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Pain Management

Pain management

Definition

If pain can be defined as a highly unpleasant, individualized experience of one of the body's defense mechanisms indicating an injury or problem, pain management encompasses all interventions used to understand and ease pain, and, if possible, to alleviate the cause of the pain.


Purpose

Pain serves to alert a person to potential or actual damage to the body. The definition for damage is quite broad: pain can arise from injury as well as disease. After the message is received and interpreted, further pain can be counterproductive. Pain can have a negative impact on a person's quality of life and impede recovery from illness or injury, thus contributing to escalating health care costs. Unrelieved pain can become a syndrome in its own right and cause a downward spiral in a person's health and outlook. Managing pain properly facilitates recovery, prevents additional health complications, and improves an individual's quality of life.

Yet, the experiencing of pain is a completely unique occurrence for each person, a complex combination of several factors other than the pain itself. It is influenced by:

  • Ethnic and cultural values. In some cultures, tolerating pain is related to showing strength and endurance. In others, it is considered punishment for misdeeds.
  • Age. This refers to the concept that grownups never cry.
  • Anxiety and stress. This is related to being in a strange, fearful place such as a hospital, and the fear of the unknown consequences of the pain and the condition causing it, which can all combined to make pain feel more severe. For patients being treated for pain, knowing the duration of activity of an analgesic leads to anxiety about the return of pain when the drug wears off. This anxiety can make the pain more severe.
  • Fatigue and depression. It is known that pain in itself can actually cause depression. Fatigue from lack of sleep or the illness itself also contribute to depressed feelings.

Precautions

The perception of pain is an individual experience. Health care providers play an important role in understanding their patients' pain. All too often, both physicians and nurses have been found to incorrectly assess the severity of pain. A study reported in the Journal of Advanced Nursing evaluated nurses' perceptions of a select group of white American and Mexican-American women patients' pain following gallbladder surgery. Objective assessments of each patient's pain showed little difference between the perceived severities for each group. Yet, the nurses involved in the study consistently rated all patients' pain as less than the patients reported, and with equal consistency, believed that better-educated women born in the United States were suffering more than less-educated Mexican-American women. Nurses from a northern European background were more apt to minimize the severity of pain than nurses from eastern and southern Europe or Africa. The study indicated how health care staff, and especially nursing staff, need to be aware of how their own background and experience contributes to how they perceive a person's pain.

In a 1990 study reported in the journal Pain, nurses were found to overestimate the severity of pain in patients with severe burns. In most other studies, nurses and physicians ascribe a lower pain severity than do patients.


Description

Before considering pain management, a review of pain definitions and mechanisms may be useful. Pain is the means by which the peripheral nervous system (PNS) warns the central nervous system (CNS) of injury or potential injury to the body. The CNS comprises the brain and spinal cord, and the PNS is composed of the nerves that stem from and lead into the CNS. PNS includes all nerves throughout the body, except the brain and spinal cord. Pain is sometimes categorized by its site of origin, either cutaneous (originating in the skin of subcutaneous tissue, such as a shaving nick or paper cut), deep somatic pain (arising from bone, ligaments and tendons, nerves, or veins and arteries), or visceral (appearing as a result of stimulation of pain receptor nerves around organs such as the brain, lungs, or those in the abdomen).

A pain message is transmitted to the CNS by special PNS nerve cells called nociceptors, which are distributed throughout the body and respond to different stimuli depending on their location. For example, nociceptors that extend from the skin are stimulated by sensations such as pressure, temperature, and chemical changes.

When a nociceptor is stimulated, neurotransmitters are released within the cell. Neurotransmitters are chemicals found within the nervous system that facilitate nerve cell communication. The nociceptor transmits its signal to nerve cells within the spinal cord, which conveys the pain message to the thalamus, a specific region in the brain.

Once the brain has received and processed the pain message and coordinated an appropriate response, pain has served its purpose. The body uses natural painkillers, called endorphins, to derail further pain messages from the same source. However, these natural painkillers may not adequately dampen a continuing pain message. Also, depending on how the brain has processed the pain information, certain hormones such as prostaglandins may be released. These hormones enhance the pain message and play a role in immune system responses to injury, such as inflammation. Certain neurotransmitters, especially substance P and calcitonin gene-related peptide, actively enhance the pain message at the injury site and within the spinal cord.

Pain is generally divided into two additional categories: acute and chronic. Nociceptive pain, or the pain that is transmitted by nociceptors, is typically called acute pain. This kind of pain is associated with injury, headaches, disease, and many other conditions. Response to acute pain is made by the sympathetic nervous system (the nerves responsible for the fight-or-flight response of the body). It normally resolves once the condition that precipitated it is resolved.

Following some disorders, pain does not resolve. Even after healing or a cure has been achieved, the brain continues to perceive pain. In this situation, the pain may be considered chronic. Chronic pain is within the province of the parasympathetic nervous system, and the changeover occurs as the body attempts to adapt to the pain. The time limit used to define chronic pain typically ranges from three to six months, although some health care professionals prefer a more flexible definition, and consider chronic pain as pain that endures beyond a normal healing time. The pain associated with cancer; persistent and degenerative conditions; and neuropathy, or nerve damage, is included in the chronic category. Also, unremitting pain that lacks an identifiable physical cause such as the majority of cases of low back pain may be considered chronic. The underlying biochemistry of chronic pain appears to be different from regular nociceptive pain.

It has been hypothesized that uninterrupted and unrelenting pain can induce changes in the spinal cord. In the past, severing a nerve's connection to the CNS has treated intractable pain. However, the lack of any sensory information being relayed by that nerve can cause pain transmission in the spinal cord to go into overdrive, as evidenced by the phantom limb pain experienced by amputees. Evidence is accumulating that unrelenting pain or the complete lack of nerve signals increases the number of pain receptors in the spinal cord. Nerve cells in the spinal cord may also begin secreting pain-amplifying neurotransmitters independent of actual pain signals from the body. Immune chemicals, primarily cytokines, may play a prominent role in such changes.


Managing pain

Considering the different causes and types of pain, as well as its nature and intensity, management can require an interdisciplinary approach. The elements of this approach include treating the underlying cause of pain, pharmacological and non-pharmacological therapies, and some invasive (surgical) procedures.

Treating the cause of pain underpins the idea of managing it. Injuries are repaired, diseases are diagnosed, and certain encounters with pain can be anticipated and treated prophylactically (by prevention). However, there are no guarantees of immediate relief from pain. Recovery can be impeded by pain and quality of life can be damaged. Therefore, pharmacological and other therapies have developed over time to address these aspects of disease and injury.

pharmacological options. General guidelines developed by the World Health Organization (WHO) have been developed for pain management. These guidelines operate upon the following three-step ladder approach:

  • Mild pain is alleviated with acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs and acetaminophen are available as over-the-counter and prescription medications, and are frequently the initial pharmacological treatment for pain. These drugs can also be used as adjuncts to the other drug therapies that might require a doctor's prescription. NSAIDs include aspirin , ibuprofen (Motrin, Advil, Nuprin), naproxen sodium (Aleve), and ketoprofen (Orudis KT). These drugs are used to treat pain from inflammation and work by blocking production of pain-enhancing neurotransmitters. Acetaminophen is also effective against pain, but its ability to reduce inflammation is limited. NSAIDs and acetaminophen are effective for most forms of acute (sharp, but of a short duration) pain.
  • Mild to moderate pain is eased with a milder opioid medication, plus acetaminophen or NSAIDs. Opioids are both actual opiate drugs such as morphine and codeine, and synthetic drugs based on the structure of opium. This drug class includes drugs such as oxy-codon, methadone, and meperidine (Demerol). They provide pain relief by binding to specific opioid receptors in the brain and spinal cord.
  • Moderate to severe pain is treated with stronger opioid drugs, plus acetaminophen or NSAIDs. Morphine is sometimes referred to as the gold standard of palliative care as it is not expensive, can be given by starting with smaller doses and gradually increased, and is highly effective over a long period of time. It can also be given by a number of different routes, including by mouth, rectally, or by injection.

Although antidepressant drugs were developed to treat depression, it has been discovered that they are also effective in combating chronic headaches, cancer pain, and pain associated with nerve damage. Antidepressants that have been shown to have analgesic (pain-reducing) properties include amitriptyline (Elavil), trazodone (Desyrel), and imipramine (Tofranil). Anticonvulsant drugs share a similar background with antidepressants. Developed to treat epilepsy, anticonvulsants were found to relieve pain as well. Drugs such as phenytoin (Dilantin) and carbamazepine (Tegretol) are prescribed to treat the pain associated with nerve damage.

Close monitoring of the effects of pain medications is required in order to assure that adequate amounts of medication are given to produce the desired pain relief. When a person is comfortable with a certain dosage of medication, oncologists typically convert to a long-acting version of that medication. Transdermal fentanyl patches (Duragesic) are a common example of a long-acting opioid drug often used for cancer pain management. A patch containing the drug is applied to the skin and continues to deliver the drug to the person for typically three days. Pumps are also available that provide an opioid medication upon demand when the person is experiencing pain. By pressing a button, they can release a set dose of medication into an intravenous solution or an implanted catheter. Another mode of administration involves implanted catheters that deliver pain medication directly to the spinal cord. Because these pumps offer the patient some degree of control over the amount of analgesic administered, the system, commonly called patient controlled analgesia (PCA), reduces the level of anxiety about availability of pain medication. Delivering drugs in this way can reduce side effects and increase the effectiveness of the drug. Research is underway to develop toxic substances that act selectively on nerve cells that carry pain messages to the brain. These substances would kill the selected cells and thus stop transmission of the pain message.


non-pharmacological options. Pain treatment options that do not use drugs are often used as adjuncts to, rather than replacements for, drug therapy. One of the benefits of non-drug therapies is that an individual can take a more active stance against pain. Relaxation techniques such as yoga and meditation are used to focus the brain elsewhere than on the pain, decrease muscle tension, and reduce stress. Tension and stress can also be reduced through biofeedback, in which an individual consciously attempts to modify skin temperature, muscle tension, blood pressure, and heart rate.

Participating in normal activities and exercising can also help control pain levels. Through physical therapy, an individual learns beneficial exercises for reducing stress, strengthening muscles, and staying fit. Regular exercise has been linked to production of endorphins, the body's natural painkillers.

Acupuncture involves the insertion of small needles into the skin at key points. Acupressure uses these same key points, but involves applying pressure rather than inserting needles. Both of these methods may work by prompting the body to release endorphins. Applying heat or being massaged are very relaxing and help reduce stress. Transcutaneous electrical nerve stimulation (TENS) applies a small electric current to certain parts of nerves, potentially interrupting pain signals and inducing release of endorphins. To be effective, use of TENS should be medically supervised.

invasive procedures. There are three types of invasive procedures that may be used to manage or treat pain: anatomic, augmentative, and ablative. These procedures involve surgery, and certain guidelines should be followed before carrying out a procedure with permanent effects. First, the cause of the pain must be clearly identified. Next, surgery should be done only if noninvasive procedures are ineffective. Third, any psychological issues should be addressed. Finally, there should be a reasonable expectation of success.

Anatomic procedures involve correcting the injury or removing the cause of pain. Relatively common anatomic procedures are decompression surgeries such as repairing a herniated disk in the lower back or relieving the nerve compression related to carpal tunnel syndrome. Another anatomic procedure is neurolysis, also called a nerve block, which involves destroying a portion of a peripheral nerve.

Augmentative procedures include electrical stimulation or direct application of drugs to the nerves that are transmitting the pain signals. Electrical stimulation works on the same principle as TENS. In this procedure, instead of applying the current across the skin, electrodes are implanted to stimulate peripheral nerves or nerves in the spinal cord. Augmentative procedures also include implanted drug-delivery systems. In these systems, catheters are implanted in the spine to allow direct delivery of drugs to the CNS.

Ablative procedures are characterized by severing a nerve and disconnecting it from the CNS. However, this method may not address potential alterations within the spinal cord. These changes perpetuate pain messages and do not cease, even when the connection between the sensory nerve and the CNS is severed. With growing understanding of neuropathic pain and development of less invasive procedures, ablative procedures are used less frequently. However, they do have applications in select cases of peripheral neuropathy, cancer pain, and other disorders.


Preparation

Prior to beginning management, pain is thoroughly evaluated. Pain scales or questionnaires are used to attach an objective measure to a subjective experience. Objective measurements allow health care workers to better understand the pain being suffered by the patient. Evaluation also includes physical examinations and diagnostic tests to determine underlying causes. Some evaluations require assessments from several viewpoints, including neurology, psychiatry and psychology, and physical therapy. If pain is due to a medical procedure, management consists of anticipating the type and intensity of associated pain and managing it preemptively.

Nurses or physicians often take what is called a pain history. This will help to provide important information that can help health care providers to better manage the patient's pain. A typical pain history includes the following questions:

  • Where is the pain located?
  • On a scale of 1 to 10, with 1 indicating the least pain, how would the person rate the pain being experienced?
  • What does the pain feel like?
  • When did (or does) the pain start?
  • How long has the person had it?
  • Is the person sometimes free of pain?
  • Does the person know of anything that triggers the pain, or makes it worse?
  • Does the person have other symptoms (nausea, dizziness, blurred vision, etc.) during or after the pain?
  • What pain medications or other measures has the person found to help in easing the pain?
  • How does the pain affect the person's ability to carry on normal activities?
  • What does it mean to the person that he or she is experiencing pain?

Aftercare

An assessment by nursing staff as well as other health care providers should be made to determine the effectiveness of the pain management interventions employed. There are objective, measurable signs and symptoms of pain that can be looked for. The goal of good pain management is the absence of these signs. Signs of acute pain include:

  • rise in pulse and blood pressure
  • more rapid breathing
  • perspiring profusely, clammy skin
  • taut muscles
  • more tense appearance, fast speech, very alert
  • unusually pale skin
  • dilated pupils of the eye

Signs of chronic pain include:

  • lower pulse and blood pressure
  • changeable breathing pattern
  • warm, dry skin
  • nausea and vomiting
  • slow speech in monotone
  • inability, or difficulty in getting out of bed and doing activities
  • constricted pupils of the eye

When these signs are absent and the patient appears to be comfortable, health care providers can consider their interventions to have been successful. It is also important to document interventions used, and which ones were successful.


Risks

Owing to toxicity over the long term, some drugs can only be used for acute pain or as adjuncts in chronic pain management. NSAIDs have the well-known side effect of causing gastrointestinal bleeding, and long-term use of acetaminophen has been linked to kidney and liver damage. Other drugs, especially narcotics, have serious side effects such as constipation, drowsiness, and nausea. Serious side effects can also accompany pharmacological therapies; mood swings, confusion, bone thinning, cataract formation, increased blood pressure, and other problems may discourage or prevent use of some analgesics .

Non-pharmacological therapies carry little or no risks. However, it is advised that individuals recovering from serious illness or injury consult with the health care providers or physical therapists before making use of adjunct therapies. Invasive procedures carry risks similar to other surgical procedures, such as infection, reaction to anesthesia, and iatrogenic (injury as a result of treatment) injury.

A traditional concern about narcotics use has been the risk of promoting addiction. As narcotic use continues over time, the body becomes accustomed to the drug and adjusts normal functions to accommodate to its presence. Therefore, to elicit the same level of action, it is necessary to increase dosage over time. As dosage increases, an individual may become physically dependent on narcotic drugs.

However, physical dependence is different from psychological addiction. Physical dependence is characterized by discomfort if drug administration suddenly stops, while psychological addiction is characterized by an overpowering craving for the drug for reasons other than pain relief. Psychological addiction is a very real and necessary concern in some instances, but it should not interfere with a genuine need for narcotic pain relief. However, caution must be taken with people who have a history of addictive behavior.


Normal results

Effective application of pain management techniques reduces or eliminates acute or chronic pain. This treatment can improve an individual's quality of life and aid in recovery from injury and disease.


Resources

books

kozier, barbara, glenora erb, kathleen blais, and judith m. wilkinson. fundamentals of nursing, concepts, process and practice, 5th edition. redwood city, ca: addison-wesley, 1995.

salerno, evelyn, and joyce s. willens, eds. pain management handbook: an interdisciplinary approach. st. louis: mosby, 1996.


periodicals

choiniere, m., r. melzack, n. girard, j. rondeau, and m. j. paquin. "comparisons between patients' and nurses' assessment of pain and medication efficacy in severe burn injuries." pain 40, no.2 (february 1990): 14352.

everett, j. j., d. r. patterson, j. a. marvin, b. montgomery, n. ordonez, and k. campbell. "pain assessment from patients with burns and their nurses." journal of burn care rehabilitation 15, no.2 (marapr 1994): 1948.

mcpherson, m. l., c. d. ponte, and r. m. respond (eds.). "profiles in pain management." journal of the american pharmacists association (june 2003).


organizations

american chronic pain association. p.o. box 850, rocklin, ca 95677-0850. (916) 632-0922. <http://members.tripod.com/~widdy/acpa.html>.

american pain society. 4700 west lake ave., glenview, il 60025. (847) 375-4715. <http://www.ampainsoc.org>.

national chronic pain outreach association, inc. p.o. box 274, millboro, va 24460-9606. (540) 597-5004.

other

what we know about pain. national institute of dental research, national institute of health, bethseda, md 20892. (301) 496-4261.


Joan M. Schonbeck Sam Uretsky, PharmD

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Pain Management

Pain management

Definition

Pain management in cancer care encompasses all the actions taken to keep people with cancer as free of pain as possible. It includes pharmacological, psychological, and spiritual approaches to prevent, reduce, or stop pain sensations.

Purpose

It is estimated that more than 800,000 new cases of cancer are diagnosed each year in the United States, and 430,000 cancer victims will die. Though recent figures are hopeful and suggest a decline in both the incidence of cancer and the number of people who die from it, studies have consistently shown that at least 70% of cancer patients in the advanced stage of the disease will experience significant pain. Pain is a localized sensation ranging from mild discomfort to an unbearable, excruciating experience. It is, in its origins, a protective mechanism, designed to alert the brain to injury or disease conditions. Unfortunately, when the cause of the pain is known, such as in diagnosed cancer, and treatment is initiated, pain can often continue.

Once the message of cancer has been received and interpreted by the brain, further pain can be counter-productive. Pain can have a negative impact on a person's quality of life, causing depression and impeding recovery. Unrelieved pain can become a syndrome in its own right and cause a downward spiral in a person's health and outlook. Proper pain management facilitates recovery, prevents additional health complications, and improves an individual's quality of life.

Several independent studies of the relief of pain have shown that pain is often under-treated by the medical profession. For this reason, in the spring and summer of 2000, the Joint Commission on Accreditation of Health-care Organizations (JCAHO) and the American Pain Society (APS) developed standards for proper pain management.

Description

What is pain?

The treatment of pain has been a major endeavor since ancient times. By 400 b.c., the father of modern medicine, Hippocrates, had theorized that the brain, not the heart, was the controlling center of the body, and Greek anatomists had begun to identify various nerves and their purposes. The pain-relieving properties of opium were already known and were being utilized to stop suffering. Two thousand years ago, in China, acupuncture was being used to reduce pain.

Pain is the means by which the peripheral nervous system (PNS) warns the central nervous system (CNS) of injury or potential injury to the body. The CNS comprises the brain and spinal cord, and the PNS is composed of the nerves that stem from and lead into the CNS. PNS includes all nerves throughout the body except the brain and spinal cord.

A pain message is transmitted to the CNS by special PNS nerve cells called nociceptors. Nociceptors are distributed throughout the body and respond to different stimuli depending on their location. For example, nociceptors that extend from the skin are stimulated by sensations such as pressure, temperature, and chemical changes.

When a nociceptor is stimulated, neurotransmitters are released from cells. Neurotransmitters are chemicals found within the nervous system that facilitate nerve cell communication. The nociceptor transmits its signal to nerve cells within the spinal cord, which conveys the pain message to the thalamus, a specific region in the brain.

Once the brain has received and processed the pain message and coordinated an appropriate response, pain has served its purpose. The body uses natural pain killers, called endorphins, that are meant to derail further pain messages from the same source. However, these natural pain killers may not adequately dampen a continuing pain message. Also, depending on how the brain has processed the pain information, certain hormones, such as prostaglandins, may be released. These hormones enhance the pain message and play a role in immune system responses to injury, such as inflammation. Certain neurotransmitters, especially substance P and calcitonin gene-related peptide, actively enhance the pain message at the injury site and within the spinal cord.

It has been hypothesized that uninterrupted and unrelenting pain can induce changes in the spinal cord. In the past, unrelenting pain has been treated by severing a nerve's connection to the CNS. However, the lack of any sensory information being relayed by that nerve can cause pain transmission in the spinal cord to go into overdrive, as evidenced by the phantom limb pain experienced by amputees. Evidence is accumulating that unrelenting pain or the complete lack of nerve signals increases the number of pain receptors in the spinal cord. Nerve cells in the spinal cord may also begin secreting pain-amplifying neurotransmitters independent of actual pain signals from the body. Immune chemicals, primarily cytokines, may play a prominent role in such changes.

What is cancer pain?

The majority of cancer pain results from a cancerous tumor pressing on organs, nerves, or bone. However, several studies by pain-pioneer Dr. John Bonica and others have shown that a predictable 78% of all cancer pain is indeed related to the disease, but an impressive 19% was found to be caused instead by treatment of the cancer. Three percent of all complaints of pain were unrelated to either the disease or treatment.

Cancer pain is generally divided into three categories:

  • Visceral pain, usually caused by pressure resulting from the invasiveness of the tumor, expansion of the hepatic capsule, or injury caused by radiation or chemotherapy .
  • Somatic pain often resulting from bone metastasis.
  • Neuropathic pain, or pain caused by the pressure of a tumor on nerves, or the trauma to nerves resulting from either radiation, chemotherapy, or surgery.

Managing cancer pain

PHARMACOLOGICAL OPTIONS.

General guidelines developed by the World Health Organization (WHO) for pain management apply to cancer pain management as well. These guidelines follow a three-step ladder approach:

  • Mild pain is alleviated with acetominophen or nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs and acetaminophen are available as over-the-counter and prescription medications, and are frequently the initial pharmacological treatment for pain. These drugs can also be used as adjuncts to the other drug therapies, which might require a doctor's prescription. NSAIDs include aspirin, ibuprofen (Motrin, Advil, Nuprin), naproxen sodium (Aleve), and ketoprofen (Orudis KT). These drugs are used to treat pain from inflammation and work by blocking production of pain-enhancing neurotransmitters, such as prostaglandins. Acetaminophen is also effective against pain, but its ability to reduce inflammation is limited. NSAIDs and acetaminophen are effective for most forms of acute (sharp, but of a short course) pain.
  • Mild to moderate pain is eased with a milder opioid medication plus acetominophen or NSAIDs. Opioids are both actual opiate drugs such as morphine and codeine, and synthetic drugs based on the structure of opium. This drug class includes drugs such as oxycodon, methadone, and meperidine (Demerol). They provide pain relief by binding to specific opioid receptors in the brain and spinal cord, and thus block the perception of pain.
  • Moderate to severe pain is treated with stronger opioid drugs plus acetominophen or NSAIDs. Morphine is sometimes referred to as the "Gold Standard" of palliative care as it is not expensive, can be given starting with smaller doses and gradually increased, and is highly effective over a long period of time. It can also be administered orally (by mouth), rectally, or by injection.

Although antidepressant drugs were developed to treat depression, they are also effective in combating chronic headaches, cancer pain, and pain associated with nerve damage. Antidepressants shown to have analgesic (pain reducing) properties include amitriptyline (Elavil), trazodone (Desyrel), and imipramine (Tofranil). Anti-convulsant drugs share a similar background with antidepressants. Developed to treat epilepsy, anticonvulsants were found to relieve pain as well. Drugs such as phenytoin (Dilantin) and carbamazepine (Tegretol) are prescribed to treat the pain associated with nerve damage.

Close monitoring of the effects of pain medications is required in order to assure that adequate amounts of medication are given to produce the desired pain relief. When a person is comfortable with a certain dosage of medication, oncologists typically convert to a long-acting version of that medication. Transdermal fentanyl patches (Duragesic) are a common example of an long-acting opioid drug often used for cancer pain management. A patch containing the drug is applied to the skin where the drug is continuously absorbed by the body, usually for three days. Pumps are also available that provide an opioid medication upon demand when the person is experiencing pain. By pressing a button, they can release a set dose of medication into an intravenous solution or an implanted catheter. Another mode of administration involves implanted catheters that deliver pain medication directly to the spinal cord. Delivering drugs in this way can reduce side effects and increase the effectiveness of the drug. Research is underway to develop toxic substances that act selectively on nerve cells that carry pain messages to the brain, killing these selected cells, and thus stopping transmission of the pain message.

NON-PHARMACOLOGICAL OPTIONS.

Pain treatment options that do not involve drugs are often used as adjuncts to, rather than replacements for, drug therapy. One of the benefits of non-drug therapies is that an individual can take a more active stance against pain. Relaxation techniques, such as yoga and meditation, are used to shift the focus of the brain away from the pain, decrease muscle tension, and reduce stress. Tension and stress can also be reduced through biofeedback, in which an individual consciously attempts to modify skin temperature, muscle tension, blood pressure, and heart rate.

Participating in normal activities and exercising can also help control pain levels. Through physical therapy, an individual learns beneficial exercises for reducing stress, strengthening muscles, and staying fit. Regular exercise has been linked to production of endorphins, the body's natural pain killers.

Acupuncture involves the insertion of small needles into the skin at key points. Acupressure uses these same key points, but involves applying pressure rather than inserting needles. Both of these methods may work by prompting the body to release endorphins. Applying heat or being massaged are very relaxing and help reduce stress. Transcutaneous electrical nerve stimulation (TENS) applies a small electric current to certain parts of nerves, potentially interrupting pain signals and inducing release of endorphins. To be effective, use of TENS should be medically supervised.

Preparation

Assessment of cancer pain is absolutely essential to good pain management. Pain scales or questionnaires are sometimes used to attach an objective measure to a subjective experience. Objective measurements allow health care workers a better understanding of the pain being suffered by the patient. Pain has been called "the fifth vital sign, " (temperature, pulse, respiration and blood pressure being the other four vital signs), by the Veterans Administration. Evaluation also includes physical examinations and diagnostic tests to determine underlying cause of the pain. Some evaluations require assessments from several viewpoints, including neurology, psychiatry and psychology, and physical therapy.

Risks

Owing to toxicity over the long term, even non-prescription drugs must be carefully monitored in chronic pain management. NSAIDs have the well-known side effect of causing gastrointestinal bleeding, and long-term use of acetaminophen has been linked to kidney and liver damage. Other drugs, especially narcotics, have side effects such as constipation, drowsiness, and nausea. Sedation can often be reduced by the timing of when medication is taken (such as at bedtime), and constipation can be reduced by increasing the amount of fruits, vegetables, and whole-grain foods in the diet, or by the use of laxatives , stool softeners, or even enemas. Serious side effects can also accompany antidepressants and anti-convulsants, which may discourage or prevent their use depending upon the circumstances. These side effects include mood swings, confusion, bone thinning, cataract formation, increased blood pressure, and other problems.

Non-pharmacological therapies carry little or no risks. However, it is advised that individuals recovering from serious illness or injury consult with their health care providers or physical therapists before making use of adjunct therapies. Invasive procedures carry risks similar to other surgical procedures, such as infection, reaction to anesthesia, iatrogenic injury (injury as a result of treatment), and heart failure.

A traditional concern about narcotics use has been the risk of promoting addiction or tolerance. As narcotic use continues over time, as in terminal cancer, the body becomes accustomed to the drug and adjusts normal functions to accommodate to its presence. Therefore, to elicit the same level of action, it is necessary to increase dosage over time. Tolerance can be defined as a gradual lessening of the effectiveness of an opioid drug from continued use.

Many studies involving cancer patients have indicated that proper dosage of narcotic medication does not create an addiction to it. A major concern for many cancer patients though, is that the medication will stop working for them. Evidence suggests this is not true. A simple increase in the dose will usually cause the medication to relieve pain again. One of the biggest dangers is abruptly stopping an opioid medication or reducing the dose, as the person can then go into withdrawal, a potentially serious medical condition characterized by agitation, rapid heart rate, profuse sweating and sleeplessness.

However, physical dependence is different from psychological addiction. Physical dependence is characterized by discomfort if drug administration suddenly stops, while psychological addiction is characterized by an overpowering craving for the drug for reasons other than pain relief. Psychological addiction is a very real and necessary concern in some instances, but it should not interfere with a genuine need for narcotic pain relief.

Normal results

Effective application of pain management techniques reduces or eliminates cancer pain. This treatment can improve an individual's quality of life and aid in recovery.

Perhaps the best measure of the results of pain management for cancer patients would be the fulfillment of the recently-developed Bill of Rights for Cancer Pain. It is as follows:

  • You have the right to have pain believed.
  • You have the right to have pain controlled.
  • You have the right to have pain resulting from treatments and procedures prevented, or at least minimized.
  • You have the right to be treated with respect at all times, when medication is needed, to not be treated like a drug abuser.

Resources

BOOKS

Clayman, Charles, MD. The American Medical Association Home Medical Encyclopedia. Random House, 1989.

Salerno, Evelyn, and Joyce S. Willens, eds. Pain Management Handbook: An Interdisciplinary Approach. St. Louis: Mosby, 1996.

Tollison, C. David, John R. Satterthwaite, and Joseph W. Tollison, eds. Handbook of Pain Management. 2nd ed. Baltimore: Williams & Wilkins, 1994.

PERIODICALS

Montauk, Susan Louisa, and Jill Martin. "Treating Chronic Pain." American Family Physician 55 (March 1997): 1151.

Perron, Vincent, MD, and Ronald S. Schonwetter, MD. "Assessment and Management of Pain in Palliative Care Patients." Cancer Control: Journal of the Moffitt Cancer Center 27 (January 2001).

Phillips, Donald M. "JCAHO Pain Management Standards Are Unveiled." Journal of the American Medical Association (July 26, 2000).

Regan, Joan M. MB, BCh, FFARCSI, and Philip Peng, MBBS, FRCPC. "Neurophysiology of Cancer Pain." Cancer Con trol: Journal of the Moffitt Cancer Center 27 (July 2000).

ORGANIZATION

American Chronic Pain Association. PO Box 850, Rocklin, CA 95677-0850. (916) 632-0922. <http://members.tripod.com/~widdy/acpa.html>.

American Pain Society. 4700 West Lake Ave., Glenview, IL 60025. (847) 375-4715. <http://www.ampainsoc.org>.

Cancer Care, Inc. "Bill of Rights for Cancer Pain." <http://www.cancerpainrelief.com/cancerpain/guide/relief/content.htm>.

National Cancer Institute. "Cancer Facts." (September 26, 2000). <http://cancer.gov>.

National Chronic Pain Outreach Association, Inc. PO Box 274, Millboro, VA 24460-9606. (540) 997-5004.

Julia Barrett

Joan Schonbeck, R.N.

KEY TERMS

Acute

A short-term pain in response to injury or other stimulus that resolves when the injury heals or the stimulus is removed.

Chemotherapy

The treatment of infections or malignant diseases by drugs that act selectively on the cause of the disorder, but which may have substantial side effects.

Chronic

Pain that endures beyond the term of an injury or painful stimulus. Also refers to cancer pain, pain from a chronic or degenerative disease, and pain from an unidentified cause.

CNS or central nervous system

The part of the nervous system that includes the brain and the spinal cord.

Hepatic capsule

The membranous bag enclosing the liver.

Iatrogenic

Resulting from the activity of the physician.

Metastasis

A secondary malignant tumor (one that has spread from a primary cancer to affect other parts of the body.

Neuropathy

Nerve damage.

Neurotransmitter

Chemicals within the nervous system that transmit information from or between nerve cells.

Nociceptor

A nerve cell capable of sensing pain and transmitting a pain signal.

Non-pharmacological

Therapy that does not involve drugs.

Palliative

Serving to relieve, or alleviate, without curing.

Pharmacological

Therapy that relies on drugs.

PNS or peripheral nervous system

Nerves that are outside of the brain and spinal cord.

Radiation

A treatment for cancer (and occasionally other diseases) by x rays or other sources of radioactivity, both of which produce ionizing radiation. The radiation, as it passes through diseased tissue, destroys or slows the development of abnormal cells.

Stimulus

A factor capable of eliciting a response in a nerve.

QUESTIONS TO ASK THE DOCTOR

  • Does my type of cancer usually cause pain, and if so, how will the pain be treated?
  • Does the radiation or chemotherapy that I may have cause pain?
  • What are the side-effects of the medications you will order?
  • What things can I do to help with my pain management?
  • Does the pain necessarily mean that the cancer is getting worse?

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Pain Management

Pain Management

Definition

Pain management encompasses pharmacological, nonpharmacological, and other approaches to prevent, reduce, or stop pain sensations.

Purpose

Pain serves as an alert to potential or actual damage to the body. The definition for damage is quite broad; pain can arise from injury as well as disease. After the message is received and interpreted, further pain can be counter-productive. Pain can have a negative impact on a person's quality of life and impede recovery from illness or injury. Unrelieved pain can become a syndrome in its own right and cause a downward spiral in a person's health and outlook. Managing pain properly facilitates recovery, prevents additional health complications, and improves an individual's quality of life.

Description

What is pain?

Before considering pain management, a review of pain definitions and mechanisms may be useful. Pain is the means by which the peripheral nervous system (PNS) warns the central nervous system (CNS) of injury or potential injury to the body. The CNS comprises the brain and spinal cord, and the PNS is composed of the nerves that stem from and lead into the CNS. The PNS includes all nerves throughout the body except the brain and spinal cord.

A pain message is transmitted to the CNS by special PNS nerve cells called nociceptors. Nociceptors are distributed throughout the body and respond to different stimuli depending on their location. For example, nociceptors that extend from the skin are stimulated by sensations such as pressure, temperature, and chemical changes.

When a nociceptor is stimulated, neurotransmitters are released within the cell. Neurotransmitters are chemicals found within the nervous system that facilitate nerve cell communication. The nociceptor transmits its signal to nerve cells within the spinal cord, which conveys the pain message to the thalamus, a specific region in the brain.

Once the brain has received and processed the pain message and coordinated an appropriate response, pain has served its purpose. The body uses natural pain killers, called endorphins, that are meant to derail further pain messages from the same source. However, these natural pain killers may not adequately dampen a continuing pain message. Also, depending on how the brain has processed the pain information, certain hormones, such as prostaglandins, may be released. These hormones enhance the pain message and play a role in immune system responses to injury, such as inflammation. Certain neurotransmitters, especially substance P and calcitonin gene-related peptide, actively enhance the pain message at the injury site and within the spinal cord.

Pain is generally divided into two categories: acute and chronic. Nociceptive pain, or the pain that is transmitted by nociceptors, is typically called acute pain. This kind of pain is associated with injury, headaches, disease, and many other conditions. It usually resolves once the condition that caused it is resolved.

Following some disorders, pain does not resolve. Even after healing or a cure has been achieved, the brain continues to perceive pain. In this situation, the pain may be considered chronic. The time limit used to define chronic pain typically ranges from three to six months, although some healthcare professionals prefer a more flexible definition, and consider chronic pain as pain that endures beyond a normal healing time. The pain associated with cancer, persistent and degenerative conditions, and neuropathy, or nerve damage, is included in the chronic category. Also, unremitting pain that lacks an identifiable physical cause, such as the majority of cases of low back pain, may be considered chronic. The underlying biochemistry of chronic pain appears to be different from regular nociceptive pain.

Some researchers have said that uninterrupted and unrelenting pain can induce changes in the spinal cord. In the past, intractable pain has been treated by severing a nerve's connection to the CNS. However, the lack of any sensory information being relayed by that nerve can cause pain transmission in the spinal cord to go into overdrive, as evidenced by the phantom limb pain experienced by amputees. Evidence is accumulating that unrelenting pain or the complete lack of nerve signals increases the number of pain receptors in the spinal cord. Nerve cells in the spinal cord may also begin secreting pain-amplifying neurotransmitters independent of actual pain signals from the body. Immune chemicals, primarily cytokines, may play a prominent role in such changes.

Scientists have long recognized a relationship between depression and chronic pain. In 2004, a survey of California adults diagnosed with major depressive disorder revealed that more than one-half of them also suffered from chronic pain.

Managing pain

Considering the different causes and types of pain, as well as its nature and intensity, management can require an interdisciplinary approach. The elements of this approach include treating the underlying cause of pain, pharmacological and nonpharmacological therapies, and some invasive (surgical) procedures.

Treating the cause of pain underpins the idea of managing it. Injuries are repaired, diseases are diagnosed, and certain encounters with pain can be anticipated and treated prophylactically (by prevention). However, there are no guarantees of immediate relief from pain. Recovery can be impeded by pain and quality of life can be damaged. Therefore, pharmacological and other therapies have developed over time to address these aspects of disease and injury.

PHARMACOLOGICAL OPTIONS. Pain-relieving drugs, otherwise called analgesics, include nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, narcotics, antidepressants, anticonvulsants, and others. NSAIDs and acetaminophen are available as over-the-counter and prescription medications, and are frequently the initial pharmacological treatment for pain. These drugs can also be used as adjuncts to the other drug therapies, which might require a doctor's prescription.

NSAIDs include aspirin, ibuprofen (Motrin, Advil, Nuprin), naproxen sodium (Aleve), and ketoprofen (Orudis KT). These drugs are used to treat pain from inflammation and work by blocking production of pain-enhancing neurotransmitters, such as prostaglandins. Acetaminophen is also effective against pain, but its ability to reduce inflammation is limited.

NSAIDs and acetaminophen are effective for most forms of acute (sharp, but of a short course) pain, but moderate and severe pain may require stronger medication. Narcotics handle intense pain effectively, and are used for cancer pain and acute pain that does not respond to NSAIDs and acetaminophen. Narcotics are classified as either opiates or opioids, and are available only with a doctor's prescription. Opiates include morphine and codeine, which are derived from opium, a substance naturally found in some poppy species. Opioids are synthetic drugs based on the structure of opium. This drug class includes drugs such as oxycodon, methadone, and meperidine (Demerol). In August 2004, the Drug Enforcement Administration (DEA) issued new guidelines to help physicians prescribe narcotics appropriately without fear of being arrested for prescribing the drugs beyond the scope of their medical practice. DEA is trying to work with physicians to ensure that those who need to drugs receive them but to ensure opioids are not abused.

Narcotics may be ineffective against some forms of chronic pain, especially since changes in the spinal cord may alter the usual pain signaling pathways. In such situations, pain can be managed with the help of with antidepressants and anticonvulsants, which are also only available with a doctor's prescription.

Although antidepressant drugs were developed to treat depression, it has been discovered that they are also effective in combating some chronic headaches, cancer pain, and pain associated with nerve damage. Antidepressants that have been shown to have analgesic (pain reducing) properties include amitriptyline (Elavil), trazodone (Desyrel), and imipramine (Tofranil). Anticonvulsant drugs share a similar background with antidepressants. Developed to treat epilepsy, certain anticonvulsants were found to relieve pain as well. Drugs such as phenytoin (Dilantin) and carbamazepine (Tegretol) are prescribed to treat the pain associated with nerve damage.

Other prescription drugs are used to treat specific types of pain or specific pain syndromes. For example, corticosteroids are effective against pain caused by inflammation and swelling, and sumatriptan (Imitrex) was developed to treat migraine headaches.

Drug administration depends on the drug type and the required dose. Some drugs are not absorbed very well from the stomach and must be injected or administered intravenously. Injections and intravenous administration may also be used when high doses are needed or if an individual is nauseous. Following surgery and other medical procedures, patients may have the option of controlling the pain medication themselves. By pressing a button, they can release a set dose of medication into an intravenous solution. This procedure has also been employed in other situations requiring pain management. Another mode of administration involves implanted catheters that deliver pain medication directly to the spinal cord. Delivering drugs in this way can reduce side effects and increase the effectiveness of the drug.

NONPHARMACOLOGICAL OPTIONS. Pain treatment options that do not use drugs are often used as adjuncts to, rather than replacements for, drug therapy. One of the benefits of non-drug therapies is that an individual can take a more active stance against pain. Relaxation techniques, such as yoga and meditation, are used to decrease muscle tension and reduce stress. Tension and stress can also be reduced through biofeedback, in which an individual consciously attempts to modify skin temperature, muscle tension, blood pressure, and heart rate.

Participating in normal activities and exercising can also help control pain levels. Through physical therapy, an individual learns beneficial exercises for reducing stress, strengthening muscles, and staying fit. Regular exercise has been linked to production of endorphins, the body's natural pain killers.

Acupuncture involves the insertion of small needles into the skin at key points. Acupressure uses these same key points, but involves applying pressure rather than inserting needles. Both of these methods may work by prompting the body to release endorphins. Applying heat or being massaged are very relaxing and help reduce stress. Transcutaneous electrical nerve stimulation (TENS) applies a small electric current to certain parts of nerves, potentially interrupting pain signals and inducing release of endorphins. To be effective, use of TENS should be medically supervised.

INVASIVE PROCEDURES. There are three types of invasive procedures that may be used to manage or treat pain: anatomic, augmentative, and ablative. These procedures involve surgery, and certain guidelines should be followed before carrying out a procedure with permanent effects. First, the cause of the pain must be clearly identified. Next, surgery should be done only if noninvasive procedures are ineffective. Third, any psychological issues should be addressed. Finally, there should be a reasonable expectation of success.

Anatomic procedures involve correcting the injury or removing the cause of pain. Relatively common anatomic procedures are decompression surgeries, such as repairing a herniated disk in the lower back or relieving the nerve compression related to carpal tunnel syndrome. Another anatomic procedure is neurolysis, also called a nerve block, which involves destroying a portion of a peripheral nerve.

Augmentative procedures include electrical stimulation or direct application of drugs to the nerves that are transmitting the pain signals. Electrical stimulation works on the same principle as TENS. In this procedure, instead of applying the current across the skin, electrodes are implanted to stimulate peripheral nerves or nerves in the spinal cord. Augmentative procedures also include implanted drug-delivery systems. In these systems, catheters are implanted in the spine to allow direct delivery of drugs to the CNS.

Ablative procedures are characterized by severing a nerve and disconnecting it from the CNS. However, this method may not address potential alterations within the spinal cord. These changes perpetuate pain messages and do not cease even when the connection between the sensory nerve and the CNS is severed. With growing understanding of neuropathic pain and development of less invasive procedures, ablative procedures are used less frequently. However, they do have applications in select cases of peripheral neuropathy, cancer pain, and other disorders.

Preparation

Prior to beginning management, pain is thoroughly evaluated. Pain scales or questionnaires are used to attach an objective measure to a subjective experience. Objective measurements allow health care workers a better understanding of the pain being experienced by the patient. Evaluation also includes physical examinations and diagnostic tests to determine underlying causes. Some evaluations require assessments from several viewpoints, including neurology, psychiatry and psychology, and physical therapy. If pain is due to a medical procedure, management consists of anticipating the type and intensity of associated pain and managing it preemptively.

Risks

Owing to toxicity over the long term, some drugs can only be used for acute pain or as adjuncts in chronic pain management. NSAIDs have the well-known side effect of causing gastrointestinal bleeding, and long-term use of acetaminophen has been linked to kidney and liver damage. Other drugs, especially narcotics, have serious side effects, such as constipation, drowsiness, and nausea. Serious side effects can also accompany pharmacological therapies; mood swings, confusion, bone thinning, cataract formation, increased blood pressure, and other problems may discourage or prevent use of some analgesics.

KEY TERMS

Acute Referring to pain in response to injury or other stimulus that resolves when the injury heals or the stimulus is removed.

Chronic Referring to pain that endures beyond the term of an injury or painful stimulus. Can also refer to cancer pain, pain from a chronic or degenerative disease, and pain from an unidentified cause.

CNS or central nervous system The part of the nervous system that includes the brain and the spinal cord.

Iatrogenic Resulting from the activity of the physician.

Neuropathy Nerve damage.

Neurotransmitter Chemicals within the nervous system that transmit information from or between nerve cells.

Nociceptor A nerve cell that is capable of sensing pain and transmitting a pain signal.

Nonpharmacological Referring to therapy that does not involve drugs.

Pharmacological Referring to therapy that relies on drugs.

PNS or peripheral nervous system Nerves that are outside of the brain and spinal cord.

Stimulus A factor capable of eliciting a response in a nerve.

Nonpharmacological therapies carry little or no risk. However, it is advised that individuals recovering from serious illness or injury consult with their health care providers or physical therapists before making use of adjunct therapies. Invasive procedures carry risks similar to other surgical procedures, such as infection, reaction to anesthesia, iatrogenic (injury as a result of treatment) injury, and failure.

A traditional concern about narcotics use has been the risk of promoting addiction. As narcotic use continues over time, the body becomes accustomed to the drug and adjusts normal functions to accommodate to its presence. Therefore, to elicit the same level of action, it is necessary to increase dosage over time. As dosage increases, an individual may become physically dependent on narcotic drugs.

However, physical dependence is different from psychological addiction. Physical dependence is characterized by discomfort if drug administration suddenly stops, while psychological addiction is characterized by an overpowering craving for the drug for reasons other than pain relief. Psychological addiction is a very real and necessary concern in some instances, but it should not interfere with a genuine need for narcotic pain relief. However, caution must be taken with people with a history of addictive behavior.

Normal results

Effective application of pain management techniques reduces or eliminates acute or chronic pain. This treatment can improve an individual's quality of life and aid in recovery from injury and disease.

Resources

PERIODICALS

Finn, Robert. "More than Half of Patients With Major Depression Have Chronic Pain." Family Practice News October 15, 2004: 38.

"New Guidelines Set for Better Pain Treatment." Medical Letter on the CDC & FDA September 5, 2004: 95.

ORGANIZATIONS

American Chronic Pain Association. P.O. Box 850, Rocklin, CA 95677-0850. (916) 632-0922. http://members.tripod.com/widdy/ACPA.html.

American Pain Society. 4700 West Lake Ave., Glenview, IL 60025. (847) 375-4715. http://www.ampainsoc.org.

National Chronic Pain Outreach Association, Inc. P.O. Box 274, Millboro, VA 24460-9606. (540) 997-5004.

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Pain Management

Pain management

Definition

Pain management covers a number of methods to prevent, reduce, or stop pain sensations. These include the use of medications; physical methods such as ice and physical therapy; and psychological methods.

Purpose

Pain serves as an alert to potential or actual damage to the body. The definition for damage is quite broad; pain can arise from injury as well as disease. Pain that acts as a warning is called productive pain. After the message is received and interpreted, further pain offers no real benefit. Pain can have a negative impact on a person's quality of life and impede recovery from illness or injury. Unrelieved pain can become a syndrome in its own right and cause a downward spiral in a person's health and outlook. Managing pain properly facilitates recovery, prevents additional health complications, and improves a person's quality of life.

For many years it was believed that infants do not feel pain the way older children and adults do. As of the early 2000s, however, there has been a better understanding of the problems of pain, even in infancy.

Description

Before considering pain management, a review of pain definitions and mechanisms may be useful.

What is pain?

Pain is the means by which the peripheral nervous system (PNS) warns the central nervous system (CNS) of injury or potential injury to the body. The CNS comprises the brain and spinal cord, and the PNS is composed of the nerves that stem from and lead into the CNS. PNS includes all nerves throughout the body except the brain and spinal cord.

Once the brain has received and processed the pain message and coordinated an appropriate response, pain has served its purpose. The body uses natural pain killers, called endorphins, that are meant to derail further pain messages from the same source. However, these natural pain killers may not adequately dampen a continuing pain message. Pain is generally divided into two categories: acute and chronic.

Acute and chronic pain

Nociceptive pain, or the pain that is transmitted by nociceptors, is typically called acute pain. This kind of pain is associated with injury, headaches, disease, and many other conditions. It usually resolves once the condition that caused it is resolved. However, following some disorders, pain does not resolve. Even after healing or a cure has been achieved, the brain continues to perceive pain. In this situation, the pain may be considered chronic. The time limit used to define chronic pain typically ranges from three to six months, although some healthcare professionals prefer a more flexible definition and consider pain chronic when it endures beyond a normal healing time. The pain associated with cancer , persistent and degenerative conditions, and neuropathy, or nerve damage, is included in the chronic category. Also, constant pain that lacks an identifiable physical cause, such as the majority of cases of low back pain, may be considered chronic.

It has been hypothesized that uninterrupted and unrelenting pain can induce changes in the spinal cord. As of 2004 evidence was accumulating that unrelenting pain or the complete lack of nerve signals increases the number of pain receptors in the spinal cord. Nerve cells in the spinal cord may also begin secreting pain-amplifying neurotransmitters independent of actual pain signals from the body. Other studies indicate that even newborn and premature infants who have constant pain will reach adulthood with greater sensitivity to pain and lower tolerance of stress.

Managing pain

Considering the different causes and types of pain, as well as its nature and intensity, management can require an interdisciplinary approach. The elements of this approach include treating the underlying cause of pain, pharmacological and nonpharmacological therapies, and some invasive (surgical) procedures.

Treating the cause of pain underpins the idea of managing it. Injuries are repaired, diseases are diagnosed, and certain encounters with pain can be anticipated and prevented. However, there are no guarantees of immediate relief from pain. Recovery can be impeded by pain, and quality of life can be damaged.

Pharmacological options

Pain-relieving drugs, otherwise called analgesics , include nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen , narcotics, antidepressants , anticonvulsants, and others. NSAIDs and acetaminophen are available as over-the-counter and prescription medications and are frequently the initial pharmacological treatment for pain. These drugs can also be used as adjuncts to other drug therapies, which might require a doctor's prescription.

NSAIDs include aspirin, ibuprofen (Motrin, Advil, Nuprin), naproxen sodium (Aleve), and ketoprofen (Orudis KT). These drugs are used to treat pain from inflammation and work by blocking production of pain-enhancing neurotransmitters, such as prostaglandins. Acetaminophen is also effective against pain, but it is not an anti-inflammatory drug.

NSAIDs and acetaminophen are effective for most forms of mild pain, but moderate and severe pain may require stronger medication. Narcotics handle intense pain effectively and are used for cancer pain and acute pain that does not respond to NSAIDs and acetaminophen.

Narcotics may be ineffective against some forms of chronic pain, especially since changes in the spinal cord may alter the usual pain signaling pathways. Furthermore, narcotics are usually not recommended for long-term use because the body develops a tolerance to narcotics, reducing their effectiveness over time. In such situations, pain can be managed with antidepressants and anticonvulsants, which are also only available with a doctor's prescription.

Although antidepressant drugs were developed to treat depression, it has been discovered that they are also effective in combating chronic headaches, cancer pain, and pain associated with nerve damage. Antidepressants that have been shown to have analgesic (pain reducing) properties include amitriptyline (Elavil), trazodone (Desyrel), and imipramine (Tofranil). Anticonvulsant drugs share a similar background with antidepressants. Developed to treat epilepsy, anticonvulsants were found to relieve pain as well. Drugs such as phenytoin (Dilantin) and carbamazepine (Tegretol) are prescribed to treat the pain associated with nerve damage.

Other prescription drugs are used to treat specific types of pain or specific pain syndromes. For example, corticosteroids are very effective against pain caused by inflammation and swelling, and sumatriptan (Imitrex) was developed to treat migraine headaches.

Drug administration depends on the drug type and the required dose. Some drugs are not absorbed very well from the stomach and must be injected or administered intravenously. Injections and intravenous administration may also be used when high doses are needed or if an individual is nauseous. Following surgery and other medical procedures, patients may have the option of controlling the pain medication themselves. By pressing a button, they can release a set dose of medication into an intravenous solution. This procedure has also been employed in other situations requiring pain management. Another mode of administration involves implanted catheters that deliver pain medication directly to the spinal cord. Delivering drugs in this way can reduce side effects and increase the effectiveness of the drug.

Nonpharmacological options

Pain treatment options that do not use drugs are often used as adjuncts to, rather than replacements for, drug therapy. One of the benefits of non-drug therapies is that an individual can take a more active stance against pain. Relaxation techniques, such as yoga and meditation, are used to decrease muscle tension and reduce stress. Tension and stress can also be reduced through biofeedback, in which an individual consciously attempts to modify skin temperature, muscle tension, blood pressure, and heart rate.

Participating in normal activities and exercising can also help control pain levels. Through physical therapy, an individual learns beneficial exercises for reducing stress, strengthening muscles, and staying fit. Regular exercise has been linked to production of endorphins, the body's natural pain killers.

Acupuncture involves the insertion of small needles into the skin at key points. Acupressure uses these same key points but involves applying pressure rather than inserting needles. Both of these methods may work by prompting the body to release endorphins. Applying heat or being massaged are very relaxing and help reduce stress. Transcutaneous electrical nerve stimulation (TENS) applies a small electric current to certain parts of nerves, potentially interrupt pain signals and induce the release of endorphins. To be effective, use of TENS should be medically supervised.

Invasive procedures

Three types of invasive procedures may be used to manage or treat pain: anatomic, augmentative, and ablative. These procedures involve surgery, and certain guidelines should be followed before carrying out a procedure with permanent effects. First, the cause of the pain must be clearly identified. Next, surgery should be done only if noninvasive procedures are ineffective. Third, any psychological issues should be addressed. Finally, there should be a reasonable expectation of success.

Anatomic procedures involve correcting the injury or removing the cause of pain. Relatively common anatomic procedures are decompression surgeries, such as repairing a herniated disk in the lower back or relieving the nerve compression related to carpal tunnel syndrome. Another anatomic procedure is neurolysis, also called a nerve block, which involves destroying a portion of a peripheral nerve.

Augmentative procedures include electrical stimulation or direct application of drugs to the nerves that are transmitting the pain signals. Electrical stimulation works on the same principle as TENS. In this procedure, instead of applying the current across the skin, electrodes are implanted to stimulate peripheral nerves or nerves in the spinal cord.

Ablative procedures are characterized by severing a nerve and disconnecting it from the spinal cord.

Preparation

Prior to beginning management, pain is thoroughly evaluated. Pain scales or questionnaires are used to attach an objective measure to a subjective experience. Objective measurements allow healthcare workers a better understanding of the pain being experienced by the patient. Evaluation also includes physical examinations and diagnostic tests to determine underlying causes. Some evaluations require assessments from several viewpoints, including neurology, psychiatry, psychology, and physical therapy. If pain is due to a medical procedure, management consists of anticipating the type and intensity of associated pain and managing it preemptively.

Risks

Owing to toxicity over the long term, some drugs can only be used for acute pain or as adjuncts in chronic pain management. NSAIDs have the well-known side effect of causing gastrointestinal bleeding, and long-term use of acetaminophen has been linked to kidney and liver damage. Other drugs, especially narcotics, have serious side effects, such as constipation , drowsiness, and nausea . Serious side effects can also accompany pharmacological therapies; mood swings, confusion, bone thinning, cataract formation, increased blood pressure, and other problems may discourage or prevent use of some analgesics.

Nonpharmacological therapies carry little or no risk. However, it is advised that individuals recovering from serious illness or injury consult with their healthcare providers or physical therapists before making use of adjunct therapies. Invasive procedures carry risks similar to other surgical procedures, such as infection, reaction to anesthesia, iatrogenic (injury as a result of treatment) injury, and failure.

A traditional concern about narcotics use has been the risk of promoting addiction . As narcotic use continues over time, the body becomes accustomed to the drug and adjusts normal functions to accommodate to its presence. Therefore, to elicit the same level of action, it is necessary to increase dosage over time. As dosage increases, an individual may become physically dependent on narcotic drugs .

However, physical dependence is different from psychological addiction. Physical dependence is characterized by discomfort if drug administration suddenly stops, while psychological addiction is characterized by an overpowering craving for the drug for reasons other than pain relief. Psychological addiction is a very real and necessary concern in some instances, but it should not interfere with a genuine need for narcotic pain relief. However, caution must be taken with people with a history of addictive behavior.

Parental concerns

Infants feel pain, but do not express it in the same manner as older children or young adults. Studies indicate that the majority of parents do not know how to recognize the signs of infant pain, and pediatricians fail to teach parents what to look for. Training of parents is essential in recognizing and dealing with pain in infants and young children.

In some cases, narcotic analgesics are essential for control of childhood pain. These drugs are safe when used properly and should not be withheld for fear of addiction.

Because exposure to chronic pain by children can lead to life-long changes in their pain response, parents must learn to recognize and treat pain promptly.

Over-the-counter pain relievers may be toxic. Parents must read the labeled directions carefully and follow them exactly. For liquids, it is essential to use the proper measuring devices, such as a measuring dropper or medicinal teaspoon. Household measures are not reliable.

KEY TERMS

Acute Refers to a disease or symptom that has a sudden onset and lasts a relatively short period of time.

Central nervous system Part of the nervous system consisting of the brain, cranial nerves, and spinal cord. The brain is the center of higher processes, such as thought and emotion and is responsible for the coordination and control of bodily activities and the interpretation of information from the senses. The cranial nerves and spinal cord link the brain to the peripheral nervous system, that is the nerves present in the rest of body.

Chronic Refers to a disease or condition that progresses slowly but persists or recurs over time.

Iatrogenic A condition that is caused by the diagnostic procedures or treatments administered by medical professionals. Iatrogenic conditions may be caused by any number of things including contaminated medical instruments or devices, contaminated blood or implants, or contaminated air within the medical facility.

Neuropathy A disease or abnormality of the peripheral nerves (the nerves outside the brain and spinal cord). Major symptoms include weakness, numbness, paralysis, or pain in the affected area.

Neurotransmitter A chemical messenger that transmits an impulse from one nerve cell to the next.

Nociceptor A nerve cell that is capable of sensing pain and transmitting a pain signal.

Nonpharmacological Referring to therapy that does not involve drugs.

Peripheral nervous system (PNS) The part of the nervous system that is outside the brain and spinal cord. Sensory, motor, and autonomic nerves are included. PNS nerves link the central nervous system with sensory organs, muscles, blood vessels, and glands.

Pharmacological Referring to therapy that relies on drugs.

Stimulus Anything capable of eliciting a response in an organism or a part of that organism.

See also Acetaminophen; Nonsteroidal anti-inflammatory drugs.

Resources

PERIODICALS

Byers, J. F., and K. Thornley. "Cueing into infant pain." MCN American Journal of Maternal and Child Nursing 29, no. 2 (March-April 2004): 8489.

Stinshoff V. J., et al. "Effect of sex and gender on drug-seeking behavior during invasive medical procedures." Academy of Radiology 11, no. 4 (April 2004: 390397.

ORGANIZATIONS

American Chronic Pain Association. PO Box 850, Rocklin, CA 956770850. Web site: <members.tripod.com/~widdy/ACPA.html>.

American Pain Society. 4700 West Lake Ave., Glenview, IL 60025. Web site: <www.ampainsoc.org>.

WEB SITES

"Instructions for the Infant Pain Scale." Virtual Children's Hospital, Acute Pain Management for Pediatric Patients. Available online at <www.vh.org/pediatric/provider/pediatrics/PediatricPainMgmt/infantpainscale.html> (accessed on September 28, 2004).

"Riley Infant Pain Scale Assessment Tool." Cancer Pain Management in Children. Available at <www.childcancerpain.org/content.cfm?content=assess09> (accessed September 28, 2004).

Julia Barrett Samuel Uretsky, PharmD

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Pain Management

PACE

See Health and long-term care program integration

PAIN MANAGEMENT

Pain is an unpleasant sensation induced by a noxious stimulus, and is transmitted along special nerve pathways to the brain. Many older adults state that it is the experience of chronic pain, more than anything else, that alters their individual sense of themselves, making them finally "feel old." While many age-related conditions give rise to pain, the experience of pain itself is nevertheless not part of normal aging. Indeed, there is evidence that the thresholds for some types of pain appear to be increased in older adults (i.e., they feel some types of pain less readily than younger adults).

Pain is one modality of the sensory system (others are the experience of light and deep touch, temperature, and vibration sense). Pain is a useful sensation that warns the body of injury, but chronic pain can be both physically wearing and psychologically debilitating. Pain sensation is perceived as a consequence of pain receptors (nocioceptors) located throughout the body. Through peripheral nerve pathways, pain impulses travel to the spinal cord and thence to the brain. In the brain several structures participate in the transmission of the pain impulses and in their appreciation in consciousness. Some part of the appreciation of pain appears to be susceptible to conscious manipulation, but many of the pain pathways are mediated as reflexes (i.e., they are not subject to conscious control).

Pain receptors function differently in different parts of the body, as reflected, in part, by differences in the ability to distinguish the source of pain. For example, pain in the hand can be localized very precisely to within millimeters of its source, whereas pain in the heart, as in a heart attack, can be experienced in the chest, arm, or jaw. Indeed, in some elderly people who have acute pain, it can be manifested as delirium, and not as any specific complaint of pain.

To understand such a broad class of sensations, pain can be approached in a number of ways. One way is to contrast acute pain with chronic pain. The latter is not just acute pain that has persisted, but pain that impacts on emotions and on an individual's sense of well-being, often in such a way that each feeds back negatively on the other.

Pain is traditionally divided by its likely source, as being somatic (e.g., pain in joints, muscles, skin), visceral (e.g., from irritation, stretching, compression, or infiltration of organs such as the heart, liver, or lungs), or neuropathic (i.e., pain arising from the peripheral nerves, the spinal cord, or certain parts of the brain, especially the thalamus). Of all the types of chronic pain, neuropathic pain can be the most difficult to treat with traditional analgesic medications. Nontraditional approaches seem to offer some benefit in all types of pain, although they apparently need to be used with regularity to achieve their greatest impact.

Pain is a particularly important problem among older adults who undergo surgery, and the discipline of anesthesia has developed many strategies for pain relief in older adults. Pain control is also an important focus of palliative care. In community-dwelling older adults who are physically frail, it appears that pain is common and its control is often inadequate. Pain is linked to the progression of disability in older adults who are functionally impaired.

The principles of pain management in older adults are similar to pain management principles in general. The lowest effective doses should be employed. Drugs for chronic pain should be given proactively on a regular basis, and not in reaction to pain. Even when patients are in the hospital, they should have a role in determining how often pain medication is given, and at what dose. Where chronic pain is poorly controlled by a single medication, combinations of medications should be used, in conjunction with nonpharmacologic approaches. Such approaches can include massage, acupuncture, and therapeutic use of heat and cold, as well as techniques such as yoga, visualization, self-hypnosis, and biofeed-back.

Pain is experienced as even more noxious when it is accompanied by emotional upset (such as fear or anger), and especially when it is accompanied by a sense of lack of control. In consequence, counseling to provide insight into these factors, as well as techniques to help patients regain control, can be particularly beneficial. For this, the setting of precise goals can be especially useful. Specifying a range of goals, from being always pain free to something short of that, allows progress to be measured and the results of intermediate states to be documented. This in turn allows more precise dose adjustments. Finally, people with chronic pain can be reassured that waxing and waning is common, and that other stressful events in their lives can make pain seem worse. Often this helps patients to cope with residual anxiety about underlying problems that provide a secondary source of worry when pain seems less easy to control.

Kenneth Rockwood

See also Anesthesia; Arthritis; Brain; Palliative Care; Touch, Sense of.

BIBLIOGRAPHY

Gregoratos G. "Clinical Manifestations of Acute Myocardial Infarction in Older Patients." American Journal of Geriatric Cardiology 10, no. 6 2001: 345347.

Landi, F.; Onder, G.; Cesari, M.; Gambassi, G.; Steel, K.; Russo, A.; Lattanzio, F.; and Bernabei, R. "Pain Management in Frail, Community-Living Elderly Patients." Archives of Internal Medicine 161, no. 22 (2001): 27212724.

Leville, S. G.; Ling, S.; Hochberg, M. C.; Resnick, H. E.; Bandeen-Roche, K. J.; Won, A.; and Guralnik, J. M. "Widespread Musculoskeletal Pain and the Progression of Disability in Older Disabled Women." Annals of Internal Medicine 135, no. 12 2001: 10381046.

Li, S. F.; Greenwald, P. W.; Gennis, P.; Bijur, P. E.; and Gallagher, E. J.; "Effect of Age on Acute Pain Perception of a Standardized Stimulus in the Emergency Department." Annals of Emergency Medicine 38, no. 6 (2001): 644647.

Rybarczyk, B.; Demarco, G.; De La Cruz, M.; Lapidos, S.; and Fortner, B. "A Classroom Mind/Body Wellness Intervention for Older Adults with Chronic Illness: Comparing Immediate and 1-Year Benefits." Behavorial Medicine 27, no. 1 (2001): 1527.

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Pain Management

Pain Management

Definition

If pain can be defined as a highly unpleasant, individualized experience of one of the body's defense mechanisms indicating an injury or problem, pain management encompasses all interventions used to understand and ease pain, and, if possible, to alleviate the cause of the pain.

Purpose

Pain serves to alert us to potential or actual damage to the body. The definition for damage is quite broad; pain can arise from injury as well as disease. After the message is received and interpreted, further pain can be counter-productive. Pain can have a negative impact on a person's quality of life and impede recovery from illness or injury, thus contributing to escalating health care costs. Unrelieved pain can become a syndrome in its own right and cause a downward spiral in a person's health and outlook. Managing pain properly facilitates recovery, prevents additional health complications, and improves an individual's quality of life.

Yet the experiencing of pain is a completely unique occurrence for each person, a complex combination of several factors other than the pain itself. It is influenced by:

  • Ethnic and cultural values. In some cultures tolerating pain is related to showing strength and endurance. In others, it is considered punishment for misdeeds.
  • Age. The concept that grownups don't cry.
  • Anxiety and stress related to being in a strange, fearful place such as a hospital, fear of the unknown consequences of the pain and the condition causing it can all make pain feel more severe.
  • Fatigue and depression. It is known that pain in itself can actually cause depression. Fatigue from lack of sleep or the illness itself also contribute to depressed feelings.

Precautions

As noted, the perception of pain is an individual experience. Health care providers play an important role in understanding their patients' pain. All too often, both physicians and nurses have been found to incorrectly assess the severity of pain. A study reported in the Journal of Advanced Nursing evaluated nurses' perceptions of a select group of American-born and Mexican-American women patients' pain following gallbladder surgery. Objective assessments of each patient's pain showed little difference between the severity for each group. Yet nurses involved in the study consistently rated all patients' pain as less than the patients reported, and with equal consistency, believed that better-educated women born in the United States were suffering more than less educated, Mexican-American women. Nurses from a Northern European background were more apt to minimize the severity of pain than nurses from Eastern and Southern Europe or Africa. Health care staff, and especially nursing staff, need to be aware of how their own background and experience contributes to how they perceive a person's pain.

Description

Before considering pain management, a review of pain definitions and mechanisms may be useful. Pain is the means by which the peripheral nervous system (PNS) warns the central nervous system (CNS) of injury or potential injury to the body. The CNS comprises the brain and spinal cord, and the PNS is composed of the nerves that stem from and lead into the CNS. PNS includes all nerves throughout the body except the brain and spinal cord. Pain is sometimes categorized by its site of origin, either cutaneous (originating in the skin of subcutaneous tissue, such as a shaving nick or paper cut), deep somatic pain (arising from bone, ligaments and tendons, nerves or veins and arteries), or visceral (appearing as a result of stimulation of pain receptor nerves around organs such as the brain, lungs, or those in the abdomen).

A pain message is transmitted to the CNS by special PNS nerve cells called nociceptors. Nociceptors are distributed throughout the body and respond to different stimuli depending on their location. For example, nociceptors that extend from the skin are stimulated by sensations such as pressure, temperature, and chemical changes.

When a nociceptor is stimulated, neurotransmitters are released within the cell. Neurotransmitters are chemicals found within the nervous system that facilitate nerve cell communication. The nociceptor transmits its signal to nerve cells within the spinal cord, which conveys the pain message to the thalamus, a specific region in the brain.

Once the brain has received and processed the pain message and coordinated an appropriate response, pain has served its purpose. The body uses natural painkillers, called endorphins, to derail further pain messages from the same source. However, these natural painkillers may not adequately dampen a continuing pain message. Also, depending on how the brain has processed the pain information, certain hormones, such as prostaglandins, may be released. These hormones enhance the pain message and play a role in immune system responses to injury, such as inflammation. Certain neurotransmitters, especially substance P and calcitonin gene-related peptide, actively enhance the pain message at the injury site and within the spinal cord.

Pain is generally divided into two additional categories, acute and chronic. Nociceptive pain, or the pain that is transmitted by nociceptors, is typically called acute pain. This kind of pain is associated with injury, headaches, disease, and many other conditions. Response to acute pain is made by the sympathetic nervous system (the nerves responsible for the fight or flight response of the body). It normally resolves once the condition that precipitated it is resolved.

Following some disorders, pain does not resolve. Even after healing or a cure has been achieved, the brain continues to perceive pain. In this situation, the pain may be considered chronic. Chronic pain is within the province of the parasympathetic nervous system, and the changeover occurs as the body attempts to adapt to the pain. The time limit used to define chronic pain typically ranges from three to six months, although some health care professionals prefer a more flexible definition, and consider chronic pain as pain that endures beyond a normal healing time. The pain associated with cancer, persistent and degenerative conditions, and neuropathy, or nerve damage, is included in the chronic category. Also, unremitting pain that lacks an identifiable physical cause, such as the majority of cases of low back pain, may be considered chronic. The underlying biochemistry of chronic pain appears to be different from regular nociceptive pain.

It has been hypothesized that uninterrupted and unrelenting pain can induce changes in the spinal cord. In the past, severing a nerve's connection to the CNS has treated intractable pain. However, the lack of any sensory information being relayed by that nerve can cause pain transmission in the spinal cord to go into overdrive, as evidenced by the phantom limb pain experienced by amputees. Evidence is accumulating that unrelenting pain or the complete lack of nerve signals increases the number of pain receptors in the spinal cord. Nerve cells in the spinal cord may also begin secreting pain-amplifying neurotransmitters independent of actual pain signals from the body. Immune chemicals, primarily cytokines, may play a prominent role in such changes.

Managing pain

Considering the different causes and types of pain, as well as its nature and intensity, management can require an interdisciplinary approach. The elements of this approach include treating the underlying cause of pain, pharmacological and nonpharmacological therapies, and some invasive (surgical) procedures.

Treating the cause of pain underpins the idea of managing it. Injuries are repaired, diseases are diagnosed, and certain encounters with pain can be anticipated and treated prophylactically (by prevention). However, there are no guarantees of immediate relief from pain. Recovery can be impeded by pain and quality of life can be damaged. Therefore, pharmacological and other therapies have developed over time to address these aspects of disease and injury.

PHARMACOLOGICAL OPTIONS. General guidelines developed by the World Health Organization (WHO) have been developed for pain management. These guidelines operate upon a three-step ladder approach:

  • Mild pain is alleviated with acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs and acetaminophen are available as over-the-counter and prescription medications, and are frequently the initial pharmacological treatment for pain. These drugs can also be used as adjuncts to the other drug therapies that might require a doctor's prescription. NSAIDs include aspirin, ibuprofen (Motrin, Advil, Nuprin), naproxen sodium (Aleve), and ketoprofen (Orudis KT). These drugs are used to treat pain from inflammation and work by blocking production of pain-enhancing neurotransmitters, such as prostaglandins. Acetaminophen is also effective against pain, but its ability to reduce inflammation is limited. NSAIDs and acetaminophen are effective for most forms of acute (sharp, but of a short course) pain.
  • Mild to moderate pain is eased with a milder opioid medication plus acetaminophen or NSAIDs. Opioids are both actual opiate drugs such as morphine and codeine, and synthetic drugs based on the structure of opium. This drug class includes drugs such as oxycodon, methadone, and meperidine (Demerol). They provide pain relief by binding to specific opioid receptors in the brain and spinal cord.
  • Moderate to severe pain is treated with stronger opioid drugs plus acetaminophen or NSAIDs. Morphine is sometimes referred to as the gold standard of palliative care as it is not expensive, can be given starting with smaller doses and gradually increased, and is highly effective over a long period of time. It can also be given by a number of different routes, including by mouth, rectally, or by injection.

Although antidepressant drugs were developed to treat depression, it has been discovered that they are also effective in combating chronic headaches, cancer pain, and pain associated with nerve damage. Antidepressants that have been shown to have analgesic (pain-reducing) properties include amitriptyline (Elavil), trazodone (Desyrel), and imipramine (Tofranil). Anticonvulsant drugs share a similar background with antidepressants. Developed to treat epilepsy, anticonvulsants were found to relieve pain as well. Drugs such as phenytoin (Dilantin) and carbamazepine (Tegretol) are prescribed to treat the pain associated with nerve damage.

Close monitoring of the effects of pain medications is required in order to assure that adequate amounts of medication are given to produce the desired pain relief. When a person is comfortable with a certain dosage of medication, oncologists typically convert to a long-acting version of that medication. Transdermal fentanyl patches (Duragesic) are a common example of a long-acting opioid drug often used for cancer pain management. A patch containing the drug is applied to the skin and continues to deliver the drug to the person for typically three days. Pumps are also available that provide an opioid medication upon demand when the person is experiencing pain. By pressing a button, they can release a set dose of medication into an intravenous solution or an implanted catheter. Another mode of administration involves implanted catheters that deliver pain medication directly to the spinal cord. Delivering drugs in this way can reduce side effects and increase the effectiveness of the drug. Research is underway to develop toxic substances that act selectively on nerve cells that carry pain messages to the brain, killing these selected cells and thus stopping transmission of the pain message.

In 2004, two popular pain medications were taken off the market. Drug maker Merck stopped production of Vioxx (rofecoxib), its arthritis and acute pain medication. The withdrawal was based on three-year data from a prospective, randomized, placebocontrolled clinical trial, the APPROVe (Adenomatous Polyp Prevention on VIOXX) trial. The trial, which was halted, was designed to evaluate the efficacy of Vioxx 25 mg in preventing recurrence of colorectal polyps in patients with a history of colorectal adenomas. In this study, there was an increased relative risk for confirmed cardiovascular events, such as heart attack and stroke, beginning after 18 months of treatment in the patients taking Vioxx compared to those taking placebo. In 2005, the U.S. Food and Drug Administration (FDA) requested that Pfizer suspend sales of Bextra in the United States. The FDA concluded that there is an increased risk of rare but serious skin reactions associated with Bextra, prescribed to treat arthritis and chronic pain. The FDA is requiring all manufacturers of prescription non-steroidal antiinflammatory arthritis medicines (NSAIDs), such as Pfizer's Celebrex (celecoxib), to provide additional information about cardiovascular and gastrointestinal risks. The FDA also asked all the manufacturers of over-the-counter NSAIDs to revise their labels to include more information on cardiovascular, gastrointestinal and skin risks.

NONPHARMACOLOGICAL OPTIONS. Pain treatment options that do not use drugs are often used as adjuncts to, rather than replacements for, drug therapy. One of the benefits of non-drug therapies is that an individual can take a more active stance against pain. Relaxation techniques, such as yoga and meditation, are used to focus the brain elsewhere than on the pain, decrease muscle tension and reduce stress. Tension and stress can also be reduced through biofeedback, in which an individual consciously attempts to modify skin temperature, muscle tension, blood pressure, and heart rate.

Participating in normal activities and exercising can also help control pain levels. Through physical therapy, an individual learns beneficial exercises for reducing stress, strengthening muscles, and staying fit. Regular exercise has been linked to production of endorphins, the body's natural pain killers.

Acupuncture involves the insertion of small needles into the skin at key points. Acupressure uses these same key points, but involves applying pressure rather than inserting needles. Both of these methods may work by prompting the body to release endorphins. Applying heat or being massaged are very relaxing and help reduce stress. Transcutaneous electrical nerve stimulation (TENS) applies a small electric current to certain parts of nerves, potentially interrupting pain signals and inducing release of endorphins. To be effective, use of TENS should be medically supervised.

INVASIVE PROCEDURES. There are three types of invasive procedures that may be used to manage or treat pain: anatomic, augmentative, and ablative. These procedures involve surgery, and certain guidelines should be followed before carrying out a procedure with permanent effects. First, the cause of the pain must be clearly identified. Next, surgery should be done only if noninvasive procedures are ineffective. Third, any psychological issues should be addressed. Finally, there should be a reasonable expectation of success.

Anatomic procedures involve correcting the injury or removing the cause of pain. Relatively common anatomic procedures are decompression surgeries, such as repairing a herniated disk in the lower back or relieving the nerve compression related to carpal tunnel syndrome. Another anatomic procedure is neurolysis, also called a nerve block, which involves destroying a portion of a peripheral nerve.

Augmentative procedures include electrical stimulation or direct application of drugs to the nerves that are transmitting the pain signals. Electrical stimulation works on the same principle as TENS. In this procedure, instead of applying the current across the skin, electrodes are implanted to stimulate peripheral nerves or nerves in the spinal cord. Augmentative procedures also include implanted drug-delivery systems. In these systems, catheters are implanted in the spine to allow direct delivery of drugs to the CNS.

Ablative procedures are characterized by severing a nerve and disconnecting it from the CNS. However, this method may not address potential alterations within the spinal cord. These changes perpetuate pain messages and do not cease even when the connection between the sensory nerve and the CNS is severed. With growing understanding of neuropathic pain and development of less invasive procedures, ablative procedures are used less frequently. However, they do have applications in select cases of peripheral neuropathy, cancer pain, and other disorders.

Preparation

Prior to beginning management, pain is thoroughly evaluated. Pain scales or questionnaires are used to attach an objective measure to a subjective experience. Objective measurements allow health care workers a better understanding of the pain being suffered by the patient. Evaluation also includes physical examinations and diagnostic tests to determine underlying causes. Some evaluations require assessments from several viewpoints, including neurology, psychiatry and psychology, and physical therapy. If pain is due to a medical procedure, management consists of anticipating the type and intensity of associated pain and managing it preemptively.

Nurses or physicians often take what is called a pain history. This will help to provide important information that can help health care providers to better manage the patient's pain. A typical pain history includes the following questions:

  • Where is the pain located?
  • On a scale of 1 to 10, with 1 meaning the least pain, how would the person rate the pain they are experiencing?
  • Describe what the pain feels like.
  • When did (or does) the pain start?
  • How long has the person had it?
  • Is the person sometimes free of pain?
  • Does the person know of anything that triggers the pain, or makes it worse?
  • Does the person have other symptoms (nausea, dizziness, blurred vision, etc.) during or after the pain?
  • What pain medications or other measures have the person found to help in easing the pain?
  • How does the pain affect the person's ability to carry on normal activities?
  • What does it mean to the person that they are experiencing pain?

Aftercare

An assessment by nursing staff as well as other health care providers should be made to determine the effectiveness of the pain management interventions employed. There are objective, measurable signs and symptoms of pain that can be looked for. The goal of good pain management is the absence of these signs:

Signs of acute pain:

  • rise in pulse and blood pressure
  • more rapid breathing
  • perspiring profusely, clammy skin
  • taut muscles
  • more tense appearance, fast speech, very alert
  • unusually pale skin
  • pupils of the eye are dilated

Signs of chronic pain:

  • lower pulse and blood pressure
  • changeable breathing pattern
  • skin is warm and dry
  • nausea and vomiting
  • slow speech in monotone
  • inability, or difficulty in getting out of bed and doing activities
  • pupils of the eye are constricted

When these signs are absent and the patient appears to be comfortable, health care providers can consider their interventions to have been successful. It is also important to document interventions used, and what ones were successful.

Complications

Owing to toxicity over the long term, some drugs can only be used for acute pain or as adjuncts in chronic pain management. NSAIDs have the wellknown side effect of causing gastrointestinal bleeding, and long-term use of acetaminophen has been linked to kidney and liver damage. Other drugs, especially narcotics, have serious side effects, such as constipation, drowsiness, and nausea. Serious side effects can also accompany pharmacological therapies; mood swings, confusion, bone thinning, cataract formation, increased blood pressure, and other problems may discourage or prevent use of some analgesics.

Nonpharmacological therapies carry little or no risks. However, it is advised that individuals recovering from serious illness or injury consult with their health care providers or physical therapists before making use of adjunct therapies. Invasive procedures carry risks similar to other surgical procedures, such as infection, reaction to anesthesia, iatrogenic (injury as a result of treatment) injury, and failure.

A traditional concern about narcotics use has been the risk of promoting addiction. As narcotic use continues over time, the body becomes accustomed to the drug and adjusts normal functions to accommodate to its presence. Therefore, to elicit the same level of action, it is necessary to increase dosage over time. As dosage increases, an individual may become physically dependent on narcotic drugs.

However, physical dependence is different from psychological addiction. Physical dependence is characterized by discomfort if drug administration suddenly stops, while psychological addiction is characterized by an overpowering craving for the drug for reasons other than pain relief. Psychological addiction is a very real and necessary concern in some instances, but it should not interfere with a genuine need for narcotic pain relief. However, caution must be taken with people with a history of addictive behavior.

Results

Effective application of pain management techniques reduces or eliminates acute or chronic pain. This treatment can improve an individual's quality of life and aid in recovery from injury and disease.

Health care team roles

Physicians, both primary care physicians (PCPs) and surgeons, treat both the conditions causing the pain, and the pain itself. The physician's role as teacher is an important one, alleviating fears about both the patient's condition and the possibility of addiction to narcotics, which is often a fear among patients on narcotic medication. Some physicians specialize in the treatment of pain, and work out of pain clinics.

Registered nurses (RNs) are the professional staff member that will likely spend the most time with the patient, whether the patient is in the hospital or other health care facility, or at home. Gathering the necessary information regarding the person's pain through a pain history, and careful observation and listening can help tremendously in the provision of pain relief. RNs also administer the medications at times, and provide information to the patient about the various medications that may be used, and allay concerns about the use of them.

Licensed practical nurses (LPNs) also spend considerable time with the patient in a health care facility or at home. Like RNs, LPNs administer medications as necessary, and provide information to patients.

Pain clinic staff may be any of the above, or psychologists, social workers, occupational or recreational therapists, or other people with specific training in group therapy, yoga, meditation, or other nonpharmacological means of relieving pain.

Pharmacists fill prescriptions for pain-relieving medications, monitor the use of narcotic medications, and provide information regarding the uses and side-effects of the medications.

KEY TERMS

Acute— Referring to pain in response to injury or other stimulus that resolves when the injury heals or the stimulus is removed.

Chronic— Referring to pain that endures beyond the term of an injury or painful stimulus. Can also refer to cancer pain, pain from a chronic or degenerative disease, and pain from an unidentified cause.

CNS or central nervous system The part of the nervous system that includes the brain and the spinal cord.

Iatrogenic— Resulting from the activity of the physician.

Neuropathy— Nerve damage.

Neurotransmitter— Chemicals within the nervous system that transmit information from or between nerve cells.

Nociceptor— A nerve cell that is capable of sensing pain and transmitting a pain signal.

Nonpharmacological— Referring to therapy that does not involve drugs.

Parasympathetic nervous system— That part of the autonomic nervous system consisting of nerves that arise from the cranial and sacral regions and function in opposition to the sympathetic nervous system.

Pharmacological— Referring to therapy that relies on drugs.

PNS or peripheral nervous system Nerves that are outside of the brain and spinal cord.

Stimulus— A factor capable of eliciting a response in a nerve.

Sympathetic nervous system— That portion of the autonomic nervous system consisting of nerves that originate in the thoracic and lumbar spinal cord and function in opposition to the parasympathetic nervous system.

Resources

BOOKS

Boswell, Mark V. Weiner's Pain Management: A Practical Guide for Clinicians Boca Raton, FL: CRC Press, 2005.

Gatchel, Robert J. Clinical Essentials of Pain Management Washington: American Psychological Association, 2004.

Warfield, Carol A., and Zahid H. Baiwa Principles & Practices of Pain Management New York: McGraw-Hill, 2004.

PERIODICALS

Armstrong, F. Daniel. "Analgesia for Children with Acute Abdominal Pain: A Cautious Move to Improved Pain Management." Pediatrics (October 2005): 1018-1019.

Bates, Betsy. "Need for Chronic Pain Management is Unmet." Family Practice News (Oct. 15, 2005): 65.

Dieppe, Paul A., and L. Stefan Lohmander. "Pathogenesis and Management of pain in Osteoarthritis." The Lancet (March 12, 2005): 965.

Jancin, Bruce. "Implications of Expected Big Drop in NSAID Use: Cardiovascular Side Effects Likely to Cause Physicians to Seek Other Options for Chronic pain Management." Family Practice News (July 15, 2005): 5.

ORGANIZATIONS

American Chronic Pain Association. P.O. Box 850, Rocklin, CA 95677-0850. (800) 533-3231. www.theacpa,org

American Pain Society. 4700 West Lake Ave., Glenview, IL 60025. (847) 375-4715. 〈http://www.ampainsoc.org〉.

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Pain Management

Pain Management

Definition

Pain management is concerned with the evaluation and treatment of pain.

Description

Pain is an unpleasant sensation that can range from mild discomfort to excruciating agony. It can be restricted to a specific body part or widespread. It can also be of short duration with a rapid onset (acute) or long-lasting (chronic), and be perceived as having different qualities such as irradiating, burning, shooting, aching, piercing, or pinching. Pain is associated with a wide range of medical conditions and disorders. It can result from trauma, which often triggers acute pain receptors, the free nerve endings of groups of nervous fibers richly distributed in the superficial layers of the skin and in some deeper tissues of the body. It can also result from nerve damage (neuropathic pain) caused by an infectious agent, such as a virus, or by chemotherapy , or by a neurodegenerative disease, such as multiple sclerosis . The conscious perception of pain is believed to occur in the thalamus, the area of the brain that helps process information from the senses, and the interpretation of the quality and degree of pain is thought to occur in the cerebral cortex, the outer layer of the brain consisting of nerve cells and the pathways that connect them.

Pain is often reversible and may require only treatment and correction of the underlying medical problem. However, chronic pain persists and its management is often complicated because the pain results from conditions that are difficult to diagnose and treat, and that may take a long time to stabilize or reverse. Some examples include cancer , disorders affecting the nervous system (neuropathies), migraines, and low back pain .

The aging process is often associated with an increased incidence of conditions giving rise to chronic pain, such as persistent musculoskeletal or neuropathic pain due to back pain, arthritis, osteoporosis , and diabetes. In elderly people, pain can lead to a marked deterioration in their quality of life. In this age group, the evaluation of pain can also be more complicated due to disorientation, confusion and communication difficulties, with the result that pain is poorly managed.

Purpose

The purpose of pain management is to eliminate or alleviate pain in sufferers. According to the American Academy of Pain Medicine, seven in ten Americans feel that pain research and management should be one of the medical community's top few priorities (16%) or a high priority (55%).

Operation

The management of mild to moderate pain is conventionally based on the use of non-steroidal

anti—inflammatory drugs (NSAIDs), such as aspirin , Alleve, Advil, Motrin, etc. and the analgesic paracetamol (acetaminophen ). However, NSAIDs can cause peptic ulcers and bleeding. A new class of medications, the selective COX-2 inhibitors, were developed to counter these adverse effects, but concerns have arisen about their own potential adverse side effects, namely cardiovascular events. The European Medicines Agency (EMEA) and the Food and Drugs Administration (FDA) in the US have issued advice to apply cautions and restrictions when prescribing COX-2 inhibitors, especially in the case of patients at increased cardiovascular risk and for long-term use. Both the EMEA and the FDA recommend prescribing the lowest effective dose for the shortest duration possible. Some physicians consider weak opioids that are not associated with organ-damaging effects combined with paracetamol as safer for long-term pain management. Combinations of paracetamol with weak opioids, such as codeine, dextropropoxyphene or tramadol are currently available. Paracetamol plus tramadol is considered effective and safe for the management of both acute and chronic moderate to severe pain. Because the effects of a medication can vary widely from person to person, pain management is usually tailored to fit each patient.

Pain can also be managed with a variety of nonpharmacological treatments, such as therapeutic exercise , heat or cold therapy, and psychoeducational approaches that seek to relieve pain or improve the patient's ability to tolerate it. Examples include deep breathing techniques, muscle relaxation exercises, meditation, and biofeedback therapy. Transcutaneous electrical nerve stimulation (TENS) is also use to manage pain. It applies a gentle electric current to the skin to relieve pain. Studies have shown that it can be effective in certain cases of chronic pain, such as low back pain, arthritic pain, neuropathic pain, visceral pain, and postsurgical pain. Patients are fitted with a small device, which can be inserted in a pocket or snapped on a belt, and which transmits electrical impulses to electrodes taped to the skin of the painful area. Acupuncture , the technique of inserting thin needles through the skin at specific points on the body, is also used to manage pain in some chronic cases.

Maintenance

Patients must inform their treating physician of all medications they are taking, including over-the-counter drugs such as aspirin and any medication taken for conditions that are not related to their pain. This is because some medications cannot be taken together either because they increase or decrease each other's action, or because their combination produces adverse effects.

Training

Doctors who manage pain are frequently anesthesiologists. Anesthesiologists are doctors of medicine (M.D.) or osteopathy (D.O.) who ensure that patients are pain—free and comfortable during and after surgery. They also provide their services in other areas of the hospital or in health care centers where painful tests or procedures are performed. Like other physicians, anesthesiologists earn a college degree and then complete four years of medical school. They spend four more years learning the medical specialty of anesthesiology and pain medicine during their residency training. Many anesthesiologists who specialize in pain medicine receive an additional year of fellowship training to become experts in treating pain. Many also have special certification in pain medicine through the American Board of Anesthesiology (ABA). The ABA is the only organization recognized by the American Board of Medical Specialties to offer special credentials in pain medicine.

KEY TERMS

Acupuncture —The technique of inserting thin needles through the skin at specific points on the body to control pain and other symptoms.

Analgesic —A medication given to reduce pain without resulting in loss of consciousness.

Anesthesiology —The branch of medicine specializing in the use of drugs or other agents that cause insensibility to pain.

Arthritis —Inflammation of a joint usually characterized by swelling, pain, and restriction of motion.

Biofeedback therapy —Therapy in which people learn to reduce their body's unproductive responses to stress, and thus decrease their sensitivity to pain.

Cerebral cortex —The outer layer of the brain, consisting of nerve cells and the pathways that connect them, responsible for cognitive functions including reasoning, mood, and perception of stimuli.

Chronic —Long-lasting and recurrent or characterized by long suffering.

COX–2 inhibitors —A category of non-steroidal anti-inflammatory drugs (NSAIDs) that blocks a form of cyclooxygenase enzyme known as COX-2, which is believed to be at the root of inflammation and pain. The drugs Vioxx and Celebrex are COX-2 inhibitors.

Migraine —Extremely painful type of throbbing headache.

Neurodegenerative disease —Disorder caused by the deterioration of nerve cells called neurons. Changes in these cells cause them to function abnormally, eventually bringing about their death.

Neuropathic pain —Pain initiated or caused by a primary lesion or dysfunction in the nervous system.

Neuropathy —Group of disorders involving nerves.

Non-pharmacological treatment —Treatments that does not rely on medication to achieve its effect.

Nonsteroidal anti-inflammatory drug (NSAID) —Medication that does not contain cortisone used to reduce the symptoms of the pain and inflammation of arthritis.

Opiate —A drug used to treat pain. It contains opium or a substance made from opium (such as morphine).

Opioid —A drug used to treat moderate to severe pain. Opioids are similar to opiates such as morphine and codeine, but they do not contain and are not made from opium.

Osteoporosis —Disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased risk of fracture.

Pain —An unpleasant sensation that can range from mild, localized discomfort to agony.

Pain medicine —The medical specialty concerned with the prevention, evaluation, diagnosis, treatment, and rehabilitation of painful disorders.

Pain receptors —Free nerve endings of groups of nervous fibers abundantly distributed in the superficial layers of the skin and in some deeper tissues of the body.

Peptic ulcer —A hole in the lining of the stomach, duodenum, or esophagus.

Sensation —A perception associated with the stimulation of a sense organ or with a specific condition of the body.

Thalamus —An area of the brain that helps process information from the senses and transmit it to other parts of the brain.

Transcutaneous electrical nerve stimulation (TENS) —Application of a gentle electric current to the skin to relieve pain.

Trauma —A physical injury or wound caused by an external force.

Resources

BOOKS

Ballantyne, Jane C., editor. The Massachusetts General Hospital Handbook of Pain Management. 3rd ed., Philadelphia, PA: Lippincott Williams & Wilkins, 2005.

Caudill, Margaret A. Managing Pain Before It Manages You, Revised Edition. New York, NY: Guilford Press, 2001.

Turk, Dennis C., and Frits Winter. The Pain Survival Guide: How to Reclaim Your Life (APA Lifetools). Washington, DC: American Psychological Association Books, 2005.

Wallace, Mark S. Pain Medicine and Management: Just the Facts. New York, NY: McGraw-Hill, 2004.

Vachss, Andrew. Pain Management (Kindle Edition). New York, NY: Knopf Group, 2001.

Warfield, Carol A., and Zahid H. Bajwa. Principles & Practice of Pain Management. New York, NY: McGraw-Hill, 2004.

PERIODICALS

Bruckenthal, P. “Assessment of Pain in the Elderly Adult.” Clinics in Geriatric Medicine 24, no. 2 (May 2008):213–236.

Burgess, F. W., and T. A. Burgess. “Pain management in the elderly surgical patient.” Medicine and Health, Rhode Island 91, no. 1 (2008): 11–14.

Cavalieri, T. A. “Pain management in the elderly.” Journal of the American Osteopathic Association 102, no. 9 (September 2002): 481–485.

Horgas, A. L. “Pain management in elderly adults.” Journal of Infusion Nursing 26, no. 3 (May–June 2003): 161–165.

Kedziera, P. L. “Easing elders' pain.” Holistic Nursing Practice 15, no. 2 (January 2001): 4–16.

Langford, R. M. “Pain management today—what have we learned?” Clinical Rheumatology 25, suppl. 1 (2006): S2–S8.

Norelli, L. J., and S. K. Harju. “Behavioral approaches to pain management in the elderly.” Clinics in Geriatric Medicine 24, no. 2 (May 2008): 335–344.

Schneider, H., and A. Cristian. “Role of rehabilitation medicine in the management of pain in older adults.” Clinics in Geriatric Medicine 24, no. 2 (May 2008):313–314.

OTHER

How is Cancer Pain Treated? University of Texas MD Anderson Cancer Center, Information Page. (March 30, 2008) http://www.mdanderson.org/topics/pain-control/display.cfm?id=AAC0BE24-7B7A-11D5-812D00508B603A14&method=displayFull

Managing Pain Arthritis Society, Information Page. (March 30, 2008) http://www.arthritis.ca/tips%20for%20living/managing%20pain/default.asp?s=1

Pain Management. Leukemia and Lymphoma Society, Information Page. (March 30, 2008) http://www.leukemia-lymphoma.org/all_mat_toc.adp?item_id=104411&cat_id=1214

Pain Medications. Medline Plus. Medical Encyclopedia (March 30, 2008) http://www.nlm.nih.gov/medlineplus/ency/article/002123.htm

The Management of Pain. American Society of Anesthesiologists (ASA), Patient Education Page. (March 30, 2008) http://www.asahq.org/patientEducation/managepain.htm

Treatment Options. A Guide for People Living with Pain. American Pain Foundation (APF). Information Booklet (March 30, 2008) http://www.painfoundation.org/Publications/TreatmentOptions2006.pdf

ORGANIZATIONS

American Academy of Pain Management (AAPM), 13947 Mono Way #A, Sonora, CA, 95370, (209)533-9744, (209)533-9750, [email protected]aapainmanage.org, http://www.aapainmanage.org.

American Chronic Pain Association (ACPA), PO Box 850, Rocklin, CA, 95677, (800)533-3231, (916)632-3208, [email protected], http://www.theacpa.org.

American Pain Foundation (APF), 201 North Charles St., Suite 710, Baltimore, MD, 21201-4111, (888)615-PAIN, [email protected], http://www.pain-foundation.org.

American Pain Society (APS), 4700 W. Lake Ave., Glenview, IL, 60025, (847)375-4715, (877)734-8758, [email protected], http://www.ampainsoc.org.

American Society of Anesthesiologists (ASA), 520 N. Northwest Highway, Park Ridge, IL, 60068-2573, (847)825-5586, (847)825-1692, [email protected], http://www.asahq.org.

National Foundation for the Treatment of Pain, P.O. Box 70045, Houston, TX, 77270-0045, (713)862-9332, (713) 862-9346, http://www.paincare.org.

Monique Laberge Ph.D.

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Pain Management

Pain Management

Definition
Purpose
Precautions
Description
Preparation
Aftercare
Risks
Normal results

Definition

Pain itself is defined by the International Association for the Study of Pain (IASP) as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” Thus, pain management encompasses all interventions used to understand and ease pain, and if possible to alleviate the cause of the pain.

Purpose

Pain serves to alert a person to potential or actual damage to the body. The definition of damage is quite broad: pain can arise from injury as well as disease. After the message is received and interpreted, further pain can be counterproductive. Pain can have a negative impact on a person’s quality of life and impede recovery from illness or injury, thus contributing to escalating health care costs. Unrelieved pain can become a syndrome in its own right and cause a downward spiral in a person’s health and emotional outlook. Managing pain properly facilitates recovery, prevents additional health complications, and improves an individual’s quality of life.

Yet the experiencing of pain is a completely unique occurrence for each person, a complex combination of several factors other than the pain itself. It is influenced by:

  • Ethnic and cultural values. In some cultures, tolerating pain is related to showing strength and endurance. In others, pain is considered punishment for misdeeds.
  • Age. Many people have been taught that grownups never cry. On the other hand, in some cultures, the elderly are allowed to complain freely about pain and discomfort.
  • Anxiety and stress. This factor is related to being in a strange or unfamiliar place such as a hospital, and the fear of the unknown consequences of the pain and the condition causing it, which can all combined to make pain feel more severe. For patients being treated for pain, knowing the duration of activity of an analgesic leads to anxiety about the return of pain when the drug wears off. This anxiety can make the pain more severe. In addition, patients who interpret their pain as meaning that their disease is recurring or getting worse often experience pain as more severe.
  • Fatigue and depression. It is known that pain in itself can actually cause emotional depression. Fatigue from lack of sleep or the illness itself also contributes to depressed feelings.

Precautions

The perception of pain is an individual experience. Healthcare providers play an important role in understanding their patients’ pain. All too often, both physicians and nurses have been found to incorrectly assess the severity of pain. A study reported in the Journal of Advanced Nursing evaluated nurses’ perceptions of a select group of white American and Mexican-American women patients’ pain following gallbladder surgery. Objective assessments of each patient’s pain showed little difference between the perceived severities for each group. Yet, the nurses involved in the study consistently rated all patients’ pain as less than the patients reported, and with equal consistency, believed that better-educated women born in the United States were suffering more than less-educated women. Nurses from a northern European background were more apt to minimize the severity of pain than nurses from eastern and southern Europe or Africa. The study indicated how healthcare staff, and especially nursing staff, need to be aware of how their own background and experience contributes to how they perceive a person’s pain.

Some patient populations are particularly susceptible to inadequate pain management. These include cancer patients; children; trauma victims receiving treatment in hospital emergency departments; and the elderly in nursing homes .

Description

Before considering pain management, a review of pain definitions and mechanisms may be useful. Pain is the means by which the peripheral nervous system

KEY TERMS

Acute— Referring to pain in response to injury or other stimulus that resolves when the injury heals or the stimulus is removed.

Central nervous system (CNS)— The part of the nervous system that includes the brain and the spinal cord.

Chronic— Referring to pain that endures beyond the term of an injury or painful stimulus. Can also refer to cancer pain, pain from a chronic or degenerative disease, and pain from an unidentified cause.

latrogenic— Resulting from the activity of the physician.

Neuropathy— Nerve damage.

Neurotransmitter— Chemicals within the nervous system that transmit information from or between nerve cells.

Nociceptor— A nerve cell that is capable of sensing pain and transmitting a pain signal.

Nonpharmacological— Referring to therapy that does not involve drugs.

Parasympathetic nervous system— That part of the autonomic nervous system consisting of nerves that arise from the cranial and sacral regions and function in opposition to the sympathetic nervous system.

Peripheral nervous system (PNS)— Nerves that are outside of the brain and spinal cord.

Pharmacological— Referring to therapy that relies on drugs.

Stimulus— A factor capable of eliciting a response in a nerve.

Sympathetic nervous system— That portion of the autonomic nervous system consisting of nerves that originate in the thoracic and lumbar spinal cord and function in opposition to the parasympathetic nervous system.

(PNS) warns the central nervous system (CNS) of injury or potential injury to the body. The CNS comprises the brain and spinal cord, and the PNS is composed of the nerves that stem from and lead into the CNS. PNS includes all nerves throughout the body, except the brain and spinal cord. Pain is sometimes categorized by its site of origin, either cutaneous (origating in the skin, or subcutaneous tissue, such as a shaving nick or paper cut), deep somatic pain (arising from bone, ligaments and tendons, nerves, or veins and arteries), or visceral (appearing as a result of stimulation of pain receptor nerves around such organs as the brain, lungs, or stomach and intestines).

A pain message is transmitted to the CNS by special PNS nerve cells called nociceptors, which are distributed throughout the body and respond to different stimuli depending on their location. For example, nociceptors that extend from the skin are stimulated by such sensations as pressure, temperature, and chemical changes.

When a nociceptor is stimulated, neurotransmitters are released within the cell. Neurotransmitters are chemicals found within the nervous system that facilitate nerve cell communication. The nociceptor transmits its signal to nerve cells within the spinal cord, which conveys the pain message to the thalamus, a specific region in the brain.

Once the brain has received and processed the pain message and coordinated an appropriate response, pain has served its purpose. The body uses natural painkillers called endorphins to derail further pain messages from the same source. However, these natural painkillers may not adequately dampen a continuing pain message. Also, depending on how the brain has processed the pain information, certain hormones such as prostaglandins may be released. These hormones enhance the pain message and play a role in immune system responses to injury, such as inflammation. Certain neurotransmitters, especially substance P and calcitonin gene-related peptide, actively enhance the pain message at the injury site and within the spinal cord.

Pain is generally divided into two additional categories: acute and chronic. Nociceptive pain, or the pain that is transmitted by nociceptors, is typically called acute pain. This kind of pain is associated with injury, headaches, disease, and many other conditions. Response to acute pain is made by the sympathetic nervous system (the nerves responsible for the fight-or-flight response of the body). It normally resolves once the condition that precipitated it is resolved.

There are some disorders that produce pain that does not resolve following the disorder. Even after healing or a cure has been achieved, the brain continues to perceive pain. In this situation, the pain may be considered chronic. Chronic pain is within the province of the parasympathetic nervous system, and the changeover occurs as the body attempts to adapt to the pain. The time limit used to define chronic pain typically ranges from three to six months, although some healthcare professionals prefer a more flexible definition and consider chronic pain as pain that endures beyond a normal healing time. The pain associated with cancer, persistent and degenerative conditions, and neuropathy, or nerve damage, is included in the chronic category. Also, unremitting pain that lacks an identifiable physical cause such as the majority of cases of low back pain may be considered chronic. The underlying biochemistry of chronic pain appears to be different from that of acute nociceptive pain.

It has been hypothesized that uninterrupted and unrelenting pain can induce changes in the spinal cord. In the past, severing a nerve’s connection to the CNS has treated intractable pain. However, the lack of any sensory information being relayed by that nerve can cause pain transmission in the spinal cord to go into overdrive, as evidenced by the phantom limb pain experienced by amputees. Evidence is accumulating that unrelenting pain or the complete lack of nerve signals increases the number of pain receptors in the spinal cord. Nerve cells in the spinal cord may also begin secreting pain-amplifying neurotransmitters independent of actual pain signals from the body. Immune chemicals, primarily cytokines, may play a prominent role in such changes.

Managing pain

Considering the different causes and types of pain, as well as its nature and intensity, management usually requires a multidisciplinary approach. The elements of this approach include treating the underlying cause of pain, pharmacological and non-pharmacological therapies, and some invasive (surgical) procedures.

Treating the cause of pain underlies the basic strategy of pain management. Injuries are repaired, diseases are diagnosed, and certain encounters with pain can be anticipated and treated prophylactically (by prevention). However, there are no guarantees of immediate relief from pain. Recovery can be impeded by pain and quality of life can be damaged. Therefore, pharmacological and other therapies have developed over time to address these aspects of disease and injury.

PHARMACOLOGICAL OPTIONS. General guidelines developed by the World Health Organization (WHO) have been developed for pain management. These guidelines operate upon the three-step ladder approach, including:

  • Mild pain is alleviated with acetaminophen or a non-steroidal anti-inflammatory drug (NSAID). NSAIDs and acetaminophen are available as over-the-counter (OTC) and prescription medications, and are frequently the initial pharmacological treatment for pain. These drugs can also be used as adjuncts to the other drug therapies that might require a doctor’s prescription. NSAIDs include aspirin, ibuprofen (Motrin, Advil, Nuprin), naproxen sodium (Aleve), and ketoprofen (Orudis KT). These drugs are used to treat pain from inflammation and work by blocking production of pain-enhancing neurotransmitters. Acetaminophen is also effective against pain, but its ability to reduce inflammation is limited. NSAIDs and acetaminophen are effective for most forms of acute (sharp, but of a short duration) pain.
  • Mild to moderate pain is eased with a milder opioid medication, plus acetaminophen or NSAIDs. Opioids include both drugs derived from the opium poppy, such as morphine and codeine, and synthetic drugs based on the structure of opium. This drug class includes drugs such as oxycodone, methadone, and meperidine (Demerol). They provide pain relief by binding to specific opioid receptors in the brain and spinal cord. One drawback of opioids, however, is that they frequently cause constipation because they slow down the rhythmic muscular contractions of the intestines that push food along during the process of digestion.
  • Moderate to severe pain is treated with stronger opioid drugs, plus acetaminophen or NSAIDs. Morphine is sometimes referred to as the gold standard of palliative care as it is not expensive; can be given by starting with smaller doses and gradually increased; and is highly effective over a long period of time. It can also be given by a number of different routes, including by mouth, rectally, or by injection.

Although antidepressant drugs were developed to treat depression, it has been discovered that they are also effective in combating chronic headaches, cancer pain, and pain associated with nerve damage. Antidepressants that have been shown to have analgesic (pain-reducing) properties include amitriptyline (Ela-vil), trazodone (Desyrel), and imipramine (Tofranil). Anticonvulsant drugs share a similar background with antidepressants. Developed to treat epilepsy, anticonvulsants were found to relieve pain as well. Drugs such as phenytoin (Dilantin) and carbamazepine (Tegretol) are prescribed to treat the pain associated with nerve damage.

In some cases, chronic pain caused by complications of diabetes or cancer can be eased by administering local anesthetics. The most commonly used are mexiletine (Mexitil) and a lidocaine patch.

Corticosteroids are another class of drugs commonly given to manage chronic pain caused by arthritis or other diseases affecting the muscles and joints; they may also be given to control nausea. Dexamethasone (Decadron) and prednisone are the most commonly used corticosteroids in pain management. They work by reducing inflammation and suppressing the immune system.

Close monitoring of the effects of pain medications is required in order to assure that adequate amounts of medication are given to produce the desired pain relief. When a person is comfortable with a certain dosage of medication, oncologists typically convert to a long-acting version of that medication. Transdermal fentanyl patches (Duragesic) are a common example of a long-acting opioid drug often used for cancer pain management. A patch containing the drug is applied to the skin and continues to deliver the drug to the person for an average of three days. Pumps are also available that provide an opioid medication upon demand when the person is experiencing pain. By pressing a button, they can release a set dose of medication into an intravenous solution or an implanted catheter. Another mode of administration involves implanted catheters that deliver pain medication directly to the spinal cord. Because these pumps offer the patient some degree of control over the amount of analgesic administered, the system, commonly called patient-controlled analgesia (PCA), reduces the level of anxiety about availability of pain medication. Delivering drugs in this way can reduce side effects and increase the effectiveness of the drug. Research is underway to develop toxic substances that act selectively on nerve cells that carry pain messages to the brain. These substances would kill the selected cells and stop transmission of the pain message.

NONPHARMACOLOGICAL OPTIONS. Pain treatment options that do not use drugs are often used as adjuncts to, rather than replacements for, drug therapy. One of the benefits of nondrug therapies is that an individual can take a more active role in pain management. Such relaxation techniques as yoga and meditation are used to focus the brain elsewhere than on the pain, decrease muscle tension, and reduce stress. Tension and stress can also be reduced through biofeedback, in which an individual consciously attempts to modify skin temperature, muscle tension, blood pressure, and heart rate.

Hypnosis is another nonpharmacological option for pain relief. Although doctors do not yet fully understand how hypnosis works, it is used successfully in some patients to manage pain related to childbirth, oral surgery, burn treatment, and other procedures that require the patient to remain conscious.

Participating in normal activities and exercising can also help control pain levels. Through physical therapy, an individual learns beneficial exercises for reducing stress, strengthening muscles, and staying fit. Regular exercise has been linked to production of endorphins, the body’s natural painkillers.

Acupuncture involves the insertion of small needles into the skin at key points. Acupressure uses these same key points, but involves applying pressure rather than inserting needles. Both of these methods may work by prompting the body to release endorphins. Applying heat or being massaged are very relaxing and help reduce stress. Transcutaneous electrical nerve stimulation (TENS) applies a small electric current to certain parts of nerves, potentially interrupting pain signals and inducing release of endorphins. To be effective, use of TENS should be medically supervised.

INVASIVE PROCEDURES. There are three types of invasive procedures that may be used to manage or treat pain: anatomic, augmentative, and ablative. These procedures involve surgery, and certain guidelines should be followed before carrying out a procedure with permanent effects. First, the cause of the pain must be clearly identified. Next, surgery should be done only if noninvasive procedures are ineffective. Third, any psychological issues should be addressed. Finally, there should be a reasonable expectation of success.

Anatomic procedures involve correcting the injury or removing the cause of pain. Relatively common anatomic procedures are decompression surgeries such as repairing a herniated disk in the lower back or relieving the nerve compression related to carpal tunnel syndrome. Another anatomic procedure is neurolysis, also called a nerve block, which involves destroying a portion of a peripheral nerve.

Augmentative procedures include electrical stimulation or direct application of drugs to the nerves that are transmitting the pain signals. Electrical stimulation works on the same principle as TENS. In this procedure, instead of applying the current across the skin, electrodes are implanted to stimulate peripheral nerves or nerves in the spinal cord. Augmentative procedures also include implanted drug-delivery systems. In these systems, catheters are implanted in the spine to allow direct delivery of drugs to the CNS.

Ablative procedures are characterized by severing a nerve and disconnecting it from the CNS. However, this method may not address potential alterations within the spinal cord. These changes perpetuate pain messages and do not cease, even when the connection between the sensory nerve and the CNS is severed. With growing understanding of neuropathic pain and development of less invasive procedures, ablative procedures are used less frequently. However, they do have applications in select cases of peripheral neuropathy, cancer pain, and other disorders.

Preparation

Prior to beginning management, the patient’s pain should be thoroughly evaluated, including a psychosocial as well as a physical assessment. Pain scales or questionnaires can be administered by a member of the healthcare team, although there is no single questionnaire that is universally accepted as of 2007. Some questionnaires are verbal, while others use pictures or drawings to help the patient describe the pain. Some questionnaires are filled out by the patient, while others may be given to relatives or friends to complete. It is often necessary to ask other family members to complete a pain questionnaire if the patient is cognitively impaired.

In spite of their limitations, questionnaires and self-report forms do allow healthcare workers to better understand the pain being suffered by the patient. Evaluation also includes physical examinations and diagnostic tests to determine the underlying physical causes of the pain. Some evaluations require assessments from several viewpoints, including neurology, psychiatry and psychology, and physical therapy. If the pain is caused by a medical procedure, management consists of anticipating the type and intensity of associated pain and managing it preemptively.

Nurses or physicians often take what is called a pain history. This history will help to provide important information that can help health care providers to better manage the patients pain. A typical pain history includes the following questions:

  • Where is the pain located?
  • On a scale of 1 to 10, with 1 indicating the least pain, how would the person rate the pain being experienced?
  • What does the pain feel like?
  • When did (or does) the pain start?
  • How long has the person had it?
  • Is the person sometimes free of pain?
  • Is the pain constant, or is it episodic?
  • Does the person know of anything that triggers the pain or makes it worse?
  • Does the person have other symptoms (nausea, dizziness, blurred vision, etc.) during or after the pain?
  • What pain medications or other measures has the person found to help in easing the pain?
  • How does the pain affect the person’s ability to carry on normal activities?
  • What does it mean to the person that he or she is experiencing pain?

Aftercare

An assessment by nursing staff as well as other healthcare providers should be made to determine the effectiveness of the pain management interventions employed. There are objective, measurable signs and symptoms of pain that can be looked for. The goal of good pain management is the absence of these signs. Signs of acute pain include:

  • rise in pulse and blood pressure
  • more rapid breathing
  • perspiring profusely, clammy skin
  • taut muscles
  • more tense appearance, fast speech, very alert
  • unusually pale skin
  • dilated pupils of the eye

Signs of chronic pain include:

  • lower pulse and blood pressure
  • changeable breathing pattern
  • warm, dry skin
  • nausea and vomiting
  • slow or monotone speech
  • inability or difficulty in getting out of bed and performing activities of daily living (ADLs)
  • constricted pupils of the eye

When these signs are absent and the patient appears to be comfortable, healthcare providers can consider their interventions to have been successful. It is also important to document interventions used, and which ones were successful.

Risks

Owing to toxicity over the long term, some drugs can only be used for acute pain or as adjuncts in chronic pain management. NSAIDs have the well-known side effect of causing gastrointestinal bleeding, and long-term use of acetaminophen has been linked to kidney and liver damage. Other drugs, especially narcotics, have such serious side effects as constipation, drowsiness, and nausea. Serious side effects can also accompany pharmacological therapies; mood swings, confusion, bone thinning, cataract formation, increased blood pressure, and other problems may discourage or prevent use of some analgesics.

Nonpharmacological therapies carry little or no risks. However, individuals recovering from serious illness or injury should consult with the health care providers or physical therapists before making use of adjunct therapies. Invasive procedures carry risks similar to other surgical procedures, such as infection, reaction to anesthesia, and iatrogenic (injury as a result of treatment) injury.

A traditional concern about narcotics use has been the risk of promoting addiction. As narcotic use continues over time, the body becomes accustomed to the drug and adjusts normal functions to accommodate to its presence. Therefore, to elicit the same level of action, it is necessary to increase dosage over time. As dosage increases, an individual may become physically dependent on narcotic drugs.

However, physical dependence is different from psychological addiction. Physical dependence is characterized by discomfort if drug administration suddenly stops, while psychological addiction is characterized by an overpowering craving for the drug for reasons other than pain relief. Psychological addiction is a very real and necessary concern in some instances, but it should not interfere with a genuine need for narcotic pain relief. However, caution must be taken with people who have a history of addictive behavior.

Normal results

Effective application of pain management techniques reduces or eliminates acute or chronic pain. This treatment can improve an individual’s quality of life and aid in recovery from injury and disease.

Resources

BOOKS

Gould, Harry J., III. Understanding Pain: What It Is, Why It Happens, and How It’s Managed. St. Paul, MN: American Academy of Neurology Press, 2007.

Hughes, John, ed. Pain Management: From Basics to Clinical Practice. New York: Churchill Livingstone/Elsevier, 2008.

Main, Chris J., Michael J. L. Sullivan, and Paul J. Watson. Pain Management: Practical Applications of the Biop-sychosocial Perspective in Clinical and Occupational Settings. Edinburgh and New York: Churchill Livingstone, 2008.

PERIODICALS

Cleary, J. F. “The Pharmacologic Management of Cancer Pain.” Journal of Palliative Medicine 10 (December 2007): 1369–1394.

Coyle, N. “Assessing Cancer Pain in the Adult Patient.” Oncology (Williston Park) 20 (September 2006): 41–49.

Curtis, K. M., H. F. Henriques, G. Fanciullo, et al. “A Fentanyl-based Pain Management Protocol Provides Early Analgesia for Adult Trauma Patients.” Journal of Trauma 63 (October 2007): 819–826.

D’Arcy, Yvonne. “Keep Your Patient Safe during PCA.” Nursing 38 (January 2008): 50–55.

Marx, T. L. “Partnering with Hospice to Improve Pain Management in the Nursing Home Setting.” Journal of the American Osteopathic Association 105 (March 2005): S22–S26.

McPherson, M. L., C. D. Ponte, and R. M. Respond (eds.). “Profiles in Pain Management.” Journal of the American Pharmacists Association (June 2003).

Schwartz, S. R. “Perioperative Pain Management.” Oral and Maxillofacial Surgery Clinics of North America 18 (May 2006): 139–150.

ORGANIZATIONS

American Chronic Pain Association (ACPA). P.O. Box 850, Rocklin, CA 95677-0850. (800) 533-3231. http://www.theacpa.org/index.asp (accessed April 2, 2008).

American Pain Society. 4700 West Lake Ave., Glenview, IL 60025. (847) 375-4715. http://www.ampainsoc.org (accessed April 2, 2008).

International Association for the Study of Pain (IASP). 111 Queen Anne Avenue North, Suite 501, Seattle, WA 98109-4955. (206) 283-0311. http://www.iasp-pain.org//AM/Template.cfm?Section=Home (accessed April 2, 2008).

OTHER

National Cancer Institute (NCI). Pain, health professional version. Bethesda, MD: NCI, 2007. http://www.cancer.gov/cancertopics/pdq/supportivecare/pain/HealthProfessional (accessed April 2, 2008).

National Institute of Neurological Disorders and Stroke (NINDS). Pain: Hope through Research. NIH Publication 01-2406. Bethesda, MD: NINDS, 2007.

Joan M. Schonbeck

Sam Uretsky, PharmD

Rebecca Frey, PhD

Pain relievers seeAnalgesics

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Pain Management

Pain management

Definition

If pain can be defined as a highly unpleasant, individualized experience of one of the body's defense mechanisms indicating an injury or problem, pain management encompasses all interventions used to understand and ease pain, and, if possible, to alleviate the cause of the pain.

Purpose

Pain serves to alert us to potential or actual damage to the body. The definition for damage is quite broad; pain can arise from injury as well as disease. After the message is received and interpreted, further pain can be counter-productive. Pain can have a negative impact on a person's quality of life and impede recovery from illness or injury, thus contributing to escalating health care costs. Unrelieved pain can become a syndrome in its own right and cause a downward spiral in a person's health and out-look. Managing pain properly facilitates recovery, prevents additional health complications, and improves an individual's quality of life.

Yet the experiencing of pain is a completely unique occurrence for each person, a complex combination of several factors other than the pain itself. It is influenced by:

  • Ethnic and cultural values. In some cultures tolerating pain is related to showing strength and endurance. In others, it is considered punishment for misdeeds.
  • Age. The concept that grownups don't cry.
  • Anxiety and stress related to being in a strange, fearful place such as a hospital, fear of the unknown consequences of the pain and the condition causing it can all make pain feel more severe.
  • Fatigue and depression. It is known that pain in itself can actually cause depression. Fatigue from lack of sleep or the illness itself also contribute to depressed feelings.

Precautions

As noted, the perception of pain is an individual experience. Health care providers play an important role in understanding their patients' pain. All too often, both physicians and nurses have been found to incorrectly assess the severity of pain. A study reported in the Journal of Advanced Nursing evaluated nurses' perceptions of a select group of American-born and Mexican-American women patients' pain following gallbladder surgery. Objective assessments of each patient's pain showed little difference between the severity for each group. Yet nurses involved in the study consistently rated all patients' pain as less than the patients reported, and with equal consistency, believed that better-educated women born in the United States were suffering more than less educated, Mexican-American women. Nurses from a Northern European background were more apt to minimize the severity of pain than nurses from Eastern and Southern Europe or Africa. Health care staff, and especially nursing staff, need to be aware of how their own background and experience contributes to how they perceive a person's pain.

Description

Before considering pain management, a review of pain definitions and mechanisms may be useful. Pain is the means by which the peripheral nervous system (PNS) warns the central nervous system (CNS) of injury or potential injury to the body. The CNS comprises the brain and spinal cord , and the PNS is composed of the nerves that stem from and lead into the CNS. PNS includes all nerves throughout the body except the brain and spinal cord. Pain is sometimes categorized by its site of origin, either cutaneous (originating in the skin of subcutaneous tissue, such as a shaving nick or paper cut), deep somatic pain (arising from bone, ligaments and tendons, nerves, or veins and arteries), or visceral (appearing as a result of stimulation of pain receptor nerves around organs such as the brain, lungs , or those in the abdomen).

A pain message is transmitted to the CNS by special PNS nerve cells called nociceptors. Nociceptors are distributed throughout the body and respond to different stimuli depending on their location. For example, nociceptors that extend from the skin are stimulated by sensations such as pressure, temperature, and chemical changes.

When a nociceptor is stimulated, neurotransmitters are released within the cell. Neurotransmitters are chemicals found within the nervous system that facilitate nerve cell communication. The nociceptor transmits its signal to nerve cells within the spinal cord, which conveys the pain message to the thalamus, a specific region in the brain.

Once the brain has received and processed the pain message and coordinated an appropriate response, pain has served its purpose. The body uses natural painkillers, called endorphins, to derail further pain messages from the same source. However, these natural painkillers may not adequately dampen a continuing pain message. Also, depending on how the brain has processed the pain information, certain hormones, such as prostaglandins, may be released. These hormones enhance the pain message and play a role in immune system responses to injury, such as inflammation. Certain neurotransmitters, especially substance P and calcitonin gene-related peptide, actively enhance the pain message at the injury site and within the spinal cord.

Pain is generally divided into two additional categories, acute and chronic. Nociceptive pain, or the pain that is transmitted by nociceptors, is typically called acute pain. This kind of pain is associated with injury, headaches, disease, and many other conditions. Response to acute pain is made by the sympathetic nervous system (the nerves responsible for the fight or flight response of the body). It normally resolves once the condition that precipitated it is resolved.

Following some disorders, pain does not resolve. Even after healing or a cure has been achieved, the brain continues to perceive pain. In this situation, the pain may be considered chronic. Chronic pain is within the province of the parasympathetic nervous system, and the changeover occurs as the body attempts to adapt to the pain. The time limit used to define chronic pain typically ranges from three to six months, although some health-care professionals prefer a more flexible definition, and consider chronic pain as pain that endures beyond a normal healing time. The pain associated with cancer , persistent and degenerative conditions, and neuropathy, or nerve damage, is included in the chronic category. Also, unremitting pain that lacks an identifiable physical cause, such as the majority of cases of low back pain, may be considered chronic. The underlying biochemistry of chronic pain appears to be different from regular nociceptive pain.

It has been hypothesized that uninterrupted and unrelenting pain can induce changes in the spinal cord. In the past, severing a nerve's connection to the CNS has treated intractable pain. However, the lack of any sensory information being relayed by that nerve can cause pain transmission in the spinal cord to go into overdrive, as evidenced by the phantom limb pain experienced by amputees. Evidence is accumulating that unrelenting pain or the complete lack of nerve signals increases the

number of pain receptors in the spinal cord. Nerve cells in the spinal cord may also begin secreting pain-amplifying neurotransmitters independent of actual pain signals from the body. Immune chemicals, primarily cytokines, may play a prominent role in such changes.

Managing pain

Considering the different causes and types of pain, as well as its nature and intensity, management can require an interdisciplinary approach. The elements of this approach include treating the underlying cause of pain, pharmacological and nonpharmacological therapies, and some invasive (surgical) procedures.

Treating the cause of pain underpins the idea of managing it. Injuries are repaired, diseases are diagnosed, and certain encounters with pain can be anticipated and treated prophylactically (by prevention). However, there are no guarantees of immediate relief from pain. Recovery can be impeded by pain and quality of life can be damaged. Therefore, pharmacological and other therapies have developed over time to address these aspects of disease and injury.

PHARMACOLOGICAL OPTIONS. General guidelines developed by the World Health Organization (WHO) have been developed for pain management. These guidelines operate upon a three-step ladder approach:

  • Mild pain is alleviated with acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs and acetaminophen are available as over-the-counter and prescription medications, and are frequently the initial pharmacological treatment for pain. These drugs can also be used as adjuncts to the other drug therapies that might require a doctor's prescription. NSAIDs include aspirin, ibuprofen (Motrin, Advil, Nuprin), naproxen sodium (Aleve), and ketoprofen (Orudis KT). These drugs are used to treat pain from inflammation and work by blocking production of pain-enhancing neurotransmitters, such as prostaglandins. Acetaminophen is also effective against pain, but its ability to reduce inflammation is limited. NSAIDs and acetaminophen are effective for most forms of acute (sharp, but of a short course) pain.
  • Mild to moderate pain is eased with a milder opioid medication plus acetaminophen or NSAIDs. Opioids are both actual opiate drugs such as morphine and codeine, and synthetic drugs based on the structure of opium. This drug class includes drugs such as oxy-codon, methadone, and meperidine (Demerol). They provide pain relief by binding to specific opioid receptors in the brain and spinal cord.
  • Moderate to severe pain is treated with stronger opioid drugs plus acetaminophen or NSAIDs. Morphine is sometimes referred to as the gold standard of palliative care as it is not expensive, can be given starting with smaller doses and gradually increased, and is highly effective over a long period of time. It can also be given by a number of different routes, including by mouth, rectally, or by injection.

Although antidepressant drugs were developed to treat depression, it has been discovered that they are also effective in combating chronic headaches, cancer pain, and pain associated with nerve damage. Antidepressants that have been shown to have analgesic (pain-reducing) properties include amitriptyline (Elavil), trazodone (Desyrel), and imipramine (Tofranil). Anticonvulsant drugs share a similar background with antidepressants. Developed to treat epilepsy, anticonvulsants were found to relieve pain as well. Drugs such as phenytoin (Dilantin) and carbamazepine (Tegretol) are prescribed to treat the pain associated with nerve damage.

Close monitoring of the effects of pain medications is required in order to assure that adequate amounts of medication are given to produce the desired pain relief. When a person is comfortable with a certain dosage of medication, oncologists typically convert to a long-acting version of that medication. Transdermal fentanyl patches (Duragesic) are a common example of a long-acting opioid drug often used for cancer pain management. A patch containing the drug is applied to the skin and continues to deliver the drug to the person for typically three days. Pumps are also available that provide an opioid medication upon demand when the person is experiencing pain. By pressing a button, they can release a set dose of medication into an intravenous solution or an implanted catheter. Another mode of administration involves implanted catheters that deliver pain medication directly to the spinal cord. Delivering drugs in this way can reduce side effects and increase the effectiveness of the drug. Research is underway to develop toxic substances that act selectively on nerve cells that carry pain messages to the brain, killing these selected cells and thus stopping transmission of the pain message.

NONPHARMACOLOGICAL OPTIONS. Pain treatment options that do not use drugs are often used as adjuncts to, rather than replacements for, drug therapy. One of the benefits of non-drug therapies is that an individual can take a more active stance against pain. Relaxation techniques, such as yoga and meditation , are used to focus the brain elsewhere than on the pain, decrease muscle tension and reduce stress. Tension and stress can also be reduced through biofeedback, in which an individual consciously attempts to modify skin temperature, muscle tension, blood pressure , and heart rate.

Participating in normal activities and exercising can also help control pain levels. Through physical therapy , an individual learns beneficial exercises for reducing stress, strengthening muscles, and staying fit. Regular exercise has been linked to production of endorphins, the body's natural pain killers.

Acupuncture involves the insertion of small needles into the skin at key points. Acupressure uses these same key points, but involves applying pressure rather than inserting needles. Both of these methods may work by prompting the body to release endorphins. Applying heat or being massaged are very relaxing and help reduce stress. Transcutaneous electrical nerve stimulation (TENS) applies a small electric current to certain parts of nerves, potentially interrupting pain signals and inducing release of endorphins. To be effective, use of TENS should be medically supervised.

INVASIVE PROCEDURES. There are three types of invasive procedures that may be used to manage or treat pain: anatomic, augmentative, and ablative. These procedures involve surgery, and certain guidelines should be followed before carrying out a procedure with permanent effects. First, the cause of the pain must be clearly identified. Next, surgery should be done only if noninvasive procedures are ineffective. Third, any psychological issues should be addressed. Finally, there should be a reasonable expectation of success.

Anatomic procedures involve correcting the injury or removing the cause of pain. Relatively common anatomic procedures are decompression surgeries, such as repairing a herniated disk in the lower back or relieving the nerve compression related to carpal tunnel syndrome . Another anatomic procedure is neurolysis, also called a nerve block, which involves destroying a portion of a peripheral nerve.

Augmentative procedures include electrical stimulation or direct application of drugs to the nerves that are transmitting the pain signals. Electrical stimulation works on the same principle as TENS. In this procedure, instead of applying the current across the skin, electrodes are implanted to stimulate peripheral nerves or nerves in the spinal cord. Augmentative procedures also include implanted drug-delivery systems. In these systems, catheters are implanted in the spine to allow direct delivery of drugs to the CNS.

Ablative procedures are characterized by severing a nerve and disconnecting it from the CNS. However, this method may not address potential alterations within the spinal cord. These changes perpetuate pain messages and do not cease even when the connection between the sensory nerve and the CNS is severed. With growing understanding of neuropathic pain and development of less invasive procedures, ablative procedures are used less frequently. However, they do have applications in select cases of peripheral neuropathy, cancer pain, and other disorders.

Preparation

Prior to beginning management, pain is thoroughly evaluated. Pain scales or questionnaires are used to attach an objective measure to a subjective experience. Objective measurements allow health care workers a better understanding of the pain being suffered by the patient.


KEY TERMS


Acute —Referring to pain in response to injury or other stimulus that resolves when the injury heals or the stimulus is removed.

Chronic —Referring to pain that endures beyond the term of an injury or painful stimulus. Can also refer to cancer pain, pain from a chronic or degenerative disease, and pain from an unidentified cause.

CNS or central nervous system —The part of the nervous system that includes the brain and the spinal cord.

Iatrogenic —Resulting from the activity of the physician.

Neuropathy —Nerve damage.

Neurotransmitter —Chemicals within the nervous system that transmit information from or between nerve cells.

Nociceptor —A nerve cell that is capable of sensing pain and transmitting a pain signal.

Nonpharmacological —Referring to therapy that does not involve drugs.

Parasympathetic nervous system —Pertaining to that part of the autonomic nervous system consisting of nerves that arise from the cranial and sacral regions and which oppose the action of the sympathetic nervous system.

Pharmacological —Referring to therapy that relies on drugs.

PNS or peripheral nervous system —Nerves that are outside of the brain and spinal cord.

Stimulus —A factor capable of eliciting a response in a nerve.

Sympathetic nervous system —The portion of the autonomic nervous system consisting of nerves that originate in the thoracic and lumbar spinal cord and that function in opposition to the parasympathetic nervous system.


Evaluation also includes physical examinations and diagnostic tests to determine underlying causes. Some evaluations require assessments from several viewpoints, including neurology, psychiatry and psychology, and physical therapy. If pain is due to a medical procedure, management consists of anticipating the type and intensity of associated pain and managing it preemptively.

Nurses or physicians often take what is called a pain history. This will help to provide important information that can help health care providers to better manage the patient's pain. A typical pain history includes the following questions:

  • Where is the pain located?
  • On a scale of 1 to 10, with 1 meaning the least pain, how would the person rate the pain they are experiencing?
  • Describe what the pain feels like.
  • When did (or does) the pain start?
  • How long has the person had it?
  • Is the person sometimes free of pain?
  • Does the person know of anything that triggers the pain, or makes it worse?
  • Does the person have other symptoms (nausea, dizziness, blurred vision , etc.) during or after the pain?
  • What pain medications or other measures has the person found to help in easing the pain?
  • How does the pain affect the person's ability to carry on normal activities?
  • What does it mean to the person that they are experiencing pain?

Aftercare

An assessment by nursing staff as well as other health care providers should be made to determine the effectiveness of the pain management interventions employed. There are objective, measurable signs and symptoms of pain that can be looked for. The goal of good pain management is the absence of these signs:

Signs of acute pain:

  • rise in pulse and blood pressure
  • more rapid breathing
  • perspiring profusely, clammy skin
  • taut muscles
  • more tense appearance, fast speech, very alert
  • unusually pale skin
  • pupils of the eye are dilated

Signs of chronic pain:

  • lower pulse and blood pressure
  • changeable breathing pattern
  • skin is warm and dry
  • nausea and vomiting
  • slow speech in monotone
  • inability, or difficulty in getting out of bed and doing activities
  • pupils of the eye are constricted

When these signs are absent and the patient appears to be comfortable, health care providers can consider their interventions to have been successful. It is also important to document interventions used, and what ones were successful.

Complications

Owing to toxicity over the long term, some drugs can only be used for acute pain or as adjuncts in chronic pain management. NSAIDs have the well-known side effect of causing gastrointestinal bleeding, and long-term use of acetaminophen has been linked to kidney and liver damage. Other drugs, especially narcotics, have serious side effects, such as constipation, drowsiness, and nausea. Serious side effects can also accompany pharmacological therapies; mood swings, confusion, bone thinning, cataract formation, increased blood pressure, and other problems may discourage or prevent use of some analgesics .

Nonpharmacological therapies carry little or no risks. However, it is advised that individuals recovering from serious illness or injury consult with their health care providers or physical therapists before making use of adjunct therapies. Invasive procedures carry risks similar to other surgical procedures, such as infection , reaction to anesthesia, iatrogenic (injury as a result of treatment) injury, and failure.

A traditional concern about narcotics use has been the risk of promoting addiction. As narcotic use continues over time, the body becomes accustomed to the drug and adjusts normal functions to accommodate to its presence. Therefore, to elicit the same level of action, it is necessary to increase dosage over time. As dosage increases, an individual may become physically dependent on narcotic drugs.

However, physical dependence is different from psychological addiction. Physical dependence is characterized by discomfort if drug administration suddenly stops, while psychological addiction is characterized by an overpowering craving for the drug for reasons other than pain relief. Psychological addiction is a very real and necessary concern in some instances, but it should not interfere with a genuine need for narcotic pain relief. However, caution must be taken with people with a history of addictive behavior.

Results

Effective application of pain management techniques reduces or eliminates acute or chronic pain. This treatment can improve an individual's quality of life and aid in recovery from injury and disease.

Health care team roles

Physicians, both primary care physicians (PCPs) and surgeons, treat both the conditions causing the pain, and the pain itself. The physician's role as teacher is an important one, alleviating fears about both the patient's condition and the possibility of addiction to narcotics, which is often a fear among patients on narcotic medication. Some physicians specialize in the treatment of pain, and work out of pain clinics.

Registered nurses (RNs) are the professional staff member that will likely spend the most time with the patient, whether the patient is in the hospital or other health care facility, or at home. Gathering the necessary information regarding the person's pain through a pain history, and careful observation and listening can help tremendously in the provision of pain relief. RNs also administer the medications at times, and provide information to the patient about the various medications that may be used, and allay concerns about the use of them.

Licensed practical nurses (LPNs) also spend considerable time with the patient in a health care facility or at home. Like RNs, LPNs administer medications as necessary, and provide information to patients.

Pain clinic staff may be any of the above, or psychologists, social workers, occupational or recreational therapists, or other people with specific training in group therapy, yoga, meditation, or other non-pharmacological means of relieving pain.

Pharmacists fill prescriptions for pain-relieving medications, monitor the use of narcotic medications, and provide information regarding the uses and side-effects of the medications.

Resources

BOOKS

Kozier, Barbara, RN, MN, Glenora Erb, RN, BSN, Kathleen Blais, RN, EdD, and Judith M. Wilkinson, RNC, MA, MS. Fundamentals of Nursing, Concepts, Process and Practice. 5th ed. Redwood City, CA: Addison-Wesley, 1995.

Salerno, Evelyn, and Joyce S. Willens, eds. Pain Management Handbook: An Interdisciplinary Approach. St. Louis: Mosby, 1996.

ORGANIZATIONS

American Chronic Pain Association. P.O. Box 850, Rocklin, CA 95677-0850. (916) 632-0922. <http://members.tripod.com/~widdy/acpa.html>.

American Pain Society. 4700 West Lake Ave., Glenview, IL 60025. (847) 375-4715. <http://www.ampainsoc.org>.

National Chronic Pain Outreach Association, Inc. P.O. Box 274, Millboro, VA 24460-9606. (540) 597-5004.

OTHER

What We Know About Pain. National Institute of Dental Research, National Institute of Health, Bethseda, MD20892. (301) 496-4261.

Joan M. Schonbeck

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