The Patient in Pain
Learning Objectives
Glossary
Acute pain– Pain, usually of shorter duration, that acts as a warning and protective mechanism. Usually subsides as healing takes place.
Addiction– A psychological process, in contrast to drug tolerance, that involves the repeated use of a drug or drugs for psychological, not medical, reasons. Patients who are psychologically dependent on a drug (addicted) will continue to desire the drug even though the pain is resolved.
Cancer pain – Usually placed in a category of its own. Even if it lasts for more than 6 months, it is often treated like acute pain because of its progressive nature. Sometimes referred to as malignant pain.
Chronic pain– Pain that lasts beyond the ordinary duration of time that an insult or injury to the body needs to heal. Types of chronic pain include recurrent acute pain with potential for recurrence over a prolonged period, with pain-free intervals between episodes; chronic acute pain, which may last months or years, but has a high probability of ending; and chronic, benign (noncancer) pain, which occurs almost daily and has existed for 6 or more months. It is now believed that different mechanisms may be involved in development of chronic pain and it is not just a matter of a longer occurrence of acute pain.
Drug tolerance – A physiological response of the body, not under the person's control, in which the drug loses its effectiveness after repeated use. Occurs in almost all patients using opioids longer than 7 to 10 days. Needs to be taken into consideration when determining correct dosage of analgesic because the patient may require increased doses to achieve the same effect.
Pain – An unpleasant sensory and emotional experience arising from actual or potential tissue damage caused by a noxious stimulus.
Pain tolerance– Duration and intensity of pain that an individual is willing to tolerate at any one time. Pain tolerance changes within an individual from one pain experience to another.
Placebo– Any medical or nursing measure that works because of its implicit or explicit therapeutic intent rather than its chemical or physical properties.
Pseudo-addiction– Patient behaviors that may mimic drug-seeking behaviors and occur when pain in under-treated.
Referred pain– Pain felt at a site other than the injured or diseased organ or body part. The pain of coronary artery insufficiency, for example, is often referred to the left shoulder, arm, or jaw, and pancreatic pain may be referred to the middle back.
Pain is what the person experiencing it says it is, exists when and where he or she says it does. The patient is the authority about his/her own pain. (McCaffery, 1968)
Pain is a universal experience occurring in all age groups and is the most frequent reason why people seek health care. It is also the most feared symptom (Daudet, 2002). Much progress has been made over the last decade in understanding pain mechanisms and the epidemiology of pain. The subject is important for all clinicians because the frequency and perhaps the severity of pain may increase now that progress in medical science has increased survival through old age and chronic illness, and now affects more people than ever before.
Studies continue to show that pain is underassessed and undertreated by health-care professionals. The American Pain Society (2003) reports that the most common reason for unrelieved pain in the American health-care system is the failure of medical personnel to routinely assess pain and pain relief. The classic study by Marks and Sachar (1973) reported that 73% of hospitalized medical patients experienced moderate to severe pain despite receiving parenteral opioid analgesics. Recent research indicates that nurses and physicians continue to undertreat pain in patients because they do not understand pain management principles, they fear causing the patients' dependence on opioids, and they have poor knowledge of opioids, adjuvant therapies, and the components of pain assessment (McCaffery & Ferrell, 1997). Despite the establishment of federal guidelines on pain management (Agency for Healthcare Policy and Research, 1992, 1994), many patients of all ages still suffer unnecessary pain in all healthcare settings and at home (Twycross, 1999; Weiner, Peterson, Ladd, McConnell, & Keefe, 1999; Paice & Fine, 2006). In 2001, the Joint Commission on Accreditation of Healthcare Organizations implemented pain management standards that mandate frequent assessment and appropriate interventions.
Pain is a multidimensional and complex phenomenon, requiring effective assessment and management. Many disciplines are involved in pain management in a variety of clinical settings. Optimal pain management depends on cooperation among the different members of the health-care team throughout the patient's course of treatment (Stratton, 1999).
The nurse usually has the most significant influence on management of the patient's pain because of having the most frequent contact with the patient. Consequently, the nurse is in a unique position to identify the patient who has pain; to appropriately assess the pain and its impact on the patient and family, to initiate action to alleviate pain using available resources, and to evaluate the effectiveness of those actions.
Patients vary greatly in their responses to pain and its interventions, as well as in their personal preferences and expectations regarding pain relief. Therefore rigid prescriptions for the management of pain are inappropriate. An effective pain management program will incorporate the following requirements and principles (McCaffery, 1999; American Pain Society, 2003):
The exact mechanism of transmission and perception of pain are not completely understood; however, neurophysiological, psychological, and sociological research has contributed to the formation of pain theories.
The Gate Control theory, originally proposed in 1965 by Melzack and Wall, suggests that pain occurs when smaller diameter type A nerve fibers and very small diameter type C fibers are stimulated. These afferent, or sensory, fibers penetrate the dorsal horn of the spinal cord and end in the substantia gelatinosa. When the sensory stimulation reaches a certain critical point, the “gate” opens and allows nearby transmission cells to project the pain message to the brain. In contrast, the large-diameter type A sensory fibers inhibit pain transmission. When these fibers are stimulated, fast-conducting afferent fibers oppose the smaller fibers' input and activate the substantia gelatinosa “gate” to close, thus blocking nerve transmission.
This theory explains why external methods of pain control work. For example, stimulating the large-diameter type A fibers by massage, applying heat or cold, acupuncture, or transcutaneous electric nerve stimulation (TENS) can override sensory input in the smaller diameter type A fibers and block pain transmission at the gate. Cognitive techniques, such as distraction, biofeedback, relaxation, and guided imagery, operate through the efferent fibers, closing the gate.
In the 1970s, the body's own internally secreted opioid-like substances, called endorphins, were identified. Research found that the brain triggers the release of endorphins, which lock into the narcotic receptors at nerve endings in the brain and spinal cord to block the transmission of pain signals, preventing the impulse from reaching consciousness. This research has helped to explain why pain perception and the need for analgesia can vary greatly from one person to another. Endorphins are depleted with prolonged pain, recurrent stress, and the prolonged use of morphine or alcohol. Endorphin levels are increased during brief pain episodes, brief stress, physical exercise and sexual activity, massive trauma, some types of acupuncture, and some types of TENS, and possibly with placebos. Much of the recent research in this area supports patient-controlled interventions for pain (Ellis, Blouin, & Lockett, 1999).
A number of neurotransmitters have been discovered that are found to contribute to the carrying of the pain impulse. These include glutamate and substance P. A number of drugs are being investigated that inhibit binding of excitatory amino acids such as glutamate that normally binds to N-methyl-D-aspartate (NMDA). NMDA antagonists including drugs that contain dextro-mathorphan and ketamine seem to block the transmission of the pain impulse. This may be one of the mechanisms of actions of methadone.
The multiple opioid receptor theoryrecognizes that not all opioids work the same way and some cannot be switched back and forth without adverse consequences. There are at least three types of opioid receptor sites in the spinal column. Each type binds somewhat differently with different types of opioids. For example, opioids like butorphanol tartrate (Stadol) or nalbuphine (Nubain) (agonist-antagonist drugs) antagonize the effects of other narcotics like morphine and can contribute to withdrawal rather than pain relief. Knowledge of this theory enhances appropriate selection of analgesics (Ripamonti, Zecca, & Bruera, 1997).
Gender and social and cultural factors also affect the pain response by influencing how the individual interprets pain and how he or she responds emotionally. Through family, social, and cultural values and attitudes, the patient learns which types of pain responses are appropriate within his or her group. Of course, family and social influences change as a child matures. By the time adulthood is reached, the individual may have modified or even rejected many family values or taken on the values of another subgroup. If the patient's values conflict with those of his or her family, additional stress and anxiety may be felt. This may explain why certain patients act differently when family members are present (Fillingim, 2000; Wessman & McDonald, 1999).
Other factors influencing pain behaviors may include the body part involved, the patient's socioeconomic status and religious beliefs, and experience with folk medicine or alternative therapies. A patient's language and vocabulary affect the way in which pain is described. Do not be too quick to assume that you understand what the patient is trying to say, especially if his or her native language and ethnic background are different from yours.
Chronic pain is a significant health problem. For example, 10% to 15% of adults in the United States are estimated to have some form of disability from back pain (Borsook, McPeek, & Lebel 1996). One in five Americans suffer from chronic pain (Sternberg, 2005). In addition to disrupting employment, chronic pain can contribute to family problems and social isolation.
Although acute pain is associated with anxiety, chronic pain is more associated with depression. Chronic pain patients are also at higher risk for dependence and abuse of medication because their pain is often not relieved and they begin taking larger doses in hopes of obtaining relief and treating their depression. Health-care professionals may become frustrated and eventually deny the patient the pain medications, making assumptions that the patient is drug-seeking (pseudo-addiction). The chronic pain patient usually requires a multidisciplinary pain team.
The physiological and psychological risks associated with untreated pain are greatest in frail patients with other illnesses, such as heart or lung disease; those undergoing major surgical procedures; and very young or very old patients. Untreated pain can contribute to complications because the patient is unable to cough or deep breathe or get adequate rest or nutrition. Uncontrolled pain in dying patients contributes to the wish to hasten death and is the most frequently stated fear. In patients with psychiatric diagnoses such as depression, schizophrenia, dementia, malingering, and hypochondriasis, pain may be the chief presenting complaint. Treating the underlying psychiatric disorder should lead to reduction in pain. Patients with alcohol or drug withdrawal syndromes need special consideration in their pain management, especially if they also have other medical problems.
Patients with a history of substance abuse are often undertreated for pain leading to increased hospital length of stay, frequent readmissions, and increased outpatient and emergency visits (Kirsh & Passik, 2006; Grant, Cordts, & Doberman, 2007). Long term use of opioids can result in hypersensitivity to pain resulting in further complications. Undertreatment of these patients is often caused by healthcare professionals' misconceptions about addiction.
Each individual experiences and expresses pain in a unique manner, depending on age, gender, culture, and previous pain experience (Box 15-1 Factors Influencing Pain Tolerance). All pain is real to the person experiencing it, regardless of its physical or psychological etiology. Each person's ability to tolerate pain is also unique. Depending on the situation, pain tolerance can vary even in the same individual. Anxiety or depression can decrease pain tolerance. Most people with severe or prolonged pain also have emotional changes related to their pain.
About one third of all patients with a diagnosed physical cause for their pain respond to placebos. Nurses should be aware that a positive response, meaning that the patient gets relief after taking the placebo, cannot be used to prove that the pain is psychologically induced. Sometimes just listening to the patient, acknowledging the pain, and the act of giving a medication can enhance pain relief. Today, it is generally considered unethical for a doctor to prescribe a placebo to treat pain without informing the patient that he/she may be receiving one (Oncology Nursing Society, 1996).
The benefits of adequate and consistent pain management are significant. Benefits include earlier and easier mobilization, shorter hospital stays, increased productive rehabilitation, and earlier return to previous work or lifestyle; or if the patient's condition is terminal, increased comfort and peace of mind. These outcomes should be expected and worked toward with every patient experiencing pain (de Rond, deWit, vanDam, & Miller, 2000; Raines, 2000).
As with adults, pain is one of the most feared symptoms in children (Collins & Walker, 2006). Research indicates that younger children, including neonates, may experience some pain more intensely than older children. For children who cannot communicate verbally about their pain, one needs to assess pain by observing physiologic changes, nonverbal behavior, and vocalizations, such as crying or groaning. Consult parents or guardians about how the child expresses pain at home. Knowledge of the child's age, health status and developmental level gives insight into how pain may be expressed (McGrath & Finley, 1999; Twycross, Moriarity, & Betts, 1998; Hunt, 2006).
If painful procedures are needed, be sure they are performed outside the child's room or playroom so that his or her bed, room, and playroom continue to be safe places. If the child is verbal, try to use his or her words for pain when asking about the discomfort. The Wong-Baker Faces Pain Rating Scale is particularly geared to children as well as adults with dementia (Fig. 15-2 Pain Rating Scales).
Most dosage recommendations for opioid analgesics in children are not supported by double-blind studies, and underdosing is especially common. Using weight in kilograms to determine doses is useful in many cases when opioids are needed. Initial recommended doses must be viewed as educated guesses and should be adjusted either up or down according to the individual child's response. Toddlers and older children may obtain pain relief from cutaneous stimulation such as massage and TENS and distraction, similar to adults. Adolescents may report more pain than younger children, especially if the pain is chronic.
Pain is not an inevitable part of aging; however, elderly people are at greater risk for many disorders that may result in pain, such as arthritis, cardiovascular disease, osteoporosis, falls, hip fractures, and cancer (Horgas & Elliot, 2004; Barkin, Barkin & Barkin, 2005). Older patients may deny pain more frequently than other age groups because they fear the consequences of admitting pain, such as longer hospitalization or more tests, or they have the mistaken belief that pain is normal for their age. Special efforts must be taken to adequately assess pain, especially in confused elderly people. Dementia patients are particularly vulnerable to under treatment of pain because of their inability to express themselves. Some myths about pain in older adults include that pain is a normal part of aging and opioids cannot be used safely with this population (Curtis, 2006).
Polypharmacy is of special concern in elderly persons. Because of the physiological changes that occur with aging, drug half-life and clearance times are increased. This can lead to increased and unexpected side effects and toxicity, making pain control more difficult in this group. Unrelieved pain may also contribute to confusion and dementia. Adjuvant analgesics must be used with caution in elderly patients because sedation, confusion, and the sedative and anticholinergic effects of many of these drugs can contribute to many other problems. Low starting doses are recommended. Long-acting analgesics may be more likely to cause side effects. A trial of low-dose immediate release analgesics given on a routine basis can be helpful to determine if the dementia patient's behavior is due to pain.
Older adults are more likely to be fearful of using narcotic analgesics owing to long-held beliefs that morphine is associated with death or narcotic use leads to addiction. This can present a significant barrier to effective pain relief. Assess any fears the patient may have regarding taking narcotics. Fear of constipation is also a frequently seen barrier.
Thoughts, Beliefs, and Perceptions
Relationships and Interactions
Behavior and Appearance
Mood and Emotions
Thoughts, Beliefs, and Perceptions
Relationships and Interactions
Physical Responses
Pertinent History
Several types of drugs are available to treat pain. Selection is based on the cause of the pain, its intensity and duration, and the patient's response. Mild intermittent pain may be treated with salicylate analgesics, acetaminophen, or nonsteroidal anti-inflammatory agents (NSAIDS). These drugs have specific upper dose limits due to their side effects. More severe, acute pain may need opioid analgesics such as morphine or oxycodone. Determining the most effective medication requires careful assessment of the cause of the patient's pain and his or her perception of the pain and underlying condition. Opioid analgesics generally have no upper dose limits short of side effects.
Factors that influence the effectiveness of medication to relieve pain include:
The patient experiencing pain needs to be constantly reevaluated to ensure that he or she receives maximal relief with the least potent drug. For instance, a surgical patient may require parenteral opioid analgesics immediately after surgery. As healing occurs, the drug can be titrated to a less invasive method and a lower dose while still maintaining adequate pain control. An equianalgesic list (Table 15-2 Opioid Analgesics Commonly Used for Severe Pain) gives the dose and route of administration of one drug that produces approximately the same degree of analgesia as the dose and route of administration of another drug. There are many differences among individual patients, so these lists serve only as guidelines to the relative equivalences of various analgesics. Dose and time intervals must be titrated for each patient (Agency for Health Care Policy and Research, 1992, 1994). Patients with chronic pain may need opioids, and the long-acting preparations are particularly useful because they avoid the fluctuating blood levels of analgesics. The World Health Organization Pain Ladder is a useful model to follow for cancer pain (WHO, 2006).
Patients on one or more other medications need to be evaluated for possible drug interactions. Drug pharmacokinetics may change because of alterations in cardiac, renal, and liver function; respiratory rate; and gastrointestinal absorption. Fever, sepsis, burns, and shock also affect drug effectiveness. Patients with psychiatric conditions who take antianxiety agents or psychoactive drugs must also be evaluated for possible drug interactions, in particular, the added sedative effects of opioids and many of the psychotropic drugs. Clinicians should be aware that patients in these categories might not respond as expected to pain medication (Borsook, McPeek, & Lebel, 1996).
A factor contributing to undertreatment of pain can be created by the patient who fears taking opioids. Some patient barriers to taking adequate analgesics include fear of side effects (particularly constipation and sedation), and association of opioids with addiction and death.
A variety of herbal products are being used to treat pain, including capsicum ointments, evening primrose for arthritis, and chamomile for migraines. A variety of alternative approaches that may be used include acupuncture, magnet therapy, and biofeedback.
PAIN, ACUTE evidenced by report of moderate pain, changes in autonomic nervous system (increased heart rate and blood pressure), and reduced ability to perform ADLs related to surgery, injury, or illness
Interventions
PAIN, CHRONIC evidenced by ongoing episodes of pain, difficulty performing usual activities, and other effects of chronic pain, such as sleep disturbance or poor nutrition related to effects of illness, surgery, or injury more that lasts beyond the ordinary duration of time that body needs to heal.
Patient Outcomes
Interventions
Patient & Family Education
When to Call for Help
Who to Call for Help
Community-Based Care