Course Book 1

A Nurse’s Guide to Pain
Management
Course #150 6 Contact Hours
Margo McCaffery, MS, RN, FAAN

and Chris Pasero, MS, RN
© Copyright 1992
Revised 1997, 1999, 2001, 2003
A Nurse’s Guide to Pain Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
Table of Contents
How to Take This Course · · · · · · · · · · · · · · · · · · · iii
Course Objectives · · · · · · · · · · · · · · · · · · · · · · v
About the Authors · · · · · · · · · · · · · · · · · · · · · vii
Chapter One: Understanding the New Joint Commission

Standards · · · · · · · · · · · · · · · · · 1
Chapter Two: Pain Assessment:

Debunking the Myths and Misconception · · · · 13
Chapter Three: Techniques of Pain Assessment · · · · · · · · 25
Chapter Four: Using Analgesics · · · · · · · · · · · · · · 39
Chapter Five: Pain Management: Equianalgesia · · · · · · · 53
Chapter Six: Nondrug Pain Relief Measures· · · · · · · · · 67
Appendix: Educational Resources · · · · · · · · · · · · 79
Examination · · · · · · · · · · · · · · · · · · · · · · · · 85
Course Evaluation· · · · · · · · · · · · · · · · · · · · · · 91
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How to Take This Course
F ollow the steps below to maximize the efficiency with which you progress
through the examination and receive your certificate of completion. Your
total learning package includes the course text, a Scantron answer sheet, and a
home study course evaluation. This course must be completed and the exam
received within two years of purchase for you to receive a certificate of
completion that is valid for relicensure.
1 –Review the objectives

The objectives provide an overview of the entire course and each chapter.
Focus your attention on the learning goals for the course and each chapter.
2 –Study the chapters in order

Each chapter contains information essential to understanding material in suc-
ceeding sections.
3 –Complete the examination

After thoroughly studying the course, you may take your examination.
Note: Do not return the examination from the book; return only the inserted
Scantron answer sheet and the home study course evaluation form. Keep
your exam for future reference.
4 –Mail your answer sheet to NurseWeek

Your certificate of completion will show the date we receive your answer
sheet, which is the date you will give your licencing agency.
Students must earn a score of 70 percent or more to pass. If your score is un-
der 70 percent, we will automatically sent you another test at no charge so
you can try again.
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A Nurse’s Guide to Pain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Course Objectives
T he purpose of this course is to help nurses—who spend more time with

patients with pain than any other members of the healthcare team—to assume
an active role in the team approach to pain management.
When you complete this course, you will be able to:
1. Describe activities involved in implementing JCAHO standards for pain
management.
2. Discuss the myths and misconceptions related to pain assessment and
treatment.
3. Describe pain assessment techniques, including pain assessment tools and
the pain flow sheet.
4. Explain the use of analgesics for pain management.
5. Discuss the use of the equianalgesia chart for pain management.
6. Describe four types of nondrug pain relief measures.
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About the Authors
M argo McCaffery, MS, RN, FAAN, is a consultant in the nursing care of patients
with pain. She lectures in the United States and abroad on the subject of pain.
Chris Pasero, MS, RN, is a pain management specialist who provides educational and
consulting services to individual practitioners and healthcare facilities interested in
improving pain management. McCaffery and Pasero are co-authors of Pain: Clinical
Manual (Mosby, 1999) and the CD-ROMs “Assessment and Overview of Analgesics”
and “The Nurse’s Active Role in Opioid Administration” (Lippincott, Williams &
Wilkins, 2000).
Acknowledgment
T he original course, published in 1992, was written by Margo McCaffery, Kathie

Ritchey, MSN, RN, and Michelle Rhiner, RN.
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....................................................... 1
Chapter One
Understanding the New Joint

Commission Standards
When you complete this chapter, you will be able to:

1. Explain why the JCAHO released pain assessment and treatment standards.
2. Identify the recommended approaches for implementing the JCAHO pain
standards.
3. Describe activities involved in implementing the JCAHO standards.
By Margo McCaffery, MS, RN, FAAN, and Chris Pasero, MS, RN.
P ain specialists estimate that at least 90 percent of patients with pain should
1
experience satisfactory relief. Yet at least 50 percent of patients needlessly suffer
moderate to severe pain despite two decades of efforts to educate health professionals.
Clinical practice guidelines for pain management have been available since the
mid-1980s from organizations such as the American Pain Society (APS), but they have
not been widely followed. Current guidelines from the APS include one for acute pain
1,2
and cancer pain and one for arthritis pain.
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At the beginning of 2000, the Joint Commission on Accreditation of Healthcare

Organizations (JCAHO) released revised standards for the assessment and management
of pain for all patients in healthcare institutions.3 Healthcare facilities are surveyed for
compliance with these standards, and they risk losing accreditation if they cannot
demonstrate that processes are in place to assess and manage pain appropriately in all
patients. The JCAHO’s requirement for compliance probably will have the most
profound effect on improving pain management of any single event to date.
Nurses have played and will continue to play a critical role in pain management. This
chapter will inform nurses about the new standards and how they will affect their care of
patients with pain.
Why standards are needed

The need for pain management standards arose as the JCAHO recognized mounting
evidence that pain is undertreated and that unrelieved pain has the potential for harmful
effects. For example, in a four-year study from 1989 to 1993 of more than 9,000
hospitalized, terminally ill patients in five teaching hospitals, 50 percent of conscious
patients who died in the hospital experienced moderate to severe pain at least half of the
4
time. Researchers studying acute pain in hospitalized patients found that more than half
the patients reported severe pain during the previous 24 hours, and about half had
5
moderate to severe pain at the time of the interview.
Undertreated pain places patients at risk. Our cultural attitude of “no pain, no gain” has
proved to be dangerously wrong. Research now shows that unrelieved pain can inhibit the
immune system and even enhance tumor growth. Pain causes increased oxygen demand,
respiratory dysfunction, decreased gastrointestinal motility, and confusion. Severe acute
6
pain is a major risk for the development of chronic neuropathic pain.
Barriers to pain management

In many instances, age-old institutional practices pose barriers to pain management.
These include the lack of standardized methods of communicating about pain, such as
failure to include pain ratings in documentation forms. In many acute care settings, use of
the intramuscular route is widespread, although research shows that the intravenous or
7
intraspinal route for analgesics is usually safer and more effective. Meperidine
(Demerol) remains popular despite evidence that its active metabolite—a product of the
7
breakdown of a drug—accumulates and causes seizures. Morphine and hydromorphone
are known to be safer. Although many patients have pain almost constantly, analgesics
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Understanding the New Joint Commission Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
continue to be given p.r.n. rather than as scheduled doses at intervals designed to keep
7
pain under control. Overall, in most institutions pain management has not yet become a
priority.
A pain care committee is one mechanism for promoting an interdisciplinary approach
8,9
to improving pain management throughout an institution. The committee usually
consists of seven to 10 people and includes a nurse educator, an anesthesiologist or a
certified registered nurse anesthetist, another physician, a pharmacist, and several staff
nurses. Staff nurses are indispensable because pain assessment and treatment are
performed by nurses at the bedside. Their input will help prevent many implementation
failures, such as those that may occur when revised documentation forms are first put into
use. The pain care committee usually becomes a standing committee because improving
pain management is an ongoing need.
The committee begins by identifying the problems in the institution. Surveys such as
chart audits and patient interviews may be conducted to determine how well pain is being
assessed and treated. Knowledge and attitude surveys are a common method of assessing
the educational needs of the staff and helping them become aware of their current level of
knowledge related to pain management. Many do not realize that they may have received
inaccurate or insufficient education about pain management.
Nurses may use the accompanying “Pain Knowledge and Attitude Survey” (see next
page) to assess the knowledge of fellow nurses, physicians and pharmacists about pain and its
management. To increase the number of respondents, the survey is brief, and the data can be
tabulated quickly and shared with staff immediately. Posters can be used to show the
percentage of right and wrong answers along with a brief rationale for the correct answers.
Upcoming programs on pain can be promoted at the same time to encourage staff to find out
about the new recommendations for pain assessment and management.
Certain common institutional practices have been focal points for pain care
committees. For example, the frequent use of meperidine has prompted many committees
to educate physicians about alternatives and to establish policies that limit its use for
patients who are allergic to or intolerant of all other opioids (as recommended in the APS
1
guidelines). Many hospitals also have developed policies prohibiting the deceptive use of
placebos and restricting their use to approved clinical trials.
The JCAHO standards for pain management apply to all patients in all clinical
settings. The following activities, described in a videotape available from the JCAHO,
10
are related to compliance with the standards.
1. Recognize the right of patients to appropriate assessment and management of
pain. This should be included in the patients’ bill of rights and may be posted in the lobby
and waiting areas.
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Pain Knowledge and Attitude Survey

Part 1
Answer true or false to questions 1-12.
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Part 2
First read the three American Pain Society definitions below. Then
read the question and circle the percentage closest to the correct
answer for 13, 14, and 15.
■ Opioid (narcotic) addiction psychological dependence
■ Tolerance
■ Physical dependence
Question:
Answers to Questions 1-15
SOURCE: Copyright Margo McCaffery (1994; revised October 2001). May be

duplicated for use in clinical practice.
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Inherent in recognizing the right of a patient to appropriate pain management is the

recognition of and respect for the patient’s personal beliefs, including spiritual, cultural,
and ethnic influences. By working with a patient to set comfort/function goals, providing
patient teaching, encouraging a patient to make decisions about care, and accepting the
patient’s reports of pain, the nurse honors the patient’s beliefs.
2. Screen for the existence, nature and intensity of pain. Many institutions have
followed the American Pain Society’s suggestion that pain be considered the fifth vital
sign and be recorded with vital signs. (This is not required by the JCAHO.) Some
institutions, such as the VA, have incorporated this and included pain ratings on the vital
sign graphic record. This helps screen for pain in all patients who have their vital signs
taken, usually the majority of patients. Another way of screening for pain is to include
questions on the nursing admission form, such as “Do you have pain now or have you
experienced any pain recently?”
In California, Assembly Bill 791 designating pain as the fifth vital sign became law
on Jan. 1, 2000. As a condition of healthcare facilities’ licensure, pain must be assessed
at the time a full set of vital signs is taken and noted in the patient’s chart with other vital
signs.
Virtually all pain care committees make pain assessment a priority. This involves
adoption of a pain rating scale that is appropriate for the majority of patients in the
facility. Self-reporting of pain is the single most reliable method of assessing pain
intensity, and it is used whenever possible. Vital signs and behavior are never used
instead of the patient’s self-report, because they are not valid as indicators of pain. If
most patients in the institution are cognitively intact adults, the 0-to-10 (0 = no pain, 10 =
worst pain) pain rating scale usually is used. To accommodate culturally diverse
populations, the pain rating scale can be translated into languages other than English. A
0-to-5 pain rating scale or “faces” pain rating scale usually is more appropriate for
children as young as 3 and also may be preferred by elderly patients. Behavioral pain
measures must be identified for other populations, such as the cognitively impaired adult,
the infant and the preverbal child. If no behaviors are present, such as in patients who are
unconscious or on neuromuscular blocking agents, the presence of pathology or
procedures that are usually painful is sufficient to assume pain is present. The acronym
“APP” (assume pain is present) may be recorded instead of a pain rating.11
3. If pain is identified, perform a more comprehensive pain assessment that includes
location, quality, onset, frequency, and intensity. These items are self-explanatory, and it is
easy to ask the patient about them. Location can be assessed by asking the patient to point to
the site of pain on his or her body or on a figure drawing. To assess quality, you may need to
give the patient some examples, such as “Is it burning, aching, knife-like, or shooting?”
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With this assessment, a comfort/function goal is established by asking the patient

what pain level rating would make it easy for him or her to perform specific activities
required for recovery or quality of life. For example, a patient who has abdominal surgery
may need to use the incentive spirometer to prevent pulmonary complications. The
patient would be asked, “What pain rating will make it easy for you to use the incentive
spirometer regularly?” The patient may respond that 2 on a scale of 0-10 would be
sufficient. The comfort/function goal would be documented as “2/10 to use incentive
spirometer.” When establishing comfort/function goals, keep in mind that research has
shown that pain ratings above 4 significantly interfere with activities and mood.12
Giving adequate doses of opioids and titrating them to relieve pain without
unacceptable side effects are among the JCAHO principles of pain management. The
need to adjust doses and intervals between doses are determined by the patient’s
comfort/function goal. For example, if the patient using the incentive spirometer
experienced a pain rating of 4, that would indicate the need to increase the dose, provided
it was safe to do so.
4. Record the results of assessment in a way that facilitates regular reassessment and
follow-up. Documentation forms often need to be revised to include pain assessments and
to make them visible so that the need for intervention can be identified quickly. At the
very least, the forms should include the comfort/function goal and regular assessment of
pain intensity.
5. Determine and assure staff competency in pain assessment and management.
Competency needs to be addressed in the orientation of all new staff and arrangements
made for continuing education of all staff. An annual pain conference or a pain awareness
week are typical ways of doing this.
6. Establish policies and procedures that support the appropriate prescription of pain
medications. The pain care committee is responsible for ensuring that physicians
prescribe appropriate analgesics. The committee reviews and revises policies and
procedures to assure that all patients receive the best possible pain relief within the realm
of safety. This approach is coupled with education of physicians about alternatives to
dangerous and ineffective methods of managing pain. As previously mentioned, a policy
that restricts meperidine use often is necessary. Revising intravenous patient-controlled
analgesia order forms often is a helpful way to guide physicians in the prescription of
appropriate drugs and dosages.
7. Educate patients and their families about the importance of effective pain
management. On admission, patients should be informed—both by staff and in printed
patient information—that effective pain relief is their right, that they should tell staff about
unrelieved pain, and that staff will quickly respond. An institution may develop its own
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For More Information

To order the new standards for hospitals, Comprehensive Accreditation Manual for Hospitals:
The Official Handbook (CAMH), call the JCAHO, (630) 792-5800, or visit its Web page,
www.jcaho.org. Also available are standards for ambulatory care, behavioral health care, health
care networks, home care, and long-term care.
written materials and videotapes or may obtain them from pharmaceutical companies. An
example is a brochure from Endo Pharmaceuticals, Understanding Your Pain: Using a
Pain Rating Scale. The JCAHO supported the development of this brochure, which may
be ordered free of charge by calling (800) 462-3636.
8. Address patient needs for symptom management in the discharge planning
process. Before discharge, the patient should be assessed for the presence of pain. If pain
exists, appropriate arrangements are made, such as prescriptions for analgesics. For
ambulatory surgery, contact the patient the evening of discharge to determine the
effectiveness of pain management.
9. Include patient outcomes in measuring the effectiveness and appropriateness of
pain assessment and management. Ask clinical units to include pain in their quality
improvement plans.
The JCAHO’s revised standards may end up doing more to improve pain
management than any single development so far. Progress will be slow, however, and
mistakes are inevitable. Those asked to implement the standards may not have received
the education they need about principles of pain management. Successful implementation
ultimately will depend on the nurse at the bedside. Nurses must recognize that they may
need to enhance their basic education about pain management by taking continuing
education courses and reading professional journals and the clinical practice guidelines.
These guidelines help dispel many misconceptions about assessment and treatment of
pain. Improving pain management will be a process spanning many years, an effort that
will know no end.
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References
1. American Pain Society. Principles of Analgesic Use in the Treatment of Acute
Pain and Cancer Pain, 4th ed. Glenview, Ill.: APS. 1999.
2. American Pain Society. Guidelines for the Management of Pain in
Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis.
Glenview, Ill.: APS. 2002.
3. Joint Commission on Accreditation of Healthcare Organizations. Pain
Assessment and Management: An Organizational Approach. Oakbrook
Terrace, Ill.: JCAHO. 2000
4. The SUPPORT principal investigators. “A controlled trial to improve care for
seriously ill patients.” Journal of the American Medical Association,
274(20), 1591-1598. 1995.
5. Ward, S.E., & Gordon, D. “Application of the American Pain Society quality
assurance standards.” Pain, 56(3), 299-306. 1994.
6. Pasero, C., Paice, J.A., & McCaffery, M. “Basic mechanisms underlying the
causes and effects of pain.” In McCaffery, M. , & Pasero, C. Pain: Clinical
Manual (2nd ed.) (pp. 15-34). St. Louis: Mosby. 1999.
7. Pasero, C., Portenoy, R.K., & McCaffery, M. “Opioid analgesics.” In
McCaffery, M., & Pasero, C. Pain: Clinical Manual (2nd ed.) (pp.
161-299). St. Louis: Mosby. 1999.
8. Pasero, C., et al. (1999). “Building institutional commitment to improving pain
management.” In McCaffery, M., & Pasero, C. Pain: Clinical Manual (2nd
ed.) (pp. 711-744). St. Louis: Mosby. 1999.
9. Pasero, C. “Making your pain care committee effective.” American Journal of
Nursing, 97(3), 17-19. 1997.
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10. Joint Commission on Accreditation of Healthcare Organizations. “Assessing

compliance with the new pain management standards: effective
implementation strategies.” [videotape]. Oakbrook Terrace, Ill.: JCAHO.
2000.
11. Pasero, C., & McCaffery, M. “Pain in the critically ill.” American Journal of
Nursing, 102(1), 59-60. 2002.
12. Serlin, R.C., et al. “When is cancer pain mild, moderate or severe? Grading
pain severity by its interference with function.” Pain, 61(2), 277-284. 1995.
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Understanding the New Joint Commission Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Review Questions
1. There is little evidence that persistent, unrelieved pain has harmful effects.
True
False
2. The pain care committee is not responsible for ensuring that physicians
prescribe appropriate analgesics.
True
False
3. A pain care committee’s work includes evaluating physician and staff

knowledge and attitudes about pain assessment and management.
True
False
4. The 0-10 pain sale is not appropriate for all patients.

True
False
5. Self-report pain rating scales are recommended for assessing pain intensity in
cognitively intact patients.
True
False
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12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Understanding the New Joint Commission Standards
Review Answers
1. False
2. False
3. True
4. True
5. True
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Chapter Two
Pain Assessment: Debunking

the Myths and Misconceptions

1. Define pain.
2. Identify myths and fallacies that accompany pain
assessment and management.
3. Recognize two ways to dispel myths in clinical practice.
4. Identify steps to improve pain assessment.
2003 revisions by Margo McCaffery and Chris Pasero.

Originally by Margo McCaffery and Kathie Jo Ritchey, MSN, RN, 1992.
N urses play a pivotal role in assessment and management of pain. Nurses probably
spend more time with patients than any other members of the healthcare team.
Yet a survey of National League for Nursing accredited baccalaureate programs found
1
2
that 48 percent spent less than four hours on the subject of pain.
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14 . . . . . . . . . . . . . . . . . . . . . . . . . . Pain Assessment: Debunking the Myths and Misconceptions
Despite limited preparation, nurses are held accountable professionally for their
knowledge and understanding of pain management. In November 1990 a North Carolina
jury awarded $15 million in damages to the family of a man whose final days were filled
with unbearable pain because of the decision of a nurse to withhold or reduce pain
3
medication.
Pain is increasingly being recognized as a priority by both national and international
agencies. The World Health Organization (WHO), the American Pain Society (APS), and
the National Institutes of Health, to name a few, have all contributed publications,
guidelines, or consensus conferences focused on pain.
In the 1990s, a division of the Department of Health and Human Services in
Washington, the Agency for Health Care Policy and Research (AHCPR), published two
sets of clinical guidelines for pain management—one for acute pain and one for cancer
4,5
pain. As described in the previous chapter, the JCAHO released revised standards on
the assessment and management of pain in January 2000. Beginning in 2001, healthcare
facilities are expected to comply with these standards. In addition, many states have
formed voluntary statewide networks, cancer pain initiatives, devoted to developing care
standards for cancer pain management.
Clearly, awareness of the problem of inadequate pain management is growing. But
lack of knowledge is only one reason why patients are undermedicated. Other barriers to
the assessment and management of pain include the misconceptions and myths
surrounding assessment and treatment.
Definition of pain
Pain is completely subjective. A widely used definition is “Pain is whatever the
6
experiencing person says it is and exists whenever he or she says it does.” The
self-report of pain by a patient should be considered sufficient evidence to establish pain
as a nursing diagnosis.
The AHCPR guidelines support this with such statements as “The single most
reliable indicator of the existence and intensity of pain—and any resultant distress—is the
patient’s self-report,” and “Observations of behavior and vital signs should not be used
4
instead of a self-report unless the patient is unable to communicate.”
The cornerstone of an assessment of pain is the acceptance that the pain “belongs” to
the patient. The patient, not the healthcare team or the family, is the authority about the
presence of pain. Nurses should accept and respect the patient’s report of pain and
proceed with interventions to promote relief. This ensures that the patient will not suffer
needlessly and helps guarantee a higher quality of care.
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Pain Assessment: Debunking the Myths and Misconceptions . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Expected pain behaviors

Many nurses have been taught that visible physiologic and behavioral signs will
accompany pain and can be used as the basis for objective pain assessment. In the
acute pain model, physiologic signs of pain include elevated blood pressure,
tachycardia, tachypnea, dilated pupils, and behaviors such as grimacing and moaning.
In reality, physiologic and behavioral adaptation occurs, resulting in periods during
which patients with severe pain show no signs of pain. Thus, lack of pain expression
does not necessarily mean lack of pain.
Physiologically, the body adapts to pain after a period of time, and vital signs
normalize. This return to equilibrium is necessary to prevent physical harm and undue
stress on the body. It does not necessarily mean pain has disappeared.
Patients also show a behavioral adaptation to both acute and chronic pain. They may
minimize their expressions of pain for a number of reasons. A patient may wish to be
seen as a “good patient” or may place a personal value on a stoic response to pain. The
patient may become too exhausted to respond vigorously to pain. Sometimes patients use
distraction techniques to focus away from pain.
If a nurse adheres to the acute pain model to guide assessment, there will be times
when a patient’s behavior and physical signs do not correlate with the patient’s report of
pain. In other words, patients may even experience severe pain without acting like they
are in pain.
Identifiable cause of pain

Another common misconception is the belief that all pain has an identifiable physical
cause, or that the etiology of the pain can be diagnosed and isolated. We erroneously
believe that if there is pain, there is a cause we can find; if we can’t find the cause, we
inaccurately conclude that there is no pain. All pain is real, regardless of its cause and
regardless of whether the cause can be identified.
Many patients who are forced to endure chronic pain become depressed and anxious.
The depression and anxiety can be exacerbated if it is difficult to establish a cause for the
pain. These patients may begin to question their sanity, fear they will be perceived as
malingering, and worry that pain relief will be withheld because the pain is not “real.”
These emotional responses may cause some health care providers to think that the
pain is psychogenic or all in a patient’s head. However, psychogenic pain is extremely
rare and cannot be diagnosed merely on lack of ability to find a physical cause.
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The pain experience usually includes a physical and a mental component. Just as
purely psychogenic pain is very rare, pain that is purely physical (experienced without
thoughts or feelings about it) also is extremely rare. While physical and behavioral signs
of pain and a diagnosis of its cause are useful, they do not substitute for the patient’s
report that pain exists.
Pain threshold
The definition of a pain threshold is the point at which a stimulus is perceived as
painful. Many healthcare professionals labor under the misconception that everyone
perceives the same pain intensity from like stimuli. However, there is no research to
7
support the theory of a uniform pain threshold. The duration and severity of pain cannot
be predicted based on the type of pain stimulus.
Over time, healthcare workers may develop fairly accurate estimates of the amount
of pain patients usually feel as a result of certain painful events such as a bone marrow
aspiration. However, it is detrimental to quality patient care to assume that there will be
no exceptions. A patient who experiences more pain than expected with a treatment or
diagnostic procedure or during a postoperative recovery period should not be labeled as
exaggerating pain.
For example, most nurses expect that the most severe pain following surgery will
occur in the first 48 hours and will gradually subside. However, in a study of 88
postsurgical patients, 31 percent reported pain that persisted after the fourth postoperative
8
day.
Patient credibility
The basis for pain assessment is the patient’s report of pain, and pain cannot be
proved or disproved. As nurses we must sometimes deal with the conflict of believing a
patient who seems untrustworthy or whose lifestyle is contrary to our personal belief
system, such as the substance abuser. A professional approach to pain does not include
the application of personal biases or values.
Because the sensation of pain is totally subjective, it is understandable that nurses
might look for clues to support the truthfulness of the patient’s report. However, even
when a patient’s moral code, value system, and lifestyle are unacceptable to us, “no
healthcare professional has the right to deprive a patient of appropriate assessment and
9
treatment [of pain] simply because he or she believes the patient is lying.”
A related fear and misconception is that lying about the existence of pain, called
10,11
malingering, is common. In fact, research shows that fabrication of pain is very rare.
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By definition, the true malingerer does not feel pain but acts and reports pain that is
nonexistent. The malingerer consciously fakes pain, usually as an avoidance behavior or
to gain something (like attention from family members or medical professionals).
No true test exists to detect a malingerer. In rare cases we may give analgesics to
someone who is deliberately trying to deceive us. Despite this small risk, our professional
responsibility remains to respect and treat all patients who present with pain.
Pain tolerance
Tolerance may be defined as “the duration or intensity of pain that a person is willing
12
to endure.” Pain tolerance, pain perception and the expression of pain are all unique to
the individual. A patient’s tolerance varies from one situation to another. The patient’s
emotional state, degree of fatigue, and the value or meaning of pain for that patient can
influence individual tolerance to pain.
Many healthcare professionals believe that the more experience patients have with
pain, the greater tolerance of pain they will have. In fact, experience with pain usually is
associated with a lower tolerance—and a higher level of anxiety—because the patients
learn how severe pain is and how hard it can be to get relief.
Relief from placebos

A placebo may be defined as any treatment or procedure that produces a response in
a patient because of its intent and not because of any actual physiologic or therapeutic
properties. A patient who responds to a placebo is said to have a positive placebo
response. A patient who responds positively to a placebo may be perceived by caregivers
as one who is malingering or fabricating the pain.
The use of a placebo is never justified to determine the existence of pain. Since the
majority of patients will have some response to a placebo, no conclusion other than that
the patient believes in the intent and efficacy of the treatment should be drawn from a
13
placebo response.
Legal and ethical considerations exist about the use of placebos without informed
consent. While placebos have a place in structured research trials, to use them without a
patient’s consent and knowledge could seriously damage the nurse-patient relationship
and destroy the patient’s trust in the healthcare system if the deception is discovered.
Because of the seriousness of this problem, the Oncology Nursing Society has issued a
position statement on placebo use. It states that placebos should not be used to assess or
manage cancer pain and that nurses should not administer a placebo under these
14
circumstances even if there is a medical order.
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Table 1
Misconceptions That Hamper

Pain Assessment
Misconceptions Corrections
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The American Pain Society states that placebos should not be used to assess the
nature of pain and that “the deceptive use of placebos and the misinterpretation of the
placebo response to discredit the patient’s pain report are unethical and should be
13(p. 32)
avoided.” The American Society of Pain Management Nurses “adamantly opposes
the use of placebos in the assessment and treatment of pain in all patients.” (For a copy
of the ASPMN’s position on pain management, call [888] 34APMN). Nurses in
California put their license at risk if they administer a placebo in a deceitful manner. In
1997, the California Board of Registered Nursing stated that to use placebos for the
15
management of pain “would not fulfill informed consent parameters.” (For a copy of the
BRN’s complete pain management policy, write to the agency at P.O. Box 944210,
Sacramento, CA 94244-2100.) In 2001, the BRN filed accusations against registered
nurses who administered placebos in a deceitful manner, despite the fact that a physician
16
had written the order.
Dispelling the myths

The acceptance of pain as a subjective experience is difficult for many nurses and
healthcare professionals. Personal opinion, coupled with a lack of education, often
incorrectly guides pain assessment.
The assessment and documentation of pain were studied in a series of patient
17
vignettes. In the study, nurses were told to rate the pain of two patients with normal
vital signs who were recovering from identical surgical procedures but exhibiting
different behavioral expressions of pain. One patient smiled; the other grimaced. The
patient-reported number from the pain rating scale was the same in both vignettes, 8
on a scale of 0-10. In both cases, many nurses recorded different, lower numbers than
the patients had reported, especially for the smiling patient. This indicated that the
nurses erroneously relied on patient behaviors and appearance rather than on the
patient’s self-report of pain.
Overcoming the myths and misinformation that abound regarding pain assessment
and treatment is a challenge. Suggestions for implementing a uniform approach to pain
management include:
• Reinforce the fact that pain is subjective.
• Accept and act on the patient’s report of pain.
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• Provide articles and references to support and document your position, for
example, the American Pain Society’s Principles of Analgesic Use in the
Treatment of Acute Pain and Cancer Pain, which says, “The clinician must
3
accept the patient’s report of pain.”
Improving pain assessment

As you become more aware of the problem of pain, you can improve the assessment
and management of pain in your workplace. According to Ferrell, “The first step to
18
change is demonstrating that a problem exists.” Once awareness of pain is enhanced,
you can inform physicians, staff, and administrators of the need to address this critical
issue.
Do a pain audit, and adopt an ongoing system for pain assessment based on the use
of consistent assessment tools, especially a pain rating scale. Assessment of pain is
useless unless there is consistent communication and documentation to all members of
the healthcare team regarding assessment, comfort/function goals, interventions, and
evaluation. Find a way to document this valuable information.
Summary
One of the greatest challenges in nursing is to ensure patient comfort. All patients are
entitled to the best pain relief that can safely be achieved. Yet the problem of pain is
pervasive, and the myths and misconceptions surrounding the pain experience and the
assessment of pain often preclude adequate comfort and quality care. An understanding
of the facts and the correction of misinformation are the first steps in breaking down the
barriers to successful pain management.
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References
1. McCaffery, M., & Pasero, C. Pain: Clinical Manual, 2nd ed. St. Louis:
Mosby. 1999.
2. Graffam, S. “Pain content in the curriculum—a survey.” Nurse Educator,
15:20-23. 1990.
3. Angarola, R., & Donato, B. “Inappropriate pain management results in high
jury award.” Pain and Symptom Management, 16:7, 407. 1991.
4. Acute Pain Management Guideline Panel. “Acute Pain Management:
Operative or Medical Procedures and Trauma.” Clinical Practice Guideline.
AHCPR Pub No. 92-0032. Rockville, Md.: Agency for Health Care Policy
and Research, Public Health Service, U.S. Department of Health and
Human Services. 1992.
5. Jacox, A., et al. Management of Cancer Pain. Clinical Practice Guideline
No. 9, AHCPR Publication No. 94-0592, Rockville, Md.: Agency for Health
Care Policy and Research, U.S. Department of Health and Human Services,
Public Health Service. 1994.
6. McCaffery, M. Nursing Practice Theories Related to Cognition, Bodily
Pain, and Man-Environment Interactions. University of California, Los
Angeles. 1968.
Mosby. 1999.
8. Melzack, R., et al. “Pain on a surgical ward: a survey of the duration and
intensity of pain and the effectiveness of medication.” Pain, 29:67-72.
1987.
Mosby. 1999.
10. Leavitt, F., & Sweet, J. “Characteristics and frequency of malingering
among patients with low back pain.” Pain, 25:357-364. 1986.
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11. Reesor, K., & Craig, K. “Medically incongruent chronic back pain:
physical limitations, suffering, and ineffective coping.” Pain, 32:35-45.
1988.
12. McCaffery, M., & Pasero, C. Pain: Clinical Manual (2nd ed.). St.
Louis: Mosby. 1999.
13. American Pain Society. Principles of Analgesic Use in the Treatment of
Acute Pain and Cancer Pain,, 4th ed. Glenview, Ill. 1999.
14. McCaffery, M., Ferrell, B.R., & Turner, M. “Ethical issues in the use of
placebos in cancer pain management.” Oncology Nursing Forum
23:1587-1593, 1996.
15. “BRN focuses on pain management.” The BRN Report-California, 10(1):
12, spring 1997.
16. Tucker, K.L. “Deceptive placebo administration.” American Journal of
Nursing, 101(8), in press, 2001.
17. McCaffery, M., Ferrell, B., & Pasero, C. “Nurses’ personal opinions about
patients’ pain and their effect on recorded assessments and titration of
opioid doses.” Pain Management Nursing, 1(3): 79-87. 2000.
18. Ferrell, B., & Leek, C. “Pain.” In Creasia and Parker (Eds.). Conceptual
Foundations of Professional Nursing Practice. Philadelphia: The C.V.
Mosby Co. 1989.
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Review Questions
1. Pain exists whenever the patient says it does.
True
False
2. All pain has an identifiable physical cause.

True
False
3. Pain tolerance varies from patient to patient.

True
False
4. If a patient has a positive placebo response (pain relief), the pain probably
was imaginary.
True
False
5. Increasing the awareness of pain as a problem by doing a pain audit is a good

way to improve pain assessment and management.
True
False
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Review Answers
1. True
2. False
3. True
4. False
5. True
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Chapter Three
Techniques of Pain Assessment

1. Recognize the components of an initial pain assessment
tool.
2. Identify two types of pain rating scales.
3. Identify the purpose of a flow sheet to document pain
assessment and intervention.

I t is the nurse’s responsibility to assess pain, to evaluate the findings of the assessment,
and to institute a plan of care based on information gathered. However, nurses must
be careful not to let their own personal experiences with pain adversely affect their
1
assessments of pain.
Everyone has experienced the sensation of pain. The difficulty in measuring someone
else’s level of pain stems from the subjective or individual nature of the pain experience.
Research shows that when clinicians do not use patient rating scales and ask the patient to
2
rate the pain, they are likely to underestimate pain, especially moderate to severe pain.
3
As the American Pain Society states, “Pain is always subjective” and “The clinician
3
must accept the patient’s report of pain.”
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26 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Techniques of Pain Assessment
A patient’s self-report of pain is the most reliable indicator of pain, but many nurses
were taught to assess pain by identifying and documenting observable, objective,
physical signs of pain such as tachycardia, tachypnea, dilated pupils, grimacing, and
moaning. However, patients may or may not exhibit these signs. Fatigue, for example,
may result in minimal behavioral and physiologic responses to pain even when the pain is
severe.
If objective signs of pain are present, they may serve as clues to the existence of
pain; but the absence of physical signs of pain should never be equated with the lack
of pain in a patient who verbally reports its existence.
The effective use of pain rating scales to assess pain, adequate documentation of the
assessment, and evaluation of the effectiveness of pain interventions are essential to
successful pain management.
Pain assessment
During the assessment process, you will gather information on the existence of pain
and its effect on many aspects of the person’s life. Since pain is rarely a static process,
the assessment process is ongoing, not simply a one-time event. The information obtained
in the assessment allows you, the patient, and the physician to formulate a plan of care
with goals related to pain management.
Unfortunately, this basic step in managing pain never happens for some patients. In a
study on 353 hospitalized medical/surgical patients experiencing pain, fewer than half
4
could recall being asked about their pain. The assessment of pain need not be
time-consuming or overwhelming, but unless an assessment of pain is done, the basis for
an accurate nursing care plan for pain management cannot exist.
Assessment tools
A wide variety of pain assessment tools are available. No one “best” assessment form
or tool exists.
Adapt the following tools to meet the needs in your clinical setting. The following
sections describe an initial pain assessment tool and a pain flow sheet. The essential
element in both of these tools is the patient’s use of a pain rating scale.
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Techniques of Pain Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Initial pain assessment tool

This tool is composed of 10 sections. (See Table 2.) When possible, obtain this
information directly from the patient. Indicate if the information is gathered from another
source, like a spouse or parent. Remember, in some settings, such as ambulatory surgery,
not all of this information is necessary. Decide what will be useful to you.
• Location: Anatomical diagrams are provided to illustrate the location of pain.
Many patients have more than one painful site; indicate multiple sites with
letters, e.g., A. B. C.
The patient may draw the pain sites on the form or trace the locations on his or her
body, and you or a family member can mark the figures on the assessment form.
• Intensity: The person experiencing pain is the only one capable of accurately
rating its intensity.
Two types of common pain rating scales are the numerical scale with word
descriptors and the faces scale. In fact, they are often combined (Table 3.) Many clinical
settings use a 0-10 scale with word descriptors. Institutions should select pain rating
scales that are appropriate for their populations, and these should be used consistently for
all patients who understand them. When a patient cannot use these scales, another should
be selected. Whichever scale is selected to assess pain intensity in a patient should be
used consistently with that patient.
To use the numerical scale, ask the patient: “On a scale of 0 to 10, with 0 equaling no
pain and 10 meaning the worst possible pain, what number would you give your pain
5
right now?”
The Wong-Baker FACES scale may be used with children as young as 3 years, and
adults like it, as well. Elderly patients and those who have difficulty with the 0-10 scale
may be able to use this scale. Directions for using the Wong-Baker FACES scale with
children and adults are included in Table 3.
Another faces scale for children and adults is now available, called Faces Pain
8
Scale-Revised (FPS-R). It may be viewed at www.painsourcebook.ca and downloaded.
Explain the purpose of the scale to the patient. Emphasize the fact that nurses or
caregivers do not automatically know when a patient has pain. Caregivers should ask
about pain regularly, but patients must understand that they also need to volunteer
information.
For those with limited English, try to obtain appropriate translated scales. (See
Reference 2, McCaffery and Pasero, pp. 64-65, 68-73, for foreign language translations
of these pain rating scales.)
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Table 2
Initial Pain Assessment Tool Date: _____

Patient’s name:____________________________________ Age:_______ Room: _________
Diagnosis: _________________________________________________________________
Physician: _______________________________ Nurse: ______________________________
1. LOCATION: Patient or nurse marks drawing.
2. INTENSITY: Patient rates the pain. Scale used _____________________________________________

Present: _________________________________ Worst pain gets________________________
Best pain gets: ____________________________ Acceptable level of pain __________________
3. QUALITY: (Use patient’s own words, e.g., prick, ache, burn, throb, pull, sharp) _______________________
________________________________________________________________________________
4. ONSET, DURATION, VARIATIONS, RHYTHMS: ______________________________________________

________________________________________________________________________________
5. MANNER OF EXPRESSING PAIN: _______________________________________________________

________________________________________________________________________________
6. WHAT RELIEVES THE PAIN? __________________________________________________________

________________________________________________________________________________
________________________________________________________________________________
7. WHAT CAUSES OR INCREASES THE PAIN? _______________________________________________

________________________________________________________________________________
8. EFFECTS OF PAIN: (Note decreased function, decreased quality of life.)

Accompanying symptoms (e.g., nausea) __________ Sleep _______________________________
Appetite _________________________________ Physical activity _______________________
Relationship with others (e.g., irritability)__________ Emotions (e.g., anger, suicidal, crying) _______
Concentration _____________________________ Other _______________________________
9. OTHER COMMENTS: _______________________________________________________________
________________________________________________________________________________
10. PLAN: _________________________________________________________________________

________________________________________________________________________________
May be duplicated for use in clinical practice.

SOURCE: McCaffery, M., & Pasero, C. Pain: Clinical Manual, 2nd ed. St. Louis: Mosby.
1999.
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Table 3
Pain Rating Scales

Numerical Rating Scale With Anchors
Wong-Baker FACES Pain Rating Scale
SOURCE: From Wong, D.L., et al. Wong’s Essentials of Pediatric Nursing, 6th ed. St. Louis: Mosby Inc.
2001. Copyrighted by Mosby Inc. Reprinted by permission. May be duplicated for clinical practice.
When teaching the pain rating scale, discuss the definition of pain, using examples of
ways pain can be described. For example, rather than the word pain, most people use
adjectives such as aching, hurting, tight, burning, or pricking sensation.
Finally, have the patient practice using the pain rating scale with present pain or a
past pain experience.
One of the most important reasons for using a pain rating scale is to set a
comfort/function goal with each patient. Comfort means pain rating, and function refers
to activities the patients needs to perform, such as coughing and deep breathing
postoperatively, or activities of daily living, such as bathing. Select an activity that is
important for the patient to perform and one that is also likely to cause the most pain. Ask
the patient what pain rating would make it easy for him or her to perform the activity. For
example, one patient might need a pain rating of 2 out of 10 to ambulate, and another
patient might need a pain rating of 3 to participate in physical therapy. Document the
comfort/function goal and try to maintain this goal as much of the time as possible.
Intervention is aimed at keeping the patient at the selected pain level.
A patient teaching brochure, “Understanding Your Pain: Using a Pain Rating Scale,”
has been developed in cooperation with the JCAHO, and free copies are available from
Endo Pharmaceuticals, (800) 462-3636. If your institution decides to adopt this brochure,
Endo will provide a disk for making copies.
Regardless of the type of scale chosen, the advantages of using a scale to assess and
document pain intensity are numerous. You and the patient achieve consistency in
interpretation and communication; it gives you a better understanding of the patient’s
pain experience; and it provides a method for you to evaluate the effectiveness of
interventions.5
• Quality: In this section of the assessment form, patients are asked to
describe the type of pain or what the pain feels like to them. They may use
such words as throbbing, burning, stabbing, tender, or heavy. Some
patients may be unaccustomed to thinking about their pain in these terms.
A question such as “What would you have to do to me to make me feel the
pain that you have?” can help elicit this information.
• Onset, duration, variations, and rhythms: Many patients in pain have
variations in their pain experiences over a 24-hour period. In planning care, it
is important to assess these fluctuations, to anticipate painful procedures, and
to modify activities (when possible) to decrease discomfort. If pain is present
12 or more hours out of 24, around-the-clock scheduling of analgesics may be
necessary.
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• Manner of expressing pain: Information about possible pain behaviors is

essential when patients cannot communicate. Family members are a good
source for information about typical facial expressions, body posturing, or
behaviors that may indicate pain in the nonverbal patient. Pain behaviors may
be your only assessment guideline if the patient cannot communicate.
• Pain relief: Determine successful pain management strategies already in use,
including pharmacologic interventions, nondrug measures like heating pads or
cold packs, and effective distraction techniques such as listening to music or
watching television.
• Identifying causes of pain: Identify situations or behaviors that precipitate or
promote pain, if possible. Along with determining pain patterns, this
information allows you to anticipate particularly painful events and plan
interventions to decrease or eliminate discomfort.
• Effects of pain: Pain has been described by some patients as an experience that
7
overwhelms them and consumes every aspect of life. Pain can easily affect
sleep, appetite, physical mobility, and interpersonal relationships. A complete
assessment of pain encompasses the impact of pain on patients and their
families.
• Other: Ask the patient for any additional information that may be significant to
the pain experience. For example, the patient may want to identify the aspects
of pain that are most distressing.
• Nursing plan: At the completion of the assessment, develop an initial, brief
plan for pain management. A successful plan is a cooperative effort between
the healthcare team, the patient, and (in some cases) the family. Reassure the
patient that the plan’s effectiveness will be continually evaluated and the plan
adjusted until an acceptable level of comfort is achieved.
The pain flow sheet

The flow sheet (Table 4) is one way to document your assessment and ongoing
evaluation of pain management interventions. Flow sheets may be appropriate when new
analgesics are instituted and evaluated; when close monitoring of patient response is
indicated, as with high doses of opioids; or when there has been a significant change in
5
the patient’s pain. Pain assessment and documentation before and after intervention are
critical in identifying the safety and effectiveness of the intervention and in improving the
management of the patient’s pain.
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Table 4
Flow Sheet—Pain
Patient: ______________________________ Date: ___________________
Pain rating scale used: ___________ Comfort/function goal: _______________
Purpose: To evaluate the safety and effectiveness of the analgesic(s).
Analgesic(s) prescribed: ___________________________________________
Time Pain Analgesic R P BP Sedation Other Plan & comments

Rating level
The pain flow sheet documents your assessment and ongoing evaluation.
SOURCE: Margo McCaffery, MS, RN, FAAN
The flow sheet contains columns to record the time, the pain rating, the analgesic
administered, the vital signs, plans, comments, and more. For example, it can be adapted
to record bowel pattern or the presence of side effects such as nausea or itching. To
prevent respiratory depression in patients at high risk, such as the postoperative patient
with severe pain who is receiving opioids for the first time, sedation levels should be
monitored. To minimize duplicate charting, the items on the flow sheet should be
incorporated into existing documentation forms.
Flow sheets are especially useful in the home care setting, where patients or
caregivers complete and record an ongoing assessment and evaluation for the nurse (who
cannot be there 24 hours a day). The flow sheets are easily applied to the care of
8
hospitalized patients, as well, and have been shown to improve pain management.
Placing the flow sheet at the bedside allows anyone who comes in contact with the
patient to become familiar with the pain management plan and its effectiveness.
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An example of how a flow sheet could be used is provided in Table 5. This flow
sheet represents the pain rating of a postoperative patient changing from morphine sulfate
(MS) IV to oral medication. The nurse would contact the physician to report that four
Table 5
Flow Sheet—Pain
John Smith
Patient: ______________________________Date: May 1
_____________________
2/ambulate
Pain rating scale used: _______________Comfort/function goal: _____________
Purpose: To evaluate the safety and effectiveness of the analgesic(s).
Tylenol #3
Analgesic(s) prescribed: ____________________________________________
Time Pain Analgesic R P BP Sedation Other Plan & comments

Rating level
Discontinue
IV MS
Start P.O.
analgesic.
1200 6 Tylenol #3 18
1330 4-5 Notify physician.
1600 6
This example of a flow sheet represents the pain rating of a postoperative patient
changing from morphine sulfate (MS) IV or oral medication. It documents inadequate
pain relief.
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hours after the patient received the first dose of one Tylenol #3 orally, the patient’s pain
is rated 6 on a scale of 0-10 and never got below 4. The comfort/function goal for this
patient to ambulate is 2 on the 0-10 scale. There were no adverse side effects. This
documents the need for an increase in the dose of Tylenol #3. Once the new dose is
administered, the nurse would continue to evaluate the effectiveness of the new dose on
the flow sheet until the goal of 2 is reached.
Summary
The inadequate assessment and treatment of pain are well-documented in the
literature and are often due to the lack of recognition that a pain problem exists. Every
patient should be assessed for the presence or absence of pain, with an assessment
complete enough to determine an appropriate nursing care plan for pain management.
Pain affects every aspect of quality of life. Nurses have the primary responsibility for
pain management, and patients have a basic right to maximum comfort and an optimum
quality of life.
Course #150
References
1. Holm, K. et al. “Effect of personal pain experience on pain assessment.”
Image: Journal of Nursing Scholarship, 21(2):72-75. 1989.
Mosby. 1999.
Acute Pain and Cancer Pain, 4th ed. Glenview, Ill. 1999.
4. Donovan, M., Dillon, P., & McGuire, D. “Incidence and characteristics of
pain in a sample of medical-surgical inpatients.” Pain, 30:69-78. 1987.
Mosby. 1999.
6. Hicks, C.L., et al. “The Faces Pain Scale-Revised: toward a common
metric in pediatric pain measurement.” Pain, 93(2), 173-183. 2001.
7. Ferrell, B., et al. “The experience of pain and perceptions of quality of life:
validation of a conceptual model.” The Hospice Journal, 7(3):9- 23. 1991.
8. Faries, J.E., et al. “Systematic pain records and their impact on pain
control.” Cancer Nursing, 14(6), 306-313. 1991.
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Course #150
Review Questions
1. The nurse, not the patient, is the expert on a patient’s pain.
True
False
2. The best source of assessment information is the patient.

True
False
3. Numerical scales with word anchors are one type of pain rating scale.
True
False
4. One goal of analgesic administration can be identified by asking the patient

to indicate on a pain rating scale the level of pain that would make it easy for
him or her to perform activities essential for recovery.
True
False
5. Pain behaviors or expressions of pain are a very reliable indicators of the

presence of pain in any patient.
True
False
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Review Answers
1. False
2. True
3. True
4. True
5. False
Course #150
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Chapter Four
Using Analgesics

1. Identify two reasons why patients are undertreated for pain.
2. Define the terms addiction, physical dependence, and tolerance.
3. Give examples and describe side effects of nonopioid and opioid
medications.
4. Identify the rationale behind the use of adjuvant medications in
pharmacologic pain management.

T he problem of undertreatment of acute pain and of prolonged pain in the terminally

1,2,3
ill patient has been recognized for almost 20 years. This undertreatment results
in needless suffering of patients and families. It is estimated that 90 percent of patients
with acute pain or the prolonged pain of terminal illness could be made comfortable if
4
analgesics were properly used.
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40. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Using Analgesics
There are a number of ways that undertreatment of pain can occur. Physicians may
underprescribe opioids for reasons such as a lack of knowledge about the medications
and their proper use, fear of repercussion from medical regulatory boards and the legal
system, and societal pressures caused by enhanced awareness of substance abuse
problems.
Nurses may administer less than a patient could receive under the physician’s order
for many of the same reasons. Nurses may administer opioids at longer intervals than
ordered or decrease the dose of opioid below the dose ordered (a legally questionable
practice).3,5,6
Finally, some patients do not take or request pain medications when needed.
Possible reasons include fear and misunderstanding about opioid analgesia, especially
related to addiction and physical dependence.
Concerns about addiction

Physicians, nurses, patients, and families share misconceptions and fears about
addiction, physical dependence, tolerance, and the side effects of opioid analgesics.
These fears and misconceptions mean patients suffer in pain although relief or a greater
degree of comfort is possible with the use of analgesics.
Both health professionals and the public fear addiction and sometimes equate it with
the legitimate use of opioids for pain relief. According to the APS, addiction may be
defined as a behavioral pattern of compulsive drug use characterized by continued
craving for an opioid and the need to use the opioid for effects other than pain relief (or
7
use for nonmedical reasons.) This means that a patient who takes opioids simply for pain
relief is not an addict, no matter how much opioid the patient consumes or how long the
patient has been taking opioids.
Patients who take opioids for a week or longer do, however, often develop physical
dependency and tolerance. These are physiological changes that should be expected after
repeated administration of opioids although they do not occur in all patients. They should
not be equated with addiction. Also, they are not difficult clinical problems to handle.
Physical dependence on opioids is revealed when the opioid is suddenly stopped or
7
an antagonist such as naloxone (Narcan) is given. This is referred to as “withdrawal” or
“abstinence syndrome” and is characterized by anxiety, chills, runny nose, diarrhea, and
other symptoms that resemble a mild cold or severe influenza. To avoid signs of
withdrawal in a physically dependent patient, decrease the opioid dose slowly over seven
to 10 days.
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Using Analgesics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Opioid tolerance is characterized by a decrease in one or more effects of the opioid,

such as decreased analgesia, sedation, or respiratory depression. Tolerance to analgesia
requires an increase in the opioid dose or a decreased interval between doses.7 Tolerance
to analgesia appears to stabilize after a few weeks. Stable pain leads to stable doses.
Further increases in dose are likely to be due to increased pain. Fortunately, tolerance to
respiratory depression continues to increase. Therefore, it is usually safe to administer
larger opioid doses to patients who require them because of increased disease, such as
often occurs in the terminally ill patient.
Tolerance, physical dependence, and addiction are separate entities. (See Table 6 for
a comparison of definitions.) They do not necessarily occur together. Many patients
receiving opioids daily for pain relief are physically dependent and tolerant but not
addicted.
One of the most frequently cited reasons for undertreating pain is the fear of causing
opioid addiction. Health professionals have unrealistic and unfounded fears about causing
addiction in patients who receive opioids for pain.
Table 6
Definitions of Opioid Addiction, Tolerance,

and Physical Dependence
Term Definition
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The literature reports that the actual incidence of opioid addiction in patients who
8
were not previously addicted to opioids is very low, bordering on nonexistent; yet the
fear of addiction persists. In a 1989 survey of 1,781 nurses, 31 percent believed that
addiction would occur in 25 percent or more of their patients who receive opioids for
9
pain control.
This misinformation about addiction may be traced to basic nursing education. In a
survey of 14 nursing textbooks published between 1985 and 1990, only one, a
10
pharmacology textbook, correctly stated the definition of opioid addiction. Many of the
textbooks used confusing and misleading terminology and provided inaccurate
information that could promote irrational fears of addiction.
Another reason for undertreatment of pain is misunderstandings about tolerance, e.g.,
thinking that we should “save the morphine” until pain becomes severe. One study
showed that a major reason for cancer patients’ undermedicating themselves was their
fear that the opioids’ effectiveness would decrease over time.11 Fortunately, the
morphine-like opioids have no analgesic ceiling; opioid doses can be increased
4
indefinitely to maintain effective analgesia.
Principles of analgesic use

The management of pain is a team effort involving the patient, who feels and reports
pain; the physician, who prescribes analgesics; the pharmacist, who prepares and
dispenses the analgesics; and the nurse, who administers medications and monitors their
effectiveness. A patient’s family may be a part of the team, as well. Other disciplines
such as physical therapy may also be needed.
Authorities on pain management suggest that analgesics be used in a preventive
4,7,12-15
approach for patients with prolonged or acute pain. For any patient who has pain
7
most of the day, a routine, around-the-clock (ATC) dosing schedule is indicated. Some
benefits of a preventive approach are that the patient spends less time in pain, a steady
plasma level of analgesic can be maintained, and the patient’s anxiety about the return of
13
the pain decreases.
Safety in medication administration is a prime tenet of nursing practice. Nurses need
to know the initial recommended dosage of a given medication and understand the need
to titrate (increase or decrease the dosage) as necessary to achieve the desired pain relief
7,13,15
with the fewest side effects.
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The increased pain that accompanies advancing disease (such as cancer) means that
some patients need to take very high doses of morphine-like opioids to maintain
analgesia. However, since patients also develop tolerance to respiratory depression and
7
sedation, higher doses are usually safe. Morphine-like opioids lack an analgesic ceiling,
meaning that pain relief can be obtained by continuing to increase the dose.
The numbers of milligrams given to patients on long-term opioids can be shocking to
those who don’t understand the gradual process of titration and individualization of dose.
For example, some patients require the equivalent of 30,000 to 40,000 milligrams of IV
16
morphine per 24 hours. In summary, the safe and effective way to administer opioids is
to watch the patient’s response to the medication, not the dose.
Three major classes of analgesics

Nonopioid analgesics
The nonopioids are usually divided into two major groups: acetaminophen, which is
in the only drug in that group, and nonsteroidal anti-inflammatory drugs (NSAIDs). In
contrast to opioids, nonopioids have a ceiling effect for maximum analgesia, i.e., beyond
a certain dose no more analgesia can be obtained. Also unlike opioids, use of nonopioids
does not result in tolerance to analgesia or physical dependence. Unfortunately, the
analgesic effect of nonopioids is often underestimated, and they are underused in
situations in which they could prove beneficial. For example, the average dose of aspirin
or acetaminophen (650mg PO) provides approximately the same pain relief as 30-60mg
7
of codeine orally. Dosing guidelines for nonopioid analgesics may be downloaded from
the Web site www.mosby.com/PAIN.
The NSAIDs are cyclooxygenase (COX) inhibitors. Two forms of COX are COX-1
and COX-2. Blocking COX-1 causes side effects such as increased bleeding time,
17
gastrointestinal (GI) bleeding, and ulcers. Blocking COX-2 relieves pain.
Based on the COX forms that are inhibited, the NSAIDs are subdivided into two
groups: nonselective NSAIDs and selective COX-2s (or coxibs). The nonselective
NSAIDs block both COX-1 and COX-2 while the selective COX-2s selectively block
COX-2. The result is that selective COX-2 NSAIDs produce less incidence of GI
17
toxicity and cause no increase in bleeding time. However, both types of NSAIDs have
7
the potential for renal damage.
The nonselective NSAIDs include aspirin, diflunisal (Dolobid), ibuprofen, ketorolac
(Toradol), naproxen, and piroxicam (Feldene). The selective COX-2s include celecoxib
(Celebrex), rofecoxib (Vioxx), and valdecoxib (Bextra).
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NSAIDs are useful analgesics for most types of acute and chronic pain, including
inflammatory conditions (rheumatoid arthritis), musculoskeletal pain, dysmenorrhea,
bone metastasis, and postoperative pain. Unless contraindicated, a nonopioid should be
7
considered in all analgesics regimens even if pain is severe enough to require an opioid.
Because they do not increase bleeding time, COX-2s may be used preoperatively and
postoperatively. Research has shown that preoperative administration of a COX-2, e.g.,
valdecoxib 50 mg orally one to two hours before general anesthesia, can reduce opioid
18,19
doses postoperatively by 30-40 percent. Further, patients who are on daily
nonselective NSAIDs are often asked to stop the NSAID up to two weeks before surgery
to reduce the possibility of operative side bleeding. Instead of being without analgesia
during that time, these patients can take a selective COX-2.
Opioid (narcotic) analgesics

Opioids, formerly called narcotics, probably primarily relieve pain at the level of the
15
central nervous system by attaching to receptors in the brain and spinal cord. Opioids
may be divided into two groups: full agonists (mu agonists or morphine-like drugs) and
agonist-antagonists. Those in the agonist-antagonist group, such as pentazocine (Talwin),
nalbuphine (Nubain), and butorphanol (Stadol), have a very limited place in pain
management because there is a ceiling on their analgesia. Also, their antagonist effect
(e.g., naloxone-like effect) is strong enough that it sometimes reverses analgesia when
these opioids are given following a dose of morphine-like drug. The full agonists are the
mainstay of opioid analgesia and include morphine, hydromorphone (Dilaudid), fentanyl,
methadone (Dolophine), levorphanol (Levo-Dromoran), oxymorphone (Numorphan),
oxycodone (e.g., OxyContin), and codeine. The side effects commonly associated with
opioid use are respiratory depression, constipation, sedation, nausea, and vomiting.
Respiratory depression is a potentially life-threatening side effect that can be
prevented by the nurse’s monitoring of sedation levels and can be easily treated if it
occurs. It is critical to assess for sedation levels and respiratory status when you start
opioids on a patient who has moderate to severe pain and has not been receiving opioids
regularly. When an opioid causes the patient to be so sedated that he or she has difficulty
staying awake, the dose should be decreased to prevent respiratory depression. The
likelihood of respiratory depression decreases the longer the patient has been on opioids
because tolerance to respiratory depression develops and information about the patient’s
response to opioids is known.
The antidote for respiratory depression is naloxone (Narcan) administered
intravenously (or IM if necessary). Narcan is a pure opioid antagonist that can reverse
both analgesic effects and respiratory depression. Sufficient amounts of Narcan should be
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given to decrease sedation and increase respirations to an acceptable level without

completely reversing analgesia. Giving too much naloxone can also precipitate
hypertension and ventricular dysrhythmias. Therefore, dilute 0.4 mg of naloxone in 9 to
13
10 ml of saline and administer 0.5 ml over two minutes.
Be alert to the possibility of respiratory depression when you administer opioids, but
remember that clinically significant respiratory depression is relatively rare.
Perhaps the most distressing side effect for patients who receive opioids is
constipation. Any patient who receives an opioid analgesic should be started on a bowel
13
program to prevent constipation. A combined stool softener and mild peristaltic
stimulant like Peri-Colace, Doxidan, or Senokot-S taken daily is usually enough to
prevent constipation. Stronger stimulants, laxatives, cathartics, or enemas are employed
if necessary.
Opioid-induced nausea and vomiting may occur when a regimen is first begun, but
often subside after a few days. In acute postoperative pain, nausea may be handled by
decreasing the opioid dose and adding ketorolac (Toradol), a parenteral nonopioid
analgesic, to prevent pain from increasing. A nonsedating antiemetic, such as
ondansetron (Zofran) 8 mg PO or IV, may be used. An antiemetic such as
metoclopramide (Reglan) may be used. If pain is chronic and the patient can tolerate it, it
is helpful to wait to see whether the nausea subsides or can be controlled with
anti-emetics before discontinuing or changing opioids.
Other causes of nausea—such as other medications, hypercalcemia, uncontrolled
pain, copious sputum, or co-existing medical conditions—may be overlooked. Carefully
review signs, symptoms, and the patient’s case history before targeting opioids as the
cause of nausea.
Sedation is a dose-limiting side effect for some patients with chronic pain. Most
patients develop a tolerance to sedation after a few days on opioids. Some patients, such
as the elderly, may be more sensitive to the sedating effects of these drugs.
Each patient’s situation should be reviewed separately to determine the acceptable
level of sedation and to assess the potential for harm from decreased sensorium. Some
patients choose to endure more discomfort if it means less sedation. If the sedation level
is still unacceptable after a few days of adaptation, another opioid can be substituted until
a satisfactory one is found, or stimulants such as caffeine or dextroamphetamine may be
helpful.
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Adjuvant analgesics for neuropathic pain

Adjuvant analgesics are drugs that were not originally indicated for pain but are
nonetheless effective analgesics for selected types of pain. These drugs are most often
used for chronic pain states and seem to be especially helpful for neuropathic pain such
as neuropathy, postherpetic neuralgia, and trigeminal neuralgia. These drugs include:
• Tricyclic antidepressants (amitriptyline, nortriptyline, doxepin, imipramine),
which have been used successfully to manage dull, aching neuropathic pain
(such as peripheral neuropathy) as well as to treat painful states associated with
sleep disorders (fibromyalgia).
• Anticonvulsants (gabapentin, phenytoin, carbamazepine, clonazepam,
valproate), which are sometimes helpful for lancinating neuropathic pain (such
as trigeminal neuralgia or phantom pain).
• Local anesthetics, which are, of course, used to numb painful areas. They also
can be used for analgesia. For example, a 5 percent lidocaine patch
(Lidoderm) may relieve pain when it is applied to painful areas associated with
postherpetic neuralgia. A eutectic mixture of local anesthetics (EMLA) may be
13
applied to the skin to decrease the pain of immunizations.
First-line treatment for almost all types of neuropathic pain is usually gabapentin
and, if the pain is well localized and somewhat superficial (not deep tissue), the Lidoderm
20
patch. Both of these approaches tend to have minimal side effects and are relatively
easy to dose. Up to four Lidoderm patches may be safely applied to the area that hurts
21
for up to 72 hours while changing them every 12-24 hours. Then the patches probably
need to be removed for 12 hours before applying again.
Gabapentin is dosed three times a day, but it may be started at low doses, e.g., 300
mg HS, and escalated every three days (adding doses in the morning and midday) to
allow tolerance to the side effects of dizziness and sedation to develop. The dose should
be increased until pain relief is achieved or side effects are unacceptable. The effective
dose range is usually 900-2700 mg a day, but some patients require up to 6000 mg a
20
day.
Dosing guidelines for adjuvant analgesics may be downloaded from the Internet at
www.mosby.com/PAIN.
Note that phenothiazines are not included in this discussion. They maybe useful as
antiemetics for opioid-induced nausea, but sedation and orthostatic hypotension are limiting
7
side effects. Further, they do not potentiate opioid analgesia, and, except for methotrimeprazine
7
(Levoprome), they do not relieve pain.
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Figure 1
WHO Analgesic Ladder for Cancer Pain Relief
SOURCE: Adapted from the World Health Organization. Cancer Pain Relief, 2nd ed.
Geneva: World Health Organization, 1996.
The WHO analgesic ladder

Cancer pain relief is one of the priorities of organizations such as the World Health
Organization and the APS. The pain-relief method endorsed by the WHO is useful in a
variety of pain situations. (See Figure 1.) It involves a progression of management
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beginning with nonopioids with or without adjuvants and advancing to the addition of
opioids (such as codeine) for relief of mild pain. For severe pain, opioids (such as
morphine) and possibly nonopioids and adjuvants are recommended.
This method not only guides pain management through the terminal stages of illness,
but serves as an excellent reminder in any pain management situation. Better pain control
may be achieved through a combination of drugs with differing analgesic actions and side
effects.
As previously discussed, NSAIDs relieve pain primarily by inhibiting COX-2 while
opioids relieve pain by attaching to opioid receptor sites in the brain and spinal cord.
Combining an opioid with an NSAID attacks pain in two different ways and reduces the
required dose of opioid. Adding an adjuvant further reduces the dose of opioid and
relieves pain still another way.
This concept is applied to surgical pain and is known as balanced analgesia or
multimodal analgesia.22 An example is to attack pain in three ways by using epidural
fentanyl with bupivacaine and a nonopioid such as rofecoxib. Ideally, all of these
analgesic approaches are begun before or during surgery.
Summary
The successful pharmacologic management of pain involves a team approach. It
includes assessing pain, administering appropriate analgesics, adjusting the dose and
interval according to patient responses, monitoring and managing side effects, and
evaluating effectiveness of the treatment plan. How an analgesic is used is probably more
13
important than which one. In the complex healthcare environment, it is a challenge for
healthcare personnel to maintain a current, accurate understanding of the pharmacology
of pain management. In addition, we are faced with many myths and misconceptions
about addiction and opioid use that may prevent adequate pain control. Despite the
barriers, we must strive for state-of-the-art pain management. The results of comfort,
satisfaction, and enhanced quality of life are well worth the effort.
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References
1. Angell, J. “The quality of mercy.” New England Journal of
Medicine, 306:98-99. 1982.
2. Charap, A.D. “The knowledge, attitudes, and experience of medical
personnel treating pain in the terminally ill.” Mount Sinai Journal of
Medicine, 45:561-580. 1978.
3. Marks, R.M., & Sachar, E.J. “Undertreatment of medical inpatients with
narcotic analgesics.” Annals of Internal Medicine, 78:173-181. 1973.
4. World Health Organization. Cancer pain relief and palliative care. WHO
Technical Report Series, No. 804, Fig. 1. Report of a WHO expert
committee. Geneva. 1990.
5. Cohen, F.L. “Postsurgical pain relief: patients’ status and nurses’
medication choices.” Pain, 9:265-274. 1980.
6. Fox, L.S. “Pain management in the terminally ill cancer patient: an
investigation of nurses’ attitudes, knowledge, and clinical practice.”
Military Medicine, 147:455-460. 1982.
Acute Pain and Cancer Pain, 4th ed. Glenview, Ill., 1999.
8. Friedman, D.P. “Perspectives on the medical use of drugs of abuse.”
Journal of Pain and Symptom Management, 5(S2-S5). 1990.
9. McCaffery, M., & Ferrell, B.R. “Opioid analgesics: nurses’
knowledge of doses and psychologic dependence.” Journal of Nursing Staff
Development, 8, 77-84. March/April 1992.
10. Ferrell, B., McCaffery, M., & Rhiner, M. “Pain and addiction: an urgent
need for change in nursing education.” Journal of Pain and Symptom
Management, 7(2), 117-124. 1992.
11. Ward, S.E., et al. “Patient-related barriers to management of pain.”
Pain, 52:319-324. 1993.
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12. Hill, C. S. “Narcotics and cancer pain control.” In Pain Control in the
Patient with Cancer, 2-6. Atlanta: American Cancer Society. 1989.
Mosby. 1999.
14. Cherny, N. I., & Portenoy, R.K. “The management of cancer pain.” Cancer,
72 (suppl):3393-3415. l993.
No. 9, AHCPR Publication No. 94-0592, Rockville, Md. Agency for Health
16. Weinstein, S.M. “Inpatients with chronic pain, what is the suggested
maximum dose of sustained-release morphine?” Primary Care & Cancer
14:1:15. 1994.
17. Pasero, C., & McCaffery, M. “Selective COX-2 inhibitors.” American
Journal of Nursing, 101(4)55-56. 2001.
18. Reuben, S. S., et al. “Postoperative analgesic effects of celecoxib or
rofecoxib after spinal fusion surgery.” Anesthesiology & Analgesia, 91,
1221-1225. 2000.
19. Reuben, S. S., et al. “The preemptive analgesic effect of robecoxib after
ambulatory arthroscopic knee surgery.” Anesthesia & Analgesia,
94, 55-59. 2002.
20. Farrar, J.T., & Portenoy, R. K. “Neuropathic cancer pain: the role of
adjuvant analgesics.” Oncology, 15(11)1435-1445. 2001.
21. Gammaitoni, A. R., et al. “Pharmacokinetics and safety of continuously
applied lidocaine patches 5%.” American Journal of Health-System
Pharmacy, 59, 2215-2220. 2002.
22. Kehlet, H. “Multimodal approach to control postoperative pathophysiology
and rehabilitation.” British Journal of Anaesthesia, 78(5), 606-617. 1997.
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Review Questions
1. Societal pressure regarding the use of drugs sometimes
leads to undertreatment of patients in pain.
True
False
2. Physical dependence and tolerance are involuntary,

physiologic responses to repeated administration of
opioids.
True
False
3. Aspirin, acetaminophen, and ibuprofen are examples of

nonopioids.
True
False
4. Opioids relieve pain primarily by attaching to receptor sites

at the level of the peripheral nerves.
True
False
5. Constipation is a common side effect of opioid use.

True
False
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Review Answers
1. True
2. True
3. True
4. False
5. True
Course #150
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Chapter Five
Pain Management: Equianalgesia

1. Identify the rationale behind equianalgesic conversions.
2. Calculate equianalgesic doses using the equianalgesic chart.
3. Differentiate between the long-acting and the
short-acting opioids.

Originally by Margo McCaffery and Michelle Rhiner, RN, 1992.
T his chapter will attempt to help the clinician understand and use an equianalgesic
chart. Equianalgesia, which literally means “equal analgesia,” is a term that is
used to compare the effectiveness of different opioids in managing pain relief.
An equianalgesic chart on the following pages lists analgesics at doses that are
approximately equal to each other in the ability to provide pain relief. That is, all the
analgesics at the doses listed are approximately interchangeable.
The equianalgesic chart enables the clinician to compare the pain relief likely to be
achieved by opioids at different doses and via different routes. The lack of this
knowledge when a change is made in opioid choice, dose, or route has been linked with
1
the undertreatment of pain.
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54 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pain Management: Equianalgesia
The equianalgesic chart used in this course is based on APS recommendations

(1999). The chart is a guideline for determining the appropriate starting dose of an opioid.
After the first dose is administered, the dose and interval of the drug are adjusted to the
individual’s response. The effectiveness of the medication regimen must be monitored
through ongoing pain assessments and the use of pain rating scales.
The equianalgesic chart

The first equianalgesic chart (Table 7) is divided into four columns: analgesics, doses
for parenteral routes, doses for PO route, and comments. (In the second equianalgesic
chart, Table 8, for oral doses, the parenteral route column is omitted.) In Chart 1, the
analgesic column lists opioids used to manage moderate to severe pain such as
postoperative pain or chronic, cancer-related pain. Morphine is listed first as it is the
standard by which all other opioids are compared.2,3 The others are listed alphabetically by
generic name. The list includes only analgesics available and approved in the United
States. Opioid selection is based on pharmacologic properties and various patient
4
variables. Some considerations under pharmacologic properties include presence of
active metabolites, half-life, and duration of effect.
The second and third columns list the parenteral (IM, subcutaneous, and IV) doses
and PO doses that are approximately equal in their ability to relieve pain. A dash in either
column means the drug is not available in the United States by that route. The fourth
column lists specific considerations in the use of each drug, such as other routes of
administration or special precautions.
Converting parenteral opioids

The IM route is no longer recommended because of unreliable absorption. The IM
route is especially undesirable for treatment of chronic pain. Preferred routes include oral
or continuous infusion subcutaneously or intravenously. However, we will begin with the
IM route since it is the easiest route to learn to convert. Then we will progress to
problems involving the IV route.
To change a patient from one opioid to another by the IM or subcutaneous (SC) route
of administration, refer to the first column of the equianalgesic chart. Locate the
analgesic the patient currently receives and the desired new analgesic. Use the second
column to determine the dose of each.
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Table 7
Equianalgesic Chart: Approximate Parenteral and Oral Doses

for Moderate to Severe Pain
Equianalgesic doses* (mg) for severe to moderate pain
Opioids/narcotics IM/SQ/IV** Oral Comments
Opioid agonists: morphine-like, mu agonists
Morphine 10 30
Standard of comparison. Also available as controlled-release tablets and rectal suppositories.
Single oral dose may require 60 mg.
Codeine 130 200 NR***

Doses over 65 mg may produce diminished incremental analgesia. Oral tablets
usually compounded with nonopioid.
Fentanyl 100 mcg —

Transdermal (Duragesic) patches available in 25, 50, 75, 100 mcg/hour.
Equianalgesic conversion is controversial. Using oral/parenteral ratio 3/1 for morphine, 1 mcg/hr
of transdermal fentanyl roughly equivalent to oral morphine 2 mg/24 hr. Also available
sublingually as Fentanyl Oralet and Actiq.
Hydromorphone 1.5 7.5

Also available as rectal suppositories; 3 mg rectally = about 650 ASA.
(Dilaudid)
Levorphanol 2 4
Accumulates on days 2-3.
(Levo-Dromoran)
Methadone 10 20
Accumulates on days 2-5. In opioid-tolerant patient converted to methadone,
(Dolophine) reduce equianalgesic starting dose by 75%.
Meperidine (Demerol) 75 300 NR***

Normeperidine (toxic metabolite) accumulates with repetitive doses, causing CNS excitation.
Avoid high frequent doses, chronic use, and use in patients with impaired renal function.
Table 7, continued
Oxycodone — 20 Often compounded with nonopioid (e.g., Percocet) for moderate pain; available
as a single entity in immediate- or controlled-release (e.g., OyxContin)
for moderate or severe pain.
Oxymorphone 1 (10 rectal) Available in 5 mg suppositories.

(Numorphan)
Partial agonists
Buprenorphine 0.4 — May produce withdrawal in very opioid-dependent patients.
(Buprenex, Temgesic)
Dezocine (Dalgan) 10 — May be given with mu agonists.
Mixed agonist-antagonists: limited usefulness in cancer pain

Butorphanol 2 — Available as nasal spray; 1 mg/spray
(Stadol)
Nalbuphine (Nubain) 10 —
—
Pentazocine (Talwin) 60 180 —
Equianalgesic doses are approximate; use only as a guide. All doses must be titrated to individual’s response. Parenteral doses are
initial IM doses for acute pain in adults; may be used to convert doses for IV infusions and repeated small IV boluses. For single IV bolus,
use half IM dose. For patients over 70, consider lowering starting parenteral doses by 25-50%. The oral doses are not necessarily starting doses.
**Given over approximately 4 hr. or q4h
***NR = not recommended at that dose.
SOURCES: American Pain Society. (1999) Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, (4th ed.). Glenview, Ill.: American Pain Society.
Acute Pain Management in Adults: Operative Procedures. (1992) AHCPR Pub. No. 92-0019. Rockville, Md.: AHCPR, U.S. Dept. of Health and Human Services.
Note: A more extensive equianalgesic chart may be downloaded from www.mosby.com/PAIN.

Pain Management: Equianalgesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Table 8
C
Equianalgesic Chart 2: Equivalent Doses of PO Analgesics
for Mild to Moderate Pain
Analgesic PO dosage (mg)
Acetaminophen (Datril, Tylenol) 650
Aspirin (ASA, acetylsalicylic acid) 650
Codeine 32
Hydrocodone (as in Vicodin) 5
Meperidine (Demerol) 50
Pentazocine (Talwin) 30
Propoxyphene napsylate (as in Darvon-N) 100
For example:
According to the equianalgesic chart, there are several alternatives to giving a
patient meperidine (Demerol) 75mg IM while continuing to achieve
approximately the same pain relief. Meperidine 75mg IM is equivalent to 10mg
morphine SC or IM, 1.5mg hydromorphone (Dilaudid) SC or IM, 2mg
levorphanol (Levo-Dromoran) SC, and 10mg of methadone SC or IM. (See
Example 1 on page 59.)
If the dose of an ordered analgesic is not the same dose that appears in the IM
column, you can still calculate the dose by using a ratio. For example, if a child is
receiving meperidine 50mg IM and you want to switch to morphine IM, calculate
that 50mg is two-thirds of 75mg and that you will need two-thirds of any IM dose
listed, or about 6.5mg of morphine IM.
The listed parenteral doses are also used to calculate IV doses if you are
switching from one opioid analgesic to another via the IV route or switching from
IM to IV. Most clinicians consider the total daily doses by the IM, SC, and IV
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routes to be equivalent.
For example, a patient may be changed from repetitive IM injections to a
continuous infusion of IV morphine simply by calculating the total daily dose of
morphine IM and dividing by 24 for an hourly IV rate. If the patient is receiving
morphine 10mg IM q4h, the total daily parenteral dose of morphine is 60mg. That
dose is divided by 24 hours for an hourly infusion rate of 2.5 mg/hr IV or SC
morphine.
To convert from one IV opioid to another IV opioid, follow the directions
above for changing from one IM opioid to another. Since bolus or hourly IV doses
are likely to be smaller than the IM doses, the use of a ratio or percentage is often
necessary. (See Example 2 on page 60.)
Converting PO opioids
The PO route (mg) column lists the oral doses of analgesics that are approximately
equal to each other in relieving pain. To change from one PO opioid to another, refer to
this column. (See Example 3 on page 60.).
The opioids often given PO to clients with mild to moderate pain are codeine,
propoxyphene, oxycodone, and hydrocodone. The so-called stronger opioids are
morphine, hydromorphone, levorphanol, and methadone. Although these drugs are
considered more effective, the ability of an opioid to relieve pain largely depends on the
dose given.
In a survey of nurses, less than 44 percent knew that hydromorphone (Dilaudid) 2mg
PO was approximately equal to codeine 30mg compounded with acetaminophen 300mg
5
PO (Tylenol #3). When nurses think of hydromorphone as strong without taking into
account the doses, pain relief can be inadequate. This is another reason to use an
equianalgesic chart as a guide.
Changing opioid routes

Refer to the equianalgesic chart when changing the route of administration from IV
or IM to PO. If the route is changed and not the drug, first refer to the IM column, then to
the PO column next to it, and determine the ratio between IM and PO administration. A
patient receiving meperidine 75mg IM q3h would have to receive 300mg of meperidine
PO q3h; a patient receiving morphine 10mg IM q4h would need morphine 30mg PO
q4h. The large increase in dosage from IM to PO can be explained by what is known as
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“first pass effect.” Not all of the medication taken PO is absorbed by the stomach and
upper gastrointestinal tract. The medication that is absorbed into the bloodstream is
carried by the portal vein to the liver, where enzyme induction may cause further
metabolism, resulting in further loss of the drug.
Note also that the ratios of IM to PO doses are different for the various opioids. The
6
ratio for meperidine is 1:4; for morphine, it is 1:3. The practical application of this
information is that it gives the number by which an IM, SC, or IV dose must be
multiplied to determine the PO dose that would relieve the same amount of pain. Thus, a
parenteral dose of morphine must be multiplied by three to obtain the oral dose that
relieves the same amount of pain. (See Example 4 on page 61.)
Summary
Conversions provide the clinician a basis on which to formulate recommendations
for adequate pain relief. The initial calculation of an analgesic dose is an educated guess.
Adjusting the dose based on the patient’s response is essential for the effective use of
analgesics.
Examples of using equianalgesic charts

Example 1:
Robert, a 64-year-old male with renal insufficiency, is receiving meperidine
75mg IM q4h for postoperative pain. He has received this therapy for two days.
Your assessment reveals that Robert’s pain rating is 3 on a 0-10 scale, and he says
this is satisfactory. However, he has uncontrollable tremors in his hands and his
sleep is disturbed frequently by twitching and jerking. These are signs of
accumulation of the active metabolite of meperidine, normeperidine, and further
accumulation could lead to seizures.2,3 Therefore, it is essential to switch this
patient to another morphine-like drug, or mu agonist. Hydromorphone is an
excellent choice since it has a shorter half life than morphine and is devoid of any
known problematic active metabolites that are likely to accumulate with renal
dysfunction. Using the equianalgesic chart, the dose of hydromorphone that will
relieve approximately the same amount of pain as meperidine 75mg IM is 1.5mg
IM or SC. An hourly ongoing pain assessment is necessary at first to assure that
both the dose and the interval of the new opioid provide adequate pain relief.
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Example 2:
John, a 26-year-old male, was admitted to the hospital with multiple fractures
and facial trauma sustained in a motor vehicle accident. It is two days after the
accident, and he is receiving meperidine (Demerol) 25mg/hour IV. He reports his
pain is 2 (0-10 scale). However, he is experiencing nausea that has not been
responsive to antiemetics. Unmanageable side effects are one reason to switch a
patient from one opioid to another. Thus, Demerol IV is discontinued and
morphine IV is ordered. Using the equianalgesic chart, you find meperidine listed
at 75mg in the parenteral column. The patient is receiving one-third of that
dose. Thus, the morphine dose that probably will achieve the same analgesia is
one-third of 10mg—morphine 3-1/3mg IV/hour
Example 3:
Margaret, a 45-year-old female, is taking Tylenol #3 tabs ii PO q 4 hours
around the clock. Each Tylenol #3 tablet contains codeine 30mg and
acetaminophen 300mg for a total of codeine 60mg and acetaminophen 600mg
each dose. The pain is in the right arm related to mastectomy and lymph node
dissection and to fibrotic changes following radiation therapy to the area for
recurrence in the chest wall. Margaret rates her pain at 7 (0-10 scale). Pain
intensity one hour after taking two tablets of Tylenol #3 is reported at 5, but her
pain rating goal is 2. Increasing the dose of codeine is likely to produce
considerable nausea, especially since she is experiencing some nausea from the
present dose. To achieve greater pain relief without unmanageable side effects,
choose another opioid such as morphine or oxycodone PO, which are both
available in extended release formulation for oral administration. (Acetaminophen
can be continued separately.) What dose is required to provide more analgesia?
Using morphine, first determine how much morphine would be required for the
same analgesia she received from the codeine. Locate codeine in the PO column;
note the dose is listed at 200mg. The current dose of 60mg is approximately
one-third of 200mg. The dose listed for morphine PO is 30mg, and one-third of
that dose is 10mg. Next, determine how much to increase the morphine dose of
Course #150
10mg to achieve more pain relief. Usually a 25 to 50 percent increase is

recommended for a moderate improvement in pain relief.7 Thus, a dose of
morphine 15mg PO might be tried.
Example 4:
Mary is a 51-year-old female with a diagnosis of adenocarcinoma of the lung
with a large mediastinal mass. She experienced dysphagia secondary to the tumor
mass and received radiation to the mediastinal mass. Pain was controlled with
morphine 4mg SC per hour continuous infusion via an infusion pump, with bolus
doses of 1mg every 15 minutes. Two bolus doses have been used for breakthrough
pain within the last 24 hours. Pain is reported as 1 (0-10 scale). Radiation therapy
successfully reduced tumor bulk, and the patient can now swallow. The physician
decides to change from morphine SC to morphine PO. The ratio of SC morphine
to oral morphine is 1:3 for around-the-clock dosing based on survey data and
clinical experience.6 The first step is to calculate the total number of milligrams of
morphine received SC per 24 hours, including the bolus doses. Morphine 4mg SC
times 24 doses per day equals 96 mg/24 hours. Two bolus doses of 1mg each
equal 2mg/24 hours. Add 96mg plus 2mg morphine for a total of 98mg morphine
SC per 24 hours. The next step is to convert the SC dose to a PO dose by
multiplying the 98mg times three (ratio of SC to PO is 1:3) to get 294mg per day.
The last step is to divide the 294mg by the number of doses per 24 hours, i.e., six
(immediate release oral morphine is usually effective for approximately four hours) to
arrive at approximately 49mg PO q 4 hours. To convert the patient to extended release
morphine that is administered q12h, the 294 mg is divided by 2, so the patient would
receive extended release morphine (e.g., MS Contin) 150mg q12h (tablets are
available in 15mg, 30mg, 60mg, 100mg, and 200mg.)
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Course #150
References
Mosby. 1999.
Acute Pain and Cancer Pain, 4th ed. Glenview, Ill. 1999.
3. Agency for Health Care Policy and Research. Acute Pain Management:
Operative for Medical Procedures and Trauma. U.S. Department of Health
and Human Services. 1992.
4. Portenoy, R.K. “Opioid analgesics.” pp. 248-276. In Portenoy,
R.K. & Kanner, R.M., Eds.: Pain Management: Theory and
Practice. Philadelphia: F.A. Davis. 1996.
5. McCaffery, M., & Ferrell, B.R. “Opioid analgesics, nurses’ knowledge of
doses and psychological dependence.” Journal of Nursing Staff
Development, 77-84. March/April 1992.
6. Kaiko, R.F. “Commentary: equianalgesic dose ratio of intramuscular/oral
morphine, 1:6 vs. 1:3.” In K.M. Foley and E.C. Inturrisi (Eds.) Advances in
Pain Research and Therapy, 8:87-94. New York: Raven Press. 1986.
No. 9, AHCPR Publication No. 94-0592, Rockville, Md. Agency for Health
Course #150
Course #150
Review Questions
1. The term equianalgesia means approximately the same pain relief between
drugs or forms of the same drug.
True
False
2. When being converted from morphine 10mg IM to morphine PO, the patient
would require 15mg of morphine PO to obtain the same pain relief.
True
False
3. Opioids with long half-lives include morphine and hydromorphone.

True
False
4. The analgesia of morphine 10mg IV per hour is approximately equivalent to

the analgesia of hydromorhpone 1.5mg IV per hour.
True
False
5. Meperidine is the opioid of choice for patients with impaired renal function.
True
False
Course #150
Review Answers
1. True
2. False
3. False
4. True
5. False
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Chapter Six
Nondrug Pain Relief Measures

1. Name three methods of cutaneous stimulation used for pain relief.
2. Explain the rationale for the effectiveness and use of three nondrug methods.
3. Explain one simple behavior (action) that produces relaxation.

S ome simple pain relief methods include distraction, relaxation, and cutaneous
stimulation such as heat, cold, and massage. The nurse plays an important role in
initiating nondrug methods. If you do not suggest their use, nondrug therapies probably
will not be prescribed by the physician or initiated by the patient. These methods are not
intended to replace analgesics, but to enhance their effects.
When initiating nondrug techniques, the greatest obstacle you may encounter is the
hesitancy of patients to try them. This often is related to experience: The patient may
have used heat or relaxation techniques with no relief. Failure of nondrug approaches
may result from trying inappropriate methods for the type of pain or may be related to
misinformation about how to use the technique or to lack of skill in using the technique.
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68 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nondrug Pain Relief Measures
Sometimes patients mistakenly believe that even partial success with nondrug
methods will result in analgesics being decreased or withheld. Emphasize to patients and
families that nondrug methods will be used in addition to analgesics and should be used
before pain becomes severe. For example, when a patient first feels pain, an analgesic
should be given and the nondrug method employed. The rationale is that while the
analgesic is being metabolized, which takes about 20 to 30 minutes, the patient can obtain
some pain relief from the nondrug method.
Cutaneous stimulation
Cutaneous stimulation involves stimulating the skin to relieve pain. It includes heat,
cold, massage, vibration, counterirritants, and transcutaneous electrical nerve stimulation
(TENS). These are especially suited for relief of localized pain.
Heat—hot tub baths, heating pads, or heat packs—promotes relaxation. A chemical
pack can be heated in a microwave oven or in boiling water and enclosed in an elastic
bandage with Velcro. The patient can remain mobile while wearing it, and the wrap
provides some degree of support, which is comforting to the patient.
Cold is often more effective in relieving pain than heat, but is less likely to be used
by patients. Because of cold’s effectiveness, you should strongly encourage its use even
if a patient is reluctant.
Most people (even healthcare professionals) are taught to use heat rather than cold
for joint or muscle pain relief. In a review of the therapeutic uses of cold, researchers
point out that cold applications may reduce muscle spasms secondary to underlying joint
1
pathology or nerve root irritation. Cold breaks the cycle of secondary muscle spasms,
ischemia, pain, and more spasms.
Methods of cold application include ice massage, ice bags, and gel packs.
Commercially prepared gel packs are inexpensive, can be reused, and are convenient.
Champ Cold Wrap is a gel-pack counterpart to the hot wrap mentioned above.
One way you can increase a patient’s acceptance of cold is to avoid the shock of
sudden, intense cold by gradually cooling the area until the patient begins to feel relief.
Apply a well-wrapped cold pack and gradually remove layers of cloth from the ice bag
until the area is sufficiently cold. Clinical experience indicates this method effectively
relieves abdominal and lower back pain.
Alternating heat and cold is even more effective than using heat or cold alone. It can
be extremely effective even for severe pain. One technique, contrast bathing, involves
immersing a limb alternately in hot water and then in cold water. The same results can be
obtained by alternating the use of heat and cold packs.
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Nondrug Pain Relief Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Massage is soothing and relaxing, both physically and mentally. Massage decreases
pain by relaxing muscle tension and increasing capillary circulation, which improves
general circulation. Almost everyone enjoys a massage, and a review of the literature
reveals that a simple three-minute backrub enhances comfort and has a positive effect on
2
cardiovascular parameters.
Vibration is a form of electric massage. It is not widely used, but research suggests it
can be very effective (possibly as a substitute for TENS in some patients). Vibration
applied with moderate pressure can cause numbness, paresthesia, or anesthesia of the
3
area. Vibration applied to an area for 25 minutes can promote relief for several hours.
Counterirritants are substances such as menthol-containing preparations that provide
warmth or coolness to an area. These may distract the patient from the sensation of pain
or decrease the patient’s perception of pain. Menthol-containing products such as
Ben-Gay, Icy Hot, and Vicks are popular home remedies often used with sports-related
injuries. Menthol probably does not change skin temperature, but it does produce
sensations of temperature change.
Counterirritants should not be used with heat (such as heating pads, heat packs, or
the sun) as heat can increase absorption of counterirritants and cause burns. Many
counterirritants contain salicylate, which may be contraindicated in patients with
decreased platelet function.
TENS provides low-voltage electricity to the body via electrodes placed on the skin.
It can be effective with acute or chronic pain. The success rate of TENS varies. Relief of
4
chronic nonmalignant pain varies, but certainly some patients benefit from TENS.
Relief of postoperative incisional pain using TENS appears to have been overestimated in
5
the past, but it may still have a role along with analgesics for some patients.
Stimulation of trigger points and acupuncture points within the area of pain or at a
distance from the pain also may provide relief. The mechanism is unclear; perhaps
stimulation of an acupuncture point balances energy along the meridian, or maybe
4
stimulation of a trigger point reduces its irritability.
Locations of acupuncture points and trigger points are similar and can be identified
by probing the painful site and its surrounding area with your fingertips. The sensitive
areas identified by the patient are most likely to be trigger points or acupuncture points.
Use the location of these points as a guide for placement of cutaneous stimulation
techniques.
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Cutaneous stimulation sites

Selecting an appropriate site involves trial and error. Directly over or around the
painful site is usually, but not always, the best place. If the area is too painful, use the
6
area proximal (“between the pain and the brain”) or distal to (beyond) the pain. Use
.7
contralateral sites if an area is too painful for a nondrug method to be applied (See
Figure 2.)
The duration and frequency of cutaneous stimulation also are matters of trial and
error, convenience, and practicality. The most frequently suggested time period for
cutaneous stimulation techniques, except ice massage, is 20 to 30 minutes. Usually, the
longer stimulation is used, the longer pain relief lasts. If possible, use cutaneous
stimulation before pain occurs or increases; discontinue if pain increases or skin irritation
occurs.
Limit ice massage to 10 minutes or less. Discontinue if there is numbness, alternating
blanching and dilation of vessels, or shivering. If the patient desires ice massage for
longer than 10 minutes for longer-lasting relief of low back pain, divide the painful area
into different sites. Massage each site for seven minutes with a three-minute pause
between sites.
If pain or skin irritation occurs while using a method, stop. Extreme heat or cold is
contraindicated in areas receiving radiation therapy since the skin is fragile and sensitive
to temperature changes.
Distraction
Distraction from pain involves focusing attention on stimuli other than the pain
sensation. The stimuli can be auditory, visual, or tactile-kinesthetic (hearing, seeing,
touching, and moving). Distraction does not make pain go away, nor does the
effectiveness of distraction indicate an absence of pain.
Music is an effective distraction method. In one study, 94 patients from pediatric,
oncology, and burn units selected music and listened via headsets during brief, painful
8
procedures such as bone marrow aspirations. All patients reported that distraction was
helpful. The directions in the following sample form are similar to those used in the
study. These directions may be duplicated and given to patients and families. (See
Table 9.)
Humor is another effective means of distraction. Patients can listen to humorous
9
tapes or watch funny videos before or during painful procedures. In research comparing
nonhumorous distraction, relaxation, and laughter, only laughter increased discomfort
10
thresholds. The effects continued for at least 10 minutes after laughter subsided.
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Figure 2
Cutaneous Stimulation Sites
This figure illustrates four

possible sites for cutaneous
stimulation: site of pain,
proximal to pain, distal to pain,
and contralateral.
SOURCE: Margo McCaffery, MS, RN, FAAN
If these exercises are not successful, ask if the patient likes the selection. Ask the
patient if he or she is being distracted from the distraction; if so, determine the cause and
correct it if possible.
Relaxation
Relaxation is a state of relative freedom from both anxiety and skeletal muscle
4
tension, a quieting or calming of the mind and muscles. Relaxation can be used as an
adjunct treatment for pain; it is not intended to eliminate the need for analgesics.
Although relaxation is a learned technique, it can be achieved without taking much time.
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0
Table 9
Patient Information: Active Listening

to Recorded Music for Distraction
Use:
• The following suggestions may help you with a brief period of pain, that is, pain that
lasts from a few minutes up to an hour.
• Use these suggestions along with your pain medicine.
Instructions:
1. Obtain a cassette player or tape recorder, earphones or headset, and a cassette of the music
you like. (Most people prefer fast, lively music, but some select relaxing music. Other
options include comedy routines, sporting events, old radio shows, or stories.)
2. Listen to the music at a comfortable volume. If the discomfort increases, try increasing the
volume; decrease the volume when the discomfort deceases.
3. Mark time to the music. (Tap out the rhythm with your finger or nod your head, for instance.)
This helps you concentrate on the music rather than your discomfort.
4. Keep your eyes open and focus steadily on one stationary spot or object If you wish to close
your eyes, picture something about the music.
5. If this is not effective enough, try adding or changing one or more of the following: massage
your body in rhythm to the music; try other music; mark time to the music in more than one
manner (for instance, tap your foot and finger at the same time.)
Additional points: Many patients have found this technique helpful. It tends to be very popular
among patients, probably because the equipment is usually readily available and part of daily
life—you see many people exercising and listening to a recording through a headset. Other
advantages are that it is easy to learn and is not physically or mentally demanding. For these
reasons, it may be used for up to an hour. If you are very tired, you may simply listen to the
music and omit marking time or focusing on a spot.
SOURCE: From McCaffery, M., & Pasero, C. Pain: Clinical Manual, 2nd ed. St. Louis:
Mosby. 1999.
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Many relaxation techniques depend on classic conditioning or behavior already

paired with relaxation such as deep breathing, abdominal breathing, yawning, or memory
of peaceful experiences. These promote rapid relaxation. One very simple relaxation
technique is to clench your fists; breathe in deeply and hold for a moment. Breathe out
slowly, and go limp like a rag doll. Start yawning.
Relaxation audiocassettes are available in bookstores. Patients can select auditory
stimulation in the form of nature sounds such as birds, surf, or forest noises. Some
relaxation tapes incorporate breathing exercises or contraction/relaxation exercises with
soothing music to reduce tension.
You can create a personalized relaxation tape by recording the patient’s recollection
of an event or a location that was comforting or relaxing. (See Table 10.) The patient is
already conditioned to relax during this event, and the “sameness” of each relaxation
session is ensured, thereby increasing conditioning.
If the experience is taped, the patient need not make an effort to recall it. The patient
should use headphones to eliminate distracting noises.
To appropriately use relaxation, you must understand its limitations. Relaxation
should not substitute for other therapies, such as analgesics for patients with cancer.11
Successful relaxation should not be interpreted to mean that pain is psychogenic or due to
anxiety.
Conclusion
The combination of pharmacological and nonpharmacological approaches to pain is
the most effective means of pain management. The method is based on a patient’s
personal preference and the type of pain present. Nondrug techniques may be tried on a
trial-and-error basis until the right method for maximum pain relief is discovered. We
hope this chapter challenges you to recognize the importance of your role in nondrug
techniques for pain relief. Research has shown that a structured nondrug intervention
12
program is inexpensive and well received by patients.
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Table 10
Patient/Family Teaching Point:

Peaceful Past Experiences
To: (patient’s name) Date:
Something may have happened to you a while ago that can be of use to you now.
Something may have brought you deep joy or peace. You may be able to draw on that
experience for peace or comfort. Think about these questions:
• Can you remember any situation, even when you were a child, when you felt
calm, peaceful, secure, hopeful, comfortable?
• Have you ever kicked off your shoes and daydreamed about something
peaceful? What were you thinking of?
• Do you get a dreamy feeling when you listen to music? Do you have any favorite
music?
• Do you have any favorite poetry that you find uplifting or reassuring? Are you
now or have you ever been religiously active? Do you have favorite readings,
hymns or prayers? Even if you haven’t heard or thought of them for many years,
childhood religious experiences still may be very soothing.
Very likely some of the things you think of in answer to these questions can be
recorded for you, such as your favorite music or a prayer read by your clergyman.
Then you can listen to the tape whenever you wish. Or, if your memory is strong, you
may simply close your eyes and recall the events or words.
From: (nurse’s name) Phone:
May be duplicated for use in clinical practice.
Course #150
References
1. Lehmann, J.F., & de Lateur, B.J. “Diathermy and superficial heat and cold
therapy.” In Kottke, F.J., Stillwell, C.K., & Lehmann, J.F., Eds. Krusen’s
Handbook of Physical Medicine and Rehabilitation, 275-350. Philadelphia:
W.B. Saunders Co. 1982.
2. Labyak, S., & Metzger, B.L. “The effects of effleurage backrub on the
physiological components of relaxation: a meta-analysis.” Nursing
Research 46:59-62. 1997.
3. Luneberg, T. “Long-term results of vibratory stimulation as a pain relieving
measure for chronic pain.” Pain, 20:13-23. 1984.
Mosby. 1999.
5. Carroll, D., et al. “Randomization is important in studies with pain
outcomes: systematic review of transcutaneous electrical nerve stimulation
in acute postoperative pain.” British Journal of Anaesthesia 77:798-80.
1996.
6. Shore, et al. “The effect of two sites of high frequency vibration on
cutaneous pain threshold.” Pain, 25:133-138. 1986.
7. Melzack, R., & Schuster, B. “Itch and vibration.” Science, 147:1047-1048.
1985.
8 Eland, J. Personal communication. Iowa City: University of Iowa. Feb. 11,
1987.
9. McCaffery, M. “Nursing approaches to nonpharmacological pain control.”
International Journal of Nursing Studies, 27(1):1-5. 1987.
10. Cogan, R., et al. “Effects of laughter and relaxation on discomfort
thresholds.” Journal of Behavioral Medicine, 10:139-144. 1987.
11. Cleeland, C.S. “Nonpharmacological management of cancer pain.” Journal
of Symptom Management, 2:S23-S28. Spring, 1987.
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12. Rhiner, M., et al. “A structured nondrug intervention program for cancer
pain.” Cancer Practice, 2(1):137-143. 1993.
Course #150
Review Questions
1. Distraction, relaxation, and cutaneous stimulation are
methods of nondrug pain relief.
True
False
2. It is important to employ the use of heat/cold massage

before pain becomes severe.
True
False
3. Cold breaks the cycle of secondary muscle spasm,

ischemia, pain, and additional muscle spasm.
True
False
4. Counterirritants such as Ben-Gay and Icy Hot should be

used with heat to provide maximum pain relief.
True
False
5. Contralateral sites can be used for cutaneous stimulation

when the site of pain is too sensitive to stimulate.
True
False
Course #150
Review Answers
1. True
2. True
3. True
4. False
5. True
Course #150
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Appendix
Educational Resources

T he following resources contain information on chronic and acute pain for

healthcare professionals, patients, and caregivers. By using these resources you can
obtain the latest information on pain management techniques.
Selected periodicals on pain

• American Journal of Hospice & Palliative Care. Circulation Department, 470
Boston Post Road, Weston, MA 02193; fax (617) 899-4900.
• Analgesia (free). Abbott Laboratories, Hospital Products Division, Medical
Department, AP30, 1 Abbott Park Road, Abbott Park, IL 60640-3500.
• Cancer Pain Release (newsletter). 1900 University Ave., Madison, WI 53705.
• Clinical Journal of Pain. Lippincott-Raven Publishers, P.O. Box 1600,
Hagerstown, MD 21741-9910.
• Journal of Pain and Symptom Management. Elsevier Science Inc., Regional
Sales Office, Elsevier Science, P.O. Box 945, New York NY 10150-0945;
(212) 633-3730.
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80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Educational Resources
• Network News (newsletter, cancer pain.) Network Project, MSKCC, Box 421,
1275 York Ave., New York, NY 10021.
• Palliative Medicine. Turpin Distribution Services Limited, Blackhouse Road,
Letchworth, Hertfordshire SG6 1HN UK. Fax +44(0)1462 480947.
• Topics in Pain Management: Current Concepts and Treatment Strategies.
Lippincott, Williams & Wilkins, P.O. Box 23291, Baltimore, MD 21203-9990.
Videos and CDs on pain management

• “McCaffery on Pain: Nursing Assessment & Pharmacologic Intervention in
Adults.” 1991. Four videotapes, 30 minutes each (4/$595). Lippincott,
Williams & Wilkins Electronic Media Division, 351 W. Camden St.,
Baltimore, MD 21201; (800) 326-1685; fax (410) 528-4422.
• “McCaffery: Contemporary Issues in Pain Management.” 1994. Four
videotapes, 30 minutes each. To order, see above.
• “Assessment and Overview of Analgesics” (CD 1) and “The Nurse’s Active
Role in Opioid Administration” (CD 2) 2000. M. McCaffery and C. Pasero. To
order, see above.
Organizations
• American Pain Society, 4700 W. Lake Ave., Glenview, IL 60025-1485; (847)
375-4715; www.ampainsoc.org. (Membership includes subscription to the
Journal of Pain.)
• American Society of Pain Management Nurses, 7794 Grow Drive, Pensacola,
Fl 32514; (888) 34ASPMN; www.aspmn.org. (Membership includes
subscription to Pain Management Nursing.)
• International Association for the Study of Pain (IASP), 909 N.E. 43rd St.,
Room 306, Seattle, WA 98105-6021; (206) 547-6409; www.iasp-pain.org.
(Membership includes subscription to the journal Pain.)
• National Hospice and Palliative Care Organization, 1700 Diamond Road, Suite
300, Arlington, VA 22314; (703) 873-1500; www.nhpco.org/
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Educational Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Clinical practice guidelines for establishing

standards of practice in pain management
• Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain,
4th ed., 1999. Contact the American Pain Society, 4700 W. Lake Ave.,
Glenview, IL 60025-1485; fax (847) 375-6315.
• Guideline for the Management of Acute and Chronic Pain in Sickle Cell
Disease, American Pain Society, 1999 (87 pages). To order contact the APS,
4700 W. Lake Ave., Glenview, IL 600125-1485; (847) 375-4715; fax: (847)
375-6315; www.ampainsoc.org.
• Pediatric Chronic Pain: A Position Statement From the American Pain
Society, 2001. Available at www.ampainsoc.org/advocacy/pediatric.htm.
• Consensus Statement: The Use of Opioids for Treatment of Chronic Pain,
1997, the American Academy of Pain Medicine and the American Pain
Society. Available at www.ampainsoc.org; published in the Clinical Journal of
Pain, Volume 13, No. 1, pages 6-8.
• Pain Management in Patients with Addictive Disease, 2002 (position
statement). Available at: www.aspmn.com.
• Neonatal Circumcision Pain Relief, 2001 (position statement). Available at:
www.aspmn.com
• The Management of Persistent Pain in Older Persons. Published in Journal
of American Geriatric Society (suppl) 50:S205-S224. 2002. For one free copy,
call (866) 788-3939.
• PACU Pain Management Algorithm. Published in Journal of PeriAnesthesia
Nursing 17(1)11-20. 2002.
• Clinical Policy on Abdominal Pain, American College of Emergency
Physicians, 1994 ($5). Order from the ACEP, 1125 Executive Circle, Irving,
TX 75038-2522; (800) 798-1822.
• Pediatric Analgesia and Sedation, 1992, ACEP (reprint #47/1/53110, free).
To order, see above.
Course #150
• Evidence-Based Guidelines for Migraine Headache in the Primary Care

Setting: Pharmacological Management of Acute Attacks, Pharmacological
Management for Prevention, U.S. Headache Consortium: Migraine, 2000.
Endorsed by the ACEP. Available at www.aan.com/public/
practiceguidelines/headache_gl.htm
Pain information resources for patients

• Understanding Your Pain: Using a Pain Rating Scale, a teaching pamphlet
developed with the support of the JCAHO and Endo Pharmaceuticals. To order
free samples, call (800) 462-3636. Endo will provide a disk for duplication to
facilities that adopt the pamphlet for use.
• American Chronic Pain Association, P.O. Box 850, Rocklin, CA 95677-0850;
(916) 632-0922.
• National Pain Foundation. www.painconnection.org.
• Fibromyalgia Network (newsletter, contacts), P.O. Box 31750, Tucson, AZ
85751; (800) 853-2929.
• National Headache Foundation (for lay public and professionals; membership
and newsletter $15), 428 W. St. James Place, 2nd Floor, Chicago, IL
60614-2750; (800) 843-2256.
• Interstitial Cystitis Association, P.O. Box 1553, Madison Square Station, New
York, NY 10159; (212) 979-6057.
• International Polio Network (post-polio syndrome), 5100 Oakland Ave., Suite
206, St. Louis, MO 63110; (314) 534-0475. Polio Network News.
• Reflex Sympathetic Dystrophy Syndrome Association, P.O. Box 821,
Haddonfield, NJ 08033; fax (609) 795-8845.
• Pain: Clinical Manual, by Margo McCaffery and Chris Pasero. (800)
426-4545. Contains over 30 patient information forms.
• No More Pain, 1991. For a free copy, information on bulk sales: Pain
Management Center, Fox Chase Cancer Center, 7701 Burholme Ave.,
Philadelphia, PA 19111; (215) 728-6900.
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Educational Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Additional information
• Pain Resource Center, a clearinghouse for materials related to pain. For an
index contact Pain Resource Center, City of Hope Medical Center, 1500 E.
Duarte Road, Duarte, CA 91010; (626) 359-8111, Ext. 63829; fax (626)
301-8941.
• State Cancer Pain Initiatives, Resource Center for State Cancer Pain Initiatives,
1300 University Ave., Madison, WI 53706; (608) 265-4013; fax (608)
265-4014.
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Course #150
A Nurse’s Guide to Pain Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Examination
P lease circle one letter corresponding to the nearest correct answer and transfer your
answers to the Scantron answer sheet provided. Mail the Scantron sheet and the
evaluation form to NurseWeek, 1156-C Aster Ave., Sunnyvale, CA 94086. Keep this
examination for future reference. This course must be completed and the exam received
within two years of purchase for you to receive a certificate of completion that is valid for
relicensure.
1. A temporary pain task force consisting of nurse managers is the

recommended approach to implementing the JCAHO pain
assessment and treatment standards.
a. True
b. False
2. The widespread dissemination of clinical practice guidelines and efforts to

educate healthcare professionals have been relatively unsuccessful in
improving the assessment and management of pain in institutions
nationwide.
a. True
b. False
3. One step in the implementation of the JCAHO pain standards is to list the
right to appropriate pain assessment and treatment in the patients bill of
rights and to post a copy in the lobby and waiting areas of the institution.
a. True
b. False
Course #150
86. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A Nurse’s Guide to Pain Management
4. All patients must be screened for the existence, nature, and intensity of pain
on admission to a treatment facility.
a. True
b. False
5. Pain documentation should be done in a way that facilitates regular

reassessment and follow-up, such as recording pain ratings on the graphic
sheet.
a. True
b. False
6. The patient’s self-report of pain is not sufficient to

establish a nursing diagnosis of pain.
a. True
b. False
7. Patients will exhibit observable behavioral signs whenever

they are in pain.
a. True
b. False
8. The nurse’s personal and moral biases are useful in

deciding if patients are trustworthy and are telling the
truth about their pain.
a. True
b. False
9. All patients will experience the same response and pain

intensity to similar painful stimuli.
a. True
b. False
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10. Two ways to dispel myths about pain are to reinforce the
fact that pain is a subjective experience and to provide
information and articles to support your position.
a. True
b. False
11. The absence of physical signs of pain (grimacing,

moaning, elevated heart rate, and blood pressure) means
that the patient is not in pain.
a. True
b. False
12. The assessment of pain is an ongoing process, not a

one-time event.
a. True
b. False
13. Numerical pain rating scales are time-consuming and

sometimes difficult to score.
a. True
b. False
14. An advantage of using a pain rating scale is consistency

in communication and interpretation of assessment
findings.
a. True
b. False
15. The pain flow sheet provides documentation of

interventions and their effectiveness.
a. True
b. False
Course #150
16. Addiction is a psychological dependence on opioids.

a. True
b. False
17. Nonopioids have no analgesic ceiling.

a. True
b. False
18. Opioids include morphine, codeine, oxycodone, and naproxen.

a. True
b. False
19. The effectiveness of morphine-like opioids is limited by

the presence of an analgesic ceiling.
a. True
b. False
20. Adjuvant medications are particularly useful in treating

pain of a neuropathic origin.
a. True
b. False
21. Equianalgesic tables are used when switching analgesics

from one route of administration to another.
a. True
b. False
22. First pass effect explains why it is necessary to give more

of an opioid when converting from the IM, SC, or IV
route to PO.
a. True
b. False
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23. Morphine 5mg PO provides about the same analgesia as

levophanol (Levo-Dromoran) 2mg PO.
a. True
b. False
24. Hydromorphone (Dilaudid) 4mg IV per hour over 4 hours

(total dose of 16mg IV) would require 80mg of
hydromorphone PO for the same analgesic effect.
a. True
b. False
25. Oxycodone 30mg PO is equivalent to morphine 15mg PO.

a. True
b. False
26. When nondrug methods are used, the analgesic taken by

the patient can be decreased or eliminated.
a. True
b. False
27. Heat is usually more effective than cold in relieving pain.

a. True
b. False
28. The location of painful trigger points can be used as a

guide for placement of cutaneous stimulation techniques.
a. True
b. False
29. Alternating heat and cold is usually more effective than either
heat or cold alone.
a. True
b. False
Course #150
30. Laughter is an effective means of distraction.

a. True
b. False
End of the examination
Course #150

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A Nurse’s Guide to Pain

Margo McCaffery, MS, RN, FAAN

How to Take This Course · · · · · · · · · · · · · · · · · · · iii

About the Authors · · · · · · · · · · · · · · · · · · · · · vii

Chapter One: Understanding the New Joint Commission

Chapter Two: Pain Assessment:

Chapter Three: Techniques of Pain Assessment · · · · · · · · 25

Chapter Four: Using Analgesics · · · · · · · · · · · · · · 39

Chapter Five: Pain Management: Equianalgesia · · · · · · · 53

Chapter Six: Nondrug Pain Relief Measures· · · · · · · · · 67

Appendix: Educational Resources · · · · · · · · · · · · 79

How to Take This Course

1 –Review the objectives

2 –Study the chapters in order

3 –Complete the examination

4 –Mail your answer sheet to NurseWeek

T he purpose of this course is to help nurses—who spend more time with

About the Authors

T he original course, published in 1992, was written by Margo McCaffery, Kathie

Understanding the New Joint

When you complete this chapter, you will be able to:

At the beginning of 2000, the Joint Commission on Accreditation of Healthcare

Why standards are needed

Barriers to pain management

Pain Knowledge and Attitude Survey

Answers to Questions 1-15

SOURCE: Copyright Margo McCaffery (1994; revised October 2001). May be

Inherent in recognizing the right of a patient to appropriate pain management is the

With this assessment, a comfort/function goal is established by asking the patient

For More Information

10. Joint Commission on Accreditation of Healthcare Organizations. “Assessing

3. A pain care committee’s work includes evaluating physician and staff

4. The 0-10 pain sale is not appropriate for all patients.

Pain Assessment: Debunking

When you complete this chapter, you will be able to:

2003 revisions by Margo McCaffery and Chris Pasero.

Expected pain behaviors

Identifiable cause of pain

Relief from placebos

Misconceptions That Hamper

Dispelling the myths

Improving pain assessment

2. All pain has an identifiable physical cause.

3. Pain tolerance varies from patient to patient.

5. Increasing the awareness of pain as a problem by doing a pain audit is a good

Techniques of Pain Assessment

When you complete this chapter, you will be able to:

2003 revisions by Margo McCaffery and Chris Pasero.

Initial pain assessment tool

Initial Pain Assessment Tool Date: _____

1. LOCATION: Patient or nurse marks drawing.

2. INTENSITY: Patient rates the pain. Scale used _____________________________________________

4. ONSET, DURATION, VARIATIONS, RHYTHMS: ______________________________________________

5. MANNER OF EXPRESSING PAIN: _______________________________________________________

6. WHAT RELIEVES THE PAIN? __________________________________________________________

7. WHAT CAUSES OR INCREASES THE PAIN? _______________________________________________

8. EFFECTS OF PAIN: (Note decreased function, decreased quality of life.)

10. PLAN: _________________________________________________________________________

May be duplicated for use in clinical practice.

Pain Rating Scales

Wong-Baker FACES Pain Rating Scale

• Manner of expressing pain: Information about possible pain behaviors is

The pain flow sheet

Time Pain Analgesic R P BP Sedation Other Plan & comments