Non-Cancer Pain Management for New Mexico Advanced Practice Nurses
Online Continuing Education Course
MANDATORY NURSING CEU FOR NEW MEXICO ADVANCED PRACTICE NURSES (APRN). This nursing continuing education course fulfills the requirement for 5 hours of CE on the management of noncancer pain for advanced practice nurses in New Mexico. Covers pain assessment, strategies and interventions for treating and managing pain, NM Board of Nursing rules for managing chronic pain with controlled substances, and issues related to opioid prescribing, use, abuse, and diversion.
Course Price: $50.00
Contact Hours: 5
"Very well-written and understandable. Covered a broad spectrum of information. Impressive and definitely recommended. " - Susan, APRN in New Mexico
"This course was very helpful and relevant to the treatment of pain. Thank you. " - Karin, APRN in New Mexico
"Excellent course. " - Julianne, APRN in New Mexico
"Good overall course needed for my APN recert. Thank you! " - Vitina, APN in New Mexico
Accreditation / Approval Information
This course fulfills the requirement for 5 hours of continuing education on the management of noncancer pain for New Mexico advanced practice nurses with a DEA registration and licensure that permits prescribing opioids.
Non-Cancer Pain Management for New Mexico Advanced Practice Nurses
Copyright © 2019 Wild Iris Medical Education, Inc. All Rights Reserved.
LEARNING OUTCOME AND OBJECTIVES: Upon completion of this course, you will be better prepared to manage pain based on evidence of its nature, sources, assessment, and interventions, and to consider issues related to opioid use. Specific learning objectives to address potential knowledge gaps include:
- Explain the experience and physiology of pain.
- Outline the elements of a comprehensive pain assessment.
- Describe pharmacologic and nonpharmacologic interventions and self-management strategies.
- Discuss the issues of opioid misuse, abuse, and diversion and drug-seeking behaviors.
- List and explain the rules of the New Mexico Board of Nursing for prescriptive practices.
- Consider issues involved in pain management for palliative and end-of-life care.
TABLE OF CONTENTS
The word pain comes from the Greek (poiné) and Latin (poena) words for punishment or penalty. In the time of Aristotle and other Greek philosophers, pain was believed to be visited on a person from external sources, in particular, the gods. During the Renaissance, pain was believed to arise from an internal mechanical process, and this theory of pain persisted well into the twentieth century.
Modern pain research began in the 1960s, and in recent decades, there has been a change in the perception of pain that has profoundly influenced scientific and medical pain research and treatment. Pain is no longer viewed as a symptom but rather a disease in and of itself. Its occurrence, severity, duration, response to treatment, and disabling consequences vary from person to person. Like other diseases, pain is more than a biological phenomenon; it has profound emotional and cognitive effects.
In 2010 the Council of the International Association for the Study of Pain issued the Declaration of Montreal, which asserts that “withholding of pain treatment is profoundly wrong, leading to unnecessary suffering which is harmful.” The Declaration further asserts:
- Article 1. The right of all people to have access to pain management without discrimination
- Article 2. The right of people in pain to acknowledgment of their pain and to be informed about how it can be assessed and managed
- Article 3. The right of all people with pain to have access to appropriate assessment and treatment of the pain by adequately trained healthcare professionals
To meet this obligation, effective management of pain requires an in-depth knowledge of the complexity of the pain experience, enhanced assessment skills, treatment modalities currently available, and policies that affect how these modalities may be utilized.
A study done on the global burden of chronic pain found that at least 10% of the world’s population is affected by a chronic pain condition and that every year an additional 1 in 10 people develops chronic pain (Raffaeli & Arnaudo, 2017).
In 2018 the CDC reported that an estimated 50 million Americans (20.4% of the adult population) experienced chronic pain and that about 20 million of them have “high-impact chronic pain” (pain severe enough that it frequently limits the person’s life or work activities). These estimates are based upon the 2016 National Health Interview Survey of over 33,000 adults, which revealed the following:
- Women, unemployed older adults, adults living in poverty, rural residents, and people without some form of public health insurance are significantly more likely to have chronic pain.
- The prevalence of chronic pain and high-impact chronic pain were significantly lower among adults with at least a bachelor’s degree compared with all other education levels.
- Non-Hispanic white adults had a significantly higher age-adjusted prevalence of chronic pain than did all other racial and ethnic subgroups, but there were no significant differences in high-impact chronic pain by race/ethnicity.
- Prevalence of chronic pain was found to be significantly higher among veterans than among nonveterans, but there were no significant differences in the prevalence of high-impact chronic pain.
- Chronic pain contributes to an estimated $560 billion each year in direct medical costs, lost productivity and disability programs.
(Dahlhamer et al., 2018)
THE EXPERIENCE OF PAIN
Pain is a universal experience and an unavoidable part of being human. Pain has a protective function, motivating people to withdraw from damaging or potentially damaging situations and to avoid those same situations in the future. Pain also protects an injured body part while it heals.
Why humans feel pain, what causes pain, the meaning of pain, and how pain can be prevented or reduced has been pondered and discussed throughout history. Pain has been regarded as a fundamental part of human existence, a powerful driver of emotions, and an effective learning tool. Pain is also the single most common reason people seek medical care (NIH, 2018a).
What Is Pain?
Traditionally, pain has been considered merely a physical symptom of illness or injury, a simple stimulus-response mechanism. Though the historic role of caregivers has been to relieve pain and suffering, there has been little understanding of the complexity of pain and only limited ways to manage it. Recent research indicates that pain is the net effect of a complex interaction of the ascending and descending nervous systems involving biochemical, physiologic, psychological, and neocortical processes (Rashid, 2017).
The task of defining pain is particularly difficult because each person’s experience is unique. By way of analogy, the person who is color-blind may experience a visual sensation differently than one who is not color-blind. Each person sees the same image but experiences the color differently. For example, a person who is not color-blind has the experience of seeing a ripe tomato as red, and the person who is color-blind has the experience of seeing it as green even though they are looking at the same tomato. Neither person would be aware that the phenomenal qualities of their visual experiences differ because both have learned that the color they are experiencing is “red.” This analogy could be applied to pain.
In 1979 the International Association for the Study of Pain (IASP, 2017) defined pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. …[P]ain is always subjective… . [I]t is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience.”
Pain is a construct of the mind, an output of the brain. Many people report pain in the absence of tissue damage or any likely pathophysiological cause, and this usually occurs for psychological reasons. However, there is no way to distinguish this experience of pain from the experience of pain due to tissue damage based on subjective reporting. If people regard their experience as pain and report it in the same ways as pain caused by tissue damage, it should be accepted as pain. According to IASP, this understanding “avoids tying pain to the stimulus” (IASP, 2017).
Pain alters the quality of life more than any other health-related problem. It interferes with sleep, mobility, nutrition, thought, sexual activity, emotional well-being, creativity, and self-actualization. Surprisingly, even though pain is such an important obstacle to comfort, it is one of the least understood, most undertreated, and oft-discounted problems of healthcare providers and their patients.
CONSEQUENCES OF UNTREATED/UNDERTREATED PAIN
When pain is untreated or undertreated, nerve fibers that transmit impulses to the brain become “trained” to be more efficient at sending those signals, and when the signals increase, the brain becomes more sensitive to them and the person experiences increasing intensity of the sensation even though illness or injury is not worsening. At this point, pain loses its significance as a signal of tissue damage or illness and is now considered chronic. Untreated pain has a major impact on a person’s quality of life, affecting physical, psychological, social, and economic well-being (Stöppler, 2018).
Clinical outcomes of untreated postoperative pain include an increased risk of atelectasis, respiratory infection, myocardial ischemia, infarct or cardiac failure, and thromboembolic disease. Common sequelae of untreated chronic pain include decreased mobility, impaired immunity, decreased concentration, anorexia, and sleep disturbances. In addition, researchers have found that chronic pain in older adults accelerates memory decline, increases the probability of developing dementia, and increases the risk of mortality by 29% (Whitlock et al., 2017; Smith et al., 2017).
- Pain due to a stimulus that does not normally provoke pain
- Absence of pain in response to stimulation which would normally be painful
- A syndrome of sustained burning pain, allodynia, and hyperpathia after a traumatic nerve lesion
- An unpleasant abnormal sensation, whether spontaneous or evoked
- Increased pain from a stimulus that normally provokes pain
- A painful syndrome characterized by an abnormally painful reaction to a stimulus, especially a repetitive stimulus, as well as an increased threshold
- Diminished pain in response to a normally painful stimulus
- Pain in the distribution of a nerve or nerves
- Neuropathic pain
- Pain caused by a lesion or disease of the somatosensory nervous system
- Nociception pain
- Pain arising from actual or threatened damage to non-neural tissue due to the activation of nociceptors (high-threshold sensory receptors of the peripheral somatosensory nervous system)
- Pain threshold
- Amount of pain required before individuals feel the pain; the lower the threshold, the less pain can be endured; the higher the threshold, the more pain can be endured
- Pain tolerance level
- Maximum intensity of a pain-producing stimulus that a subject is willing to accept in a given situation; the subjective experience of the individual
- An abnormal sensation whether spontaneous or evoked
Classification of Pain
The classification of pain is complicated, and there are several different classification systems, many of which overlap. Among other characteristics, pain can be classified by duration and source.
Pain is classified by duration as acute or chronic.
The New Mexico Board of Nursing defines acute pain as “the normal, predicted physiological response to a noxious chemical or thermal or mechanical stimulus, typically associated with invasive procedures, trauma, or disease and generally time-limited” (NMAC, 2018).
Acute pain is protective in that it motivates a person to take action immediately. Acute pain is caused by noxious stimulation due to injury, a disease process, or the abnormal function of muscle or viscera. Acute pain begins suddenly, is usually sharp in quality, and correlates with the amount of damage. It is temporary and subsides as healing takes place. In acute pain, the central nervous system is intact and acute pain is a symptom.
There are two types of acute pain:
- Somatic pain results from superficial injury to skin and subcutaneous tissue (e.g., burns, cut, abrasions) or deep injury to muscle, bone, joint, and connective tissues (e.g., fractures, arthritis, fibrositis, rupture of muscle belly).
- Visceral pain results from injury to the internal organs (e.g., peptic ulcer, angina pectoris, renal colic).
In most instances, acute pain does not last longer than six months and disappears when the underlying cause of pain has been treated or has healed. Severe acute pain activates the sympathetic nervous system, causing diaphoresis, increased respiratory and pulse rates, and elevated blood pressure. Psychological effects of unrelieved pain can lead to anxiety and depression, and unrelieved acute pain may lead to chronic pain (Rashid, 2017).
There is overwhelming evidence that chronic pain is not just acute pain that lasts longer. It is an insidious, complex chronic condition that involves pathological changes in tissues, the nervous and immune systems, and the personality (Hunter, 2018).
The New Mexico Board of Nursing defines chronic pain as “pain that persists after reasonable efforts have been made to relieve the pain or its cause and that continues, either continuously or episodically, for longer than three consecutive months. Chronic pain does not, for purposes of the Pain Relief Act requirements, include pain associated with a terminal condition or with a progressive disease that, in the normal course or progression, may reasonably be expected to result in a terminal condition” (NMAC, 2018).
Because the central nervous system may be dysfunctional, chronic pain may be considered a disease state. Chronic pain serves no biologic purpose and has no obvious end-point. If pain is associated with a disease or injury, it outlasts the normal period of healing, and the severity does not correlate with damage.
Chronic pain may be the result of damaged tissue but very often is attributable to nerve damage. It can arise from many different conditions, such as:
- Musculoskeletal disorders
- Headaches and migraines
- Neurologic disorders
- Urologic disorders
- Peripheral vascular disease
- Surgical complications
The nature of chronic pain is that it is ongoing and, in some instances, seems almost constant. This makes the person who has chronic pain more susceptible to psychological consequences, including depression and anxiety, and this psychological distress can in turn amplify the pain (Rashid, 2017).
The sources (causes) of pain are divided into the categories of nociceptor, neuropathic, psychogenic, and idiopathic.
Nociceptor pain is acute pain that results when tissue damage produces a stimulus that sends an electrical impulse across a receptor (nociceptor) by way of a nerve fiber to the central nervous system. Receptors for this type of pain are located all around the body, particularly under the skin and the internal organs. Some body tissues, such as the brain and lung, have no nociceptors, and some tissues have many.
Nociceptor pain is:
- Worse with movement
- The result of obvious tissue injury or illness
- Caused by inflammation
Neuropathic pain is caused by a primary lesion or dysfunction within the nervous system itself. Unlike nociceptive pain, neuropathic pain is most often classified as chronic pain, which may increase in intensity over time.
Although the mechanisms underlying neuropathic pain are not completely understood, several mechanisms that influence the peripheral nervous system and central nervous system have been identified. Three primary mechanisms that may be responsible for peripheral nervous system neuropathy include unprompted firing of damaged nerves, increased sensitivity of the afferent pathways because of loss of nerve supply, and sympathetically sustained pain (pain dependent on sympathetic nervous system activity). Neuropathic pain of the central nervous system may result from sensitization at the synapses or restructuring of higher processing operations (Barbee et al., 2018).
Neuropathic pain caused by lesion or disease in the peripheral nerves can be due to:
- Traumatic brachial plexus injury
- Diabetes mellitus
- Carpal tunnel syndrome
- Post-herpetic neuralgia
Neuropathic pain caused by a lesion or disease of the central nervous system may be due to:
- Central post-stroke pain
- Spinal cord injury
- Is not well-localized
- May be burning or shooting
- May be a feeling of numbness
- Can be experienced as “pins and needles”
- May be due to tissue injury that is not evident
- Is pathological
Psychogenic pain is believed to be sustained mainly by psychological factors. It does not refer to the common idea that pain experienced by some patients is exacerbated by psychological factors, or the finding of high pain-related distress or comorbid psychiatric disease. Instead, it implies that the pain is best understood as a result of psychological processes. It is classified as a somatic symptom disorder with prominent pain, which is diagnosed on the basis of excessive thoughts, feelings, or behaviors related to pain that are distressing, impair function, and appear out of proportion to physical findings.
It must be remembered that psychogenic pain is truly experienced and is not a deception. This distinguishes it from disorders that reflect a serious mental disorder in which reports of pain may not indicate a true experience of pain, and malingering (Portenoy & Dhingra, 2019).
Characteristics of psychogenic pain include:
- Nonlocalized pains that encompass large parts of the body
- Constant discomfort despite treatment
- Difficulty describing location, quality, and depth of pain
- Worsening pain independent of any underlying medical condition
In contrast to nociceptor and neuropathic pain, idiopathic pain exists without underlying neural or tissue damage. Idiopathic pain is heterogeneous in nature and can be described as burning, itching, stinging, irritating, stabbing, and/or sharp. Pain severity and type can vary with factors such as age, gender, culture, and economic status. Idiopathic pain is characterized by a state of pain amplification, psychological distress, and enhanced inflammation. Depression, anxiety, and anhedonia (inability to feel pleasure) are often comorbidities alongside idiopathic pain (Ciszek, 2016).
Physiology of Pain
Basically, pain occurs when a noxious signal sends impulses to the spinal cord, which relays it to the brain, where it is interpreted as pain and localized. The brain determines the meaning of the signal and what should be done about it and then sends back instructions to the body about how to respond. This system is the same for everyone, but the sensitivity and efficacy of these brain circuits determines how much the person feels and how the person copes with pain.
Most of what we know about pain is theoretical. Several theoretical frameworks have been proposed to explain the physiologic basis of pain, but none as yet completely accounts for all aspects of pain perception.
- Tissue damage
- Mediation (the process of causing something to happen)
(Kendroud & Hanna, 2019)
Pain is associated with tissue damage.
Receptors (nociceptors) located in the skin and other tissues are nerve fibers with endings that can be excited by three types of stimuli—mechanical, thermal, and chemical. Some of these nerve endings respond mainly to one type of stimulation and others can detect all types. Whenever a part of the body comes in contact with an object capable of causing harm, skin receptors send nerve impulses to the spinal cord via sensory neurons, and a response (known as the reflex arc) occurs before the signal even reaches the brain. This reflex is the body’s way of removing the body part from the stimulus in order to prevent further tissue damage (Kendroud & Hanna, 2019).
When tissue is damaged, there is an immediate release of inflammatory chemicals (called excitatory neurotransmitters) such as histamine and bradykinin, a powerful vasodilator. Increased blood in the area causes the injured area to swell, redden, and become tender. The bradykinin stimulates the release of prostaglandins and substance P, a potent neurotransmitter that enhances the movement of impulses across nerve synapses.
Pain is mediated (caused) by two major types of nociceptor nerve fibers (A-delta fibers and C fibers), which are the nerve endings of the first-order neurons in the pain pathway.
The A-delta fibers are the larger of the two and the most rapidly conducting (12–30 m/sec) because of their thin myelin covering. They have small receptive fields and are responsible for the sharp, well-localized pain that first is perceived. A-delta fibers are activated by mechanical and thermal stimuli.
C fibers are smaller, and because they are unmyelinated, impulse signals are slower (0.5 m/sec). C fibers respond to chemical, mechanical, and thermal stimuli and are associated with the longer-lasting, dull, poorly localized sensations that follow the first sensation of pain.
Impulse signals travel via the spinal nerves to the spinal cord, where they synapse with second-order neurons in the dorsal horn of the spinal cord. The second-order neurons then cross over to the other side of the spinal cord before ascending to the opposite side of the brain from that part of the body sending the impulse. The impulse then travels up along the spinothalamic tract to the thalamus, synapses with third-order neurons, and is relayed on to different parts of the brain, including the somatosensory cortex of the brain (responsible for physical sensation) and the frontal cortex (in charge of thinking).
Other second-order neurons travel along the spinoretricular tracts to the brainstem before running up to the thalamus and then to the cortex. This tract is responsible for the arousal and emotional aspects of pain (Kendroud & Hanna, 2019).
Neurologic transmission of pain stimuli. Source: Jason M. Alexander. © 2005, Wild Iris Medical Education.
In the cortex of the brain, a sensory strip receives the nerve impulse. This sensory strip, the somatosensory homunculus (Latin for “little man”), is basically a brain map of the body. Nerve impulses travel to the area in the homunculus that corresponds to the part of the body the signal is coming from. All information from each body part (e.g., the finger) end up in one specific area of the homunculus after entering the sensory strip in the cortex of the brain (Kahn Academy, 2019).
Sensory strip. Source: BodyParts3D, © The Database Center for Life Science.
The somatosensory homunculus (“little man”) shows a distorted image of the human body because the size of each region of the map is related to the density of sensory receptors in the body part. (Source: OpenStax College, Anatomy & Physiology.)
When the message is received in the homunculus, the brain recognizes the pain stimulus and interprets its significance. Several factors can affect how the brain interprets the pain, including:
- Emotional and psychological states
- Memories of previous pain
- Expectations of and attitudes toward pain
- Beliefs and values
- Social and cultural influences
Once the brain perceives the pain and determines its meaning, it sends messages downward to affect the sensitivity and behavior of nerves. The body releases neuromodulators, such as endogenous opioids (endorphins and enkephalins), serotonin, norepinephrine, and gamma aminobutyric acid. These chemicals hinder the transmission of pain and help produce an analgesic, pain-relieving effect. This inhibition of the pain impulse is called modulation.
The descending paths of the efferent fibers extend from the cortex down to the spinal cord and may influence pain impulses at the level of the spinal cord. This system provides a necessary survival function, as it regulates fear and anxiety, allowing the pain experience to be altered according to the situation rather than having pain dominate (Winters et al., 2017).
In 1965 Melzack & Wall suggested that there is a gate or control system in the dorsal horn of the spinal cord through which all information regarding pain must pass before reaching the brain. An open gate means transmission cells (t-cells) can carry signals to the brain, where pain is perceived. A closed gate stops the transmission, and no pain signal is sent to the brain.
The substantia gelatinosa (SG) in the dorsal horn of the spinal cord controls whether the gate is open or closed. The SG has both excitatory (SG+) and inhibitory (SG-) synapses with the t-cells. There are three kinds of neurons that send signals to the SG. Two of them, A-delta fibers and C fibers, transmit pain signals and open the gate. The third type of neuron, A-beta fibers, responds to nonpainful stimuli such as touch, inhibits the transmission of pain signals, and closes the gate.
An understanding of how this gate-control theory works can be realized by considering a bump to the elbow. When the injury to the elbow occurs, the A-delta fibers are activated, followed by activation of the C fibers, and the pain signal is transmitted. By rubbing the bump, the large, fast- conducting A-beta fibers are stimulated. This stimulation is nonpainful, and the signal is transmitted faster than the A-delta and C fiber signals. The A-beta transmission reaches the SG-, closes the gate, and inhibits the further transmission of pain.
Because the perception of pain has a large cognitive component (e.g., distraction, thoughts, emotions), fast-conducting fibers from the thalamus and cerebral cortex areas of the brain can diminish pain by sending an inhibitory signal through the SG and thus close the gate (Weber, 2019).
Factors That Influence the Experience of Pain
The experience of pain is influenced by both physiologic and psychosocial factors, all of which clinicians must consider in pain management.
Physiological factors that influence pain include age, gender, genetic makeup, and stress response.
There is growing evidence that age affects pain, but how aging affects pain perception remains unclear. Young children have been found to be more sensitive to noxious stimuli than older children and adolescents. There is a consistent positive relationship between age and the experience of chronic pain; and there is increased frequency, severity, impact, and anatomic distribution of persistent pain associated with aging. Aging, however, has no strong effect on pain tolerance.
Clear evidence exists that there is a high prevalence of chronic pain in the older adult, and this can be attributed partly to the physiologic changes of the peripheral and central pain mechanisms. Myelinated fibers tend to show more decline in density and function than unmyelinated fibers, and there is a decrease in nerve conduction velocity and structural modification in the older adult. There is also extensive degenerative alteration in the spinal dorsal horn sensory neurons as well as structural and physiologic aging-related changes of many brain regions (the prefrontal cortex being most strongly affected) involved in nociceptive processing (Eltumi & Tashani, 2019; Lautenbacher et al., 2017).
Studies have shown a significant gender-related difference in pain perception and responses, suggesting that women are more sensitive to noxious stimuli than men and experience pain more often and of higher intensity and longer duration. In addition, brain imaging has shown sex-related differences concerning the spatial distribution and magnitude of acute pain responses.
Increased sensitivity characterizes mainly women of reproductive age, but this difference is not observed in older women. Gonadal hormones may affect the peripheral and central nociceptive pathways and, consequently, the processing of nociceptive stimuli, as well as sensitivity, threshold, and tolerance to pain. Also, the function of the endogenous analgesic modulation systems differs between men and women (Staikou et al., 2017).
It has been found that the differences between males and females regarding sensitivity to pain are affected by psychological factors such as anxiety, which is more associated with pain in males. Although postsurgical pain is more intense in women than in men, men are more troubled by low and persistent levels of pain (Eltumi & Tashani, 2019).
Genetic studies over the last 20 years have been extremely helpful in understanding individual differences in pain sensitivity and the predisposition to chronic pain. Numerous pain-related genes and their functional polymorphisms have been identified, and studies have shown that many chronic pain conditions have a 50% heritability.
Fibromyalgia has demonstrated a predominant association with COMT enzyme and serotonergic system variations. Chronic low back pain risk is increased by variants in the opioid receptor OPRM1, SOX5, CCDC26/GSDMC, and DCC genes. Gene variants are thought to be involved in the vascular etiology of migraines. Other conditions shown to be the result of genetic polymorphisms include diabetic painful peripheral neuropathy and trigeminal neuralgia (Suri et al., 2018; Knezevic et al., 2018).
Pain and stress are both adaptive in protecting the body. However, if either of the two processes becomes chronic, it can lead to long-term maladaptive changes in physiology and, consequently, behavior resulting in compromised well-being. The responses to stress include neural, endocrine, and behavioral changes, and there are built-in coping strategies in place to address stressors. Some people are more sensitive and reactive to stress, and others are more resilient.
Recent studies have found that stress modulates pain perception either by inducing analgesia or hyperalgesia. Decreased pain modulation occurred only among those who have a high stress responsiveness, and increased pain adaptation occurred only among those who have low stress responsiveness (Geva & Defrin, 2018; Abdallah & Geha, 2017).
Psychosocial factors may include mood dysfunction (such as depression and anxiety) as well as maladaptive coping strategies (such as fear and catastrophizing). They also include a person’s beliefs and knowledge about pain.
It is often difficult to determine whether an individual’s personality characteristics contribute to how they perceive and experience pain or, conversely, whether it is their pain condition that has affected their personality. In general, however, personality traits that include anxiety, excessive worrying, emotional instability, sensitivity, and dependency may serve to influence pain stimulus appraisal or threat of a potential pain stimulus. Such personality traits may even reduce the threshold at which pain is perceived as threatening and at which point pain elicits catastrophic thoughts (Banozic et al., 2018).
Pain Appraisal and Beliefs
Pain appraisal refers to the meaning ascribed to pain by an individual. Primary appraisal involves evaluation of the significance of the pain as either a threat or irrelevant, and secondary appraisal involves evaluation of the controllability of pain and one’s coping resources. Beliefs refer to assumptions about reality that shape how the person interprets events.
Appraisal and beliefs about the meaning of pain can have a strong impact on an individual’s response to pain. If a pain signal is interpreted as harmful, it may be perceived as more intense or more unpleasant and evoke more escape or avoidance behaviors.
Pain appraisal and pain beliefs are also determinants of adjustment to chronic pain. Pain that is viewed as a signal of damage, leading to disability, uncontrollable, and a permanent condition has been shown to affect an individual’s responses (Ballantyne et al., 2019).
Fear and Catastrophizing
Pain catastrophizing is an exaggerated, negative cognitive and emotional orientation toward actual or anticipated pain experiences. Catastrophizing has been associated with an increased perception of severity and disability in both acute and chronic pain among persons with many different pain diagnoses. Catastrophizing also alters perception of noxious stimulation.
People who experience chronic pain often anticipate that specific activities will increase pain or induce further injury, and these fears may contribute to avoidance of activity and subsequently greater physical deconditioning, emotional distress, and ultimately, greater disability (Ballantyne et al., 2019).
Emotion and pain interact in several ways. Emotional distress may predispose a person to experience pain, be a cause of symptoms, be a modulating factor amplifying or inhibiting the severity of pain, be a consequence of persistent pain, or be a perpetuating factor. Emotional distress is commonly observed in people with chronic pain.
Anxiety is common for patients with pain. Up to 45% of patients with chronic pain screen positive for an anxiety disorder. Those with chronic pain who have comorbid anxiety may have a lower pain tolerance, be more prone to medication side effects or fearful of having side effects, and be more fearful of pain itself (Ballantyne et al., 2019).
Up to 50% of patients with chronic pain experience depression, and on average, 65% of depressed individuals also report pain symptoms. There is evidence of a strong association between chronic pain and depression, but evidence is lacking as to whether chronic pain causes depression or depression causes chronic pain (Ballantyne et al., 2019).
A precise and systematic assessment of pain is important for making an accurate diagnosis and for the development of an effective treatment plan. Pain is a multidimensional phenomenon that produces strong emotional reactions that can affect an individual’s function, quality of life, emotional state, social and vocational status, and general well-being. Therefore, it is recommended that pain be assessed using a multidimensional approach and that these various impacts be addressed and included in the diagnostic formulation.
A comprehensive pain assessment includes a history of the pain, behavioral observations, past medical history, medications, family history, a physical examination, and if necessary, diagnostic testing.
A pain assessment begins with the history of the problem and can be obtained from written documents and from interviews with the person in pain as well as family members and other caregivers. Pain is a subjective symptom and pain assessment is, therefore, based on the patient’s own perception of pain and its severity.
ELEMENTS OF PAIN HISTORY
A pain history addresses the following elements:
- When did the pain start?
- Did the pain start suddenly or gradually?
- What were the first symptoms?
Etiology or mechanism of injury:
- Was there an obvious triggering event?
Location and distribution:
- Where is the pain felt? (Ask the patient to point to the location.)
- Does the pain move/radiate anywhere?
- Has the location changed over time?
- What words does the patient use to describe the pain (e.g., achy, sharp, burning, squeezing, dull, sore, etc.)?
- Besides pain, are there any other unusual sensations, such as numbness?
- Using a pain measurement scale, how much pain is the patient experiencing now?
- What is the least pain the patient has experienced in the past (24 hours, one week, month)?
- What is the worst pain the patient has experienced in the past (24 hours, one week, month)?
- How often does the patient experience severe pain (hours per day, days per week)?
- How long has the pain been experienced?
- Is the pain acute or chronic?
Course or pattern:
- Is the pain described as constant or intermittent?
- Is there a predictable pattern (e.g., worse in the morning or in the evening)?
- What makes the pain worse?
- What makes the pain better?
- When was the best relief obtained?
- How much relief was obtained?
- How long does relief last?
- Is there erythema, warmth, or local edema indicating inflammation?
- Are there mechanical symptoms, such as joint-locking, giving-way, popping, catching, or clicking?
- Are there preceding symptoms or aura?
- How does the pain affect the patient’s sleep, activity, appetite, work, relationships?
- Does the patient have signs and symptoms of depression?
- Does the patient have signs and symptoms of anxiety?
Past responses, preferences:
- What medications have been tried, how long was the drug taken?
- Has the patient been treated by physical or occupational therapy, and was it helpful?
- What other non-drug methods have helped in the past?
Expectations, goals, meaning:
- What does the patient think is causing the pain?
- What does the patient think should be done to treat the pain?
- What does the patient want to be able to do that is prevented by the pain?
- What does the patient fear about the pain (e.g., cancer)?
(Kishner, 2018; UFHealth, 2019)
In the absence of objective measures, clinicians must depend on the patient for the report of pain and its severity. Pain scores have been accepted as the most accurate and reliable measure for assessing patients’ pain and response to pain treatment. Scales have been developed to estimate and/or express the patient’s pain using two methods: unidimensional and multidimensional measures.
Unidimensional scales assess and measure only pain intensity. They are used for assessing acute pain or when the etiology is known.
- Verbal rating scales (VRS)
- Visual analogue scales (VAS)
- Numerical rating scales (NRS)
- Faces scale
Unidimensional scale measuring pain intensity. (Source: Lukpedclub/Bigstock.com)
Multidimensional scales measure intensity, quality, and location as well as the impact pain is having on mood or activity. These scales are useful in complex or persistent acute or chronic pain. Examples include:
- Multidimensional Pain Inventory
- McGill Pain Questionnaire (MPQ)
- Brief Pain Inventory Short Form (BPI-SF)
Some organizations, however, are abandoning pain-rating scales and instead assessing patients by asking how much their function is impaired and how much time they are spending in bed because of pain. This kind of assessment allows a patient to better articulate pain levels and gives the provider more insight into how the patient’s pain in affecting day-to-day living, providing an ability to create a more effective treatment plan (Moore, 2018).
Most people who are experiencing pain usually show it either by verbal complaint or nonverbal behaviors or indicators. It is important, however, to remember that people in pain may or may not display behaviors that are considered an indication of “being in pain,” and making judgments about their honesty is inappropriate. The following table lists some typical behavioral and physiologic indicators of pain that healthcare providers may observe when completing a pain assessment.
|Type of Indicator||Examples|
|Source: Toney-Butler, 2019.|
|Mental status changes||
Relevant past medical history includes:
- Prior medical illness (e.g., renal or hepatic insufficiency/disease, which affect choice of analgesic and dosing)
- Prior psychiatric illnesses
- Prior surgeries, scarring, repeated surgeries (may increase sensitivity to pain)
- Past injuries and accidents
- Coexisting acute or chronic illnesses
- Chemical dependence
- Prior problems with pain and treatment outcomes
- Renal or hepatic insufficiency/disease (affect choice of analgesic and dosing)
A complete list of current medications and usage, including over-the-counter medications, are obtained, as well as the patient’s report of their effectiveness. Evaluation of physiologic tolerance (diminished response) related to chronic use of some medications and use of alcohol and illicit drugs is also included.
Family history is important, as it may give a clue to any predisposition to pain-causing illnesses and conditions that may involve the connective tissues (e.g., kyphoscoliosis), metabolism (e.g., sickle cell disease), and neurological system (e.g., familial amyloid neuropathy). Other types of disorders that may cluster in families include fibromyalgia, persistent back pain, irritable bowel syndrome, and some types of arthritis (Tennant, 2017; USDHHS, 2019a).
The psychosocial history includes inquiries into past or current developmental, marital, or vocational problems, stressors or depressive symptoms, and reinforcers of the pain (e.g., compensation/litigation issues) (Tennant, 2017).
A systematic, targeted, pain-focused physical examination is most fruitful when the pain history interview and behavioral observations are conducted at the same time. Because pain may be referred from some other area of the body, the examination should include a full scan from head to toe.
- Mental status examination. This includes cognitive function, mood and affect, thought process and content, judgment, and insight.
- Vital signs. These may be elevated when a patient is experiencing acute pain. Elevated temperature may signal an infectious cause for pain.
- General inspection. This begins when the clinician first encounters the patient and notes any obvious sign of pain, such as limping, unusual posture of the body, splinting or guarding, facial expression, vocalizations, and the presence of obesity. The examiner looks at skin color and pigment changes, which may indicate inflammation, sympathetic dysfunction, or a prior herpes zoster eruption. Atrophy may indicate guarding and lack of use or denervation. Poor healing indicates poor perfusion possibly associated with ischemic injuries, diabetic neuropathy, or sympathetic dysfunction.
- Auscultation of the lungs, heart, and bowel sounds. This should be done as part of a routine examination, and especially if pertinent to the complaint.
- Palpation. Touch is used to gather information such as skin temperature, pulses, internal masses, tenderness, or rigidity. The painful area is demarcated, with the clinician feeling for changes in pain intensity within the area, trigger points, and changes in sensory or pain processing.
- Musculoskeletal examination includes both inspection and palpation for abnormal movements, range of motion, functional limitations, swelling and tenderness of the joints, temperature and color changes, crepitation, and deformity. It is important to determine secondary pain, even in patients whose primary source of pain is musculoskeletal. For example, if there is a knee problem, structures that directly affect the function of the knee (such as the low back, hip, foot, ankle, and supporting structures of the knee) are evaluated.
- Neurologic examination evaluates level of alertness, degree of orientation, behavior and mood, intellectual function, and motor system (muscle tone and strength). A comprehensive sensory examination includes tests for light touch, pinprick, pressure vibration, joint position, and heat and cold sensation. This involves observation of the individual’s gait, coordination, and balance and testing for abnormal deep tendon reflexes.
- Abdominal, pelvic, or rectal examination may be done to assess for suspected disease conditions that can cause pain referred to the back, such as pelvic inflammatory disease, endometriosis, or prostatitis.
(UFHealth, 2019; Scholten, et al., 2018)
Although there are no diagnostic tests available as yet to determine how much pain a person is experiencing, and no test that can measure the intensity or location of pain, there are a number of tests that can be done to determine the cause or source of pain.
Routine blood studies are not indicated, but directed testing should be ordered when specific causes of pain are suggested by the patient’s history of physical examination.
- Complete blood count (CBC) to detect the presence of an infection and some kinds of cancer
- Comprehensive metabolic panel (CMP) to give a picture of a person’s general health
- Erythrocyte sedimentation rate (ESR) to assess for inflammation
- C-reactive protein (CRP) to assess for inflammation and possible elevation due to polymyalgia rheumatica or rheumatoid arthritis
- Vitamin B12 and folate levels to assess for deficiencies that cause neurologic symptoms
- Fasting blood sugar (FBS) and glycated hemoglobin (HbA1C) to test for diabetes or to monitor control of diabetes
- Hemoglobin S (HbS or Hgb) to test for sickle cell disease
- HIV antibodies (ELISA or Western Bloc) to detect HIV infection
- HSV antibodies to assess for herpes simplex virus infection
- Rheumatologic tests (rheumatoid factor, ESR, ANA) to rule out rheumatoid arthritis and other autoimmune diseases (e.g., systemic lupus erythematosus) and infections (e.g., hepatitis, syphilis)
(Rosenquist, 2018; Clark & Galati, 2015)
IMAGING AND ELECTRODIAGNOSTIC TESTING
- Plain X-ray films to demonstrate bony pathology and some soft tissue tumors
- Ultrasound to help diagnose strains, sprains, tears, and other soft tissue conditions
- Myelograms using a contrast injected intrathecally to assess the spinal cord, subarachnoid space, or other structures for changes or abnormalities
- Computerized tomography (CT) to obtain images that give details of anatomic structures
- Discogram to view and assess internal structure of a disc to determine if it is the source of pain
- Magnetic resonance imaging (MRI) for superior soft tissue visualization; valuable in diagnosing spinal disc disease or neural compression; best for evaluation of spinal alignment and investigation for infections or tumors
- Functional MRI to provide data on metabolic and functional measurements in addition to anatomic details
- Bone scans to help diagnose tumors of the bone or metastatic disease, osteomyelitis, fractures, joint disease, avascular necrosis, and Paget’s disease
- Electromyography (EMG) to detect abnormal electrical activity in many diseases and conditions
- Nerve conduction studies (NCS) measure changes in the peripheral sensory and motor nerves
- Somatosensory evoked potential (SSEP) to assess for generalized disorders of the nervous system (e.g., multiple sclerosis)
(Agranoff, 2019; Morton et al., 2016; Kishner, 2018)
A psychological evaluation for a patient with pain contributes to the understanding of factors that precede and perpetuate the pain. The evaluation most often includes a combination of clinical interview and standardized self-report scales or questionnaires to evaluate psychological, behavioral, and social factors.
Areas that are of concern include perceived pain-related disability, emotional distress (e.g., depression, anxiety), and sleep disturbance.
For patients experiencing chronic pain, special focus is given to suicide risk assessment. For chronic pain patients, risk factors include the presence of comorbid depression, high pain intensity and duration, the presence of sleep-onset insomnia, high catastrophizing, and feelings of helplessness.
Due to the significant prevalence of alcohol/substance use and prescription opioid misuse among persons with chronic pain, a comprehensive screening is generally indicated. When symptom exaggeration or malingering is suspected, it is important to consider that it may occur because of psychological processes or environmental factors that shape the person’s response to pain (Lerman & Haythornthwaite, 2018).
Meredith, a 59-year-old African American woman, visited her neighborhood walk-in clinic Friday afternoon with a complaint of unexplained sharp, stabbing pains in her chest as well as her right shoulder and upper back. She reported that the pain started in the early morning and gradually worsened as the day progressed. She also complained of a nonproductive cough for the past couple of days. When asked if anything made the pain better or worse, she replied that pain increases when she takes a deep breath or when she coughs. Meredith stated that she took Tylenol for the pain with no effect.
Using a visual analogue scale, the nurse practitioner asked Meredith to rate her pain from 0 to 10, with 0 being no pain and 10 being the worse possible pain. Meredith identified her pain as a 6 when breathing normally and a 9 when taking a deep breath or coughing.
Her history revealed that she has asthma and uses an albuterol inhaler as needed. She has hypertension and takes hydrochlorothiazide 25 mg every day. She has no known allergies, no history of heart disease, and no recent history of injury to the chest. She denies a history of immune disorders or sickle cell anemia.
On examination the nurse practitioner noted that Meredith was a well-nourished, well-developed female in acute distress due to pain in the chest, right upper back, and shoulder. She sat upright with tensed muscles, and her arms were wrapped across her chest in a protective manner. Her temperature was 100.6 °F, pulse 82, respirations shallow at 16, and blood pressure 132/85. Her lungs were clear to auscultation and percussion, with a pleural friction rub heard over the right middle lobe anterolaterally. The remainder of the examination was within normal limits. Mental status, neurologic, and psychological examinations were deferred.
A chest X-ray was obtained, which showed full inflation of the lungs with no evidence of infiltrate. There was no air or fluid in the pleural space. A complete blood count was done and found to be normal. Oxygen saturation (SpO2) was 95%.
Meredith was diagnosed with pleurisy and was sent home with the following discharge instructions:
- Take ibuprofen (Advil, Motrin) or naproxen (Aleve) as needed to reduce pain and inflammation.
- Take OTC cough syrup for cough as needed.
- Find a comfortable position, such as lying on the affected side.
- Use pressure to prevent pain, such as a pillow.
- Return to the ER or see the primary care provider for temperature of 103 °F or higher or shortness of breath.
- Contact the primary healthcare provider if pain gets worse.
The following day Meredith called her nurse practitioner because she was having a great deal of pain and the medications recommended were having no effect. Her nurse practitioner called her pharmacy for a two-day (8 pills) prescription for Percocet (oxycodone hydrochloride; acetaminophen) 5mg/325mg, 1 tablet every 6 hours for pain, with instructions to follow up on Monday. The nurse practitioner further counseled Meredith on issues pertaining to safe opioid use and the epidemic of opioid misuse and diversion.
Barriers to Assessing Pain
Optimal comprehensive pain assessment requires removal of barriers in the healthcare system; among healthcare professionals; and in patients, family, and society.
A healthcare system may lack criteria or culturally sensitive instruments for pain assessment as well as institutional policies for accountability for pain assessment performance and documentation.
Among medical professionals it has been recognized that pain management is given a low priority in medical schools and residency training programs, leaving clinicians with gaps in knowledge and inadequate assessment skills. Among all healthcare professionals, barriers may include insufficient knowledge of pain management, a failure to identify pain assessment and relief of pain as a priority for patient care, and the belief that there is inadequate time to conduct and document the results of a pain assessment. Continuity of care may be lacking as well as communication among members of the healthcare team (ASPMN, 2018).
Research findings suggest that a provider’s expectations of and empathy for the pain experience of a patient are influenced by the stereotypes and biases they have about different genders, races, and ages. Healthcare providers may demonstrate differences in pain expectations based upon these demographic characteristics, which can influence pain assessment and treatment decisions. Healthcare professionals may also feel they are being deceived by someone who is seeking drugs, which can result in inadequate treatment of pain (ASPMN, 2018).
Patient / family / cultural / social barriers may include an inability to communicate, age, and/or culturally related stoicism. Patients may be reluctant to report pain or may fear not being believed. Psychological factors such as depression, fear, anger, anxiety, and malingering can all influence and complicate assessment and effective pain management (ASPMN, 2018).
Erin is a recent nursing school graduate who is working in an orthopedic unit. Today she admitted a new patient from the emergency room. Diego is a young male, 16 years old, who was playing football and during the game was tackled and fell. Another player came crashing down on Diego’s leg, and he sustained a nondisplaced fracture of the right tibia. In the emergency room he was given pain medication, the leg was X-rayed and casted, and he was admitted for observation.
Later in the evening, Diego’s coach and teammates came to visit him in the hospital. Erin heard them laughing and talking. They seemed to be really enjoying themselves, including Diego. Finally, all his visitors left and Diego rang his call bell. He told Erin that he was having a lot of pain and needed some medication. Erin replied that she felt he was doing okay and didn’t think he needed anything at that time.
Shortly thereafter, the charge nurse came to see how Erin was doing and asked about her patients. Erin told her about Diego and his request for pain medication. She said his behavior did not seem to indicate he was having any pain, and she thought he might just be drug seeking.
The charge nurse explained to Erin that just because someone does not appear to be in pain doesn’t mean he is not. Erin was helped to understand that Diego’s behavior with his coach and teammates may have been his way to appear “manly” and not a “sissy.” She told Erin that when persons say they are in pain, they are in pain, and that she has the responsibility to accept their statements of pain and provide medications as prescribed.
Assessing Pain in Special Populations
Accurate pain assessment can be challenging in certain populations, including infants, children, and cognitively impaired individuals, due to communication barriers. Because pain is a subjective experience, being unable to obtain this subjective information can lead to a less than optimal assessment.
ASSESSMENT OF PAIN IN NEONATES
Since the 1980s evidence has shown that preterm and term infants experience pain and stress in response to noxious stimuli. As general rule, anything that causes pain in adults or older children will also cause pain in neonates. Effective neonatal pain assessment is essential for optimal pain management and requires appropriately sensitive and accurate clinical pain assessment tools as well as clinical staff that is trained to detect neonatal pain using such tools.
Neonatal pain assessment tools rely on surrogate measure of physiologic and behavioral response to pain or noxious stimuli. Examples of scales most commonly used for acute pain assessment include:
- PIP (Premature Infant Pain Profile)
- NIPS (Neonatal Infant Pain Scale)
- NFCS (Neonatal Facial Coding System)
- BIPP (Behavioral Infant Pain Profile)
There are challenges, however, that limit the accuracy of using such tools, as they require evaluation by observers among whom there may be significant variability. These tools also require observation, mental calculation, and recording of 3 to 10 parameters in real time, all while the provider is performing a painful procedure. At this time there is no “gold standard” established for assessment of pain in the neonate (Anand, 2018).
ASSESSMENT OF PAIN IN INFANTS AND CHILDREN
Assessment of pain severity in children is performed by self-report or by behavioral observational scales in those unable to self-report. Self-reporting relies on the cognitive ability to understand that pain severity can be measured along a continuum. Younger children (3 to 8 years) are capable of quantifying pain and translating it to a visual representation. Visual analogue pain scales based on a series of faces showing an increase in distress or pain are used for this age group. The reliability of pain assessment increases with age and cognitive ability of the child.
Assessment of pain in older children (8 to 11 years) is generally performed utilizing visual analogue tools that rate the intensity of pain on a horizontal or numeric scale. Adolescents can also rate pain using a numerical scale, and a description of pain can usually be obtained from pain history.
The following pain-location tools that can be used to determine location of pain in both children and adolescents. These tools use a graphic outline of the body, and the patient is asked to color in the area of the body where pain is being experienced.
- Adolescent and Pediatric Pain Tool
- Pediatric Pain Questionnaire
The following are tools used for assessing pain in infants and children who are unable to self-report. They are based on facial expressions, ability to be consoled, level of interactions, limb and trunk motor responses, and verbal responses:
- rFLACC (Revised Face, Legs, Activity, Cry, Consolability) for nonverbal children
- NCCPC-PV (Non-Communicating Children Pain Checklist–Postoperative Version) for nonverbal children
- NAPI (Nursing Assessment of Pain Intensity) for newborn to 16 years of age
- PPP (Pediatric Pain Profile) for nonverbal children
Pain can also be assessed by identifying the impact it has on participation in school activities, sports, and relationships (Hauer & Jones, 2019).
When assessing infants and children, it is important to be aware that an infant who is lying very still may be in pain and that a sleeping child may actually be in significant pain without crying or whimpering. Sleeping and withdrawn behavior in a child may be attempts to control pain by limiting activity and interactions. Children also may underreport pain in order to avoid future injections or other procedures meant to alleviate pain (Kishner, 2018).
ASSESSMENT OF PAIN IN THE COGNITIVELY IMPAIRED
Many conditions can lead to cognitive impairment that can make pain assessment difficult, such as head trauma, memory deficits, unconsciousness, and delirium. Dementias are the leading cause of impaired cognition in older adults. These individuals may have communication barriers and challenges when complex pain assessment tools are used. In these instances, behavioral observation–based assessments are optimal. Behaviors include:
- Facial expressions: frowning, grimacing, rapid blinking
- Verbalizations/vocalizations: moaning, sighing, verbal abuse
- Body movements: rigid, tense, guarding, fidgeting, inactive, pacing
- Altered interpersonal interactions: aggression, resistance to care, disruption, withdrawal
- Activity patterns: changes in appetite or sleep, cessation of regular routines
- Mental status changes: increased confusion, irritability
In addition, physiologic pain indicators may be used to assess for pain, such as elevated vital signs, diaphoresis, and pupil dilatation (Venable, 2018).
Pain assessment tools for the cognitively impaired include:
- PACSLAC (Pain Assessment Checklist for Seniors with Limited Ability to Communicate)
- PAINAD (Pain Assessment in Advanced Dementia)
- Comprehensive Pain Assessment Form: Cognitively Impaired
ASSESSMENT OF PAIN IN THE OLDER ADULT
Both acute and chronic pain are common in the elderly. Pain may limit activities and mobility, and an effective assessment and pain management is vital for the individual to maintain functional independence. Several factors create barriers to an adequate assessment of pain in older adults, one of which is inadequate communication of pain. Many older adults subscribe to stoicism, the belief that pain is an essential part of aging. Multiple medical comorbidities may also lead to underreporting of pain.
Adequate pain assessment may also be hindered by decreased hearing and visual acuity, making tools that require extensive explanation or visualization more difficult and less reliable. The verbal descriptor scale may be the easiest tool for the older adult without cognitive impairment. This type of tool allows for the patient to describe what is being felt using common words rather than having to convert how they feel to a number, facial representation, or a point on a straight line.
One important factor in the assessment of pain in the older adult is the determination of the effect that pain has on day-to-day living. Although the older adult may maintain the necessary basic activities of daily living, the effect on activities such as social functions or advanced activities of daily living may depend on severity of pain (Kishner, 2018).
STRATEGIES FOR TREATING AND MANAGING PAIN
A comprehensive pain management approach includes:
- Appropriate pharmacologic and nonpharmacologic interventions
- Education of patient, family, and caregivers about the plan
- Ongoing assessment of the treatment outcomes
- Regular review of the treatment plan
Pharmacologic interventions can be broadly categorized as primary analgesic medications and adjuvant (co-analgesic, or “helper”) medications. Analgesics include nonopioid analgesics and opioid analgesics. Nonopioids are non-narcotic analgesics used to treat mild pain and also to serve as adjuvant medication for relief of moderate to severe pain. Opioids are narcotics used for moderate to severe pain. Cannabinoids are a unique class of drugs that may be used for pain and that do not fit into these categories.
Nonopioid analgesics include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). Many are available over the counter; some are available by prescription only.
Acetaminophen is a pain reliever and a fever-reducing agent widely used to treat both acute and chronic pain. Acetaminophen is a p-aminophenol derivative whose exact mechanism is not yet fully known. It may inhibit the nitric oxide pathway mediated by a variety of neurotransmitter receptors, resulting in elevation of the pain threshold. The antipyretic activity may result from inhibition of prostaglandin synthesis and release in the central nervous system and prostaglandin-mediated effects on the heat-regulating center in the anterior hypothalamus.
Acetaminophen is harmless at low doses but has direct hepatotoxic potential when taken as an inadvertent overdose (e.g., patients not recognizing the presence of the drug in multiple over-the-counter and/or prescription products being taken), and can cause acute liver injury and death from acute liver failure.
In the United States, acetaminophen is sold under the brand name Tylenol and is used to treat a variety of conditions including:
- Minor osteoarthritis pain
- Back pain
- Dental pain
- Menstrual cramps
Nonsteroidal Anti-Inflammatory Drugs
There are more than 20 different NSAIDS available over the counter or by prescription. There are two main types of NSAIDS: nonselective and selective. Nonselective NSAIDS include those commonly available without prescription (aspirin, ibuprofen, and naproxen). Selective NSAIDs, also called COX-2 inhibitors, are as effective in relieving pain and inflammation as nonselective NSAIDs but are less apt to cause gastrointestinal injury.
NSAIDS are inhibitors of cyclo-oxygenase, the enzyme that mediates the conversion of arachidonic acid to prostaglandins. There are two types of cyclo-oxygenase: COX-1 and COX-2. Both enzymes produce prostaglandins that promote inflammation, pain, and fever; however, only COX-1 produces prostaglandins that support platelet blood clotting function and protect the stomach lining from the effects of acid. NSAIDs work by blocking these enzymes, thereby reducing prostaglandins. This results in reduction of inflammation, pain, and fever. Because NSAIDs reduce blood clotting, they can cause stomach ulcers and promote bleeding (Solomon, 2019).
NSAIDs can be administered orally, rectally, parenterally, and topically. Side effects can include:
- Decreased appetite
- Kidney failure (primarily with chronic use)
- Liver failure
- Prolonged bleeding after injury or surgery
NSAIDs (with the exception of low-dose aspirin) may increase the risk of potentially fatal heart attacks, stroke, and related conditions (Curfman, 2017).
Opioid analgesics are human-made drugs that are chemically similar to opiates found in the seedpod of the poppy (Papaver somniferum). There are more than 20 opiates found in the opium poppy seedpod, and six occur in large amounts. Of those six, four are used for medical purposes: morphine, codeine, thebaine, and papaverine.
Morphine and codeine are the most well-known opiates. Thebaine is not used as a pain medication in its natural state but is converted into other chemicals such as oxycodone or hydrocodone, which are examples of semisynthetic opioids. Diacetylmorphine, more commonly known as heroin, is an example of a semisynthetic opioid manufactured from morphine.
Drugs that are created in laboratories that mimic effects of opiates but are not derived from the opium poppy are synthetized drugs. Examples include methadone, fentanyl, and meperidine (McLain, 2016).
Opioid Receptors and Mechanism of Action
Opioid receptors are found in the central nervous system, pituitary gland, gastrointestinal tract, grey matter of the brain, and dorsal horn of the spinal cord. Opioid analgesics produce pain relief by acting on these central and peripheral opioid receptors to inhibit the transmission of nociceptive input and the perception of pain. There are four types of opioid receptors, which produce the following effects:
The mu opioid receptors impart most of their analgesic effect in the central nervous system, along with many side effects such as sedation, respiratory depression, euphoria, and dependence. The delta opioid receptors are more widespread in the peripheral nervous system, where they have their analgesic effect. The kappa opioid receptors contribute to analgesia in the spine and may cause dysphoria and sedation but do not generally lead to dependence (McLain, 2016; Alford et al., 2017).
Opioids are classified by the effect (intrinsic activity) they have on the mu receptors and include full agonists, partial agonists, and antagonists.
Full agonists are opioid drugs that bind to mu opioid receptors and cause them to produce endorphins, which provide pain relief, and depending on the dose and frequency, addictive effects and feelings of euphoria. Examples of full agonists are oxycodone, methadone, codeine, heroin, and morphine.
Partial agonists are drugs that bind primarily to mu opioid receptors and cause them to produce endorphins but to a much lesser extent than full agonists. When the dosage of a partial agonist is increased, there is only a small increase, if any, in the production of endorphins. Buprenorphine, Suboxone, and Subutex are partial agonists.
Antagonists are drugs that bind to the mu opioid receptors but have no intrinsic activity and prevent other opioids from stimulating the mu receptors and producing endorphins. Naloxone and naltrexone are opioid antagonists (McLain, 2016).
Adverse Effects of Opioid Analgesics
Both short- and long-term use of opioids is associated with a high rate of adverse effects involving multiple body systems. Such adverse effects can occur at all dose ranges (see table).
|Sources: Portenoy et al., 2018; McLain, 2016.|
|Central Nervous System||
|Skin and Eye||
Following her visit to the walk-in clinic, Meredith’s condition began to deteriorate. Her pain remained severe at 9 to 10 on a 10-point pain scale. By Sunday evening she began experiencing respiratory distress that required her to sleep semi-upright in a lounging chair. With the increase in respiratory distress, her pain level remained high, and she took the Percocet around the clock. As a result, she became severely constipated over the next two days. She called her nurse practitioner Monday morning and was seen in the afternoon, when a chest X-ray revealed extensive pleural and pericardial effusions.
Meredith was admitted to the hospital. An IV was started, and she was given 4 mg of morphine IV for pain. An order was written for morphine 15 mg orally every 4 hours as needed. Because of her constipation, milk of magnesia 30 ml was ordered to be given with each dose of morphine. There was also an order for acetaminophen 650 mg every 4 hours to be given between doses of morphine. Meredith’s pain was well controlled on this regimen.
Opioids and Managing Breakthrough Pain
Most patients with chronic pain due to advanced disease report having episodic pain referred to as breakthrough pain. Breakthrough pain is a transitory, severe, acute pain that occurs in patients with chronic pain that has been adequately controlled by an opioid regimen.
Breakthrough pain includes the following:
- Incident pain occurs with specific activities and can be predicted. Pain management requires a proactive approach using a quick-acting, short-term-lasting pain medication before the patient is involved in those activities. Dosage should be adjusted based on the level and duration of the activity that is expected to cause pain.
- Spontaneous pain is unpredictable, not associated with any specific activity, and more difficult to treat. A quick-acting, short-term-lasting pain medication should be given as soon as the patient feels pain. Better control of pain may result from use of adjuvant medications.
- End-of-dose medication failure is pain that occurs toward the end of the timeframe in which the medication is intended to be effective. The treatment may involve shortening the interval between scheduled doses or increasing the dose.
Breakthrough pain episodes are typically managed with a short-acting oral opioid drug referred to as a rescue dose taken on an as needed basis in conjunction with the fixed-schedule, long-acting medication. A typical dose for rescue is 5% to 15% of the basal daily requirement of opioid.
Breakthrough pain may also be treated with one of the newer rapid-onset, transmucosal fentanyl formations. There are several formulations available in the United States:
- Actiq (oral transmucosal fentanyl lozenge)
- Abstral (immediate-release transmucosal tablet)
- Fentora (effervescent fentanyl buccal tablet)
- Lazanda (nasal spray)
- Subsys (sublingual spray)
To prescribe any of these drugs, clinicians must complete online education. In addition, each patient treated requires registrations of the patient, the prescribing clinician, and the pharmacist. Because of the cost and limited experience, the transmucosal drugs are generally considered only after a patient has demonstrated a poor response to an oral rescue dose (Portenoy et al., 2019).
Opioids and Drug Tolerance, Dependence, and Addiction
When an opioid drug is used on a regular basis, generally after more than two weeks, the same dose of the drug has less of an effect. This is referred to as tolerance. A person who is developing tolerance may require larger amounts of the drug to get the same effect. Tolerance levels vary between individuals and occur when parts of the body affected by the drug begin to respond less to repeated stimulation. The body may also get better and faster at breaking down the drug (NIH, 2019b).
With repeated use of opioids, dependence occurs. Dependence is characterized by the symptoms of tolerance and withdrawal. The brain adapts to repeated exposure to the drug and can only function normally in the presence of the drug. When the drug is withdrawn, physiological reactions occur, which can be mild or even life-threatening. Withdrawal symptoms include:
- Nausea or vomiting
Addiction occurs when neither the body nor mind can function without the drug. The biological basis of addiction is damage to the prefrontal cortex. Brain imaging studies show decreased activity in this region of the brain, which is involved in essential decision-making. When this area fails to function properly, the person is unable to make a decision to stop taking the drug. Teens are especially vulnerable to addiction since their brains have not yet fully developed, particularly the frontal regions involved with impulse control and risk assessment.
It is not yet understood why some people become addicted while others do not. Addiction tends to run in families, and certain genes have been linked to different forms of addiction. Other factors that increasing the risk of addiction include:
- History of substance abuse
- Depression or other psychiatric disorders
- Childhood abuse or neglect
- Certain personality traits, including impulsivity and sensation-seeking
- Living in poverty and in rural areas
- Associating with others who abuse opioids or other substances
- Having easy access to prescription or illegal opioids
(NIH, 2019b; USDHHS, 2019b)
Due to their pharmacological effects, opioids in high doses can cause respiratory depression and death. Most drug-related deaths worldwide are attributable to opioids. An opioid overdose can be identified by a combination of three signs and symptoms, referred to as the opioid overdose triad, which include:
- Pinpoint pupils
- Respiratory depression
Combining opioids with alcohol and sedative medication increases the risk of respiratory depression, and combinations of opioids, alcohol, and sedatives are often present in fatal drug overdoses (WHO, 2018).
(See also “Opioid Misuse, Abuse, and Diversion” later in this course.)
Adjuvant analgesics (co-analgesics) are drugs that were developed for uses other than pain but have been found to enhance analgesic effects. These are “helper drugs,” not substitutes for analgesics. Clients in pain still need analgesics.
The following table describes some common adjuvant analgesics.
|Class / Indications / Primary Effects||Drugs|
|Source: Portenoy et al., 2019.|
|Antidepressants: Neuropathic pain, burning sensation; improves sleep, enhances mood and analgesic effects||
|Anticonvulsants: Neuralgic and neuropathic pain; sharp, prickling, shooting pain||
|Antispasmodic: Reflex sympathetic dystrophy syndrome (a disorder of the sympathetic nervous system causing chronic, severe pain)||
|Anxiolytics: Help manage anxiety and pain by encouraging muscles to relax||
|Neurotoxin: Migraine headache||
|Topical anesthetics: Neuralgic, neuropathic, and musculoskeletal pain||
|Corticosteroids: Inflammatory conditions, metastatic bone pain, neuropathic pain, and visceral pain||
|Anesthetic drugs: Neuropathic pain, phantom leg pain||
WORLD HEALTH ORGANIZATION PAIN MANAGEMENT LADDER
Over 30 years ago, the World Health Organization (WHO) established a treatment, or analgesic, ladder for adult patients with cancer pain that continues to be widely used today for all patients with either acute or chronic pain who require analgesics. The ladder has three steps:
- Step 1: For mild pain, use a nonopioid with or without adjuvant analgesic.
- Step 2: For mild to moderate pain, use a mild or weak opioid (e.g., codeine) plus a nonopioid medication with or without adjuvant analgesic.
- Step 3: For moderate to severe pain, use a strong opioid (e.g., morphine) plus nonopioid with or without adjuvant analgesic.
To maintain freedom from pain, drugs should be given “by the clock.” This is every 3 to 6 hours, rather than “on demand.” This three-step approach of administering the right drug in the right dose at the right time is inexpensive and 80% to 90% effective. Surgical intervention on appropriate nerves may provide further pain relief if drugs are not wholly effective.
The WHO also provides guidelines on the pharmacologic treatment of persisting pain in children with medical illness (WHO, 2019). (See also “Resources” at the end of this course.)
ROUTES OF ANALGESIC ADMINISTRATION
Analgesics can be administered by many routes. Each has advantages and disadvantages as well as indications and contraindications. The overriding considerations are effectiveness and safety. The table below lists some of the most common routes for the administration of analgesic drugs.
|Sources: AAP, 2019; Bourne, 2014; Chandane, 2014; Doctors.net/uk, n.d.; Gilani, 2012; Merck Manual, 2019; Quora, n.d.; Zamliana, 2016.|
|Oral (per os = PO)||
|Sublingual (SL) and buccal||
|Intravenous (IV) bolus||
|Continuous intravenous (IV) infusion||
|Patient-controlled analgesia (PCA)||
|Subcutaneous (SC) opioid infusion||
|Intraspinal (neuraxial), intrathecal, epidural, subarachnoid, intraventricular||
|Regional nerve blocks||
|Topical (cream-laden anesthetic)||
|Transdermal skin patch||
CANNABIS (MEDICAL MARIJUANA)
Between 1850 and 1937 cannabis was used widely in medical practice for a range of ailments and prescribed for various conditions including labor pains, nausea, and rheumatism. It was listed in the United States Pharmacopeia from 1850 until 1942, and in 1906 the Pure Food and Drug Act required the labeling of any cannabis contained in over-the-counter remedies. However, by 1931 Congress passed the Marijuana Tax Act, which effectively criminalized marijuana (WGBH, 2014; Burnett & Reiman, 2014).
The discovery in the 1990s of the endogenous cannabinoid system renewed interest in the drug and strongly stimulated new research. In 1996 California voters passed Proposition 215 allowing for the sale and medical use of marijuana for patients with AIDS, cancer, and other serious and painful diseases (WGBH, 2014; Burnett & Reiman, 2014).
At the close of 2018, 33 states and the District of Columbia had also passed laws broadly legalizing medical marijuana in some form. Twenty-seven of those states and the District of Columbia had fully legalized marijuana, and nine states and the District of Columbia had decriminalized it. Some medical marijuana laws are broader than others, with types of medical conditions that allow for treatment varying from state to state. Some states allow only for cannabis-infused products such as oils or pills. Other states have passed narrow laws allowing residents to possess cannabis only if they suffer from select medical illnesses.
Despite these new laws, cannabis is still illegal under federal law, and the government regulates it through the Controlled Substances Act (CSA), which does not recognize the difference between medical and recreational use of cannabis. The federal laws, however, are generally applied only against those who possess, cultivate, or distribute large quantities of cannabis.
Under the CSA, cannabis is classified as a Schedule 1 drug. This means that the federal government views cannabis as highly addictive and that it has no medical value. Doctors may not prescribe cannabis for medical use under federal law, although they can “recommend” its use under the First Amendment (ASA, 2019).
Recent studies have found that prescriptions filled for all opioids decreased in those states with medical marijuana laws, and other studies have found a reduction in overdose deaths from opioid pain relievers. At this point, research into the effects of cannabis on opioid use in pain patients is mixed, but cumulatively, studies suggest that medical marijuana products may play a role in reducing the use of opioids needed to control pain (NIH, 2018b).
Mechanism of Action
Marijuana is a greenish-gray mixture of the dried flowers of the plant Cannabis sativa. The main psychoactive chemical in marijuana responsible for the intoxicating effects people experience is delta-9-tetrahydrocannabinol (THC). THC’s chemical structure is similar to anandamide, an endogenous cannabinoid, and because of this similarity, it is able to attach to and activate cannabinoid receptors in brain areas that influence pleasure, memory, thinking, and concentration (hippocampus and orbitofrontal cortex); and balance, posture, coordination, and reaction time (cerebellum and basal ganglia). THC, acting through the cannabinoid receptors, also activates the brain’s reward system to release dopamine at levels higher in response to pleasurable behaviors than those in response to other stimuli.
The other chemical from the marijuana plant that is of medical importance is cannabidiol (CBD), thought to be useful in reducing pain and inflammation and in controlling epileptic seizures. CBD, however, does not cause intoxication or euphoria (the “high”) that comes from THC because it does not affect the same receptors as THC. CBD influences the body to use its own endocannabinoids more effectively by inhibiting absorption by the body of the endogenous cannabinoid anandamide, which is associated with regulating pain. Increased levels of anandamide in the blood may reduce the amount of pain a person experiences (NIH, 2018b; FDA, 2018a).
CBD is also used for the treatment of epilepsy; however, the exact mechanism in which CBD creates anticonvulsant effects is not known. Data suggests that it does not create the anticonvulsant effects through interaction with cannabinoid receptors (Drug Development Technology, 2019).
FDA-Approved Medical Marijuana Formulations
The U.S. Food and Drug Administration (FDA) has approved the following THC-based pill-form medications for the treatment of nausea in patients undergoing cancer chemotherapy and to stimulate appetite in patients with wasting syndrome due to AIDS:
- Dronabinol (Marinol, Syndros)
- Nabilone (Cesamet)
In 2018 the FDA approved the first CBD-based medication. Epidiolex (cannabidiol) is a liquid medication for the treatment of two forms of severe childhood epilepsy (Dravet syndrome and Lennox-Gastaut syndrome) in those 2 years of age and older (FDA, 2018a).
Additionally, several other marijuana-based medications have been undergoing clinical trials. Sativex (nabiximols), a combined THC and CBD drug, is a mouth spray available in the United Kingdom, Canada, and several European countries for treating the spasticity and neuropathic pain that may accompany multiple sclerosis (NIH, 2018b).
MEDICAL MARIJUANA IN NEW MEXICO
As of 2019, New Mexico law allows the use of medical marijuana for the following conditions:
- Amyotrophic lateral sclerosis (ALS, or Lou Gehrig’s disease)
- Cervical dystonia
- Chronic pain
- Crohn’s disease
- Epilepsy and other seizure disorders
- Hepatitis C infection
- Hospice patients
- Huntington’s disease
- Inflammatory autoimmune-mediated arthritis
- Intractable nausea/vomiting
- Multiple sclerosis
- Obstructive sleep apnea
- Opioid dependency or other substance abuse disorders
- Painful peripheral neuropathy
- Parkinson’s disease
- Posttraumatic stress disorder
- Severe chronic pain
- Spasmodic torticollis
- Spinal cord damage
- Ulcerative colitis
As of 2019, there are an estimated 70,743 registered patients in the state. Patients can possess eight ounces of medical cannabis (over a 90-day period) and can cultivate 16 plants (4 mature, 12 immature) in their home. There are also state-licensed dispensaries available. A primary caregiver can be designated by a patient’s practitioner as necessary to take responsibility for managing the well-being of a qualified patient with respect to the medical use of cannabis. This caregiver must be a resident of New Mexico and must be 18 years of age or older (NORML, 2019).
(See also “Pharmacologic Pain Management” under “Treating Pain in Palliative Care and End-of-Life Care” later in this course.)
Evidence-based nonpharmacologic therapies are safe when correctly administered and can be effective components of comprehensive pain management that can reduce the need for opioids. Nonpharmacologic therapies can be the sole intervention, or they can be combined with other treatments. Nonpharmacologic interventions include physical, psychological, and mind-body modalities.
Physical modalities for relief of pain refer to any therapeutic medium that uses the transmission to or through the patient of thermal, electrical, acoustic, radiant, or mechanical energy.
Thermal Modalities (Heat and Cold)
Cold (cryotherapy) is often the first treatment applied to new injuries. Cold causes vasoconstriction, which slows blood flow and leakage of fluid from capillaries into surrounding tissue spaces and reduces bruising, swelling, inflammation, and muscle spasms. Cold slows down the pain messages transmitted to the brain and numbs tissue, acting as a local anesthetic. Cold therapy can be cold compresses, chemical cold packs, immersion or soaking in cold water, massaging the area with an ice cube or an ice pack, cold air and vapocoolant sprays, and manual and electric cold compression units (Physiopedia, 2019).
Thermal modalities include superficial and deep heat. Heat may facilitate tissue healing, relax skeletal muscles, and decrease spasms and pain. Heat therapy speeds up nerve impulses, dilates blood vessels, and helps eliminate buildup of lactic acid waste. The effect of heat on pain is mediated by generating action potentials in calcium channels that are sensitive to heat. Once activated, they can inhibit the activity of purine pain receptors located in the peripheral small nerve endings. Heat can directly inhibit pain in peripheral tissues; however, when pain originates from deep tissue, heat stimulates peripheral pain receptors, which can alter gating in the spinal cord and reduce deep pain.
Heat is effective for mostly dull and persistent pain associated with stiffness, cramping, and neuropathic sensitivity. Muscle pain responds well to heat, which also promotes relaxation and comfort. Superficial heat can be applied using electric heating pads, hot water bottles, wet or dry hot packs, heat wraps, hot baths, saunas, steam baths/rooms, sunlight, or heated paraffin wax treatment.
Deep heat includes shortwave diathermy (SWD) and microwave diathermy (MWD). SWD and MWD convert electromagnetic energy to thermal energy and are commonly used to heat large areas of deep tissue and within the joints. MWD has more superficial heat penetration compared to SWD (Safer Pain Relief.org, 2019; Physiopedia, 2019; Klein, 2017). (See also “Acoustic Modalities” below.)
Manual Modalities (Massage)
Massage is the use of touch or force to areas and tissues for therapeutic purposes. Therapeutic massage involves the application of hands or elbows with the intention of solving a physical problem. Research supports the benefits of massage therapy for pain management, decreasing anxiety and depression, and reducing pain intensity in patients undergoing surgical procedures. Massage reduces pain by stimulating A-beta fibers, resulting in closing of the “gate” to impulses from the periphery, and also stimulates the release of endorphins.
Types of massage include:
- Acupressure: Application of pressure to acupuncture points
- Deep-tissue: massage to reduce pain and inflammation
- Rolfing and myofascial release: more aggressive techniques that direct force into dysfunctional muscle and fascial tissue
- Neuromuscular therapy: a technique that releases trigger points within tight muscles
- Reflexology: based on a system of points on the hands, feet and ears that correspond to other parts of the body; similar in theory to acupressure, applying pressure to these points to stimulate the flow of energy, thus helping to release pain or blockages throughout the body
- Reiki: use of light touch designed to work with the body’s energy
- Whirlpool: water massage to decrease muscle tension, improve circulation, and relieve pain
- Swedish: the most common type of massage, to decrease muscle tension, pain, stress, and depression
(Madore, 2019; AMTA, 2018)
Manipulation therapy is an evidence-based practice involving the application of pressure to the spine or other parts of the body to adjust and correct alignment for the treatment of musculoskeletal pain. Such techniques are commonly used to improve pain and function by osteopathic physicians, chiropractors, and physical therapists. Spinal manipulation, for example, is often recommended for acute, subacute, and chronic low back pain as well as osteoarthritis. It has also been found beneficial for neck pain, cervicogenic headache, and prophylaxis of migraine (Tick et al., 2017; APTA, 2018b).
Acupuncture involves placing thin needles into targeted areas of the body to ease chronic pain. According to traditional Chinese medicine, the body has patterns of energy (chi) flow. Fine needles are positioned at specific locations on the body to correct or maintain this flow. Modern medicine emphasizes how acupuncture needles stimulate nerve and muscle cells, reducing the sensation of pain and releasing the body’s endorphins. Acupuncture needles can be moved or turned once they are in place, and mild electrical pulses are sometimes used between two needles (electro-acupuncture) to expand the area of pain relief (Mayo Clinic, 2018; Ahn, 2019).
Electrotherapy is used to treat a range of chronic pain conditions using mild electric current to underlying structures.
Transcutaneous electrical nerve stimulation (TENS) is a commonly used device designed specifically for pain relief. TENS provides a low-voltage electrical current through the skin to sensory nerve fibers, producing numbness or tingling sensations that “mask” or “override” sensations of pain. The impulses from TENS fill the nerve pathways and prevent the transmission of pain signals to the brain. It may also stimulate nerves to produce endorphins, which may block the perception of pain. TENS is most commonly used to treat conditions involving muscle, joint, or bone, such as osteoarthritis, fibromyalgia, bursitis, and back and neck pain.
Although TENS may help relieve pain for some people, its effectiveness has not been proven. Many studies have been done on TENS, but most have been small or not well designed. For this reason, some experts claim TENS can give short-term pain relief; however, long-term relief has not been proven (URMC, 2019).
Interferential stimulation is more complex than TENS. It uses dual-frequency stimulation to create circuits that cross over each other to produce maximum pain signal interference at the treatment target site.
Percutaneous electric nerve stimulation (PENS) therapy uses thin needle electrodes that pierce the skin and get closer to nerve endings or muscle than does TENS therapy. It is often used if TENS therapy is unsuccessful and to treat diabetic peripheral neuropathy.
Pulse electromagnetic field stimulation (PEMF) therapy uses short bursts of low-level electromagnetic fields that can relieve continuing leg or back pain following back surgery. It has also shown promise in treating fibromyalgia and osteoarthritis (Lisi et al., 2019).
Iontophoresis allows medication to be delivered into and through the skin to a painful area without having to be injected or taken orally. Liquid medication is placed on a patch that is then applied to the painful area. A device, similar to a battery, is then attached to the patch, and the medication is delivered by a mild electrical current. Iontophoresis has been used successfully to anesthetize an area of skin with lidocaine and to treat bursitis or tendonitis with anti-inflammatory drugs (NIH, 2018c).
Therapeutic ultrasound is a form of mechanical energy. The ultrasound device converts electrical energy to high-frequency sound waves that penetrate deeply into muscle, nerve, bone, and connective tissues. The waves vibrate cell molecules and cause friction, which creates heat. This heat is deeper in the tissues than heat packs or any other heating modality can reach. Its effects are the same as those of superficial heat, and it also decreases nerve sensitivity by sedating nerve endings. Ultrasound is used to treat chronic inflammation, soft tissue injury, nerve root irritation, nonacute bursitis, and adhesive capsulitis (Watson, 2019; Physiopedia, 2019).
Shortwave diathermy (SWD) and microwave diathermy (MWD) convert electromagnetic energy to thermal energy. Diathermy heats more deeply than hot packs and can heat a larger area than ultrasound. SWD produces deep heating and can be either pulsed or continuous. Pulsed shortwave diathermy is used for patients with some acute and subacute conditions, and it prevents tissue temperature from increasing too quickly or too high. Continuous shortwave diathermy increases subcutaneous tissue temperature, and its use is generally limited to chronic conditions. It is usually applied for 20 minutes at the maximum tolerable dose and is used most commonly for treating musculoskeletal disorders. SWD penetrates bone and does not pose a risk of periosteal burning. MWD does not penetrate as deeply as shortwave diathermy and can create hotspots. It is useful in the treatment of traumatic and rheumatic conditions affecting superficial muscles, ligaments, and small superficial joints (AAPM&R, 2019).
Phonophoresis uses ultrasound’s high-frequency sound wave to drive a medication into the tissues. A topical anti-inflammatory agent is blended into the ultrasound gel and applied to the skin over the treatment area, and the ultrasound waves carry it into the tissues to reduce inflammation and also provide the benefits of therapeutic heat and vibration (Hoenig & Cary, 2018).
Low-level laser therapy (LLLT) is a form of light therapy that triggers biochemical changes within cells. Photons are absorbed by cellular photoreceptors, triggering chemical alterations and potential biochemical benefits. LLLT has been used in pain management for years and is also known as cold laser therapy. Based on recent research, the utilization of LLLT may be a complementary option for providing symptom management in patients with osteoarthritis and chronic pain (Dima et al., 2017).
Interventional Pain Modalities
When noninvasive strategies are insufficient, patients may be offered various invasive options that include:
- Injection therapies
- Soft tissue and joint injections may be used for conditions such as bursitis, tendonitis, arthritis, osteoarthritic, and carpal tunnel syndrome. Trigger point injections are used for musculoskeletal pain. Anti-inflammatory medications (corticosteroids) are the most common drugs to use in injections and often are combined with pain relievers such as lidocaine.
- Nerve blocks provide temporary pain relief by injecting a local anesthetic to temporarily interrupt peripheral nerve transmission of pain. Nerve blocks may be given in the facet joints of the spine, hip joint, sacroiliac joint, coccyx, shoulder, elbow, hand, knee, ankle, foot, occipital, saphenous, and pudendal nerves.
- Neurolytic blocks produce analgesia by destroying afferent neural pathways or sympathetic structures involved in pain transmission by injecting a material that damages the nerve (e.g., water, hypertonic saline, phenol, or alcohol).
- Epidural steroid injections send steroids directly to an inflamed nerve root and require two or three injections for maximum relief.
- Radiofrequency ablation involves using X-ray guidance to insert a needle with an electrode at the tip, which is then heated in order to temporarily turn off a nerve’s ability to transmit pain signals to the brain. Other names are radiofrequency rhizotomy and neuroablation.
- Cryotherapy ablation uses medical-grade nitrous oxide to generate extremely cold temperatures to selectively destroy nerve tissue and prevent transmission of the pain signal to the brain.
- Intrathecal pump implants provide potent medications directly to the source of pain. This is a type of neuromodulation that interrupts pain signals to the brain. It involves a small pump implanted under the skin which is programmed to deliver a specific amount of medication. The pump requires refilling every few months.
- Spinal cord stimulator. A device is implanted under the skin and sends a mild electric current to the spinal cord. Thin wires carry current from a pulse generator to the nerve fibers of the spinal cord. When turned on, nerves in the area where the pain is felt are stimulated. Pain is reduced because the electrical pulses modify and mask the pain signal.
- Intradiscal electrothermal therapy (IDET) is a minimally invasive technique for treating discogenic low back pain. It involves the percutaneous threading of a flexible catheter into a disc under fluoroscopic guidance. The catheter heats the posterior annulus of the disc, causing contraction of collagen fibers and destruction of afferent nociceptors. Studies indicate it may bring relief in about 70% of those with chronic, unremitting low back pain.
- Dry needling is a physical therapy technique (where allowed by state law) that is part of a larger treatment plan for musculoskeletal pain. Dry needling involves penetrating the skin with a thin filiform needle and stimulating underlying myofascial trigger points and muscular connective tissues. The goal is to release or inactivate trigger points to relieve pain or improve range of motion. Dry needling is found to be more effective than no treatment, sham dry needling, and other treatments for reducing pain and improving pressure pain threshold, but evidence of long-term benefit is currently lacking.
(PPM, 2018; Portenoy & Copenhaver, 2017; Thiyagarajah, 2018; APTA, 2019a; Gattie et al., 2017)
Cognitive-Behavioral Therapy (CBT)
One of the most common types of psychotherapy used in pain management is cognitive-behavioral therapy. The role of CBT is to help patients recognize the emotional and psychological factors that influence pain perception and the behaviors associated with having pain. Cognitive strategies challenge the patient’s beliefs and thoughts about pain, and then, using cognitive restructuring, the patient learns to modify negative thinking and to use positive coping self-statements. The goals of CBT are to:
- Reduce the impact pain has on the patient’s daily life
- Learn skills for better coping with pain
- Improve physical and emotional functioning
- Reduce pain and the reliance on pain medication
(Yasgur & Barclay, 2018)
Acceptance and Commitment Therapy (ACT)
The basic premise of acceptance and commitment therapy is for patients to shift their primary focus from reducing or eliminating pain to fully engaging in their lives. The goal of the therapy is to help patients accept whatever discomfort exists, both physical and emotional, while continuing to live their lives according to their values. ACT applies six core treatment processes to create psychological flexibility. These six treatment processes are:
- Acceptance: Developing and enhancing a person’s willingness to have and accept experiences
- Defusion: Helping a person notice their language processes as they unfold and watch thoughts come and go from the perspective of a neutral observer
- Being present: Equated to mindfulness
- Self-as-context: Working to let go of attachment to a conceptualized self
- Values: Learning to choose willingness to experience difficult thoughts and feelings in order to engage in valued behavior
- Committed action: Helping a person to see that choosing a valued direction is not a permanent thing and that choice must be made again and again
(Cosio & Lin, 2017)
Biofeedback is the use of instrumentation to mirror psychophysiological processes of which an individual normally is unaware and which may be brought under voluntary control. Types of biofeedback devices include:
- Electromyogram (EMG): measures muscles activity and tension
- Thermal: measures skin temperature
- Neurofeedback or electroencephalography (EEG): measures brain waves
- Electrodermal activity (ADA): measures sweating
- Heart rate variability (HRA): measures heart rate
There are three stages that occur during biofeedback training:
- Awareness of physical response is gained.
- The patient uses the signals from the biofeedback to control physical responses.
- The patient transfers control from the biofeedback equipment to the self.
(Cosio & Lin, 2019)
Relaxation therapies have been found helpful in the management of chronic headaches and other types of chronic pain in children and adolescents. Relaxation encourages reduction in muscle tension, resulting in a decrease in pain intensity. There are a number of practices—such as progressive relaxation, guided imagery, self-hypnosis and deep-breathing exercises—and the goal is similar for all: to produce the body’s natural relaxation response, characterized by slower breathing, lower blood pressure, and a feeling of increased well-being (NIH, 2018d).
Hypnosis is a procedure involving cognitive processes in which the patient is guided by a health professional to respond to suggestions for changes in perceptions, sensations, thoughts, feelings, and behaviors. It involves learning how to use the mind and thoughts in order to manage emotional distress, unpleasant physical symptoms, and certain habits or behaviors. Patients can be trained in self-hypnosis, in which they learn to guide themselves through a hypnotic procedure. Hypnosis is often combined with biofeedback and other forms of relaxation therapies (Cosio & Lin, 2019).
Distraction is shifting attention away from pain or painful stimuli to something more engaging or enjoyable. Distraction for acute pain can be:
- Internal (e.g., imagery)
- External to the individual, such as audio (e.g., music), visual (e.g., book), or audiovisual (e.g., movies)
- Require passive or interactive engagement
- Involve others (healthcare providers, parent)
There are several theories about the mechanism underlying distraction, but despite extensive research, understanding is limited as to what, when, how, and for whom distraction is effective.
Research supports the use of distraction for acute pain among infants and children, with less consistent evidence for adolescents and adults. For infants and small children, using colorful, moving objects, singing songs, telling stories, or looking at books or videos can be used. Older children and adults find watching TV or listening to music helpful (Stanford Health Care, 2019; Birnie et al., 2017).
Mindfulness-based interventions (e.g., meditation) have been found to have significant effects on chronic pain, yet the mechanisms underlying these effects are not well understood. Meditation does not use one of the body’s primary pain modulatory systems, such as the endogenous opioid system, for pain relief. But studies have seen a decrease in cortisol and epinephrine levels and an increase in serotonin and gamma-aminobutyric acid levels, which are linked to relaxation and antidepression. Study results also suggest that mindfulness practice may have a buffering effect on chronic pain by attenuating the tendency to enable the pain experience.
The goal of mindfulness meditation is not to eliminate pain or anxiety but rather to get patients to focus on breathing and relaxation techniques (focused awareness). Patients are taught to achieve nonjudgmental self-acceptance and to focus the mind on the present moment (Zeidan et al., 2016; Reiner et al., 2018).
Virtual reality (VR) therapies have been shown to effectively distract patients who suffer from chronic and acute pain. Virtual reality is a computer-generated world that simulates real-life experiences through senses and perception. An individual using VR equipment is able to look around the artificial world, move around in it, and interact with virtual features or even thoughts. This world is commonly created by using a VR headset that consists of a head-mounted display with a small screen positioned in front of the eyes.
Functional MRI studies have found that VR has the ability to reduce activation in certain areas of the brain and may help the brain change and adapt to computer-generated experiences that would be painful or otherwise difficult in ordinary physical reality (Pourmand et al., 2018).
Virtual reality has also been shown to benefit children by reducing the fear and anxiety they experience before a procedure. Children tend to be more cooperative when engaged in VR, with less movement, less fear, and lower pain scores. These effects can also last beyond the immediacy of a procedure, which may impact postprocedure behaviors (Stanford Medicine, 2017).
Mirror therapy is a rehabilitation therapy in which a mirror is placed between the arms or legs so that the image of a moving, nonaffected limb gives the illusion of normal movement in the affected limb. Using this setup, different brain regions for movement, sensation, and pain are stimulated. However, the precise working mechanisms of mirror therapy are still unclear. Mirror therapy has been used to manage phantom leg pain, reduce pain following a stroke, and for patients with a complex regional pain syndrome (Thieme et al., 2018).
Using a mirror, the brain is “tricked” into seeing two limbs. (Source: © Sköld et al., 2011.)
Yoga is a mind-body and exercise practice that helps relieve chronic pain. Yoga has many of the same benefits as mindfulness practice due to the common focus on breath, body, and present-moment awareness. There are different types of yoga, with the most evidence of benefit being shown through Iyengar yoga, hatha yoga, and Viniyoga.
It is not fully understood how yoga helps with pain, but emerging evidence suggests it might help people more effectively control how they think and feel, both mentally and physically. It may also work by improving muscle flexibility, promoting relaxation, reducing inflammation, or increasing the release of pain-relieving endorphins.
The effects of yoga have been found roughly equivalent to cognitive behavioral therapy. A meta-analysis of 17 studies concluded that yoga can improve daily function among people with fibromyalgia, migraine, low back pain, and many other types of chronic pain conditions. It is recommended by the American Pain Society for people with low back pain who do not improve with other self-care strategies (Mathersul et al., 2018; DHWA, 2019).
Tai Chi and Qigong
Tai chi and qigong are centuries-old mind-body practices. Within the framework of traditional Chinese medicine, they involve the cultivation of and unhindered flow of energy (chi). Contemporarily, they are considered to be complex interventions integrating concepts of mind and body with physical, emotional, and spiritual aspects.
Tai chi is often referred to as moving meditation. It is a series of slow, gentle motions combining mindfulness, breathing, relaxation, range-of-motion exercises, muscle relaxation, balance exercises, and stretching. Tai chi results in similar or greater improvement in symptoms than aerobic exercise for patients with fibromyalgia, and it is an approach for the prevention, treatment of functional limitation, and pain associated with osteoarthritis and rheumatoid arthritis.
Qigong (also spelled chi gong) is often referred to as the “internal” portion of tai chi. It is characterized by stationary movements that are repeated a certain number of times (3, 6, or 9). This repetition stimulates muscle, bone, heart, respiration, and other functions in the body. Traditional qigong theory states that practitioners can focus on a feeling, emotion, part of the body, concept, or goal, and that the energy goes where the mind sends it. Studies have found qigong to result in pain reduction and feelings of improved well-being (Sierpina, 2016; Wang et al., 2018; Sawynok, 2018; NIH, 2016; Holmberg et al., 2016).
Evaluating the Effectiveness of Interventions
Outcome evaluation is one of the most critical phases of pain management. If the expected outcome is pain reduction, outcome evaluation identifies its success or failure. It also identifies how much the pain has been reduced, how long it has taken, and long-term effects of the treatment.
Outcome evaluation requires gathering data from the best source of information (the patient) or the second-best source (the patient’s caregivers). To be of value, the information must address the aspects of pain that were noted before the intervention, including the location, intensity, quality, and duration of the pain. In addition, data is gathered about adverse effects of an intervention, such as an allergic reaction, hypotension, or respiratory depression.
Such feedback is essential in order to revise the plan of care to make it more effective. A positive evaluation means that an intervention was successful and probably should be continued. A negative evaluation means that an intervention was not satisfactory and should be changed. Hence the adage “negative feedback makes for change.”
OPIOID MISUSE, ABUSE, AND DIVERSION
Along with attempts to improve identification and treatment of pain, there has been an equal rise in prescription opioid addiction and abuse in the United States. Opioid misuse, abuse, and diversion are major problems, with 2.1 million people estimated to have a substance abuse problem in the United States. Serious consequences arise due to this problem.
In the past, opioids were often not prescribed for a patient because of the fear of addiction. Then they became more liberally dispensed. Now practitioners have returned to the fear of addiction and become, once again, reluctant to prescribe them. Clearly, there is a dilemma between the need to address opioid abuse and overdose while continuing to ensure people with pain receive safe, effective treatment.
Scope of the Problem
The National Institutes of Health reports that more than 130 people in the United States die every day after overdosing on opioids. The misuse of and addiction to opioids—including prescription pain relievers, heroin, and synthetic opioids such as fentanyl—is a serious national crisis that affects public health as well as social and economic welfare.
- Approximately 21% to 29% of patients who have been prescribed opioids for chronic pain misuse them.
- Between 9% and 23% of those who have been prescribed opioids for pain develop an opioid use disorder.
- An estimated 4% to 6% who misuse prescription opioids transition to heroin.
- About 80% of people who use heroin first misused prescription opioids.
The reasons for the high prevalence vary by age, gender, and other factors, but likely include ease of access. Other contributors to the problem include misinformation about the addictive properties of prescription opioids and the perception that prescription drugs are less harmful than illicit drugs (NIH, 2018e, 2019c).
Drug diversion can be defined as any act or deviation that removes a prescription drug from its intended path from the manufacturer to the patient and can occur anywhere along the continuum: manufacturer, wholesale distributor, retail pharmacy, hospitals and other healthcare organizations, prescribers, healthcare professionals who administer the medication, or the patient for whom the medication is prescribed (Bostic, 2018).
The effort to prevent misuse, abuse, and diversion involves government and regulatory agencies, drug researchers and manufacturers, as well as healthcare institutions and individual clinicians.
CDC Guidelines for Prescribing Opioids
The CDC offers the following guidelines for prescribing opioids in the treatment of pain for patients 18 years and older in primary care settings:
- Recognize that opioids are not first-line or routine therapy for chronic pain.
- Establish and measure goals for pain and function.
- Discuss the benefits and risks, as well the availability of nonopioid therapies with the patient.
- Use immediate-release opioids when starting.
- Start at the lowest possible dose and increase slowly.
- When opioids are needed for acute pain, prescribe no more than needed.
- Do not prescribe extended-release or long-acting opioids for acute pain.
- Follow-up and re-evaluate risk of harm; reduce dose, taper, and discontinue, if necessary.
- Evaluate risk factors for opioid-related harms.
- Check the state prescription drug monitoring program for high dosages and prescriptions from other providers.
- Use urine drug testing to identify prescribed substances and undisclosed use.
- Avoid concurrent benzodiazepine and opioid prescribing.
- Arrange treatment for opioid use disorder if needed.
New Mexico Board of Nursing Rules for Management of Chronic Pain with Controlled Substances
Legislation limiting opioid prescriptions began nationwide early in 2016, and by October of 2018, 33 states had enacted legislation with some type of limit, guidance, or requirement related to opioid prescribing. Among them, the New Mexico Board of Nursing has established rules regarding the management of chronic pain with controlled substances (NMAC, 2018). The Board of Nursing rules are to be used to determine whether a practitioner’s prescriptive practices are consistent with the appropriate treatment of pain.
Pain management for patients should include a contractual agreement and the use of drug screens prior to treatment with opiates and during the course of treatment to identify actual drugs being consumed and to compare with patients’ self-reports. If concerns about misuse are identified, the patient will be referred for appropriate consultation and scheduled for reevaluation at appropriate time intervals.
The prescribing, ordering, administering, or dispensing of controlled substances to meet the individual needs of the patient for management of chronic pain is appropriate if prescribed, ordered, administered, or dispensed in compliance with the following:
- Obtain a complete history and physical that includes:
- Psychological status
- Pain status
- Previous history of significant pain
- Past history of alternative treatments tried
- Potential for substance abuse
- Coexisting diseases or medical conditions
- Medical indications or contraindications against use of a controlled substance
- Be familiar with and use screening tools and the spectrum of available modalities in the evaluation and management of pain; and consider an integrative approach to pain management specialists including but not limited to:
- DOM (Doctor of Oriental Medicine)
- Exercise physiologist
- Massage therapist
- Physical therapist
- Other APN
- Develop a written treatment plan tailored to meet individual patient needs.
- Consider the patient’s age, gender, culture, and ethnicity.
- Clearly relate the objectives to be used for evaluation of treatment:
- The degree of pain relief to be expected
- Improved physical and psychological function
- Other accepted methods
- Include a statement of need for further testing, consults, referrals, or use of other treatment modalities.
- If pain relief plateaus on controlled substance analgesic(s), the treatment plan should include an evaluation of continuing or tapering the controlled substance therapy.
- Provide education and discussion about risks and benefits of using controlled substances to patient, surrogate, or guardian; document this education in the patient’s record.
- Keep complete and accurate records of care provided and drugs prescribed.
- When controlled substances are prescribed, the name of the drug, quantity, and prescribed dosage should be recorded. Prescriptions for opioids shall include indications for use.
- For chronic noncancer pain patients being treated with controlled substances, use a written agreement for treatment outlining patient’s responsibilities, including the use of one practitioner and one pharmacy for all chronic pain management prescriptions whenever possible
- Management of patients needing chronic pain control requires monitoring by the attending or consulting practitioner.
- The practitioner shall periodically review:
- The course of treatment for chronic noncancer pain
- The patient’s state of health
- Any new information about the etiology of the chronic noncancer pain at least every 3 months
- In addition, advanced practice nurses (APN) should consult, when indicated by the patient’s condition, with healthcare professionals who are experienced in chronic pain control. Such professionals need not specialize in pain control. For assessment of benefit and need, consultation should:
- Occur early in the course of long-term treatment
- At reasonable intervals during continued long-term treatment
- Drug screening is expected and should be done when other factors suggest an elevated risk of misuse or diversion.
- The practitioner shall periodically review:
- If, in the practitioner’s opinion, a patient is seeking pain medication for reasons not medically justified, the practitioner is not required to prescribe controlled substances for the patient.
(See “Resources” at the end of this course for a link to the complete text of the rules.)
PRESCRIPTION MONITORING PROGRAM REQUIREMENTS
The New Mexico Board of Nursing requires participation in the prescription monitoring program (PMP) to assist advanced practice nurses (APNs) in balancing safe use of controlled substances with the need to curtail harmful and illegal activities involving them.
- Any APN who holds a federal drug enforcement administration registration and a New Mexico controlled substance registration, must register with the New Mexico Board of Pharmacy and regularly participate in PMP inquiry and reporting.
- An APN may authorize delegate(s) to access the PMP; however, the practitioner is solely responsible for reviewing the PMP report and documenting the receipt and review of the report in the patient’s medical record.
- Before an APN prescribes or dispenses a controlled substance for the first time to a patient for a period greater than 4 days, or if there is a gap in prescribing the controlled substance for 30 days or more, the practitioner shall:
- Review a PMP report for that patient for the preceding 12 months
- When available, review similar reports from adjacent states
- Document the receipt and review of such reports in the patient’s medical record
- A PMP report shall be reviewed a minimum of once every 3 months during the continuous use of a controlled substance for each patient. The practitioner shall document the review of these reports in the patient’s medical record. The APN can review PMP reports with greater frequency than required.
- An APN does not have to obtain and review a prescription monitoring report before prescribing, ordering, or dispensing a controlled substance for pain management:
- For a period of 4 days or less
- To a patient in a nursing facility
- To a patient in hospice care
- Upon review of a prescription monitoring program (PMP) report, the APN shall identify, document and be aware of a patient currently:
- Receiving opioids from multiple prescribers
- Receiving opioids and benzodiazepines concurrently
- Receiving opioids for more than 12 consecutive weeks
- Receiving more than one controlled substance analgesic
- Receiving opioids totaling more than 90 morphine mg equivalents per day
- Exhibiting potential for abuse or misuse of opioids and other controlled substances such as:
- Requests to fill early
- Requests for specific opioids
- Requests to pay cash when insurance is available
- Receiving opioids from multiple pharmacies.
- Upon recognition of any of the above conditions, the practitioner shall take action to prevent, mitigate, or resolve any potential problems or risk and document actions taken. These actions may involve:
- Consultation with or referral to a pain management specialist
- Counseling the patient on known risks and realistic benefits of opioid therapy
- Prescription and training for naloxone
- Offering or arranging treatment for opioid or substance use disorder.
- Practitioners licensed to practice in an opioid treatment program shall review a prescription monitoring report upon a patient’s initial enrollment into the opioid treatment program and every three months thereafter while prescribing, ordering, administering, or dispensing opioid treatment medications in schedule II, III, IV or V for the purpose of treating opioid use disorder. The practitioner shall document the receipt and review of a report in the patient’s medical record.
In an attempt to respond to the abuse of opioid medications, abuse-deterrent products are being formulated and approved for use by the FDA. Abuse-deterrent drugs have been shown to meaningfully discourage use and deter abuse. However, these medications do not obstruct the use of opioids and do not prevent abuse. The science of abuse deterrence is quite new and rapidly evolving.
Abuse-deterrent formulations can be classified as a physical/chemical barrier that prevents drug release following manipulation of the drug or changes the physical form of the drug using chemicals that render it less amenable to abuse.
Agonist/antagonist combinations interfere with, reduce, or defeat the euphoria associated with abuse. The antagonist can be sequestered and released only when the product is manipulated. It is not clinically active when the drug is swallowed but becomes active when it is injected or snorted.
An aversion type of abuse-deterrent drug has a substance added that produces an unpleasant effect if the drug is manipulated or taken at a higher dosage than directed. It can include a substance that irritates the nasal mucosa if ground and snorted.
Delivery system methods can also offer resistance to abuse. Sustained-release depot injectable or subcutaneous implant formulations may be difficult to manipulate.
Other drugs may be classified as combinations in which two or more of the above methods could be combined to deter abuse.
Opioids with FDA-approved labeling describing abuse-deterrent properties include:
- Targiniq ER
- Hysingla ER
- MorphBond ER
- Xtampza ER
- Arymo ER
There are no generic opioids with FDA-approved abuse-deterrent labeling (FDA, 2018c).
Indications of Opioid Use Disorder
Clinicians must be aware of indications of opioid use disorder, which include:
- Inconsistent healthcare use patterns
- Missed appointments
- Lack of engagement with nonmedication treatments
- Lack of follow-through with recommendations
- Illicit drug use
- Problematic medication (e.g., escalating doses, early refills)
- Family concerns about use
- Decreased function and loss of roles
- Extreme difficulty with even a slow opioid taper
- Signs/symptoms of drug use (e.g., intoxication, overdose, track marks)
Should the clinician determine substance use disorder may exist, the patient is provided with information about local inpatient detoxification services, methadone maintenance programs, or buprenorphine treatment.
It is important that clinicians recognize when to taper and/or transition a patient off of opioid-based medications and document why opioid treatment can no longer be prescribed (NIH, 2019d; Schepis, 2018; Weimer, 2017).
IDENTIFYING DRUG-SEEKING PATIENTS
Most patients who complain of pain are honestly seeking relief from discomfort. Others seek drugs in order to cope with addiction or to provide income. Differentiating between the two can be very difficult.
Drug seekers include people of every age, gender, and socioeconomic status. Often these people initially used prescription drugs for valid medical conditions, and drug-seeking behaviors may have developed as a result of disease progression, undertreatment of pain, tolerance to the medication, or unrecognized addiction. Only a small number of drug seekers do so to divert opioids for illicit sale.
There are some common characteristics that can provide clues regarding the nature of a patient’s intent. The patient who is drug seeking may:
- Have seen many doctors in a short period of time
- Present with specific complaints that are often subjective (back pain, headache)
- Bring old medical records they have been carrying around to many different doctors to get a pain prescription
- Use multiple pharmacies
- Claim an allergy to all pain medications except the one they are seeking as well as do diagnostic test contrast medium to avoid tests
- Suggest the medication, dose, and quantity being sought
- Claim extraordinarily rapid relief from injectable medications and instruct staff where to place injections
- Be unwilling to consider any other treatments and does not want to listen to anything the clinician has to say
- Call or show up requesting a prescription at off hours, when the office is closing or right before the weekend/holiday when it is less likely their usual care provider(s) can be reached
- Lie or their story does not make sense (it is imperative to take a detailed history to look for inconsistencies in a made-up story)
- Exaggerate symptoms, with inconsistent behavior from waiting room to treatment room
- Become aggressive when different medications are suggested
- Give false information, such as a fake address or a disconnected phone number
- Be on multiple controlled substances, such as opioids and benzodiazepines
- Be excessively talkative, friendly, or helpful
However, drug-seeking patients with addictions are not the only ones who may engage in these behaviors. Over time, patients with true chronic pain can elicit some of these same behaviors (Girgis, 2017; Jakucs, 2018).
ADDRESSING DRUG-SEEKING BEHAVIORS
There are a number of strategies healthcare providers can utilize in the management of individuals with drug-seeking behaviors. The following are suggestions made by medical risk management advisors:
- Involve the entire team when evaluating a patient, noting any inconsistencies or suspicious actions.
- Look for consistency throughout the physical examination: posture, point tenderness, percussion tenderness, passive range of motion, as well as active resistance. All findings should tell the same story.
- Document all medications taken by or prescribed for a patient, including medical samples dispensed, and file a copy of all written prescriptions in the patient’s record.
- Request a picture ID or other ID and Social Security number and place a photocopy in the patient’s file.
- Confirm the patient’s current address and phone number at each visit.
- Consider written refill protocols for refilling prescriptions by another provider other than a clinician with prescriptive authority.
- Write prescriptions for a limited quantity, with re-evaluation as a condition for refills.
- Maintain the security of prescribers’ DEA (Drug Enforcement Administration) numbers and maintain accurate counts of medications and prescription pads. Promptly report thefts to local law enforcement.
- Coordinate care with the patient’s other healthcare providers. Verify history with the patient’s current treating physician.
- Conduct an assessment of the patient’s complaints and do not rely solely on the records of the referring physician or the patient’s description of the problem.
- Consider a referral if a substance abuse problem is identified.
- Consider the use of a pain management agreement (see below) to make sure the prescribing practitioner and the patient understand the guidelines for long-term opioid therapy.
(Adams, 2016; Jakucs, 2018)
Confronting patients believed to be seeking drugs can be difficult. Confrontation may turn out to be therapeutic, but it can also be dangerous. It is best to avoid confronting a drug-seeking patient alone. The clinician should consider involving psychiatric support, social service assistance, facility security, and in some instances, local law enforcement.
PAIN MANAGEMENT AGREEMENT
A pain management agreement documents the understanding between a prescriber and a patient regarding prescribed medications being taken for pain management. Its purpose is to prevent misunderstandings about certain medications and to help the prescriber and patient comply with laws regarding controlled substances. A typical pain management agreement:
- Requires the patient to use one pharmacy only for all prescription refills
- Identifies expected benefits of medications and the risk associated with their misuse
- Lists the possible side effects that can occur
- Requires notification when the same or similar medication is prescribed by other healthcare providers
- Lists the conditions for issuing refills or replacement prescriptions
- Requires regular evaluations of pain
- Requires random screenings for misuse of medication
- Describes the conditions under which therapy can be changed or discontinued
Drug Diversion and Addiction among Healthcare Professionals
Because healthcare professionals are trusted with our well-being, they are not often suspected of drug addiction; however, they are just as likely as anyone else to become addicted and are at a higher risk for addictive behaviors involving opioids because of their increased access to them.
ADDRESSING DRUG DIVERSION IN HEALTHCARE WORKERS
It is a legal and ethical responsibility for healthcare professionals to uphold the law and to help protect society from drug abuse, and it is a professional responsibility to prescribe and dispense controlled substances appropriately, guarding against abuse while ensuring that patients have medication available when it is needed. Each healthcare professional also has a personal responsibility to protect their practice from becoming an easy target for drug diversion and must be aware of the potential situations where it can occur and the safeguards that can be utilized to prevent such diversion.
Healthcare professionals often avoid dealing with drug impairment in their colleagues. It is natural to be reluctant about approaching such colleagues for fear of their anger since it may result in retribution. Another concern is fear for the colleague’s loss of professional practice. As a result, employers or coworkers can become enablers of those colleagues whose professional competence is being impaired by drug abuse, and thereby are being protected from the consequences of their behavior. Some enabling behaviors include:
- Ignoring poor performance
- Lightening or changing the colleague’s patient assignment
- Accepting excuses
- Allowing oneself to be manipulated
- Being fearful of confronting a colleague if patient safety is in jeopardy
When the signs and symptoms of drug abuse are evident in a colleague, it is time to become concerned and involved, taking the following steps:
- Check the agency’s written drug and alcohol policy and follow recommendations.
- Document suspicions regarding the colleague, including any complaints, concerns, behavior patterns, or witnesses to behaviors.
- Bring concerns to management.
If it is known that drugs are being sold or stolen, it is important not to intervene alone and to contact security or notify the police. If a DEA registrant becomes aware of a theft or significant loss involving controlled substances, it must also immediately be reported to the nearest DEA office, the healthcare worker’s state licensing board, as well as the local police department (USDEA, 2019).
INDICATORS OF DRUG ADDICTION
The following signs and symptoms may indicate a drug-related problem in a healthcare professional:
- Recurring absences or tardiness
- Frequent disappearances from the work site, such as long trips to the bathroom or stockroom where drugs are kept
- Excessive amounts of time spent near a drug supply
- Volunteering for overtime and being at work when not scheduled to be there
- Unreliability in keeping appointments and meeting deadlines
- Work performance that alternates between high and low productivity
- Mistakes made due to inattention, poor judgment, and bad decisions
- Confusion, memory loss, and difficulty concentrating or recalling details and instructions
- Ordinary tasks requiring greater effort and consuming more time
- Deterioration in interpersonal relations with colleagues, staff, and patients
- Rarely admitting errors or accepting blame for errors or oversights
- Sloppy recordkeeping, suspect ledger entries, and drug shortages
- Inappropriate prescriptions for large narcotic doses
- Insistence on personally administering injectable narcotics to patients
- Progressive deterioration in personal appearance and hygiene
- Uncharacteristic deterioration of handwriting and charting
- Wearing long sleeves when inappropriate
- Personality changes, mood swings, anxiety, depression, lack of impulse control
- Suicidal thoughts or gestures
- Patient and staff complaints about healthcare provider’s changing attitude/behavior
- Increasing personal and professional isolation
RED FLAGS FOR DRUG DIVERSION
- Cash-only patients and/or no acceptance of worker’s compensation or private insurance
- Prescribing of the same combination of highly abused drugs
- Prescribing the same, typically high, quantities of pain drugs to most or every patient
- High number of prescriptions issued per day
- Out-of-area patient population
- Dispensing a high percentage of controlled to noncontrolled drugs
- Dispensing high volumes of controlled substances generally
- Dispensing the same drugs and quantities prescribed by the same prescriber
- Dispensing to out-of-area or out-of-state patients
- Dispensing to multiple patients with the same last name or address
- Sequential prescription numbers for highly diverted drugs from the same prescriber
- Dispensing for patients of controlled substances from multiple practitioners
- Dispensing for patients seeking early prescription refills
Bill, a registered nurse, moved from a large city to a small rural town and took a job as the night shift nurse in the emergency room of the small local hospital that served a population of about 10,000. He found that the hospital staff and physicians were very casual and worked closely with one another, which was very different from the large teaching hospital he had come from.
During Bill’s first week on duty, Marie came in with the complaint of a migraine headache. Marie was a 46-year-old nursing assistant who worked on the hospital’s medical floor. She told Bill that there was a standing order for her to receive Dilaudid for her headaches and the dose she was to receive. She expressed frustration and annoyance when he told her he needed to call the covering ER doctor for an order. Bill also noted that Marie displayed no behaviors that could be interpreted as indicative of pain.
When the physician returned Bill’s call, he told Bill to give her the medication. Bill drew up the Dilaudid, and when he gave her the injection, he noted multiple areas of induration of the buttocks and felt a grainy sensation when the needle was inserted.
After discharging Marie, Bill did an audit of her medical record and discovered she had been visiting the ER two to three times each week for the past year for opioid treatment of migraine headaches. Bill presented his documentation to the prescribing physician, who expressed surprise and said he really wasn’t aware of the frequency he had been prescribing opioids for Marie.
Bill was informed a week later by the physician that he had referred Marie to both a pain management specialist and to a substance abuse specialist in the city 20 miles away. He thanked Bill and said he hoped Marie would benefit from his intervention.
Addressing Pain in Individuals with Substance Use Disorders
When offering pain management to an individual with substance use disorder, following several general principles leads to improved treatment.
- Create a supportive, nonjudgmental environment; listen to and engage the patient with the awareness that:
- The patient’s past experiences can shape treatment choices.
- Perceptions and expectations of treatment efficacy can impact treatment outcomes.
- The patient’s investment in a treatment plan facilitates cooperation.
- Engagement in self-management is critical to chronic pain treatment.
- Treat pain safely and effectively by:
- Resolving or reducing underlying causes of pain whenever possible
- Providing appropriate pain relief using nonmedication approaches when effective, easily available, and acceptable to the patient
- Providing less-rewarding medications when safe and effective
- Using potentially rewarding medications when needed with appropriate limitation on use
- Changing from parenteral to oral formulations of opioids as soon as possible
- Planning treatment when pain is anticipated (e.g., for elective procedures or surgery)
- Address pain facilitators common in those with acute or chronic pain, including:
- Posttraumatic stress disorder
- Sleep disturbance
- Substance withdrawal
- Functional losses
- Address opioid use disorder with the patient by:
- Acknowledging the challenge
- Assuring that it is not an obstacle to working for analgesia
- Encouraging and supporting recovery by:
- Discussing what has been valuable in the past for the patient
- Identifying or intensifying psychosocial support, which may include counselors, self-help groups, a sponsor, or faith-based interventions
- Continuing to offer pharmacologic support such as methadone or buprenorphine
- Assuring safety by providing limited access to opioids, if prescribed
- Treat withdrawal as appropriate, recognizing that if withdrawal is not treated safely and effectively, pain will not be treated.
- Anticipate opioid tolerance in opioid-dependent individuals. (Weimer, 2017; Quinlan & Cox, 2017)
THE NEUROBIOLOGY OF PAIN AND ADDICTION
A body of evidence suggests that there is a substantial overlap between brain regions that are engaged by ongoing pain and addictive analgesic drugs. Research has found that both pain and substance use disorders activate the same neurobiological pathways in the brain. Both substance use disorder and pain relief–seeking behaviors activate and overstress the reward system. Both types of stimuli are associated with massive dopaminergic surges in reward, motivation, and learning centers. In both substance use disorder and pain, when the reward system is over-activated, anti-reward neurotransmitters in the limbic system are enhanced, causing stress, negative affect, and impulsivity, inducing compulsive behaviors to alleviate the discomfort.
Because pain and addiction may share a common neurological foundation, if the effects of pain and addictive drugs tend to sensitize over time, then cross-sensitization may occur as well. If this happens, exposure to addictive drugs could increase susceptibility to the development of pain and vice versa. The addicted brain may amplify pain to justify a substance it craves, and intoxication and withdrawal can physiologically drive pain through sympathetic and psychomotor activation (Elman & Borsook, 2016; Weimer, 2017).
ASSESSING RISK FOR DEVELOPING SUBSTANCE USE DISORDERS
Before introducing any opioids into a patient’s treatment regimen, an assessment is done to determine the patient’s risk for developing a substance abuse disorder (SUD).
Screening tools available to clinicians include:
- Opioid Risk Tool (ORT)
- Drug Abuse Screen Test (DAST-10 and DAST-20 for adolescents)
- Screener and Opioid Assessment for Patient with Pain-Revised (SOAPP-R)
These tools, however, commonly result in inaccurate findings and misinterpretations. For instance, since screening tools often rely on a patient’s self-report, a patient may falsify responses on questionnaires to avoid detection as a high-risk patient.
Other recommendations include drug testing, primarily urine screening. Drug testing offers a critical adjunct to clinical assessment of SUD risk. However, due to the ease with which samples can be adulterated, providers must carefully review their collection protocols and sample validation procedures to ensure optimal accuracy, which may require observed collection (NIH, 2018f; Hadland & Levy, 2017).
NEW MEXICO RULES FOR TREATING PATIENTS WITH SUDs
The New Mexico Board of Nursing (NMAC, 2018) rules require advanced practice nurses licensed to practice in an opioid treatment program to:
- Review a PMP report upon a patient’s initial enrollment into the opioid treatment program
- Review a PMP report every 3 months thereafter while prescribing, ordering, administering, or dispensing opioid treatment medications for the purpose of treating opioid use disorder.
- Document the receipt and review of a report in the patient’s medical record.
TREATING PAIN IN PALLIATIVE CARE AND END-OF-LIFE CARE
Palliative care is specialized medical and nursing care for people with serious illness that focuses on providing patients with relief from pain, symptoms, and the stress of illness. Care is provided wherever the patient’s care takes place—the patient’s own home, care facility, hospice inpatient unit, hospital, or outpatient service. Such care is provided to patients regardless of age, prognosis, or length of time the care is needed. Palliative care is also part of hospice care given at the end of life.
As life expectancy increases because of advances in medicine and technology, there are more people expected to live longer with serious, chronic medical conditions, and many will reside in long-term care facilities where challenges for treatment of pain will include a lack of consistent assessment in persons with cognitive impairment as well as lack of recognition of the meaning of pain behaviors. This is significant, since patients consider unrelieved pain an important factor eroding dignity at the end of life.
A study of patients enrolled in hospice found the prevalence of pain was close to 60%, with one third of all of the patients in the study rating their pain as moderate or severe. In cancer patients who can no longer benefit from curative or palliative chemotherapy, the prevalence of pain increased to 75%. Interviews with family members or friends of patients who had died indicated that more than 25% of patients experienced an unmet need for pain management. Management of pain and other symptoms has been identified as one of the essential end-of-life care domains (Coyne et al., 2018).
Clinicians should assess pain frequently to avoid undertreatment and should maintain a low threshold for the conclusion that pain exists. Undertreatment of pain is more common for patients unable to speak for themselves. These include infants, children, and those who are developmentally or cognitively impaired. Other groups at risk for undertreatment are older adults, those with a past history of substance use disorder, those with limited social and economic resources, and those who do not speak the same language as their caregivers.
Pharmacologic Pain Management
Pharmacology is the primary approach for pain management at the end of life, with opioid analgesics as the main treatment for moderate to severe pain. Large surveys have found that opioids can provide adequate relief to over three quarters of patients with cancer pain when administered optimally. For patients with advanced illness, chronic pain has been found to be best treated using morphine, fentanyl, oxycodone, hydromorphone, oxymorphone, and methadone.
Drug selection is based on the clinician’s judgment and factors such as the availability of a parenteral formation. Clinicians may switch from one drug to another (“opioid rotation”) to manage the pain of a patient who is not responding well to a particular opioid regimen. Guidelines for opioid therapy often focus on selecting the route of administration, dosing, drug rotation, and treatment of expected side effects (Broglio & Portenoy, 2018).
When considering analgesic therapy for pain, goals that are normally considered important, such as the desire to be alert or to ambulate, may change in the context of an advanced illness. The clinician must explore the willingness of the patient for tolerance to side effects or function reduction in order to achieve pain relief (Broglio & Portenoy, 2018).
In most patients, pain can be effectively and adequately relieved with opioids, but for some patients with advanced illness who have refractory pain, palliative sedation may be offered. Palliative sedation is a therapeutic intervention defined as the intentional use of sedating medication (typically a short-acting benzodiazepine) to reduce consciousness with the goal of eliminating suffering. It is a last resort aimed at inducing a state of decreased or absent awareness.
Palliative sedation may be utilized in both adults and children with terminal illness. It is most commonly used in the treatment of refractory pain, severe terminal dyspnea, agitated delirium, and convulsions.
When considering palliative sedation, the care team should also recognize the potential for family and staff distress. This is particularly true if there is concern regarding the effects and ethics of palliative sedation, disagreement regarding the treatment plan among providers, and in situations where the process is prolonged. All participating staff members must understand the rationale for sedation and the goals of care (Cherny, 2017).
Family members must be informed that uncontrolled suffering at the end of life is a critical situation and that palliative sedation constitutes a proportionate and effective response that is within accepted medical guidelines. This form of care, following informed consent by the patient or surrogate, or by advance directives, poses no ethical problems (Cherny, 2017).
Barriers to Effective Pain Treatment at End of Life
Although clinicians have an ethical obligation to reduce pain and suffering, barriers remain regarding appropriate and adequate pain in palliative and end-of-life care. Such barriers may include:
Patient and family issues:
- Lack of reporting of pain or denial of pain due to its link with deterioration (a sign of the progression of the disease)
- Misconception that pain is a natural part of being ill and cannot be relieved or avoided
- Fears and concerns about pain medication, side effects, substance abuse, and/or addiction
- Lack of knowledge, skills, and time for adequate pain and symptom assessment
- Not utilizing an assessment scale for the special needs of each patient
- Lack of understanding about the global nature of pain (e.g., psychological, social, spiritual, and cultural aspects)
- Denial of the presence of pain
- Fear of doing harm or causing adverse effects, including tolerance to opioid effectiveness
- Fear of the patient becoming addicted
- Concerns about diversion or misuse of drugs by other than the patient
- Failure to include effective nonpharmacologic measures
- Fear of legal issues
- Prescriber hubris when choosing not to request assistance from pain or palliative care specialists
Healthcare system issues:
- Restrictive formularies, limited access to opioids, or cost prohibitions that prevent appropriate treatment
- Limited insurance coverage for many effective nonpharmacologic treatments
- Lack of availability of adequate pain education and resources for challenging pain cases
(Coyne et al., 2018)
CLINICIAN MISCONCEPTIONS ABOUT OPIOID USE AT END OF LIFE
One of the greatest barriers to adequate pain management results from lack of clinician training and the fear of violating ethical, moral, and legal tenets in the administration of pain medication to a patient at the end of life. The concerns of clinicians are often based on misconceptions about opioid use:
- That opioids cause unconsciousness when given in high doses, which is considered unnatural
- That it is wrong to help with pain at the cost of consciousness or length of life
- That alleviating pain to the degree of unconsciousness is legally prohibited
- That death will be hastened by administering opioids
Studies have found no evidence that initiation of treatment or increases in dose of opioids or sedatives is associated with precipitation of death. Instead, effective pain and symptom management at the end of life increases quality of life and may prolong life rather than accelerate death. The small risk of respiratory depression that opioids carry when used appropriately does not justify withholding their use in treatment of pain and other intractable symptoms at the end of life (Jackson & Nabat, 2017).
Pain is a universal human experience, the strongest motivator for an individual to seek medical care, and one of the body’s most important protective mechanisms. For the past several decades researchers have been hard at work discovering exactly what pain is and how to prevent it or alleviate it.
It is imperative that healthcare professionals understand their role in managing pain as one of their primary obligations and responsibilities. It is the duty of all involved in caring for patients in pain to do everything possible to bring them relief. To do less is to fail to provide quality patient care. In order to best carry out this responsibility, it is necessary for all professionals to continue to expand their knowledge and skills in managing this crucial healthcare issue.
Management of chronic pain with controlled substances (New Mexico Board of Nursing)
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