Point 4 of 19 1. Non-opioid 2. Mild opioid 3. Strong opioid Pain: persisting or increasing Pain: persisting or increasing Freedom from Pain Pain
5005
Drug Treatment: Adjuvant [glossary] Drugs
Some types of chronic pain do not respond fully to commonly used drugs.
These types of pain may respond to: • Antidepressants
• Anticonvulsants • Corticosteroids With these drugs:
• Pain relief is not immediate. • There may be serious side effects. References 5, 7, 18
5006
Drug Treatment: Patient Education
Patients should be educated on drugs given for pain. Education should include:
• Regimen (When to take, how to take, etc.) • Possible side effects
• Possible adverse reactions References 3, 5, 7
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5007
Drug Treatment: Monitoring and Assessment
All drug doses must be documented and assessed for effect. This helps ensure that drugs are working to control pain.
The following items should be documented: • Time of dosage
• Intensity of pain (using a pain scale) before and after dosage
• Any side effects of the medication • Any adverse reactions
• Patient vitals before and after dosage References 3, 7, 15
5008
Drug Treatment: Potential Barriers
Many studies have shown that pain is under-treated. Analgesics are often not prescribed when they should be.
Clinicians may not prescribe analgesics because: • They do not consider treating pain important. • They do not believe the patient’s report of pain. • They do not know enough about treating pain.
• They are afraid of prescribing opioids to addicts or drug dealers.
• They are afraid of regulatory audits if they prescribe opioids.
Therefore, clinicians must be trained and educated on: • The importance of treating pain
• Using opioids to treat pain
• Laws and regulations for prescribing opioids Reference 9, 12
5009
Drug Treatment: Placebos
Placebos should not be used to treat pain.
It is unethical and improper to use placebos, in place of pain medication, to:
• Assess or treat pain
• Determine whether pain is “real”
• Diagnose psychological symptoms seen with pain Reference 3
5010
Drug Treatment: The Elderly (1)
Pain is common in the elderly population and frequently is undertreated.
Inadequately treating pain in the elderly may lead to: • Decreased functional ability
• Delayed recovery or rehabilitation • Falls
• Mood changes • Appetite disturbances • Increases in the cost of care
5011
Drug Treatment: The Elderly (2)
In elderly patients, drugs may have unusually strong or weak effects. This is due to factors common in the elderly population, such as:
• Chronic disorders • Poor nutrition • Taking many drugs
• Decreased drug absorption rate
Drugs in the elderly also tend to have a longer duration of activity and a higher peak of maximum activity.
Since the medications used to treat pain may have some of the same potential side effects, it is important to be careful when giving analgesics to elderly patients.
You should monitor these patients closely. Reference 20, 21
5012
Drug Treatment: Pediatrics
Pain experienced by children is also commonly undertreated. This is because clinicians:
• Mistakenly believe that children, particularly infants, do not perceive pain like adults
• Mistakenly believe that pain does not affect children in the same way as adults
• Fear unwanted effects from drugs used for pain
• May be unwilling to take the necessary time to address a child’s pain
A key to adequate treatment of pain is to: • Anticipate painful situations
• Use available drug and nondrug approaches to minimizing pain
Providing infants a pacifier and sucrose in water may decrease pain. All children may respond to the use of massage and the application of heat. Topical local anesthetics may be requested for procedures such as venipuncture. If more severe pain is
anticipated, systemic drugs may be needed. Reference 22
5013 Review
Select the answer that best fits the question.
A patient is about to be given a dose of an opioid analgesic. Intensity of pain should be measured before and after this dosage, using a pain rating scale.
a. True b. False
Correct: A
Feedback for A: Correct. This statement is true. Feedback for B: Incorrect. This statement is true.
5014
Non-Drug Treatment
Many non-drug methods have been tried to relieve pain. These methods may be used:
• Alone
• In combination with one another • In combination with drugs Non-drug treatment can:
• Relieve pain.
• Manage pain to improve a patient’s overall functioning and quality of life.
These methods are often called complimentary and alternative medicine (CAM). There is ongoing research in progress to find evidence to scientifically support these treatments.
References 7, 14, 23
5015
Non-Drug Treatment: Guidelines
Guidelines for non-drug treatment of pain include:
• Respect alternative approaches to pain relief. Allow the patient to use these approaches, unless specifically contraindicated [glossary].
• Bear in mind that herbal remedies can interact with drugs. • Measure intensity of pain (using a pain scale) before and
after all non-drug treatments, to assess effectiveness. • Many non-drug methods focus on relieving the anxiety,
tension, and other physical symptoms that come with pain. Drugs may be necessary to relieve the pain itself.
Reference 7, 23
5016 Summary
You have completed the lesson on treating pain. Remember:
• Drugs commonly used to treat pain are acetaminophen, NSAIDs, opioids, and opioid + non-opioid combination drugs.
• Antidepressants, anticonvulsants, and corticosteroids may be used for pain that does not respond to commonly used analgesics.
• Patients should be educated on drugs given for pain. • All analgesic drug doses should be documented. Pain
intensity should be measured and documented before and after each dosage.
• Clinicians must be trained and educated on pain management. They must understand the importance of treating pain, the use of opioids to treat pain, and the laws and regulations for prescribing opioids.
• Placebos should not be used to assess or manage pain. • Elderly patients are often undertreated, but they have
altered drug metabolism. Therefore, these patients must be monitored closely to ensure safe and adequate dosing. • Children are often undertreated; therefore, it is important to
anticipate painful procedures and treat with both drug and nondrug therapies.
• Non-drug methods can help relieve or manage pain. These methods can be used alone, in combination with one another, or in combination with drugs.
• Respect alternative or complementary non-drug
approaches to treating pain. Offer drugs when indicated, as ordered.
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Point 16 of 19
References
1. International Association for the Study of Pain. Available at: http://www.iasp-
pain.org/AM/Template.cfm?Section=Pain_Defi...isplay.cfm&ContentID=1728#Pain. Accessed September 7, 2010. 2. American Heritage Dictionary. Definition of “Pain.”
3. McCaffery M. Nursing practice theories related to cognition, bodily pain and main environmental interactions. . Los Angeles: University of California Los Angeles. 1968.
4. American College of Emergency Physicians. Optimizing the treatment of pain in patients with acute presentations. Ann
Emerg Med. 2010;56:77-79
5. Laccetti MS, Kazanowski MK. Pain Management, 2nd ed. Sudbury, MA: Jones and Bartlett Publishers. 2009. 6. Vanderah T. Pathophysiology of pain. Med Clin North Am. 2007;91:1-12
7. Benzon H. Raj’s Practical Management of Pain. 4th ed. Philadelphia, PA: Mosby Elsevier; 2008
8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision. Washington, DC. American Psychiatric Association; 2000
9. Brennan F, Carr DB, Cousins M. Pain management: a fundamental human right. Anesth Analg. 2007;105:205-21. 10. Dunwoody CJ, Krenzischek DA, Pasero C, Rathmell JP, Polomano RC. Assessment, physiological monitoring, and
consequences of inadequately treated acute pain. Pain Manag Nurs. 2008;9:S11-S21.
11. Middleton C. Understanding the physiological effects of unrelieved pain. Nurs Times. 2003;99:28-31.
12. The Joint Commission. Standards, rationales, elements of performance, and scoring. Elements for performance for PC.01.02.07. In: Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, IL: The Joint Commission; 2010:RI-4-PC-8.
13. Gordon DB, Dahl JL, Miaskowski C, et al. American Pain Society recommendations for improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force. Arch Internal Med. 2005;165:1574-1580. 14. Wong DL, Hockenberry-Eaton D, Wilson D, et. al. Wong’s essentials of pediatric nursing, 6th ed. St Louis, MO: Mosby.
2001.
15. Lynch M. Pain: The fifth vital sign: Comprehensive assessment leads to proper treatment. Adv Nurse Pract. 2001;9:28-36 16. Lind L, Karlsson D, Fridlund B. Digital pens and pain diaries in palliative home health care: professional caregivers’
experiences. Med Inform Internet Med. 2007;32:287-296.
17. Herr K, Bjoro K, Decker S. Tools for assessment of pain in nonverbal older adults with dementia: A state-of-the science review. J Pain Sympt Manage. 2006;31:170-192.
18. World Health Organization (WHO). Cancer Pain Relief. Geneva: WHO; 1986. Available at:
http://www.who.int/cancer/palliative/painladder/en/. Accessed February 21, 2011.
19. Folley KM. Appraising the WHO Analgesic Ladder on its 20th anniversary. Cancer Pain Release. 2006;19:1-4. 20. American Geriatrics Society. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc.
2009;57:1331-1346.
21. Gordon D, Dahl J, Miaskowski C et al. American Pain Society Recommendations for improving the quality of acute and cancer pain management. Arch Intern Med. 2005;165:1574-1580.
22. American Academy of Pediatrics. The assessment and management of acute pain in infants, children, and adolescents.
Pediatrics. 2001:108:793-797.
Please remember that compliance is the responsibility of each organization. Provision of this list does not imply that the content of this course wholly or partially addresses the guidelines and references provided here.