and longer responses in the CNS

Factors affecting pain experiences:

- ethnical and cultural values

- middle eastern and african

Pain intensity rating scale:

- numeric rating scale -

determine extent of pain
awareness and degree of
interference with
functioning

- 11 point (0-10) rating scale

- Wong and Baker Faces

Pain Rating Scale

Barriers to Pain
Management:

- tolerance - the client’s

opioid dose, over time,
leads to a decreased sensitivity of the drug’s analgesic effect

- physical dependence - expected physical response when a client who is on long-term opioid therapy has the opioid
significantly reduced or withdrawn

- addiction - chronic, relapsing, treatable disease influenced by genetic, psychosocial, and environmental factors

- pseudoaddiction - condition that results from the undertreatment of pain where the client may become so focused on
obtaining medications for pain relief that they become angry and demanding

Pain descriptions:

Preemptive analgesia - adm of analgesics before surgery to decrease or relieve pain after surgery

WHO Three-Step Analgesic Ladder:

- clients with mild pain (1 to 3 on scale) - step 1 of the analgesic ladder, nonopioid analgesics (with or without a coanalgesic) is
the appropriate starting point

- client has mild pain that persists or increases despite using full doses of step 1 medications, or if pain is moderate *4 to 6 on
scale) - step 2, opioid for moderate pain or a combination of opioid and nonopioid medicine with or without coanalgesic
medications

- client has moderate pain that persists or increases despite using full doses of step 2 medications, or if the pain is severe (7-10
on scale) - step 3, opioid for severe pain is adm and tirated in ATC scheduled doses until the pain is relieved
Categories and Examples of Analgesics:

NONOPIOID ANALGESICS/NSAIDS FOR MILD PAIN

• Acetaminophen (Tylenol, Datril)

• Acetylsalicylic acid (aspirin)

• Choline magnesium trisalicylate (Trilisate)

• Ibuprofen (Motrin, Advil)

• Indomethacin sodium trihydrate (Indocin)

• Naproxen (Naprosyn), naproxen sodium (Anaprox)

• Ketorolac (Toradol)

• Piroxicam (Feldene)

• Meloxicam (Mobic)

• Celecoxib (Celebrex) Cox II NSAID

OPIOID ANALGESICS FOR MODERATE PAIN

• Hydrocodone (Lortab, Vicodin)

• Codeine (Tylenol No. 3)

• Tramadol (Ultram, Ultracet)

• Pentazocine (Talwin)

OPIOID ANALGESICS FOR SEVERE PAIN

• Fentanyl citrate (Sublimaze, transdermal patches,

Actiq lozenges)

• Hydromorphone hydrochloride (Dilaudid)

• Oxycodone (OxyContin)

• Morphine sulfate (morphine)

• Oxymorphone (Opana)

• Methadone (Dolophine)

COANALGESICS

• Tricyclic antidepressants (nortriptyline, amitriptyline)

• Anticonvulsants (gabapentin, pregabalin)

• Topical local anesthetic (Lidoderm)

Nonopioids/NSAIDs - include acetaminophen and nonsteroidal anti-inflammatory drugs such as aspirin or ibuprofen
Aspirin is the most common NSAID and is available over the counter

Acetaminophen (Tylenol) - does not affect platelet function and rarely causes GI distress

Common Prescription Pain Medications containing Acetaminophen:

MEDICATION

• Tylenol No. 3 (325 mg acetaminophen/30 mg codeine)

• Percocet (325 mg acetaminophen/5 mg oxycodone)

• Lortab (500 mg acetaminophen/5, 7.5, or 10 mg hydrocodone)

• Vicodin (500 mg acetaminophen/5 mg hydrocodone)

• Tylox (500 mg acetaminophen/5 mg oxycodone)

• Darvocet-N 100 (650 mg acetaminophen/100 mg

propoxyphene)

• Vicodin ES (750 mg acetaminophen/7.5 mg hydrocodone)

OPIODS

Three primary types of opioids:

1. Full agonists - pure opiod drugs bind tightly to mu receptor sites, producing maximum pain inhibition, an agonist effect

- a full agonist analgesic includes morphine, the gold standard opioid

2. Mixed agonists - antagonists - Agonist-antagonist analgesic drugs can act like opioids and relieve pain (agonist effect) when
given to a client who has not taken any pure opioids

- they can block or inactivate other opioid analgesics when given to a client who has bee taking pure opioids

3. Partial agonists - have a ceiling effect in contrast to a full agonist

- these drugs such as buprenorphine block the mu receptors or are neutral at that receptor but bind at a kappa receptor
site

Opioid analgesics for moderate pain - these include drugs such as codeine, hydrocodone, and tramadol. Most of these drugs are
combinationsof a nonopioid with an opioid

Opioid analgesics for severe pain - pure agonist opioid analgesics include opium derivatives , such as morphine,
hydropmorphone, oxycodone, fentantyl, and methadone
Opioid Side effects:

- respiratory depression

- sedation

- nausea/vomiting

- urinary retention

- blurred vision

- sexual dysfunction

- constipation

Pasero Opioid-Induced Sedation Scale:

• S = Sleep, easy to arouse

• 1 = Awake and alert

• 2 = Slightly drowsy, easily aroused

• 3 = Frequently drowsy, arousable, drifts off to sleep during conversation

• 4 = Somnolent, minimal or no response to physical stimulation

Equianalgesic - refers to the relative potency of various opioid analgesics compared to a standard dose of parenteral morphine

Coanalgesic - formerly known as adjuvant; it is a medication that is not classified as a pain medication

Intraspinal analgesia adm:

1. Bolus - single or repeated bolus dose(s) may be provided

2. Continuous infusion adm by pump - the pump may be external (for acute or chronic pain) or surgically implanted (for chronic
pain) to provide a continuous infusion of pain relievers into the epidural or intrathecal space

3. Continuous plus intermittent bolus - with this mode of operation, the client receives a continuous infusion with bolus “rescue”
doses adm for breakthrough pain

- often a pump with patient-controlled epidural analgesia (PCEA) capabilities is used for this mode of operation

Patient-controlled analgesia (PCA) - interactive method of pain management that permits client to treat their pain by
self-administering doses of analgesics

- IV route - most common in an acute care setting

Nonpharmacologic Pain Management:

- consists of a variety of physical, cognitive-behavioral, and lifestyle pain management strategies that target the body, mind,
spirit, and social interactions
Nerve block - chemical interruption of a nerve pathway, caused by injecting a local anaesthetic into the nerve