Establish Clear Goals of Care
- Keep the patient safe
- Optimize care (pain and medical treatment)
- Withholding opioids will not cure addiction
- Providing opioids will not worsen addiction
- Minimize uncertainty and inconsistency between patient & staff
- Refer interested patients for treatment
- Comprehensive assessment of pain to determine etiology and guide treatment plan
- Clear communication between all team members, including the patient/family about goals and plan of care
- Follow relevant pharmacologic principles
- Understand tolerance issues
- Investigate and clarify problematic behavior and difficulty progressing care
- Consider multidisciplinary consultation (mental health, addiction, pain, social work, spiritual care, etc.)
Laroche F, Rostaing S, Aubrun F, Perrot S. Pain management in heroin and cocaine users. Joint Bone Spine 2012;79(5). PMID:22405747 DOI:10.1016/j.jbspin.2012.01.007
Paschkis Z, Potter ML, CE: Acute pain management for inpatients with opioid use disorder. Am J Nurs 2015;115(9). PMID:26273927 DOI:10.1097/01.NAJ.0000471243.30951.92
Quinlan J, Cox F. Acute pain management in patients with drug dependence syndrome. International Association for the Study of Pain (IASP), Pain Clinical Updates, April 2017;25(1). Updated link May 30, 2019.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5741366/
Stromer W, Michaeli K, Sandner-Kiesling A. Perioperative pain therapy in opioid abuse, Eur J Anaesthesiology 2013;30(2). PMID: 23241915 DOI:10.1097/EJA.0b013e32835b822b
Components of Comprehensive Pain Assessment
Pain history, medical history, and addiction history, combined with a physical exam, psychosocial history, and mental status history that lead to a pain classification and knowledge of the extent of disease, and related discovery of psychosocial dysfunction and support systems, create the pain diagnosis.
From the pain diagnosis, therapies for the organic component of pain and therapies for the affective and cognitive components of pain and related psychosocial distress can be devised.
Pain Assessment Mnemonic: QISS-TAPED
- Q = Quality
- I = Impact
- S = Site
- S = Severity
- T = Temporal Characteristics
- A = Aggravating & Alleviating Factors
- P = Past Treatment & Response, Patient Preferences
- E = Expectations, Goals, Meaning
- D = Diagnostics, physical exam
View a version of the QISS-TAPED with examples of potentially useful questions by clicking this link: https://www.painmanagementnursing.org/article/S1524-9042(04)00103-1/fulltext
Herr K, Neuropathic pain: a guide to comprehensive assessment. Pain Manage Nurse 2004;5(4 Suppl1):9-18. PMID:15644855 DOI:10.1016/j.pmn.2004.10.004
The conversation leads to documentation, not the other way around.
Click the link to view the CAPA tool: https://www.painmanagementnursing.org/article/S1524-9042(17)30439-3/pdf
Gordon DB, Acute pain assessment tools: let us move beyond simple pain ratings. Curr Opin Anaesthesiol 2015;38(5):PMID: 26237235 DOI:10.1097/ACO.0000000000000225
A patient admitted with history of heroin use is frequently requesting higher doses of IV opioids saying there is no way pain can be controlled using oral medicine. The patient is angry, uncooperative with interviews and says that staff are constantly judging him because his is “a junkie.”
While there is no “right” answer, think about how might you best respond. Use the table to find different strategies and suggested phrasing for difficult conversations like these.
|Validate patient’s pain and frustration/fear/other emotions.||“I know that you’re in pain and you’reworried. We will do our best for your pain.”|
|Review the data objectively.||“I see that you are able to function better and sleep better than before.”|
|Set clear limits when responding to requests for inappropriate intravenous opioids which are not indicated.||“Our standard for all patients is to not give IV medication for people who are able to take pills”
“It is not so important how we get the opioid into your body. What is more important is the right amount at the right time. Though IV may seem stronger it is really only faster but it will also wear off sooner than oral medicine. Oral medicine will give you more steady pain control.”
|Use empathy. When patient replies that nothing works except for the IV opioids.||“I’m really sorry you feel that way. This sounds like it is really terrible for you. I understand how it must be difficult to understand why we are saying no to more opioids, but we care about your safety. I know there are ways we can work together so you feel better”|
|Avoid arguing.||“There is no reason for us to argue about this” or “I am not going to argue with you.”|
|Do not abandon the patient; commit to treating pain with non-opioid measures.||“I believe that you have pain, and I want to continue to work with you to treat the pain with other approaches”|
|Use risk/benefit language||“The risks of these medications are higher than the benefits for you”|
|Be empathetic when it is time to deny or stop opioids||“This must be very difficult for you...In my professional opinion (or medical research does not support), this type of pain medication, it is simply not safe for you in the long run” or “It may seem in the short run that opioids help, but they are not the best approach and can make your pain and problems worse over time”|
|Respond directly to threats to leave against medical advice||“You have the right to leave the hospital, but I still cannot give you inappropriate medications”|
Education and Engagement
- Cause of pain
- Methods of pain assessment
- Goals, expectations
- Treatment options
- Rationale for therapy
Lack of knowledge about pain and its treatment can be a major barrier to adequate pain management. Educational interventions have been found to be useful in increasing knowledge, improving patients’ involvement in their own care, as well as reducing pain intensity.
Patients need to understand goals for pain relief as well as expectations for specific pain treatments.
Information and preparation for painful procedures can also help minimize pain. In developing the pain management plan, patient’s goals and expectations should be explored.Various pain treatment options should be explained including rationale for therapies. Some patients may be suspicious and reluctant to try nonpharmacologic interventions unless they understand how they work.
Potential mechanisms of action of both pharmacologic and nonpharmacologic interventions should be described. Written materials should be provided to support information presented verbally.
Use a Balanced Rational Multi-Modal Analgesia
It is often necessary to employ a mechanistic approach to drug selection, with less emphasis on therapeutic class stratification and more attention to efficacy related to the underlying cause. This may allow for rational “multimodal” selection of therapeutic agents and improved patient outcomes.
Opioids, tramadol, tricyclic antidepressants, selective serotonin reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors can enhance the descending inhibitory pathways from the brain.
Opioids activate receptors that result in reducing the release of neurotransmitters (e.g., norepinephrine, glutamate, serotonin, substance P, acetylcholine).
Some antidepressants inhibit reuptake of biogenic amines (e.g., norepinephrine, serotonin). Tricyclic antidepressants are strong sodiumchannel modulators.
Two groups of agents modulate central sensitization at the spinal cord:
- Drugs that inhibit calcium flux, such as anticonvulsants.
- Drugs that affect N-methyl-D-aspartate (NMDA) receptors. This second group contains agents whose primary indications are unrelated. These drugs modulate central sensitization via effects on NMDA receptors and are still under study for analgesic use.
Drugs that modulate peripheral sensitization by inactivating voltagedependent sodium channels include carbamazepine, oxcarbazepine, topiramate, and lidocaine. Gabapentin inhibits Ca++ channel current in a voltage-dependent manner. Capsaicin acts at vanilloid receptors, causing initial short-term receptor activation followed by long-term Ca++- dependent desensitization.
- Analgesic, antipyretic, not an anti-inflammatory
- Few if any side effects at therapeutic doses
- Hepatotoxic at high dose
- Use caution with opioid combination drugs
- Alcoholics at special risk
- Uncertainty about risk of “analgesic nephropathy” with long-term use, especially if used in combination with aspirin or other NSAIDs
Acetaminophen is equivalent to aspirin as an analgesic and antipyretic, but it lacks anti-inflammatory properties. The conventional oral dose is 650-1000 mg.
Its advantage in the treatment of mild to moderate pain is that it has few if any side effects at therapeutic doses. The danger of the drug is that at high doses it (well really its metabolite) is toxic to the liver and can cause fatal hepatic necrosis.
Nurses must be alert to the many drugs that contain APAP: cold remedies, sleep aids, and especially combination analgesics with opioids. Patients with alcohol use disorder or hepatitis C are at special risk of acetaminophen hepatotoxicity because chronic use of alcohol results in increases in the enzyme that converts it to the toxic metabolite.
The FDA issued new warnings on pain relievers in December 2006: persons who consume more than 2-3 alcoholic drinks per day and those with hepatitis C should not take more than 2g in 24 hours.
Chronic use of acetaminophen (or aspirin for that matter) has been linked to chronic renal failure. Unfortunately, the risk has not been clearly defined. There are no data to indicate the dose level and duration of use that increase the risk of irreversible kidney damage.
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
- Anti-inflammatory, antipyretic and analgesic effects
- NSAIDs should be utilized in the multimodal management of acute pain unless otherwise contraindicated
- Principle mechanism of action is inhibition of prostaglandin synthesis
- Side effects depend partly on whether drugs are selective (COX-2) or nonselective
- Impaired hemostasis (nonselective)
- GI irritation/bleeding (nonselective)
- Cardiovascular risk
- Renal toxicity
Gabapentin (Neurontin®) and Pregablin (Lyrica®)
- Blocks a2d subunit of voltage-dependent calcium channel; reduce influx of Ca2+, less glutamate released from nerve endings
- Not metabolized, few drug interactions, monitor kidney function
- Sedation common; ataxia, peripheral edema, dizziness, diplopia, nausea
- Role in managing postop pain
- Significant anti-anxiety effects
These calcium channel modulators are the anti-epileptics with the best evidence of efficacy. They bind to the alpha 2 delta subunit of the calcium channel.
- Advantages: lack of drug interactions
- Disadvantage: need for 3 daily doses.
To decrease side effects, start gabapentin at 100 to 300 mg in a single dose at bedtime or 100-300 mg 3 times a day and titrate by 100-300 mg every 1-7 days as tolerated; between 1800 and 3600 mg/day is usually needed.
There are reports of higher dose requirements, but keep in mind that 4800 mg is the gut’s maximum absorption capacity. Allow 3-6 weeks for titration, 1-2 weeks at maximum tolerated dose.
The dose range for pregabalin is 100 –200 mg three times a day. Start with 100 mg; can titrate to 600 mg in 6 days; often see improvement within a week. Dizziness and somnolence may occur. Provides pain control, improves sleep.
Both gabapentin and pregabalin have antianxiety effects. Pregabalin is a Schedule V controlled substance.
- N-methyl-D-aspartate (NMDA) antagonist that can inhibit induction and maintenance of central sensitization (“wind-up”) after painful stimuli
- Often used intraoperatively as part of a balanced multimodal approach to pain control.
- May be particularly useful for patients who are opioid tolerant.
- Has been shown to have an opioid-sparing effect during the first postoperative days.
- Pain Reduction (rest 0.6-1.3cm; mobilization 0.4-0.5)
- Analgesic sparing (5-20mg)
- Risk reduction PONV (NNT 11)
- Most common side effects include dysphoria, hallucinations, visual changes
- Modulate sodium channels
- When administered peripherally, may produce differential—also known as sensory—block
- Interrupts some nerve conduction, but leaves motor function unaffected
- Some nerves are more readily blocked than others, depending on size and myelination
- Epidurally, interrupts pain input at the nerve roots
- Associated with few side effects
- Drugs with primary applications other than pain management
- Some are effective in certain painful conditions
- Drugs for neuropathic pain
- Local Anesthetics
- Alpha2 adrenergic agonists
- NMDA receptor antagonists
- Corticosteroids and others
- Muscle relaxants
- Hypnotics and anxiolytics
Chou R, Gordon DB, De Leion-Casasola OA, et al. Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016 Feb;17(2):131-57. PMID: 26827847 DOI:10.1016/j.jpain.2015.12.008
Kehlet H, Dahl JB. The value of “multimodal” or “balanced analgesia” in postoperative pain treatment. Anesth Analg. 1993;77:1048-1056. PMID:8105724
U.S. Food and Drug Administration. (2006). FDA Proposes Labeling Changes to Over-the-Counter Pain Relievers. Retrieved 2007, August 31. Updated link May 30, 2019 from https://www.fda.gov/drugs/bioterrorism-and-drug-preparedness/use-caution-pain-relievers
Buvanendra, A, Kroin JS, Della Valle CJ, Kari M, Moric M, Tuman KJ. Perioperative oral pregabalin reduces chronic pain after total knee arthroplasty: a prospective, randomized, controlled trial. Pain Medicine 2010;110(1):199-207. PMID:19910619 DOI:10.1213/ANE.0b013e3181c4273a
Eipe N, Penning J, Yazdi F, Mallick R, Turner L, Ahmadzai N, Ansari MT, Perioperative use of pregabalin for acute pain-a systematic review and metanalysis. Pain 2015 156(7):1284-1300. PMID: 25830925 DOI:10.1097/j.pain.0000000000000173
Singla NK, Chelly JE, Lionberger DR, Gimbel J, Sanin L, Sporn J, Yang R, Cheung R, Knapp L, Parsons B. Pregabalin for the treatment of postoperative pain: results from three controlled trials using different surgical models. J Pain Res 2014; 8:9-20. PMID:25565885 PMCID:PMC4278776 DOI:10.2147/JPR.S67841
Tippana EM, Hamunen K, Kontinen VK, Kalso E. Do surgical patients benefit from perioperative gabapentin/pregabaline? A systematic review of efficacy and safetyl. Anesth & Analg 2007;104(6):1545-1556. PMID:17513656 DOI:10.1213/01.ane.0000261517.27532.80
Snijdelaar DG, Cornelisse HB, Schmid RL, Katz J. A randomized, controlled study peri-operative low dose s(+)-ketamine in combination with postoperative patient-controlled s(+)-ketamine and morphine after radical prostatectomy. Anaesthesia 2004;59(3):222-228. PMID:14984518
Unlugenc H, Ozalevli M, Guler T, Isik G, Postoperative pain management with intravenous patientcontrolled morphine: comparison of the effect of adding magnesium or ketamine European Journal of Anaesthesiology 2003;20:416-21. PMID:12790216
Wang L, Johnston B, Kaushal A, Cheng D, Zhu F, Martin J, Ketamine added to morphine or hydromorphone patient-controlled analgesia for acute postoperative pain in adults: a systematic review and meta-analysis of randomized trials. Canadian Journal Anaesthesia 2016;63(3):311-325. PMID:26659198 DOI:10.1007/s12630-015-0551-4
Purpose is to augment pharmacologic therapy, not replace it:
- Basic comfort measures
- Physical techniques provide comfort, correct physical dysfunction, and alter physiologic responses
- Behavioral strategies help patients understand pain, alter pain behavior, coping skills and change perception of pain
Benefits of Non-Pharmacologic Strategies
- Reduced anxiety
- Improved mood
- Increased sense of control over pain
- Improved sleep
- Decreased fatigue
- Improved function
- Restored hope
- Improved quality of life
There is moderate quality evidence to recommend the use of physical and cognitive-behavioral interventions for acute pain management. Some patients may experience a reduction in pain intensity with a nonpharmacologic intervention while others may not. Regardless of their effects on pain intensity, nonpharmacologic interventions provide a variety of other beneficial effects that can positively impact pain-related outcomes. Nonpharmacologic interventions have been shown to reduce anxiety, improve mood, increase personal sense of control over pain, improve sleep, decrease fatigue, improve functional status, restore hope, and enhance quality of life.
Selecting Non-Pharmacologic Treatments
- Previous experiences and expectations for outcome
- Patient preferences and coping styles
- Type and intensity of pain
- Physical and cognitive abilities
- Concurrent symptoms
- Involvement of friends / family
Previous experiences with nondrug interventions may influence how well patients expect the treatment to work and whether or not they are willing to use them again. Patients may also have preferences for specific nonpharmacologic interventions based on their personal coping style. The clinician may ask the patient what strategies they have used to control pain in the past, how they usually cope with pain, and what nonpharmacologic interventions they found useful for pain or other symptoms in the past.
Cultural or religious preferences may influence which nonpharmacologic interventions patients are willing to use. Type of pain should also be considered.
Well-localized pain may be suitable for cutaneous stimulation interventions such as TENS or massage to a specific body area, whereas diffuse widespread pain may be better treated with a cognitive or behavioral strategy. Cutaneous stimulation interventions can be used for any level of pain, however cognitive interventions may be too difficult to use if pain is severe.
Physical or cognitive abilities will determine what types of non-pharmacologic interventions patients are capable of using or which they are particularly well suited to use. For example, imaging ability – the ability to create vivid mental images and experience them as if they were real – has been found to be related to success in achieving pain relief with guided imagery interventions.
Concurrent symptoms, which can interfere with one’s capacity to focus on a cognitive intervention, should also be considered. If family or friends are available and willing to participate, they may be able to help patients implement nonpharmacologic interventions, such as guiding an imagery exercise or providing massage.
- Basic comfort measures (lighting, noise, temperature, pacing/rest, supportive devices)
- Applications of heat and cold
- Physical Therapy
- Transcutaneous electrical nerve stimulation
- Meditation and mindfulness
- Cognitive-behavioral psychotherapy
Transcutaneous Electrical Nerve Stimulation (TENS) for Acute Pain
- There are more than 41 randomized controlled trials using TENS in acute postoperative pain demonstrating benefit.
- Studies include patients with thoracic/cardiac, abdominal/pelvic, knee, spine hip, hernia, or mixed types of surgeries
- Pooled reduction of 36% in postoperative analgesic use compared with sham (p = 0.005)
- A few studies reported decreased pain intensity
- Effects stronger with “optimal” settings and used prn with activities
Beckwee D, Bautmans I, Swinnen E, Yermet Y, Lefeber N, Lievens P, Vaes P. A systematice review investigating the relationship between efficacy and stimulation parameters when using transcutaneous electrical nerve stimulation after knee arthroplasty. SAGE Open Med 2014; Jun 16;2:2050312114539318. doi: 10.1177/2050312114539318. eCollection 2014. PMID:26770730 PMCID:PMC4607225 DOI:10.1177/2050312114539318
Bjordal JM, Johnson MI Ljunggreen AE. Transcutaneous electrical nerve stimulation (TENS) can reduce postoperative analgesic consumption. A meta-analysis with assessment of optimal treatment parameters for postoperative pain. Eur J Pain 2003;7(2):181-188. PMID:12600800 DOI:10.1016/S1090-3801(02)00098-8
Freynet A, Falcoz PE. Is transcutaneous electrical nerve stimulation effective in relieving postoperative pain after thoracotomy? Interact Cardiovasc Thorac Surg 2010;10(2):283-288. PMID:19910359 DOI:10.1510/icvts.2009.219576
Summary of General Principles for Acute Pain Management for Patients with the Disease of Addiction
- Team approach with case conferences
- Set realistic goals for pain and addiction treatment
- Treat depression and comorbid psychiatric problems
- If possible, treat the cause of the pain
- Incorporate nondrug methods of pain control
- Maximize nonopioids and adjuvants
- Use oral opioids when possible
- Minimize PRN IV doses unless necessary
- Consider tolerance - patients with opioid use disorder usually require higher doses
The team approach with ongoing case conferences is the foundation of managing pain in patients with the disease of addiction. The history of addiction should be openly discussed. Everyone involved with the patient’s care should understand the treatment plan and goals.
Principles of pain management in the presence of addictive disease involve the use of multimodal therapy including nonopioid and nondrug interventions. When parenteral is needed, IV PCA may be best. Be alert to other contributors to behavior and stress such as depression and anxiety. Patients with addictive disease or prior substance abuse may have tolerance and require high doses of opioids to control pain.