Advanced Pain Management Part II: Non-Opioid Pain Management Nursing CEU Course

Kathy Quan RN BSN PHN

Kathy Quan RN BSN PHN

Part two of the advanced pain management CEU courses from examines non-opioid pharmacological approaches as well as non-pharmacological pain management. This course is designed to provide ceus for advance practice nurses to help improve treatment options and outcomes through a multifaceted approach.  

Improving quality of life despite chronic pain is a challenge for the whole healthcare team and is usually lead by the nursing team. Best practice guidelines strongly suggest that pain management should be started on the lowest end of invasiveness and focus on the individual’s needs and responses. The ideal plan is to be adjusted as needed with the lowest possible increments until management is reached and maintained. 

Effective pain management planning

Establishing an effective pain management plan of care must be based in an understanding that pain is subjective and what the patient perceives is his reality. The plan needs to combine the biological, psychological and social facets of pain. The US Department of Health & Human Services cited in 2019 that pain management must include all three of these facets along with multiple clinical disciplines. This multifaceted plan has proven to be effective in decreasing the severity of the pain and therefore improving mood, overall functionality and quality of life. 

An effective plan of care involves two classes of pain control and must consider each for necessity as well as effectiveness. The non-pharmacological involves behavioral health, restorative and complementary therapies as well as interventional procedures.  These are used to restore functionality, reduce pain, increase comfort and hopefully diminish the amount and duration of any analgesic treatment. When used appropriately, the need for opioid therapy can be mitigated. The pharmacological component helps to provide a synergistic effect and provide a multimodal plan. This is most often useful in the management of chronic pain with analgesics which are comprised of two main categories: opioids and nonopioids. 

Non-pharmacological therapies 

Restorative therapy with physical and occupational therapy works well with both acute and chronic pain by using movement therapy and other therapeutic exercises to reduce inflammation, promote recovery form injury and restore health. This is a primary aspect of non-pharmacological pain management. 

Cutaneous (skin) stimulation uses a variety of modalities to increase circulation and reduce pain from self-care practices as an alternative to analgesics. These include modalities such as TENS therapy, heat and/or ice therapy, therapeutic touch, massage, therapeutic ultrasound, acupuncture and acupressure. 

Cognitive behavioral therapies help the patient to change how the patient perceives the pain, reduce his stress and anxiety, and induce suppress of the discomfort from the pain. CBT modalities include distraction, relaxation techniques (yoga, meditation, and progressive muscle relaxation), Reiki, biofeedback and guided imagery.

Interventional pain treatment diagnoses and treats pain with minimally invasive interventions with the goal of alleviating pain and using a minimum amount of pharmacological therapy. Many of these modalities are minimally invasive and are considered minor procedures that can be performed as an outpatient. Other more invasive modalities may require using ultrasound, fluoroscopy or competed tomography. These will be performed by an interventional radiologist in a radiology department. Some of the more common interventions include trigger-point or joint injections, peripheral or sympathetic nerve blocks, spinal cord stimulators, and implanted intrathecal pain pumps. With increased invasiveness, these therapies also include risks for infection, failure and complications caused by the invasive devices. 

Pharmacological interventions

Multimodal pain management also usually includes some portion of pharmacological therapy. As with the non-pharmacological approach, using analgesics should begin with the lowest potency and be gradually increased as needed to achieve effective management of pain. Analgesics are divided into two categories; opioids and nonopioids. Use of nonopioids is most highly recommended as a best practice in light of the recent rise in opioid over use. 

Nonopioid analgesics are effective at reducing inflammation, fever, and pain. There are two main categories Tylenol (acetaminophen) and the non-steroidal anti-inflammatory drugs (NSAIDs) such as Aspirin, Ibuprofen and COX1 and COX 2 inhibitors. These are all are highly effective in treating mild to moderate pain and without need for prescription they are readily available in over-the-counter medications. There are multiple medications available in these categories. While they are quite effective, they are not without risk.

The risks include organ damage, GI bleeding, cardiovascular effects including blood clots, myocardial infarction (MI), stroke and heart failure. Conversely, in some instances, these medications are used to prevent clotting, strokes and cardiovascular events. Patient education and careful monitoring are necessary. 

The oldest and most commonly used analgesic is aspirin (acetylsalicylic acid). In low doses it can be cardio-protective, but at higher doses it can cause GI bleeding. Similar to Tylenol, aspirin can also become quite toxic with overdose. Because these drugs are over the counter and readily available, patient education is essential to understand and avoid risk of overdose. 

These drugs are also frequently combined with other medications such as Benadryl (diphenhydramine) for a sleeping medication. Patients need to understand that all doses need to be counted and contribute to the maximum daily allowances. Tylenol is often combined with opioid medications such as Vicodin or Percocet. Again, patient education is essential because it is not obvious that these medications contain as much as 650mg per dose. And with a maximum daily dose of 3 grams, the doses can add up quickly.

Synergistic effect of adjuvant analgesics

In an effort to mitigate the use of opioids and enhance pain management, other categories of medications are added to provide a synergistic effect. These include medications such as antidepressants including tricyclic antidepressants and serotonin norepinephrine reuptake inhibitors (SNRIs). Other medications used include skeletal muscle relaxants, glucocorticoids (steroids), topical analgesics, antihistamines, and biphosphates. Each of these medications require education and monitoring. Some require specific administration such as taking the medication first thing in the morning with a full glass of water while sitting or standing. Then the patient needs to remain sitting or standing for 30-60 minutes and not to eat or drink anything for 30-60 minutes after taking the medication. 

Many of these medications are contraindicated with some conditions such as diabetes. Others have significant side effects and risks. As with any pain management plan of care, the side effects and risks must be explained and considered along with the benefits to see which outweighs the other. The goal is to achieve pain management and improve patient outcomes. 

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