Nursing Continuing Education

Pain Management

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This is Your Course on Pain Management

Syllabus

Purpose/Goal

The purpose of this module is to provide comprehensive information pertaining to pain treatment.

At the completion of this module, you will be able to:

·               Identify two definitions of pain and explain their use when providing client care.

·               Explain the gate control theory and how it is applied in client care.

·               Discuss the physiology of pain.

·               Compare and contrast acute pain and chronic pain.

·               Compare and contrast nociceptive and neuropathic pain.

·               Identify the components of a pain assessment.

·               Identify factors that affect the pain experience

·               Discuss the use of nonpharmacological pain management strategies.

·               Discuss the use of pharmacological interventions for pain management.

·               Explain strategies to reduce the risk of opioid use disorder.

·               Identify complications related to pain management and explain associated nursing interventions.

The Pain Experience

Pain is an individual experience for each client. Nurses play an important role in pain management by recognizing that each client is unique and each pain experience is unique. Nurses must recognize their role in pain management and should implement measures to reduce a client’s pain to an acceptable level.

There are two commonly used definitions of pain.

Margo McCaffery, a well- known expert on pain, defines pain this way: “Pain is whatever the experiencing person says it is, existing wherever the experiencing person says it does.”

The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage”. Both definitions serve as a foundation for a nurse to understand the meaning of pain and the importance of pain management.

Effective pain management includes the use of pharmacological and nonpharmacological pain management therapies. Clients have a right to adequate assessment and management of pain. Nurses are accountable for the assessment of pain. The nurse’s role is that of an advocate and educator for effective pain management. Nurses have a priority responsibility to measure the client’s pain level on a continual basis and to provide individualized interventions. Nurses should assess the effectiveness of the interventions 30 to 60 minutes after implementation. Assessment challenges can occur with clients who have cognitive impairment, who speak a different language than the nurse, or who are receiving prescribed mechanical ventilation. Under treatment of pain is a serious health care problem. Consequences of under treatment of pain include physiological and psychological components. Acute and chronic pain can cause anxiety, fear, and depression. Poorly managed acute pain can ultimately lead to chronic pain syndrome.      

Physiology of Pain

There are several processes associated with nociceptors, the sensory impulses that carry pain signals. Knowledge of each of these helps us to understand what causes pain, what symptoms are common and nursing interventions for treatment.

Transduction is the conversion of painful stimuli to an electrical impulse through peripheral nerve fibers (nociceptors). Mechanical, thermal or chemical stimuli are detected by the nerve endings. Transduction occurs prior to the next process, transmission.

Transmission occurs as the electrical impulse travels along the nerve fibers, where neurotransmitters regulate it. Impulses from afferent, or sensory, neurons carry impulses to the central nervous system (the brain and the spinal cord). Impulses from efferent, or motor, neurons carry impulses away from the central nervous system.

Pain threshold is the point at which a person feels pain.

Pain tolerance is the amount of pain a person is willing to bear.

Perception or awareness of pain occurs in various areas of the brain, with influences from thought and emotional processes.  There is not one specific pain center in the brain.

Modulation (the final step in the process) occurs in the spinal cord, causing muscles to contract reflexively, moving the body away from painful stimuli.

Neurotransmitters are released as the result of cellular damage.  Certain neurotransmitters work to incite during the transmission phase, while others work to inhibit during the modulation phase.  Some of the neurotransmitters involved in the pain process include:

  • Substance P, a neuropeptide that transmits impulses from the periphery to the brain
  • Prostaglandins increase sensitivity to pain
  • Bradykinin binds to receptors on peripheral nerves and increases pain stimuli
  • Histamine causes capillary dilation and increased capillary permeability
  • Serotonin decreases sensitivity to pain
  • Enkephalins and endorphins fight pain and are considered endogenous painkillers

Pain Categories

Pain is categorized by duration (acute or chronic) or by origin (nociceptive or neuropathic), or by the disease or condition that causes it (e.g. cancer, diabetes, multiple sclerosis). 

Acute pain

  • Acute pain is protective, temporary, usually self‑limiting, has a direct cause, and resolves with tissue healing.
  • Physiological responses (sympathetic nervous system) are fight‑or‑flight response (dilated pupils, tachycardia, hypertension, anxiety, diaphoresis, muscle tension).
  • Behavioral responses include grimacing, moaning, flinching, and guarding.
  • Interventions are aimed at treatment of the underlying problem.
  • Can lead to chronic pain if unrelieved.

Chronic pain

According to the American Academy of Pain Management, over 100 million Americans live with chronic pain. Common conditions causing pain include low-back pain, headache, post-herpetic neuralgia, trigeminal neuralgia, fibromyalgia, and phantom pain.

Low-back pain is the leading cause of disability in Americans. . Determining the cause of low-back pain can be difficult and costly.

Headaches are another type of common pain. The most common types of headaches are migraine, tension, and cluster headaches. Headaches account for the most common chronic pain condition that lead to loss of productive time. Migraine headaches occur more frequently in women than men.

Post-herpetic neuralgia is a complication of shingles. After the rash recedes a burning pain in the affected area can occur. The risk of this complication increases with age. The Centers for Disease Controls (CDC) recommends vaccination against shingles for all clients age 60 years or older.  The current CDC policy recommends the herpes zoster vaccine for the prevention of shingles.  The Federal Drug Administration (FDA) has recently licensed a new vaccine for the treatment of shingles, zoster vaccine recombinant, which is awaiting policy approval by the CDC.  According to the FDA, zoster vaccine recombinant is the preferred vaccine for the prevention of shingles and can be given to clients starting at age 50 years.  The FDA recommends clients who have previously received the herpes zoster vaccine also received the zoster vaccine recombinant. 

Trigeminal neuralgia is a type of chronic pain that affects the fifth cranial nerve. Clients who have trigeminal neuralgia report having sharp, excruciating pain.  Carbamazepine, a medication used to control seizures, can be used to treat this condition.

Phantom pain is pain felt after the loss of a body part. To reduce a client’s anxiety, the nurse should educate the client who has an amputation that this type of pain might occur. Antiseizure medications are often used to treat phantom pain.

Fibromyalgia is a type of chronic pain that affects five million people in the United States. Clients experience a multitude of symptoms including musculoskeletal pain, fatigue, exercise intolerance and stiffness. The condition affects women more than men and usually appears in midlife.

Click here to learn more about fibromyalgia and the medications used to treat it.

As many as 75% of older adults have a condition that causes chronic pain.  But pain does not occur just because a person is aging.   Like back pain, younger adults can also have pain from osteoarthritis, osteoporosis, and degenerative disk disease.

Unlike acute pain, chronic pain is not protective. It is ongoing or recurs frequently, lasting longer than 6 months and persisting beyond tissue healing.  Chronic pain has the following characteristics:

  • Physiological responses do not usually alter vital signs, but clients can have depression, fatigue, and a decreased level of functioning. It is not usually life‑threatening.
  • Psychosocial implications can lead to disability.
  • Management aims at symptomatic relief.  Chronic pain does not always respond to interventions.
  •  Can be malignant or nonmalignant.
  • Idiopathic pain is a form of chronic pain without a known cause, or pain that exceeds typical pain levels associated with the client’s condition.

Nociceptive pain

  • Nociceptive pain arises from damage to or inflammation of tissues, which is a noxious stimulus that triggers nociceptors.
  • It is usually throbbing, aching, and localized.
  • This pain typically responds to opioids and nonopioid medications.

Types of Nociceptive Pain

  • Somatic:  Located in bones, joints, muscles, skin, or connective tissues.
  • Visceral:  Located in internal organs such as the stomach or intestines. It can cause referred pain in other body locations separate from the stimulus.
  • Cutaneous:  Located in the skin or subcutaneous tissue.

Neuropathic pain

  • Neuropathic pain arises from abnormal or damaged pain nerves.
  • It includes phantom limb pain, pain below the level of a spinal cord injury, and diabetic neuropathy.
  •  The pain is usually intense, shooting, burning, or described as “pins and needles.”
  • This pain typically responds to adjuvant medications (antidepressants, antispasmodic agents, skeletal muscle relaxants).

Assessment/Data Collection

Video Link: Watch Now

  • Noted pain experts agree that pain is whatever the person experiencing it says it is, and it exists whenever the person says it does. The client’s report of pain is the most reliable diagnostic measure of pain.
  • Self‑report using standardized pain scales is useful for clients over the age of 7 years. Specialized pain scales are available for use with younger children or individuals who have difficulty communicating verbally. These include the Faces Pain Scale, the Wong-Baker Faces Pain Rating Scale, and the Oucher pain scale.
  •  Nurses should assess and document pain frequently.

Risk Factors

Under Treatment of Pain

  • Cultural and societal attitudes
  • Lack of knowledge
  • Fear of addiction
  • Exaggerated fear of respiratory depression

Populations at Risk for Under Treatment of Pain

  • Infants
  • Children
  • Older adults
  • Clients who have substance abuse disorder

Causes of Acute and Chronic Pain

  • Trauma
  • Surgery
  • Cancer (tumor invasion, nerve compression, bone metastases, associated infections, immobility, prescribed treatments)
  • Arthritis
  • Fibromyalgia
  • Neuropathy
  • Diagnostic or treatment procedures (injection, intubation, radiation)

Factors That Affect the Pain Experience

  • Age
    • Infants cannot verbalize or understand their pain.
    • Older adult clients can have multiple pathologies that cause pain and limit function.
  • Fatigue
    • Can increase sensitivity to pain.
  • Genetic sensitivity
    • Can increase or decrease pain tolerance
  • Cognitive function
    • Clients who have cognitive impairment might not be able to report pain or report it accurately.
  • Prior experiences
    • Can increase or decrease sensitivity depending on whether clients obtained adequate pain relief.
  • Anxiety and fear
    • Can increase sensitivity to pain
  • Support systems and coping styles
    • Presence of these can decrease sensitivity to pain.
  • Culture 
    • Can influence how clients express pain or the meaning they give to pain.

Symptom Analysis

Use anatomical terminology and landmarks to describe the location of pain (superficial, deep, referred, or radiating). 

  • “Where is your pain? Does it radiate anywhere else?”
  • Ask clients to point to the location.


Quality refers to how the pain feels: sharp, dull, aching, burning, stabbing, pounding, throbbing, shooting, gnawing, tender, heavy, tight, tiring, exhausting, sickening, terrifying, torturing, nagging, annoying, intense, or unbearable. 

  • “What does the pain feel like?”
  • Give more than two choices: “Is the pain throbbing, burning, or stabbing?”


Intensity, strength, and severity are “measures” of the pain. 

  • Use a pain intensity scale (visual analog, description, or number rating scales) to measure pain, monitor pain, and evaluate the effectiveness of interventions.
  • “How much pain do you have now?”
  • “What is the worst/best the pain has been?”
  • “Rate your pain on a scale of 0 to 10.”

 
Timing: onset, duration, frequency

  • “When did it start?”
  • “How long does it last?”
  • “How often does it occur?”
  • “Is it constant or intermittent?”

Setting: how the pain affects daily life or how activities of daily living (ADLs) affect the pain

  • “Where are you when the symptoms occur?”
  • “What are you doing when the symptoms occur?”
  • “How does the pain affect your sleep?”
  • “How does the pain affect your ability to work or interact with others?”

Document associated findings: fatigue, depression, nausea, anxiety. 

  • “What other symptoms do you have when you are feeling pain?”

Aggravating/relieving factors 

  • “What makes the pain better?”
  • “What makes the pain worse?”
  • “Are you currently taking any prescription, herbal, or over‑the‑counter medications?”

Expected Findings

  • Behaviors complement self‑report and assist in pain assessment of nonverbal clients.
  • Facial expressions (grimacing, wrinkled forehead), body movements (restlessness, pacing, guarding)
  • Moaning, crying
  • Decreased attention span
  • Blood pressure, pulse, and respiratory rate increase temporarily with acute pain. Eventually, increases in vital signs will stabilize despite the persistence of pain. Therefore, physiologic indicators might not be an accurate measure of pain over time.

Patient-Centered Care

Nonpharmacological Pain Management Strategies

Nonpharmacological strategies should not replace pharmacological pain measures, but can be used along with them.

Cutaneous (skin) stimulation: Includes transcutaneous electrical nerve stimulation (TENS), heat, cold, therapeutic touch, massage, acupuncture and acupressure.  These physical modalities increase circulation and reduce the level of pain. 

  • TENS is the use of a small electric stimulator that is attached to the skin in painful areas. An electrical current blocks the sensation of pain.
  • Heat causes vasodilation and promotes blood flow to the area. When using a heating pad or other types of heating devices, check agency policy about how long the treatment is to be used.  Generally, the treatment is discontinued after 15 to 30 minutes, because if it is applied for more than 1 hour, the body responds by reducing blood flow to the skin by a reflex vasoconstrictive response. In the health care setting, aquathermia pads, disposable heat pads are examples of dry heat. Warm moist heat is applied using a warm moist compress, or soaking a body part by using a sitz bath. Most health care agencies do not use hot water bottles because improper use can lead to burns. Instruct clients who use a hot water bottle at home to fill the bag about two-thirds full with water that is 460C to 520C (1150 F to 1250). These temperatures are appropriate for clients who do not have health problems such as a condition that leads to confusion, impaired circulation or other serious conditions. Tell the client to check the appearance of the skin after 5 minutes to make sure the hot water bottle is not burning the skin and to discontinue use after 15 to 30 minutes.
  • Cold applications reduce swelling and pain.  As with the application of heat, check agency policy about how long the treatment is to be used.  Generally, the treatment is discontinued after 5 minutes or when the area begins to feel numb.   Prolonged exposure to cold, as with heat, results in reflex vasodilation. Ice bags, ice collars, and ice gloves are used as therapy to a localized area. Cooling blankets are used to lower a client’s body temperature. Extreme caution is used when these are in use. Check with agency policy about the use of cooling blankets.
  • Therapeutic touch is believed to reduce pain through balance in the body.  The therapist places his or her hands near the client’s body to balance the client’s energy field. 
  • Massage stimulates circulation, relaxes the client’s muscles and can reduce anxiety. It decreases pain by increasing circulation to the area. Avoid massaging areas where skin integrity is impaired or there is a change in the appearance of the skin, a blood clot is possible, or an infection is present. 
Acupuncture and acupressure: Stimulating subcutaneous tissues at specific points using needles (acupuncture) or the digits (acupressure). Only individuals with special training can perform these techniques.

Cognitive‑behavioral measures: Changing the way a client perceives pain, and physical approaches to improve comfort. Distraction, relaxation, guided imagery, biofeedback and Reiki are examples of cognitive-behavioral strategies to reduce pain. 

Distraction

  • Distraction directs the client’s attention to something other than the pain. A good use of distraction is during a painful diagnostic procedure or while waiting for an analgesic to take effect.
  • Includes ambulation, deep breathing, visitors, television, games, prayer, and music
  • Decreased attention to the presence of pain can decrease perceived pain level.

Relaxation: Includes meditation, yoga, and progressive muscle relaxation

  • Meditation involves focusing on an object sitting in a comfortable position and clearing the mind of all thoughts. Using meditation for 20 minutes, twice a day decreases heart rate, blood pressure and the respiratory rate.
  • Yoga has been practiced in India for centuries. It typically includes assuming poses, breathing exercises, and meditation. Yoga increases muscle strength and tone, reduces anxiety and lowers blood pressure.
  • Progressive muscle relaxation involves slow, deep abdominal breathing while progressively tightening and relaxing the muscles. The technique is used in a logical sequence such as beginning with the feet and moving up the rest of the body. 

Guided Imagery involves pleasant mental images such as a lake or the mountains. This technique shifts the client’s thoughts away from the pain. It can be used during painful diagnostic procedures. Clients must be able to concentrate in order to use guided imagery.

Biofeedback is a therapy which uses electric sensors to assist a client to control physiological responses such as heart rate and blood pressure.

Reiki is a natural healing technique in which a therapist channels energy into a client by touch to promote physical and emotional healing.

Other nonpharmacological pain management strategies include reducing painful stimuli in the client’s environment (wrinkled bed linens, tight bandages, lying on invasive tubing, urinary incontinence, constipation)  and elevating edematous extremities to promote venous return and decrease swelling.

Pharmacological Interventions

Analgesics are the mainstay for relieving pain. The three classes of analgesics are nonopioid, opioids, and adjuvants.

Nonopioid analgesics

Nonopioid analgesics, as a group, have anti-inflammatory, antipyretic and analgesic effects. However, the properties among the different medications vary. Nonopioid analgesics include nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen. These medications are appropriate for the treatment of mild to moderate pain.

First generation NSAIDs include aspirin, ibuprofen, indomethacin, diclofenac, ketorolac and meloxicam. These medications inhibit both COX-1 and COX-2, forms of the enzyme cyclooxygenase that converts arachidonic into prostaglandins. Both COX-1 and COX-2 cause the inflammatory process, but COX-1 also protects the gastrointestinal tract and is involved in kidney and platelet function. Therefore, when COX-1 is inhibited by first generation NSAID therapy inflammation, pain, and fever is reduced, but gastric ulceration, renal impairment and bleeding can occur.  Along with decreasing inflammation, pain, and fever, first generation NSAIDs are given for prophylaxis of stroke and myocardial infarction, and to treat the discomfort of rheumatoid arthritis and osteoarthritis. Second generation NSAIDs inhibit only COX-2. Celecoxib is an NSAID COX-2 inhibitor. It decreases inflammation, pain and fever, but it does not decrease platelet aggregation. It is administered to treat osteoarthritis, rheumatoid arthritis, ankylosing spondylitis and dysmenorrhea.

Aspirin is the prototype for NSAIDs and is the oldest medication in this category.  Aspirin, also known as acetylsalicylic acid (ASA) was introduced in 1899 and soon became the most widely used medication in the world. Because of its antiplatelet properties, many providers prescribe a dose of 81 to 325 mg once daily as prophylaxis of myocardial infarction. Additionally, the emergency treatment protocols in many locations includes having the client chew and swallow a 325 mg dose of aspirin when the symptoms of a myocardial infraction occur.

Salicylism syndrome is a serious condition that occurs when aspirin levels rise above the therapeutic range.  It can occur when large doses of aspirin are given at one time or when small to large doses are given over a long period of time. Ringing in the ears, or tinnitus, is the most common manifestations of salicylism in adults. Other manifestations include dizziness, disorientation and headache. Manifestations of salicylism in children are similar to those of the adult and include dizziness, drowsiness, and disorientation. When manifestations of salicylism occur aspirin is discontinued until the symptoms reside. In some cases, aspirin therapy is resumed, typically in a lower dose once symptoms are no longer present. Overdose of other NSAIDs such as ibuprofen can occur and present with manifestations similar to those of aspirin; however, generally they are not as severe.

Reye syndrome is a rare but serious complication that occurs when aspirin is used for fever reduction in children and adolescents who have a viral illness, such as chicken pox or influenza. Awareness of this syndrome has greatly reduced its occurrence.

Acetaminophen is currently the most popular analgesic in the United States. Often it is an ingredient in over-the-counter cough and cold remedies.  Additionally, acetaminophen is frequently combined with an opioid in some pain medications.  Examples are hydrocodone/acetaminophen and oxycodone/acetaminophen). Some combination products contain as much as 650 milligrams per tablet. Clients are not always aware that acetaminophen is an ingredient in the combined tablets.

Like aspirin, acetaminophen blocks pain by inhibiting prostaglandin synthesis of COX-1 and COX-2. Also, like aspirin, it suppresses pain and fever, but acetaminophen does not suppress inflammation or platelet aggregation.  An adverse effect of acetaminophen is that large doses can cause severe liver damage. Because of this risk, intake of acetaminophen should not exceed 4 grams per day.  Clients should be taught that frequent alcohol use while taking large doses of acetaminophen contributes to the risk of developing liver damage. Clients who consume more than three alcoholic drinks per day should consult their provider before taking acetaminophen. Clients should also be advised to check the label of combination analgesics to determine the amount of acetaminophen content contained in the product.  Instruct clients to follow their providers advise before taking any products that contain acetaminophen.  Parents should be cautious when giving children acetaminophen and should follow the recommendations of their provider or pharmacist.

Acetaminophen overdose is the principle cause of acute liver failure in the United States. Acetylcysteine is the antidote for acetaminophen overdose. Acetylcysteine decreases the build-up of hepatotoxic metabolites from the acetaminophen overdose to prevent or lessen the damage to the liver. . It can be given orally or intravenously. Ideally, it should be given within 10 hours of the overdose. Oral acetylcysteine smells like rotten eggs and this might induce the client to vomit. If the client is unable to take it orally, then it can be administered by a nasogastric tube or intravenously.

Opioid Analgesics and Antagonists

Opioid analgesics, such as morphine sulfate, fentanyl, and codeine, are appropriate for treating moderate to severe pain (postoperative pain, myocardial infarction pain, cancer pain).  Most opioid analgesics reduce pain by attaching to a receptor in the central nervous system, altering perception and response to pain. Opioids are classified as agonist, agonist-antagonists, and antagonists. An agonist attaches to a receptor and produces a response. The agonist can be split into two groups: strong opioid agonists and moderate to strong opioid agonists. The prototype for strong opioid agonists is morphine. The prototype for moderate to strong opioid agonists is codeine. An agonist-antagonist binds to one receptor creating a response and binds to another receptor to prevent a response. Pentazocine is the prototype of the opioid agonist-antagonists. 

An opioid antagonist acts as a competitor at opioid receptors and reverses the effect of an opioid. The manifestations of opioid toxicity are respiratory depression, coma and pinpoint pupils (also referred to as the opioid triad). Naloxone is the prototype for opioid antagonists. It can be administered IV, IM or subcutaneously. When administered IV, effects began almost instantly and last for about an hour. With IM and subcutaneous administration, the medication begins to take effect in 2 to 5 minutes and lasts for several hours. When administering naloxone care should be taken to titrate the dosage to achieve reversal of respiratory depression without full reversal of the analgesic effects.   Rapid infusion should be avoided to reduce the risk of hypertension, tachycardia, nausea and vomiting.  Vital signs should be monitored, especially respirations, and naloxone administration repeated until the manifestations of opioid toxicity have subsided.

Additional opioid agonists are naltrexone, methylnaltrexone, and alvimopan. All of these medications compete with opioids at opioid receptor sites.

Naltrexone is used to treat substance use disorders, namely alcohol and opioids. It is also used to treat postoperative respiratory depression that is due to the use of opioids during the operative period. When used for opioid addiction, its use is to prevent euphoria and thus, the client’s desire to use opioid. The client should be opioid free for a week to 10 days prior to beginning the medication to prevent opioid withdrawal.

Methylnaltrexone is an opioid antagonist that is used for opioid-induced constipation. It is reserved for clients who traditional laxatives have been ineffective. Another medication that affects bowel function is alvimopan. It is used to treat postoperative ileus and opioid-induced constipation. Alvimopan is for short-term use only because long term use has been linked to an increased risk of myocardial infarction.

There are a number of nursing responsibilities that are critical to providing safe, effective care for the client who is receiving an opioid medication.

  • Prior to administering an opioid, assess the client’s level of pain, check blood pressure, pulse and respirations. When assessing the client’s respiratory rate, check the depth and regularity of respirations. Notify the provider if the respiratory is 12/min or less, or if respirations are irregular or shallow. Also notify the provider if the other vital signs have changed dramatically since the last time they were taken. Use the Pasero Opioid-Induced Sedation Scale (POSS) to determine the client’s level of sedation.  Use this link to review the POSS scale.

When using this scale, your client goes to sleep while you are talking to him.  What score is appropriate for this client?

  • After administering the medication, reassess the client’s level of pain, blood pressure and respirations and level of sedation. The risk of over sedation and respiratory depression is highest during the first 24 hours of opioid treatment. When administered IV, the medication peaks within 15 minutes of administration; the peak is one hour after IM, oral or rectal route.
  • Plan to manage acute, severe pain with short‑term (24 to 48 hr) around‑the‑clock administration of opioids instead of a PRN schedule.
  • Use the parenteral route for immediate, short‑term relief of acute pain; use the oral route for chronic, non- fluctuating pain.
  • Use consistent timing and dosing of opioid administration to provide consistent pain control.
  • It is essential to monitor and intervene for adverse effects of opioid use.
    • Sedation: Monitor level of consciousness and take safety precautions. Sedation usually precedes respiratory depression.
    • Respiratory depression: Check respiratory rate, depth, and regularity prior to and following administration of opioids (especially for clients who have little previous exposure to opioid medications). Initial treatment of respiratory depression and sedation is generally a reduction in the opioid dose. If necessary, slowly administer diluted naloxone to reverse opioid effects until the client can deep breathe with a respiratory rate of at least 8/min.
    • Orthostatic hypotension: Advise clients to sit or lie down if lightheadedness or dizziness occurs. Instruct clients to avoid sudden changes in position by slowly moving from a lying to a sitting or standing position. Provide assistance with ambulation.
    • Urinary retention: Monitor I&O, assess for distention, administer bethanechol to relieve retention, and try noninvasive actions before catheterizing.
    • Nausea/vomiting: Administer antiemetics, advise clients to lie still and move slowly, and eliminate odors.
    • Constipation: Use a preventative approach that includes monitoring of bowel movements, increasing fluids andfiber intake, encouraging exercise, providing stool softeners and stimulant laxatives, and administering enemas if necessary. 

Analgesic Routes of Administration

Analgesics can be administered intravenously, intramuscularly and subcutaneously. The intramuscular route and the subcutaneous routes were used frequently in the past, but use of these routes has diminished.  Information about oral, transnasal, topical, transmucosal, rectal, and transdermal administration as well as epidural analgesia is provided below:

The oral route for administration of analgesics is preferred. However, the duration of action for oral opioids is only about 4 hours. Extended release forms of morphine can provide pain control for 8  hours or more.

Transnasal analgesic administration is advantageous because the medication is rapidly absorbed. Butorphanol is a mixed opioid agonist-antagonist available as a spray for the treatment of migraine headaches.

Topical analgesics are applied directly to the skin and are absorbed by vascular uptake. Frequently, this route is used to reduce pain during a painful procedure such as a lumbar puncture. A cream that contains lidocaine and prilocaine is used for dental procedures.  . A lidocaine topical patch is available for treatment of post-herpetic neuralgia.

The transmucosal route for administration of analgesics is frequently used for hospice clients who have breakthrough pain. The oral mucosa is highly vascular providing rapid absorption. Fentanyl is available in a transmucosal form.

The rectal route for administration of analgesics can be use when rapid pain control is desired because the mucous membranes of the rectum are highly vascular causing quick absorption of the medication.   This route can be used for clients who are unconscious, have difficulty swallowing or are experiencing nausea and vomiting.

When epidural analgesia is used, an anesthesiologist or nurse anesthetists inserts a catheter into the epidural space near the spine. An analgesic such as morphine or fentanyl is infused through the catheter. The nurse should monitor the client for respiratory depression, excessive sedation, hypotension, bradycardia, and urinary retention. Avoid using other opioids or CNS depressants during the use of epidural analgesia. Be prepared to administer naloxone for respiratory depression or excessive sedation.

The transdermal route for administration of analgesics is used to treat chronic pain.  The medication is absorbed through the skin and provides pain control for several hours to days. The patch should be applied to the trunk or the abdomen. Transdermal fentanyl is indicated for clients who have severe pain and are opioid tolerant. There are numerous responsibilities related to providing safe, quality care when caring for a client who is using a fentanyl transdermal patch as fentanyl is 50 to 100 times more potent than morphine. Use the links below to learn about the administration of transdermal fentanyl.

http://www.ismp.org/Tools/highalertmedications/fentanyl.pdf

https://www.drugs.com/cdi/fentanyl-transdermal-patch.html

Facing Concerns about Opioid Use Disorder           

One in three Americans currently experience ongoing pain.  Providing adequate pain management without promoting opioid use disorder is a challenge for health care providers. Concerns about opioid use disorder should not be minimized.   According to the United States Department of Health and Human Services, in 2015, 12.5 million Americans misused prescription opioids, 2.1 million for the first time. Two million people were diagnosed with prescription use disorder and 33,091 people died from overdosing on opioids in that year.

The American Academy of Pain Management reports that 100 million Americans are experiencing chronic pain, more people than diabetes, heart disease and cancer combined.  In response to concerns about under treated pain, , providers began to  increase  the frequency of prescribing opioid analgesics.  Data from the CDC report that the number of opioid prescriptions nearly quadrupled from 1999 to 2010.  Deaths from opioid overdoses have also quadrupled since 1999.

To address the current epidemic of opioid use disorder in the U.S., the FDA and the CDC have developed actions plans to reduce the impact of this public health crisis.  The FDA’s strategic plan includes:

·               Expanding advisory committees to study new opioids that do not have abuse-deterrent properties.

·               Establish a more extensive framework for pediatric opioid medication labeling.

·               Create additional labeling for extended-release/long-acting (ER/LA) opioids to include more warnings and safety information.

·               Charge pharmaceutical companies with the task of performing more post-market research on the long-term impact of using ER/LA opioids.

·               Increase training to providers in pain management and safe prescribing of opioids.

·               Encourage pharmaceutical companies to develop generic abuse-deterrent products for pain.

·               Expand over-the-counter access to intranasal naloxone.

The CDC’s Guideline for Prescribing Opioids for Chronic Pain includes guidance for providers in initiating or continuing opioid use for clients who experience chronic pain.  The recommendations include:

·               Provide nonpharmacological and nonopioid therapy for chronic pain, using opioids only as a last resort.

·               Establish realistic treatment goals with clients.

·               Prior to prescribing, and periodically throughout treatment, educate clients on the risks and benefits of opioid therapy.

·               Begin therapy with immediate-release rather than ER/LA opioids.

·               Prescribe lowest possible doses of opioids.

·               For acute pain, limit opioid prescription duration to no more than 3 to 7 days.

·               For chronic pain, evaluate use of opioids within 1 to 4 weeks of initiating therapy, and at least every 3 months thereafter.

·               Before prescribing opioid therapy, evaluate risk potential for opioid use disorder.

·               Utilize state prescription drug monitoring programs to track other controlled substance prescription clients may be taking.

·               Before prescribing opioid therapy, and at least annually, evaluate urine drug testing for other controlled substances or illicit drug use.

·               Avoid prescribing opioids and benzodiazipines concurrently

·               Offer or arrange treatment for clients who experience opioid use disorder. 

Nursing’s role in combating this public health issue begins with the realization that opioids pose a risk to all clients.  Other actions nurses should take include:

·               Being aware of the latest clinical practice guidelines

·               Practice nonpharmacological methods of managing clients’ pain

·               Identify the major risk factors associated with opioid use disorder

·               Become an advocate and educator in managing clients’ pain

Adjuvant Analgesics

Adjuvant analgesics are used with a primary analgesic, such as an opioid analgesic, to improve pain relief while reducing the dosage of the opioid agonist. Reduced dosage of the opioid reduces adverse effects such as sedation, respiratory depression and constipation and decreases the risk of opioid dependency. The adjuvant medications canhelp alleviate other manifestations that aggravate pain (depression, seizures, inflammation), and are useful for treating neuropathic pain.

Antiseizure agents: carbamazepine, gabapentin

Antiseizure agents are useful in the reduction of neuropathic pain (sharp, stabbing pain). Carbamazepine is prescribed more frequently that other agent in this category. Use caution when the client is taking carbamazepine in combination with anticancer medications that suppress the bone marrow because carbamazepine can cause myelosupression.  Clients who are of Asian descent are at risk increased risk for Stevens-Johnson syndrome and toxic epidermal necrolysis.  Instruct clients to avoid drinking grapefruit juice while taking carbamazepine because it inhibits the metabolism of the agent and can increase its effects as well as the adverse  effects.

Tricyclic antidepressants: amitriptyline, nortriptyline

Tricyclic antidepressants (TCAs) are also helpful in reducing pain that is neuropathic in origin.  TCAs have independent analgesic properties that enhance the effects of opioids. By potentiating the effect of serotonin and norepinephrine, TCAs also treat depression, a major factor associated with chronic pain. TCAs have a number of disturbing side effects including orthostatic hypotension, anticholinergic effects, weight gain and sedation. To minimize the effects of orthostatic hypotension and sedation, recommend that clients take the medication at bedtime. Additional instructions for clients experiencing adverse effects while taking TCAs include the following:

·               Avoid sudden changes in position and sit or lie down if feeling dizzy

·               Increase fluid intake and sip fluids throughout the day

·               Increase fiber intake

·               Increase physical activity

·               Take a stimulant laxative and a stool softener as needed

Antihistamine: hydroxyzine

Antihistamines block histamine receptors in the body. They are also referred to as histamine antagonists. Hydroxyzine potentiates the effects of opioid analgesics, reduces anxiety and promotes sedation.

Glucocorticoids: dexamethasone

Glucocorticoids reduce pain by decreasing inflammation,: therefore, they are useful in treating painful inflammatory conditions such as rheumatoid arthritis and gout. Because long-term use can cause adrenal insufficiency, hyperglycemia and other adverse effects, these medications are tapered downward as soon as possible.   

Bisphosphonates: alendronate, ibandronate 

Bisphosphonates are used for the prevention and treatment of osteoporosis. They are also useful in the treatment of cancer-related bone pain. Instructions for clients who take bisphosphonates include the following:

·               Take first thing in the morning with a full glass of water while sitting or standing

·               Remain sitting or standing for at least 30 min after taking the medication (60 minutes for ibandronate)

·               Do not eat or drink anything for at least 30 min after taking the medication (60 minutes for ibandronate)

Hormones: calcitonin

 Calcitonin is used to treat bone conditions such as osteoporosis and Paget’s disease.  It works by decreasing bone resorption and promotes the renal excretion of calcium.

Patient-controlled analgesia

Patient‑controlled analgesia (PCA) is a medication delivery system that allows clients to self‑administer safe doses of opioids.

  • Small, frequent dosing ensures consistent plasma levels.
  • Clients have less lag time between identified need and delivery of medication, which increases their sense of control and can decrease the amount of medication they need.
  • Morphine, hydromorphone, and fentanyl are typical opioids for PCA delivery.
  • Clients should let the nurse know if using the PCA pump does not control the pain.
  • Many current nursing textbooks recommend that to prevent inadvertent overdosing, the client is the only person who should push the PCA button. When someone other than the client activates the pump the applicable term is PCA by proxy.  PCA by proxy is the activation of the PCA pump by someone other than the patient. Recent research studies indicate that there are times when an authorized agent to control analgesia (AACA) is appropriate. Health care professionals who support AACA contend that if a client is unable to activate the PCA, it is appropriate for a nurse or other approved individual to push the button of the PCA.  This practice has a long history in the pediatric setting. The use of AACA is supported by the American Association of Pain Management Nursing (AAPMN) as long as the agency has established guidelines that ensure client safety. Clear criteria regarding which clients should receive PCA and careful client assessment throughout PCA use is essential to ensure client safety.

Other Strategies for Effective Pain Management

  • Take a proactive approach by giving analgesics before pain becomes too severe. It takes less medication to prevent pain than to treat pain.
  • Instruct clients to report developing or recurrent pain and not wait until pain is severe (for PRN pain medication).
  • Explain misconceptions about pain (medication dependence, pain measurement and perception).
  • Help clients reduce fear and anxiety.
  • Create a treatment plan that includes both nonpharmacological and pharmacological pain‑relief measures.

Chronic Pain Relief Strategies

Strategies specific for relieving chronic pain include the above interventions, plus the following:

  • Administering long‑acting or controlled‑release opioid analgesics (including the transdermal route).
  • Administering analgesics around the clock rather than PRN.

Complications and Nursing Implications

Under treatment of pain is a serious complication and can lead to increased anxiety with acute pain and depression with chronic pain. Assess clients for pain frequently, and intervene as appropriate.

Sedation, respiratory depression, and coma can occur as a result of overdosing. Sedation always precedes respiratory depression.  To reduce the risk of overdose when administering opioids, take the following actions:

  • Identify high‑risk clients (older adult clients, clients who are opioid‑naive).
  • Carefully titrate client dose while closely monitoring respiratory status.
  • Stop the opioid and give the antagonist naloxone if respiratory rate is below 8/min and shallow, or the client is difficult to arouse.
  • Identify the cause of sedation.
  • Use a sedation scale in addition to a pain rating scale to assess pain, especially when administering opioids.

References

1.          American Academy of Pain Management: Facts on Pain: Facts and Figures on Pain (2012) Retrieved November 21, 2017

2.          Burchum, J., Rosenthal, L., (2016). Lehne’s Pharmacology for nursing care (9th ed.)St. Louis, MO: .Elsevier, Saunders.

3.          Berman, A., Snyder, S., & Frandsen, G., (2016). Kozier & Erb’s fundamentals of nursing: Concepts, processes and practice (10th ed.) .New York, NY: Pearson Education.

4.          Centers for Disease Control and Prevention (2017) What Everyone Should Know About Shingles Vaccine Retrieved November 21, 2017

5.          Centers for Disease Control and Prevention (2017) CDC Guideline for Prescribing Opioids for Chronic Pain Retrieved November 21, 2017

6.          Centers for Disease Control and Prevention (2017) Understanding the Epidemic Retrieved November 21, 2017

7.          deWit, S., Dalred, C., Stromberg, H., Medical Surgical Nursing: Concepts and Practice (3rd ed.). St. Louis, MO.  Elsevier.

8.          Federal Drug Administration (2014) Living With Fibromyalgia, Drugs Approved to Manage Pain  Retrieved October 23, 2017 

9.          Federal Drug Administration: Department of Human Services, Nonsteroidal Anti-inflammatory Drugs Retrieved November 21, 2017

10.        Federal Drug Administration (2017) FDA Opioids Action Plan Retrieved November 21, 2017 from

11.        The Fentanyl Patch Retrieved October 30, 2017

12.        Ignatavicius, D. & Workman, L. (2016). Medical-surgical nursing: Patient centered collaborative care (10th ed.). Philadelphia: Saunders.

13.        Lilley. L., Collins, S., Snyder, J. (2014) Pharmacology and the Nursing Process (7th ed.) St. Louis, MO; Elsevier.

14.        Mezack, R., Wall,P, (2012) The Gate Control Theory  Retrieved November 21, 2017  

15.        The Pasero Opioid-Induced Sedation Scale Retrieved November 21, 2017

16.        Potter, P., Perry, A., Stockert, P., Hall, A., Fundamentals of Nursing (9th ed.) St. Louis, MO. Elsevier.

17.        Top Ten Safety List for Fentanyl Patches Retrieved November 21, 2017

18.        United States Department of Health and Human Services (2017) About the Epidemic Retrieved November 21, 2017

19.        Vallerand, A., Sanoski, C. (2017). Davis’s Drug Guide for Nurses (15th ed.) Philadelphia: F. A. Davis Company



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