Pain Management
Assessment and Patient Care for Nurses and Other Healthcare Professionals

ADJUVANT ANALGESICS

Adjuvant analgesics (co-analgesics) are drugs that were developed for clinical uses other than pain but are used as an analgesic in select circumstances. The following table describes common adjuvant analgesics.

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.

CANNABIS (MEDICAL MARIJUANA)

In the United States in the late 19th century, marijuana, a cannabis plant, became a popular ingredient in many medical products and was sold openly in pharmacies. A prevalent hypothesis is that around 1910 Mexican immigrants entered the country, bringing with them the recreational use of marijuana. Well-developed prejudices already in place against Mexicans then began to associate the newcomers with marijuana, and antidrug campaigners warned against its use. By 1931, 29 states had outlawed marijuana. In 1937, Congress passed the Marijuana Tax Act, effectively criminalizing marijuana.

In the 1950s, federal laws set mandatory sentences for drug-related offenses. However, the 1960s counterculture lead to more lenient attitudes toward marijuana. By 1970, Congress repealed most of the mandatory penalties for drug-related offenses, and in 1972, laws were considered to decriminalize the personal use of marijuana, which were rejected by the president.

Public attitudes in the 1980s led to the “War on Drugs,” with mandatory prison sentences re-enacted, including the “three strikes you’re out” policy that required life sentences for repeat drug offenders. In the 1990s a major shift in public opinion was taking place, and in 1996 California passed Proposition 215, which allowed for the sale and medical use of marijuana for patients with AIDS, cancer, and other serious painful diseases.

Today, more than two thirds of the states and the District of Columbia have legalized cannabis for medical treatments. However, federal law continues to prohibit use of cannabis or its derivatives for any purpose. This means that people may be arrested and charged with possession even in states where marijuana use is legal (UGA, 2020; NIDA, 2020a; ASA, 2021).

Under the Controlled Substances Act (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 (Stonebraker, 2022).

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 in controlling epileptic seizures. The therapeutic effects of CBD are as an anticonvulsant, antipsychotic, anxiolytic, neuroprotective, sleep-promoting, and anti-inflammatory agent.

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. CBD also reduces anxiety by changing the shape of the GABA-A receptor in a way that amplifies the natural calming effect of GABA (NIDA, 2020a; Mlost et al., 202; Project CBD, 2022).

CBD is also used for the treatment of epilepsy. The exact mechanism in which CBD creates anticonvulsant effects is not known, but it possesses affinity for multiple targets resulting in functional modulation of neuronal excitability relevant to diseases such as epilepsy (Gray & Whalley, 2020).

FDA-Approved Medical Marijuana Analgesic Formulations

Whether or not the use of marijuana has therapeutic benefits that outweigh its health risks is still unresolved, but marijuana-based medications have been approved or are undergoing clinical trials. Currently the FDA has approved dronabinol (Mariol, Syndros) and nabilone (Cesamet) for relief of chronic nerve-related pain. Nabiximols (Sativest), a mouth spray for treating spasticity and neuropathic pain, is undergoing trials (UGA, 2020; ASA, 2021).

Nonpharmacologic Interventions

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

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 applied via cold compresses, chemical cold packs, ice packs, immersion or soaking in cold water, massaging the area with an ice cube or ice pack, cold air and vapocoolant sprays, and manual and electric cold compression units. More recently, whole-body cryotherapy has been used for persistent pain in patients with rheumatological conditions; more research is needed to understand the effect on the body and its relation to pain (Physiopedia, 2022b).

Thermal modalities include superficial and deep heat. Heat may facilitate tissue healing, relax skeletal muscles, and decrease spasms and pain. Superficial heat (thermotherapy) is the use of an agent that causes temperature increase and subsequent physiological changes to the superficial layers of the skin, fat, tissues, blood vessels, muscles, nerves, tendons, ligaments, and joints. Superficial heat penetration is usually less than 1 cm into the skin and subcutaneous tissue.

Heat therapy promotes pain relief, vasodilation, increased metabolism, and elasticity of connective tissues, and is used for subacute to chronic conditions. Commonly used superficial heat modalities include hot packs, heat wraps, heating pads, hydrotherapy, steam baths, saunas, paraffin bath, infrared, ultrasound, and fluid therapy (Seidel et al., 2021).

Deep heat is produced when energy is converted into heat as it passes through body tissues. Deep heat can penetrate 3 cm to 5 cm or more without overheating underlying subcutaneous tissue or skin (Hoenig & Cary, 2021). (See also “Acoustic Modalities” below.)

Manual Modalities

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, 2022; AMTA, 2022)

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, sports injuries, and prophylaxis of migraine (PPM, 2019).

Acupuncture

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. In support of this theory, there is evidence that opioid antagonists block the analgesic effects of acupuncture. 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, 2022; Ahn, 2020).

Electro-Physical Agents

Electrotherapy is used to treat a range of chronic pain conditions by directing 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 that TENS can give short-term pain relief but that long-term relief has not been proven (URMC, 2022).

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. PENS therapy does not destroy the affected nerves but makes them less sensitive to pain signals. 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 radiation to stimulate nerve or muscle. This radiation works with the body’s natural magnetic field to help increase electrolytes and ions, which naturally influences electrical changes on a cellular level and influences cellular metabolism. This combines with the body’s own recovery processes to help relieve chronic pain (Williams, 2021).

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, plantar fasciitis, or tendonitis with anti-inflammatory drugs. Although evidence is limited, studies to date indicate this modality may generally be no more effective than placebo (NLM, 2022b; Hoenig & Cary, 2021).

Acoustic Modalities

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. Ultrasound can be focused on tissues deep within the body without affecting other tissues close to the surface. It can be used to treat a wide range of health problems but is most commonly used for problems in muscle tissue. The heating effect of ultrasound helps heal muscle pain and reduce chronic inflammation. Currently, there is ongoing debate as to the effectiveness of this modality (Brennan, 2021; Murphy, 2020).

Shortwave diathermy (SWD) produces deep heating by converting high-frequency, alternating electromagnetic energy to thermal energy (friction). Diathermy heats more deeply than hot packs and can heat a larger area than ultrasound. SWD 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 short-term musculoskeletal pain relief. SWD penetrates bone and does not pose a risk of periosteal burning.

Microwave diathermy (MWD) does not penetrate as deeply as shortwave diathermy and can be focused more easily than can shortwave diathermy. Both SWD and MWD can create hotspots. MWD is useful in the treatment of traumatic and rheumatic conditions affecting superficial muscles, ligaments, and small superficial joints (Seidel et al., 2021).

Phonophoresis uses ultrasound’s high-frequency sound wave to drive a medication into the tissues by increasing cell permeability for deep heat. 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, 2021).

Vibroacoustic therapy (VAT) involves using musical sound waves to aid and facilitate in the relaxation response. VAT causes tissue to resonate, which results in physical changes such as increased blood circulation and metabolism and reduction in sympathetic activity. It is commonly used for anxiety/stress, muscular tension, fatigue, pain management, and other conditions such as fibromyalgia, tinnitus, and Parkinson’s disease (Seidel et al., 2021).

Light Therapy

Light therapy includes low-level laser therapy (LLLT), also known as cold laser therapy, and ultraviolet light (UV). UV light therapy uses the electromagnetic wavelength between X-ray and visible light to bring about a biochemical response in tissue to reduce pain. LLLT uses low-powered laser light to produce this effect.

Photons in light temporarily create a neural blockage (as an anesthetic) by decreasing mitochondrial membrane potential and ATP, which decreases the inflammatory neuropeptides. LLLT is believed to affect fibroblast function, accelerate connective tissue repair, and may have an anti-inflammatory effect by reducing prostaglandin synthesis. UV light may have similar biological effects. Both forms of light therapy are used to decrease acute and chronic pain and inflammation, stimulate collagen metabolism, and promote wound healing (Seidel et al., 2021).

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, osteoarthritis, 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, and 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; two or three injections are required for maximum relief.
• Botulinum toxin injections block chemical signals from nerves that cause muscle to contract. They are used for cervical dystonia and treatment of chronic migraine.
• Prolotherapy is used to treat joint and muscle pain. It is sometimes called regenerative injection or proliferation therapy. It involves injecting a sugar or saline substance into a joint or muscle, where it acts as an irritant, resulting in immune cells and other chemicals being sent to the area, thus starting the body’s natural healing process.
• Platelet-rich plasma (PRP) injections are used for a range of conditions, including musculoskeletal pain and injuries. Platelets contain growth factors that can trigger cell reproduction and stimulate tissue regeneration. An increased concentration of growth factors has been shown to stimulate or speed up the healing process and decrease pain.
• 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 that 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, the device stimulates nerves in the area where the pain is felt. 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.
• 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 that cannot be manually palpable. The goal is to release or inactivate trigger points to relieve pain or improve range of motion.
  (Mayo Clinic, 2021; UCSF, 2022; Brennan, 2021; Johns Hopkins Medicine, 2022;Thiyagarajah, 2020; APTA, 2021)

PSYCHOLOGICAL MODALITIES

Cognitive-Behavioral Therapy (CBT)

One of the most common types of psychotherapy used in pain management is cognitive-behavioral therapy. CBT can be described as the “gold standard” psychological treatment for persons with a wide range of pain issues. It can be used alone or in conjunction with medical or interdisciplinary rehabilitation treatments. Currently, CBT is the prevailing psychological treatment for individuals with chronic pain issues.

CBT practice varies but often includes relaxation training, setting and working toward behavioral goals, behavioral activation, guidance in activity pacing, problem-solving training, and cognitive restructuring. 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. 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
  (Physiopedia, 2022c)

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:

1. Acceptance: Developing and enhancing the willingness to have and accept experiences without trying to change or ignore them
2. Cognitive defusion: Separating the self from inner experiences, allowing the ability to see thoughts simply as thoughts, stripped of the importance the mind adds to them
3. Being present: Encouraging mindfulness of surroundings and learning to shift attention away from internal thoughts and feelings
4. Self-as-context: Working to let go of attachment to a conceptualized self and see thoughts as separate from actions
5. Values: Includes determining the areas of life that are important enough to motivate action
6. Commitment: The process that involves changing behavior based on principles covered in therapy
   (Glasofer, 2021)

MIND-BODY TECHNIQUES

Biofeedback

Biofeedback is the use of instrumentation to mirror psychophysiologic processes, such as blood pressure, heart rate, and skin temperature, of which an individual normally is unaware and which may be brought under voluntary control. Researchers aren’t exactly sure how or why biofeedback works, but they do know that it promotes relaxation, which can help relieve many conditions related to stress. 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:

1. Initial conceptualization: Awareness of physical response is gained.
2. Skills-acquisition and rehearsal: The patient uses the signals from the biofeedback to control physical responses.
3. Transfer: The patient transfers control from the biofeedback equipment to the self.
   (Watson, 2020)

Relaxation Therapies

Relaxation therapies have been found helpful in the management of chronic headaches and other types of chronic pain. Relaxation encourages reduction in muscle tension, resulting in a decrease in pain intensity. There are a number of practices—such as progressive relaxation, autogenic training, 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 (NCCIH, 2021).

Hypnosis

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 to manage emotional distress, unpleasant physical symptoms, and certain habits or behaviors. Hypnosis can provide analgesia, reduce stress, relieve anxiety, improve sleep, improve mood, and reduce the need for opioids. It can also enhance the effectiveness of other forms of relaxation therapies and biofeedback for pain (Cosio & Lin, 2020).

Distraction

The brain has a limited capacity for attention, and there are only so many things it can concentrate on at the same time. Pain sensations compete for attention with all the other things going on. Just how much attention the brain gives each thing depends on a number of factors, including:

• How long the person has been dealing with pain
• Current mood
• Propensity to anxiety, rumination, and catastrophizing

Diverting attention (distracting) from feelings and thoughts of pain is a well-researched pain coping strategy. Mental distractions actually block pain signals from the body before they ever reach the brain. Distraction is shifting attention away from pain or painful stimuli to something more engaging or enjoyable, and there are many ways to do this. Distraction techniques can be internal (e.g., imagery) or external to the individual, such as audio (e.g., music), visual (e.g., book), or audiovisual (e.g., movies). They may require passive or interactive engagement and involve others (e.g., healthcare providers, parent).

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 may find watching TV or listening to music helpful (Stanford Health Care, 2021; Keane, 2021).

Mindfulness-Based Interventions

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. There are several types of mindfulness-based interventions, including:

• Mindfulness-based cognitive therapy (MCBT) (see above)
• Primary care brief mindfulness training (PCBMT)
• Mindfulness-based exposure therapy (MBET)
• Mantra-based meditation training

The most widely used of the mindfulness-based interventions is mindfulness-based stress reduction (MBSR), which has been found to be effective in reducing the adverse impact of chronic pain. MBSR can increase the ability to tolerate or withstand distressing emotional or physical states and selectively alter the unpleasantness of pain. MBSR uses a combination of body awareness, mindfulness meditation, and movement to help people become focused on and accepting of the present moment. Topics addressed as part of MBSR include:

• Simple awareness
• Stress (responding versus reacting)
• Handling difficult emotions or physical pain
• Handling thoughts
• Mindfulness and compassion
• Mindfulness and communication
• Cultivating and maintaining mindfulness
  (Cosio & Demyan, 2021)

Virtual Reality (VR)

Virtual reality 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, stereo sound, and sensors.

Virtual reality provides immersive experiences that absorb more of the brain’s attention. With fewer mental resources left to process pain signals, people perceive less pain. VR causes a reduction of the electrical signals through which neurons communicate. Further validation tests of EEG and investigation on VR effects are needed to better understand how our brain acts while immersed in a virtual world (VirtualTimes, 2021).

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 (Children’s Hospital Los Angeles, 2021).

Mirror Therapy (MT)

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. Mirror therapy exploits the brain’s preference to prioritize visual feedback over somatosensory/proprioceptive feedback concerning limb position. The reflection “tricks” the brain into thinking there are two healthy limbs.

MT has been shown to increase cortical and spinal motor excitability, possibly through the effect on mirror neurons, which account for 20% of all the neurons present in the brain. These neurons are responsible for the ability to differentiate between left and right side. When using the mirror, these neurons get activated. However, the precise working mechanisms of mirror therapy are still unclear. Mirror therapy has been used to manage phantom leg or arm pain, reduce pain following a stroke, and for patients with a complex regional pain syndrome (Physiopedia, 2022d).

Using a mirror, the brain is “tricked” into seeing two limbs. (Source: © Sköld et al., 2011.)

Yoga

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, as well as improving confidence and the sense of self-control. Most evidence for the use of yoga is in those with chronic back pain, arthritis, headaches/migraines, irritable bowel syndrome, fibromyalgia, and carpal tunnel syndrome (DHWA, 2021).

Tai Chi and Qigong

Tai chi and qigong are forms of traditional Chinese exercise that incorporate the concepts of two opposing forces—yin and yang. Both exercises are based on the idea and core principle that increasing energy in the body, known as chi, through gentle and repeated movements can enhance a person’s well-being. Pain or sickness is believed to occur when the flow of chi is blocked or when yin and yang energies are out of balance. The joints are seen as gates that control the flow of chi and that can be opened by using slow and gentle swaying movements, deep breathing, and mental focus.

The exact mechanism behind relief of chronic pain through the practice of qigong or tai chi isn’t fully known. Some researchers theorize that pain relief is achieved by eliminating muscular tension through deep relaxation or boosting endorphins. Others believe that the exercises may affect the autonomic nervous system, increasing parasympathetic tone, which is related to a relaxed state of body with a reduction in stress hormones (Marks, 2022; Winchester Hospital, 2022).

Evaluating the Effectiveness of Interventions

There are multiple outcome measures required to adequately assess the pain experience and how it has been modified by pain management interventions. The outcome of pain management is done by assessing:

• The degree of analgesic effect in comparison to the patient’s baseline
• The time to onset of the analgesic effect and the time to maximum reduction in pain intensity
• The duration of the analgesic effect
• Measures of physical functioning
• Measures of emotional functioning
• Secondary effects related to the treatment
  (Edward, 2021)

THE INTERDISCIPLINARY NATURE OF MANAGING PAIN

The most important member of the interdisciplinary team is the person with pain—the patient. Other team members can include:

• Significant others (family, friends, etc.)
• Physicians, physician assistants, and nurse practitioners
• Nurses
• Psychologists
• Physical therapists
• Occupational therapists
• Recreational therapists
• Vocational counselors
• Pharmacists
• Nutritionists/dietitians
• Social workers
• Support staff
• Volunteers

Role of the Nurse

Many disciplines are involved in managing a patient’s pain, and nurses play a pivotal role in the assessment, monitoring, interpretation, and evaluation of pain. Effective pain management by nurses is fundamental to quality of care and is the first responsibility of the nurse.

NURSING STANDARDS OF CARE

Standards of care for nurses in the management of pain include, but are not limited to:

• Acknowledging and accepting the patient’s pain
• Identifying the most likely source of the pain
• Assessing pain at regular intervals, including each new complaint of pain, utilizing a pain assessment tool
• Assessing barriers to effective pain management
• Reporting the patient’s level of pain and developing a plan of care that includes interdisciplinary input
• Aggressively treating side effects such as nausea, vomiting, constipation, etc.
• Educating patient, family, and significant others on:
• Their role in the pain management plan and expected outcomes
• Detrimental effects of unrelieved pain
• Overcoming barriers to effective pain management
• Evaluating effectiveness of strategies and nursing interventions
• Documenting and reporting the interventions, patient responses, outcomes
• Advocating for the patient and family for effective pain management
  (MD BON, n.d.)

PATIENT EDUCATION AND OPIOID MEDICATIONS

Nurses have an important role to play in educating patients about the proper use of opioid medications. The following information should be included in the education provided to patients who are receiving opioids as well as to their caregivers:

• Take opioids as prescribed.
• In case of a missed dose or if the pain is not managed by the recommended doses:
• If pain is not managed, talk with the healthcare team and do not take extra doses.
• If a dose is missed, take it as soon as possible; however, if it is almost time for the next dose, skip the missed dose and go back on schedule.
• Do not double doses.
• For slow-release medication, if more than four hours late, do not take it.
• Oral capsules may be opened and mixed with cool foods, but extended-release medication should not be opened, crushed, broken, or chewed.
• It can be dangerous to use CNS depressants, including sedatives, alcohol, or illicit drugs, when taking opioid medications.
• Due to the addictive nature of opioids, discontinuation should be accomplished by tapering the drug’s dose with the assistance of one’s primary care provider.
• Opioids slow peristalsis and can lead to constipation; adequate fluid and fiber intake will facilitate the passage of stool.
• Opioids can impact one’s ability to drive or operate machinery and affect one’s balance, increasing the risk for falls.
• Death due to respiratory depression is a potential side effect.
• Drugs should never be shared.
• To avoid diversion, opioids should be locked in a secure location.
• Unused opioids should be disposed of safely (see table below).
  (Jackson, 2020)

ANA POSITION STATEMENT ON PAIN MANAGEMENT

The American Nurses Association Position Statement (2018) on the nurse’s role and ethical responsibility in the management of pain states that:

• Nurses have an ethical responsibility to provide clinically excellent care to relieve pain. Clinically excellent pain management considers clinical indications, mutual identification of goals for pain management, and ongoing reassessment with the patient of the effectiveness of pain control efforts.
• Nurses use the nursing process to guide actions to improve pain management and should ensure that each patient experiencing pain has an individualized pain management plan with appropriate monitoring to avoid undertreatment, overtreatment, or addiction.
• Nurses provide respectful, individualized nursing interventions to all patients experiencing pain regardless of the person’s personal characteristics, values, or beliefs.
• Nurses consider that multimodal and interprofessional approaches are necessary to achieve effective pain relief.
• Nurses use pain management modalities that are evidence-based. Lack of knowledge and understanding of best practices for assessing and optimally managing pain constrain the nurse’s ability to effectively minimize pain.
• Nurses have an obligation to assess and address factors within themselves and their practice environments that constrain ability and willingness to relieve pain and the suffering it causes.
• Nurses advocate for policies to assure access to all effective modalities. Nurses have a duty to advocate for improved parity in coverage for all effective pain relief modalities

Role of the Occupational Therapist

The role of the occupational therapist within an integrative pain management program focuses on function in daily living and takes a holistic and comprehensive approach to evaluate structural, physiologic, psychological, environmental, and personal factors that influence the experience of pain. The information obtained by patient evaluation is then used in the application of self-management strategies, functional activities, hands-on techniques, and specific exercises to improve function and participation.

OCCUPATIONAL THERAPY INTERVENTIONS

Depending on the area impacted by chronic pain, the occupational therapist provides the following interventions:

Physical mobility:

• Adaptive equipment selection and training
• Positioning equipment and strategies
• Functional mobility training (e.g., static positioning, dynamic movement, transfers, lifting and bending techniques)

Activities of daily living/self-care:

• Neuromuscular re-education
• Nerve mobilization
• Functional range of motion and strengthening exercises
• Activity pacing and energy conservation strategies
• Ergonomic and body mechanics training
• Fall prevention and safety
• Home evaluation

Instrumental activities of daily living:

• Adaptive equipment selection and training
• Transportation training, including comprehensive driver evaluations and driver rehabilitation

Health management:

• Patient education and disease self-management training, including trigger identification, symptom tracking, and pain flare-up planning
• Pain coping strategies, including physical modalities, complementary and alternative pain coping strategies, sensory strategies, self-regulation, and mobilization
• Pain and assertive communication training
• Medication management
• Eating routine strategies to avoid dietary pain triggers and improve energy management
• Establishing sustainable physical activities
• Time management strategies

Rest and sleep:

• Sleep hygiene and positioning strategies
• Cognitive behavioral therapy for insomnia
• Energy conservation and fatigue management

Education and work:

• Academic and work accommodations
• Ergonomic and body mechanics training
• Sensory strategies to monitor environmental triggers or exacerbating factors
• Advocacy and self-advocacy training
• Assertive communication training
• Community reintegration, including gradual re-entry plans
• Activity pacing and energy
• Environmental modifications
• Community and online resources exploration
• Compensatory cognitive strategies

Play, leisure, and social participation:

• Strategies to prevent social isolation
• Assertive communication strategies
• Personal values and interests exploration

(Reeves et al., 2022)

PRINCIPLES FOR OCCUPATIONAL THERAPISTS

The International Association for the Study of Pain (IASP, 2021b) identifies the following principles that should guide occupational therapists in the management of pain. These principles include:

1. Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
2. Pain is a complex phenomenon and a multidimensional experience.
3. Pain is a public health problem with social, ethical, and economic considerations.
4. People can experience pain at any stage of life.
5. The impact of pain on daily life needs to be considered in terms not only of physical limitations but also emotional and social influences on health and patient-defined well-being.
6. Activity analysis to explore the impact of pain on occupational performance (engagement in activities) needs to be considered from different perspectives, including factors (biological/psychological/spiritual/sociopolitical/environmental) that contribute to acute (or potential) challenges in the individual’s everyday life.
7. Cultural aspects relevant to pain expression and the pain experience need to be considered with all patients.
8. Self-management strategies need to focus on scheduling and adapting activities so that the person’s energy is maintained and pain is minimized.
9. Assessment and intervention plans to manage pain need to be collaborative between patient and therapist to ensure that the patient’s goals for intervention are identified and the strengths of the patient are recognized.
10. Occupational therapy assessment and management must be based on best available research evidence.
11. Prevention and intervention need to be addressed at both micro (individual) and macro (sociopolitical) levels.

Role of the Physical Therapist

Physical therapy is one of the most important nonpharmacologic measures to be considered in the management of pain. The physical therapist evaluates the patient with pain in order to:

• Determine the identity of the pain mechanism(s) to guide treatment
• Identify physical and psychosocial factors impacting pain so they can be addressed
• Assess the impact of pain on physical and psychosocial function
• Select appropriate goals
• Determine whether the patient requires referral to other healthcare providers

The goals of physical therapy include the reduction of pain, restoration of function, improved mobility, prevention or limitation of permanent physical disabilities, and encouragement of self-management through the use of physical, cognitive, and behavioral approaches to help reduce the impact of pain and disability (Sullivan et al., 2019).

PHYSICAL THERAPY INTERVENTIONS

When physical therapists work with patients who are experiencing pain, tests and measures are utilized to determine the causes of pain and to assess its intensity, quality, physical characteristics, and progression. Patients are also evaluated for risk factors for pain in order to prevent future pain issues. These factors may include disease history, cognitive and psychological factors, negative beliefs, and sedentary lifestyle.

Once contributors to the pain are identified, the therapist works with the patient to design an evidence-based management program with goals that are specific, measurable, achievable, relevant, and time-framed.

The physical therapist then implements the management program, which includes active approaches and passive approaches as indicated. These approaches include:

• Education about pain and how to manage pain, working with the patient toward regaining the ability to perform normal activities of daily living.
• Strengthening and flexibility exercises to improve movement with less pain. A graded exercise program may be instituted that gradually increases according to abilities. Exercises help to improve movement and coordination, reduce stress and strain on the body, and decrease pain.
• Manual therapies using hands-on techniques to manipulate or mobilize tight joint structures and soft tissues. Manual therapy may help increase range of motion, improve tissue quality, and reduce pain. Such therapies may include peripheral joint mobilization, myofascial mobilization, spinal mobilization, soft tissue mobilization, and therapeutic massage.
• Instruction in proper postural awareness and body mechanics, in order to help patients use their body more efficiently.
• Physical agents, which may include electrotherapies.

The therapist educates and supports the patient to adopt active rather than solely passive pain-management strategies that are meaningful to the patient and achievable, using motivational strategies and adherence techniques to support compliance.

Physical therapists include cognitive and behavioral approaches that support improved functional movement and pain outcomes, along with self-management strategies, as a key component of the management plan (IASP, 2021c).

MODALITIES

Modalities physical therapists may employ in pain management include:

• Thermotherapy
• Dry heat
• Hot packs
• Paraffin baths
• Tecar therapy
• Cryotherapy
• Ice packs
• Ice spray
• Immersion
• Ice massage
• Cryokinetics
• Biofeedback
• Manual therapies
• Massage
• Connective tissue massage
• Therapeutic massage
• Manipulation/mobilization
• Dry needling
• Soft tissue mobilization
• Spinal and peripheral joint mobilization
• Neural tissue mobilization
• Passive range of motion
• Electric stimulation
• Electric stimulation for tissue repair (ESTR)
• Functional electrical stimulation (FES)
• High-voltage pulsed current (HVPC)
• Neuromuscular electrical stimulation (NMES)
• Transcutaneous electrical nerve stimulation (TENS)
• Electrotherapeutic delivery of medications
• Iontophoresis
• Hydrotherapy
• Contrast bath
• Pools
• Pulsatile lavage
• Whirlpool tanks
• Acoustic
• Ultrasound
• Phonophoresis
• Traction devices
• Intermittent
• Positional
• Sustained
• Light therapy
  • Laser (low level and high power)
  • Ultraviolet
  • Infrared and near infrared
  • Cold laser therapy
  (Physiopedia, 2021)

PRINCIPLES FOR PHYSICAL THERAPISTS

The International Association for the Study of Pain (IASP, 2021c) identifies the following principles to guide physical therapists in the management of pain. These principles include:

1. Pain is a dynamic and complex experience involving interaction of biological, physical, psychological, social, and environmental factors specific to each individual.
2. Pain may be acute, acute on chronic, recurrent, chronic/persistent, and occur at any stage across the lifespan.
3. Pain assessment, treatment, and management are influenced by cultural, institutional, social, and regulatory factors.
4. Pain must be assessed in a comprehensive, safe, ethical, and consistent manner using valid and reliable assessment tools and outcome measures that help inform prognosis-making with consideration of risks, benefits, costs, and limitations of interventions.
5. Physical therapists should demonstrate empathic and compassionate patient communication when establishing person-centered pain-related goals and supporting self-management strategies.
6. Comprehensive pain management should be supported by sound theoretical models and empirical evidence and facilitate active patient involvement in developing lifelong healthy pain behaviors.
7. The physical therapist is an essential member of the pain management team and advocates for an individualized pain management plan that integrates the perspectives of patients, social support systems, and team members.

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 serious consequences.

In the past, opioids were often not prescribed for a patient because of the fear of addiction. In the 1980s, the opioid epidemic in the United States arose through an assemblage of well-intentioned efforts to improve pain management by doctors and through aggressive marketing by pharmaceutical manufacturers. States began to pass intractable pain treatment acts, which removed threat of prosecution for physicians who treated their patients aggressively with a controlled substance. In 1995, the American Pain Society began a campaign that framed pain as a “fifth vital sign” that should be monitored and managed in the same way as heart rate and blood pressure (DeWeerdt, 2019).

Now practitioners have returned to the fear of addiction and become, once again, reluctant to prescribe opioids. 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 Institute on Drug Abuse (2022a) reports that:

• Among people ages 12 and older in 2020, an estimated 2.3 million people in the United States had a prescription opioid use disorder in the past year.
• Nearly 92,000 persons in the United States died from drug-involved overdose in 2020 due to illicit drugs and prescription opioids. The national overdose deaths involving prescription opioids among all ages in 2020 was 16,416.
• Among young people in 2021, an estimated 4.4% of 12th graders reported misusing any prescription drug in the past 12 months.
• 50,000 individuals used heroin for the first time, and 14,480 deaths from heroin occurred in 2020.

Multiple variables contribute to the opioid crisis including:

• Geographic conditions
• Treatment accessibility
• Medication disposal services
• Workplace environment
• Prescribers’ perception of risk
• Overprescription of opioids or undertreatment of pain
• Types of prescription opioid formulation available
• Community norms
• Access to legal and illegal opioids
  (Jalali et al., 2020)

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 (ASHP, 2022).

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

In 2022, the CDC updated its guidelines for prescribing opioids for the treatment of pain. Whereas the 2016 guideline focused on recommendations for primary care physicians, the newer guideline expands the scope to additional clinicians whose scope of practice includes prescribing opioids (e.g., physicians, nurse practitioners and other advanced-practice registered nurses, physician assistants, and oral health practitioners). The 2022 guidelines address four main issues, including:

• Making a determination about whether or not to initiate opioids for pain
• Selecting the appropriate opioid and determining the dosage
• Deciding the duration of the initial opioid prescription and conducting follow-up
• Assessing the risk and addressing the potential harms of opioid use with the patient

The recommendations in the 2022 guidelines aim to improve communication between clinicians and patients about the risks and effectiveness of pain treatment; improve pain, function, and quality of life for persons with pain; and reduce the risks associated with opioid pain treatment (including opioid use disorder, overdose, and death) as well as with other pain treatment.

The practice guidelines include 12 recommendations for clinicians who are prescribing opioids for outpatients ages 18 years and older with pain that is acute (duration of <1 month), subacute (duration of 1–3 months), or chronic (duration of >3 months), excluding pain management related to sickle cell disease, cancer-related pain treatment, palliative care, and end-of-life care.

1. Nonopioid therapies are at least as effective as opioids for many common types of pain. Maximize the use of nonpharmacologic and nonopioid pharmacologic therapies appropriate for the condition and the patient, and only consider opioid therapy for acute pain if benefits are expected to outweigh risks to the patient. Discuss benefits and risks with the patient prior to prescribing opioid therapy.
2. Nonopioid therapies are preferred for subacute and chronic pain. Maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient. Consider opioid therapy if expected benefits are anticipated to outweigh risks, and work with the patient to establish treatment goals for pain and function. Consider how opioid therapy will be discontinued if benefits do not outweigh risks.
3. When starting opioid therapy for acute, subacute, or chronic pain, prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids.
4. When opioids are initiated for opioid-naive patients with acute, subacute, or chronic pain, prescribe the lowest effective dosage. If opioids are continued for subacute or chronic pain, prescribe the lowest effective dosage. Avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks.
5. For those patients already receiving opioid therapy, carefully weigh benefits and risks and exercise care when changing opioid dosages. Work closely with patients to optimize nonopioid therapies while continuing opioid therapy. If benefits do not outweigh risk of continued opioid therapy, optimize other therapies and work closely with patients to gradually taper to lower dosages, or appropriately taper and discontinue opioids. Unless there are indications of a life-threatening issue such as warning signs of impending overdose (e.g., confusion, sedation, slurred speech), opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages.
6. When opioids are needed for acute pain, prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids.
7. Evaluate benefits and risks with patients within 1–4 weeks of starting opioid therapy for subacute or chronic pain or of dosage escalation. Regularly re-evaluate benefits and risks of continued opioid therapy with patients.
8. Before starting and periodically during continuation of opioid therapy, evaluate risks for opioid-related harms and discuss risks with patients. Work with patients to incorporate into the management plan strategies to mitigate risk, including offering naloxone.
9. When prescribing initial opioid therapy for acute, subacute, or chronic pain, and periodically during opioid therapy for chronic pain, review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program data to determine whether the patient is receiving opioid dosages or combinations that put the patient at high risk for overdose.
10. When prescribing opioids for subacute or chronic pain, consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances.
11. Use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depressants.
12. Offer or arrange treatment with evidence-based medications for patients with opioid use disorder. Detoxification on its own, without medications for opioid use disorder, is not recommended because of increased risks for resuming drug use, overdose, and overdose death.
    (Dowell et al., 2022)

Legislative Efforts

Most state legislation limits first-time opioid prescriptions to a certain number of days’ supply, and in a few cases, states also set dosage limits. Nearly half the states with limits specify that they apply to treating acute pain, and most states set exceptions for chronic pain treatment.

In addition to exceptions for chronic pain, most laws also exempt treatment for cancer and palliative care from prescription limits. Many also allow exceptions for the treatment of substance use disorder or medication-assisted treatment, or for the professional judgment of the clinician prescribing the opioid. Many laws stipulate that any exceptions must be documented in the patient’s medical record.

In addition, states are enacting laws related to prescription drug monitoring programs, access to naloxone, pain clinic regulation, provider education and training, as well as other topics (NCSL, 2022).

The Comprehensive Drug Abuse Prevention and Control Act has been in effect since 1971. This act created a schedule of controlled substances, ranking them according to their potential for abuse. Through revisions since 1971, the act now places drugs in categories based upon the substance’s potential for abuse and accepted medical use.

Abuse-Deterrent Opioids

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:

• Oxycontin
• Hysingla ER
• Xtampza ER
• RoyBond

Generic opioids with FDA-approved labeling describing abuse-deterrent properties include:

• Hydrocodone bitartrate

(U.S. FDA, 2021)

Management of Opioid Overdose

It is important to consider opiate overdose or toxicity in a lethargic patient with no other identifiable cause. Care of the patient at the scene depends on the vital signs. If the patient is comatose and in respiratory distress, airway control must be obtained prior to any other action. Endotracheal intubation is highly recommended for all patients unable to protect their airways.

If there is a suspicion of opiate overdose, naloxone is administered to reverse respiratory depression. Naloxone, an opioid antagonist, rapidly reverses an opioid overdose. One should be aware that naloxone can also cause agitation and aggression when it reverses the opiate.

If the patient is a known drug abuser, the lowest dose of naloxone to reverse respiratory distress should be administered. In the ambulance, the patient may become combative or violent, and use of restraints may be required. If the individual has no intravenous access, naloxone can be administered intramuscularly, intranasally, intraosseous, or via the endotracheal tube. Data show that the intranasal route is as effective as the intramuscular route in the prehospital setting (Schiller et al., 2022).

Clinician Efforts to Reduce Opioid Abuse

Clinicians have an important role to play in the detection and prevention of prescription drug misuse and abuse. It is critical that prescribers employ risk-reduction strategies when prescribing opioid medications. Before prescribing opioids, clinicians should become familiar with the CDC guidelines for prescribing opioids for chronic pain (see above) and utilize the prescription monitoring program to check for frequent or overlapping narcotic prescriptions. These programs are often state-run databases that collect pharmacy data on controlled substances that are dispensed.

There are a number of validated screening tools available for use to aid clinicians in early detection of problematic substance use. The Screener and Opioid Assessment for Patients with Pain (SOAPP-R) is one of several such tools used for screening, brief intervention, and referral to treatment.

An informed consent should be considered for patients who are beginning long-term therapy with opioid analgesics to help ensure they understand the side effects, risks, conditions, and purpose of their treatment. This document can clearly define treatment expectations and resolve any questions or concerns patients may have before treatment is initiated.

Clinicians frequently monitor patients in person to assess for and document benefits and harms of treatment, including concerning behaviors that may indicate misuse or a use disorder. Guidelines vary, but visits should generally occur at least every three months and more frequently in higher risk circumstances, such as during periods of dose adjustment.

Urine testing is commonly performed prior to and during chronic opioid therapy for patients with chronic pain. Scheduled or random urine drug testing (with informed consent) is often part of the opioid agreement.

Patients receiving long-term opioid therapy are monitored for the three components of addiction:

• Loss of control
• Craving and preoccupation with use
• Use despite negative consequence

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 (NIDA, 2020b; Mahajan, 2021; Becker & Starrels, 2021).

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:

• Come from a location that is far away, perhaps across state lines
• 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 to diagnostic test contrast medium to avoid tests
• Suggest the medication, dose, and quantity being sought
• 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, 2021).

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:

• Perform a complete review of the patient’s pertinent history, and conduct a thorough medical evaluation, addressing and documenting all objective signs and symptoms of pain.
• Exercise concern when dealing with patients who are not interested in having a physical examination, are unwilling to authorize release of prior medical records, or have no interest in a diagnosis or a referral.
• Be cautious if a new patient has an unusual knowledge of controlled substances or requests a specific controlled substance and is unwilling to try any other medication.
• Utilize the state prescription monitoring program (PDMP) to identify patients at risk for drug diversion and/or “doctor shopping.”
• Implement a systematic procedure for refilling prescriptions and educating appropriate staff regarding the policy.
• Inform patients verbally and in writing about the medication refill procedure.
• Establish a treatment agreement with the patient that outlines the provider’s expectations, which should address:
• Number and frequency of prescription refill
• Early refills
• Replacement of lost or stolen medications
• Specific reasons for discontinuing or changing the drug therapy
• Consider referral to or consultation with a pain management specialist for patients not responding to the treatment plan.
• Exercise the right to terminate a patient who fails to follow the treatment plan or adhere to the treatment agreement.
  (Jakucs, 2021; Johnson, 2017)

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.

Drug Diversion and Addiction among Healthcare Professionals

Because healthcare professionals are trusted with others’ health and well-being, they are not often suspected of drug addiction themselves; 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 (U.S. DEA, 2019).

INDICATORS OF DRUG ADDICTION IN THE WORKPLACE

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
  (U.S. DEA, 2019)

Addressing Pain in Individuals with Substance Use Disorders (SUDs)

Opioid use for pain management for patients with a history of SUDs may be considered if their use is carefully managed. This involves selecting the appropriate opioid, dosage titration, treatment agreements, and testing and monitoring.

When choosing the appropriate opioid, providers should select a medication that is safe and start with a low dose to ease pain, then titrate as needed to maintain pain relief without decreasing function or risking addiction or relapse.

When an effective dose has been determined, total opioid dose is increased slowly and only if needed, as tolerance develops. When monitoring for dosage, providers must be aware of both tolerance and hyperalgesia concerns. Tolerance can occur regardless of opioid type, dosage, route of administration and dosage schedule. Clinicians should be aware that hyperalgesia, or oversensitivity to pain, can occur in some patients using opioids for chronic pain.

When patients develop tolerance to the analgesic effects of a particular opioid, providers can consider either escalating the dosage or switching from one opioid to another, at a low dose that will effectively relieve pain without increasing the risk of relapse.

Before initiating opioid treatment, providers should determine whether the patient has access to a naloxone kit and prescribe one if they do not. (See also “Management of Opioid Overdose” earlier in this course.)

When pain has been resolved, the provider should gradually discontinue opioid therapy. Other reasons for discontinuing opioid treatment include:

• Opioids are no longer effective
• Adverse effects are unmanageable
• The patient does not adhere to the treatment agreement
• The patient is misusing or diverting the medication

If the reason is due to nonadherence to the treatment agreement or misuse of opioids, the patient should be referred for addiction treatment (SAMHSA, 2021).

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)
• Brief Screener for Alcohol, Tobacco, and other Drugs (BSTAD)

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 (NIDA, 2022b; Rosenquist, 2022).

TREATING PAIN IN PALLIATIVE CARE AND END-OF-LIFE CARE

Palliative care and end-of-life care involves specialized medical and nursing care for people with serious and/or life-threatening 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.

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

Palliative care is used to manage a disease or medical condition that is serious or life-threatening by easing pain and other associated physical, emotional, or psychosocial symptoms. Palliative care may last for weeks, months, or years, and the relief of moderate to severe pain during that time can greatly improve the quality of life. By starting palliative care early, and by using the right type of pain management, nearly all pain problems can be relieved or reduced.

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. There are three important principles to keep in mind when deciding how to manage pain:

• Pain should always be treated right away; delay allows pain to worsen.
• Do not be concerned about the patient becoming addicted to pain medicine.
• Most pain problems can be controlled by using the step-care approach.

An effective guideline for administration of analgesics includes:

• Oral dosing of drugs whenever possible
• Around-the-clock administration rather than on-demand
• Prescribing analgesics according to pain intensity as evaluated by a pain severity scale
• Individualizing therapy, which presupposes that there is no standardized dosage in the treatment of pain
• Adhering to pain medication and dosing, as any alteration can lead to recurrence of pain
  (Johns Hopkins Medicine, 2022; Anekar & Cascella, 2022)

Palliative Sedation

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.

Although the data are limited, compared with patients at the end of life who did not receive palliative sedation, the use of palliative sedation does not appear to shorten survival. 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, 2021).

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)
• Difficulty in accepting the prognosis
• Misconception that pain is a natural part of being ill and cannot be relieved or avoided
• Stoicism
• Fears and concerns about pain medication, side effects, substance abuse, and/or addiction

Clinician issues:

• 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)
• Prejudice against a particular group or the use of stereotypes to categorize a particular patient, or particular illness as not having 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
• Tendency to under assess pain and under treat pain in certain groups like older people or children
• Fear of legal issues

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
  (CARESEARCH, 2021)

ETHICAL CONCERNS IN ASSESSING AND TREATING PAIN

There is a universal agreement that patients have a right to adequate pain management and clinicians have a duty to provide it. The widespread issue of undertreated pain appears to be a product of a risk/benefit calculation by clinicians that the risks of addiction to opioids were unacceptably high, whereas the benefits of pain relief were relatively inconsequential.

Ethical concerns include:

• Is there an ethical and moral duty to relieve pain and suffering?
• There is no acceptable objective measure of pain.
• Is it ever ethically permissible to allow pain to continue untreated?
• Are people who complain that pain is ongoing being manipulative?
  (Bernhofer, 2021)

Ethical Principles and Pain Management

Adherence to ethical principles by clinicians is critical in effectively managing pain.

Autonomy is the individual’s right to make healthcare decisions based on their own beliefs and values, even if a clinician disagrees. If a patient chooses not to receive a treatment that could potentially provide a benefit, the healthcare provider must respect that choice. When a practitioner does not honor the patient’s right to make a choice regarding pain treatment, this right is violated. It is important to understand, however, that pain may impact a person’s autonomy or that a practitioner may make an assumption that the person is incompetent.

Beneficence is the act a provider takes that benefits the patient, minimizes harm, and promotes the good. This means that pain relief will be provided as quickly as possible and to the highest degree possible in order for an act to be considered “good” care. Healthcare providers must make the management of pain a priority, and to not do so is neglecting the principle of beneficence.

Nonmaleficence means to do no harm. Many treatments for pain have potentially harmful side effects; however, it is important to recognize that untreated pain may be more harmful to the patient than the side effects of drugs used to treat it. Withholding a medication for safety reasons can be a violation of this principle. This principle is likely the most difficult to uphold.

Justice means that treatment for pain is equitable. This principle is violated when treatment for pain is withheld or not administered solely on the basis of a person’s age, race, religion, or social or economic status, unless these factors have a distinct bearing on treatment (e.g., drug choices or doses based on a patient’s age).

Ethical Dilemmas in Pain Management

An ethical dilemma requires a choice between conflicting alternatives, each of which is based on an ethical principle. Ethical dilemmas may occur when there is a conflict with the clinician’s personal values or with their code of ethics. For example, clinicians may be faced with an ethical dilemma when there is no advance directive and families or other surrogates refuse to consent to pain medications for the patient or insist on lower doses than medically appropriate despite obvious signs of pain in the patient.

In such an instance, without the explicit direction from the patient, an ethical assumption must be made that the patient would want relief from pain and suffering. The provision of pain medication is assumed as part of basic care for the patient in accordance with the principle of nonmaleficence (Faubion, 2022).

CONCLUSION

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.