What Can We Do About Pain?

What Can We Do About PAIN? Mary J. Aigner RN, MSN, FNPC

Pain classification Underlying pathology  

Nociceptive Neuropathic

Another classification  

Acute Chronic

Nociceptive Pain Damage to somatic or visceral tissue   

Pain surgery site Arthritis Cardiac ischemia

Usually responds to  

5 lb. lobster ! ! !

Nonopioids opioids

Somatic Aching or throbbing pain Not well localized Arises from bone, joint, muscle, skin, or connective tissue

Visceral May result from stimuli such as  

Tumor Obstruction

Arises from internal organs such as  

Bladder intestines

Neuropathic Pain Not well controlled by opioid analgesics alone RX often includes use of 

Adjuvant analgesics Tricyclic antidepressants

Centrally or peripherally generated pain

Neuropathic: Centrally generated Deafferentation pain 

Caused by injury to either peripheral or CNS

Sympatheticallymaintained pain 

Associated with dysregulation of autonomic nervous system Eg. reflex sympathetic dystrophy

Administration Routes Flexibility of routes enables 

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Targeting particular anotomic source Achieve therapeutic blood levels quickly Avoid certain SEs Provide analgesia to pts unable to swallow

Interrupting Pain Pathways Transduction (step 1)    

NSAIDs Local anesthetics Anticonvulsants Corticosteroids

Transmission (step 2) 

opioids

Let’s Do A Quick Review

4 steps to physiologic pain:  Transduction 1. 2.

3.

Conversation of stimuli to action potential Occurs at level of peripheral nerve (free endings or nocioceptors) Causes release of chemicals into area around peripheral afferent nociceptor or PAN Some will excite/sensitize PAN

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If PAN activited – action potential produced

Step 2: Transmission Generated action potential travels    

Along entire nerve route to spinal cord very long cell (eg toe to s.c.) This is called the afferent fiber Can be blocked by Na channel inhibitor or a lesion in the fiber

Two fiber types  

A (alpha, beta, delta) C

Once again … Transduction responds to NSAIDs, local anesthetics, anticonvulsants, and corticosteroids Transmission resonds to opioids

Interrupting perception & modulation Perception   

Opioids NSAIDs Adjuvants (eg. antidepressants)

Modulation 

Tricyclic antidepressants

Surgical Therapies are not new

Trepanation

Surgical Therapies Nerve blocks 

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Reduces pain by interrupting transmission of nociceptive input Neural blockade w/local anesthetics sometimes used for perioperative pain For intractable chronic pain when conservative Rx fails

More surgical therapy Performed for severe pain unresponsive to all other Rx Neurosurgical interventions – 3 groups   

Implantation of drug-infusion system Neuroablation Neuroaugmentation

Vertebroplasty – interventional radiology

Vertebroplasty

Nonpharmacologic Therapy Can decrease dose of analgesia needed 

Thus decreases potential side effects

Some strategies believed to  

alter ascending nociceptive input Stimulate descending pain modulation mechanism

Examples of nonpharmacologic therapy – Physical strategies Acupuncture Application of heat and/or cold Exercise massage

More physical strategies Percentaneous electrical nerve stimulation (PENS) Transcutaneous electrical nerve stimulation (TENS) Vibration Others?????

Cognitive therapies Distraction Hypnosis Imagery Relaxation

Collaborative Management Effective communication 

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Patients need to feel they are believed and not “just complaining” Nurse needs to communicate concern and assure patient of commitment to helping him/her

Diagnoses - Pain Activity intolerance Acute pain Anxiety Chronic pain Constipation Disturbed sleep pattern Disturbed thought process

More diagnoses Fatigue Fear Hopelessness Ineffective coping Ineffective role performance Powerlessness Social isolation

Barriers to effective pain management Tolerance can occur with chronic exposure to variety of drugs 

Can manage tolerance by Increase analgesic dose Substitute another drug same class Add drug from different class to augment relief without increasing SEs

Physical dependence if using a drug that has response of withdrawal syndrome if suddenly decreased/stopped

More on barriers Addiction is a complex neurobiologic condition 

Drive to obtain and take substances for other than prescribed therapeutic value

Tolerance and physical dependence are NOT indicators of addiction

Ethics & Pain Mgmt Fear of hastening death Requests for assisted suicide Use of placebos in pain assessment and treatment

Gerontology considerations Chronic pain common problem Pain often associated with  

Physical disability Psychosocial problems

58-70% community swelling elders 

Estimated to have chronic pain

Most common conditions causing pain in elderly Musculoskeletal   

Osteoarthritis Low back pain Previous fracture sites

The lady in leotards was 81 years young!

Chronic pain in elders often results in: Depression Sleep disturbances Decreased mobility Decreased health care utilization Physical and social role dysfunction

More on elders Despite prevalence – pain often not 

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Assessed adequately, and as a consequence Not treated adequately Pain assessment tools may need adaptation for elders

Special populations & pain Cognitively impaired  

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Severe – prevents pt from communicating Behavioral/physiologic changes may be only indicators of pain UNT Behavioral Resource Center

Scales have been developed to help assess pain in elders with cog. Impairment 

Based on common behavioral indicators

Nurse tips Not always possible to validate meaning of behavior 

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Nurses must rely on knowledge of patient’s usual behavior If nurse/physician doesn’t know patient – need to rely on informants (family, caregiver) 1832 lithograph

Pts with substance abuse problems Still can have pain   

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Have right to effective pain mgmt Comprehensive pain assessment a must Goal of assessment is to facilitate development of Rx plan to relieve pain … and prevent/minimize withdrawal symptoms Requires a multidisciplinary approach if possible

Barriers to Pain Mgmt related to healthcare professionals Inadequate/inaccurate info Inadequate/sub-optimal assesment techniques Concern about addiction, overuse of controlled substances Concern about adverse effects (over concern) Concern about possible tolerance

System barriers Pain control may be low priority Inadequate reimbursement for pain mgmt Restrictive regulations (controlled subst.) Inadequate availability or access to care   

Rural areas Inter-city Working poor/middle class

Client barriers Cost of medications Reluctance to report pain or take meds Worried about being a “complainer” Concern about possible SEs Concern about tolerance or addiction Cost of medications 

Some pharmaceutical companies have programs to help with this

Client education Reassure patient   

Pain control is their right Need to report pain Good control improves QOL

Be proactive 

Provide info re tolerance, addiction, SEs, etc.

Learn patient’s concerns May get “hooked” on drug May become “immune” to effects of drug and pain will return May develop physical dependence and need drug “forever” How would you handle these concerns???

Almost last JACHO (Joint Commission for Accreditation of Healthcare Organizations) 

Clients have a right to pain assessment Facility must provide assess. Tools If facility cannot treat pt for pain, must refer to facility that can treat pain

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Clients must be treated for pain and involved in own pain mgmt Discharge planning and teaching will include pain mgmt strategies

Definition of pain Pain is whatever the person experiencing the pain says it is, existing wherever the person says it does.