STRATEGIES FOR TREATING AND MANAGING PAIN

A comprehensive pain management approach includes:

  • Appropriate pharmacologic and nonpharmacologic interventions
  • Education of patient, family, and caregivers about the plan
  • Ongoing assessment of treatment outcomes
  • Regular review of the treatment plan

Pharmacologic Interventions

Pharmacologic interventions can be broadly categorized as primary analgesic medications and adjuvant (co-analgesic, or “helper”) medications. Analgesics include nonopioid analgesics and opioid analgesics. Nonopioids include acetaminophen and nonsteroidal anti-inflammatory drugs used to treat mild pain and also to serve as adjuvant medication for relief of moderate to severe pain. Opioids are narcotics used for moderate to severe pain.

OPIOID ANALGESICS

Opioids are synthetized compounds used for moderate to severe pain and may include:

  • Oxycodone
  • Hydrocodone
  • Oxymorphone
  • Buprenorphine

Drugs that are created in laboratories that mimic effects of opiates but are not derived from the opium poppy are synthetized drugs. Examples include methadone, fentanyl, and meperidine (OR ADPC, 2022).

OPIOIDS AND DRUG TOLERANCE, DEPENDENCE, AND ADDICTION

When an opioid drug is used on a regular basis, generally after more than 2–3 weeks, the same dose of the drug has less of an effect. This is referred to as tolerance, a physiological state in which an increased dosage is needed to produce the same effect, or reduced effect is observed with constant use.

With repeated use of opioids and the development of tolerance, dependence occurs. Physical dependence is a physiological state of neuro-adaptation characterized by emergence of withdrawal syndrome if the drug is stopped, decreased abruptly, or an antagonist is administered. Physical dependence does not equate with addiction. Dependence is characterized by the symptoms of tolerance and withdrawal. The brain adapts to repeated exposure to the drug and can only function normally in the presence of the drug. When the drug is withdrawn, physiologic reactions occur, which can be mild or even life-threatening.

Addiction is a neurobehavioral syndrome with genetic and environmental influences that results in psychological dependence on the use of substances for their psychic effects and is characterized by compulsive use despite harm (State of Michigan Department of Community Health, n.d.)

ADJUVANT ANALGESICS

Adjuvant analgesics (co-analgesics) are drugs that were developed for clinical uses other than pain but are used to enhance the analgesic effects of drugs used for pain. These may include:

  • Antidepressants
  • Anticonvulsants
  • Antispasmodics
  • Antihypertensives
  • Osteoclast inhibitors
  • Radiopharmaceuticals
  • Anxiolytics
  • Neurotoxins
  • Topical anesthetics
  • Corticosteroids
  • Anesthetic drugs
  • Cannabinoids
  • Anticholinergics
    (Portenoy et al., 2022)

CANNABIS (MEDICAL MARIJUANA)

The majority of states, including Michigan, allow for the use of medical marijuana. However, federal law continues to prohibit use of cannabis or its derivatives for any purpose. This means that people may be arrested and charged with possession even in states where marijuana use is legal (Kellogg et al. 2022).

Michigan laws regarding medical marijuana state:

  • An adult may possess up to 2.5 ounces of marijuana, up to 15 grams of which may be marijuana concentrate.
  • Within a residence, an adult may possess up to 10 ounces of marijuana and any marijuana produced by marijuana cultivated on the premises.
  • An individual can cultivate less than 12 plants for personal use.
  • An adult may transfer up to 2.5 ounces of marijuana to another adult as long as there is no remuneration and the transfer is not advertised or promoted to the public.
    (NORML, 2022)

Nonpharmacologic Interventions

Evidence-based nonpharmacologic therapies are safe when correctly administered and can be effective components of comprehensive pain management that can reduce the need for opioids. Nonpharmacologic therapies can be the sole intervention, or they can be combined with other treatments. Nonpharmacologic interventions include physical, psychological, and mind-body modalities.

PHYSICAL MODALITIES

Physical modalities for relief of pain refer to any therapeutic medium that uses the transmission to or through the patient of thermal, electrical, acoustic, radiant, or mechanical energy.

  • Thermal modalities (heat and cold)
  • Manual modalities (massage, manipulation therapy)
  • Acupuncture
  • Electrophysical agents (TENS, iontophoresis, percutaneous electric nerve stimulation)
  • Acoustic modalities (ultrasound, phonophoresis, shortwave and microwave diathermy, vibroacoustic therapy)
  • Light therapy (low-level laser, ultraviolet light)
  • Interventional modalities (injection, radiofrequency ablation, intrathecal pump, spinal cord stimulator)
  • Dry needling

PSYCHOLOGICAL MODALITIES

One of the most common types of psychotherapy used in pain management is cognitive-behavioral therapy (CBT). CBT can be described as the “gold standard” psychological treatment for persons with a wide range of pain issues. It can be used alone or in conjunction with medical or interdisciplinary rehabilitation treatments. Currently, CBT is the prevailing psychological treatment for individuals with chronic pain issues (Physiopedia, 2022a).

Acceptance and commitment therapy (ACT) helps patients to shift their primary focus from reducing or eliminating pain to fully engaging in their lives. The goal of the therapy is to help patients accept whatever discomfort exists, both physical and emotional, while continuing to live their lives according to their values (Glasofer, 2021).

MIND-BODY TECHNIQUES

Biofeedback is the use of instrumentation to mirror psychophysiologic processes, such as blood pressure, heart rate, and skin temperature, of which an individual normally is unaware and which may be brought under voluntary control. Types of biofeedback devices include:

  • Electromyogram (EMG)
  • Thermal
  • Neurofeedback or electroencephalography (EEG)
  • Electrodermal activity (ADA)
  • Heart rate variability (HRA)

Relaxation therapies have been found helpful in the management of chronic headaches and other types of chronic pain. Relaxation encourages reduction in muscle tension, resulting in a decrease in pain intensity (NCCIH, 2022).

Hypnosis can provide analgesia, reduce stress, relieve anxiety, improve sleep, improve mood, and reduce the need for opioids. It can also enhance the effectiveness of other forms of relaxation therapies and biofeedback for pain (Cosio & Lin, 2020).

Diverting attention (distraction) from feelings and thoughts of pain is a well-researched pain coping strategy. Mental distractions actually block pain signals from the body before they ever reach the brain (Stanford Health Care, 2021; Keane, 2021).

Mindfulness-based interventions (e.g., meditation) have been found to have significant effects on chronic pain, yet the mechanisms underlying these effects are not well understood. There are several types of mindfulness-based interventions, including:

  • Mindfulness-based stress reduction (MBSR)
  • Mindfulness-based cognitive therapy (MBCT) (see above)
  • Primary care brief mindfulness training (PCBMT)
  • Mindfulness-based exposure therapy (MBET)
  • Mantra-based meditation training
    (Cosio & Demyan, 2021)

Virtual reality provides immersive experiences that absorb more of the brain’s attention. With fewer mental resources left to process pain signals, people perceive less pain. VR causes a reduction of the electrical signals through which neurons communicate. Further validation tests of EEG and investigation on VR effects are needed to better understand how our brain acts while immersed in a virtual world (VirtualTimes, 2021).

Mirror therapy is a rehabilitation therapy in which a mirror is placed between the arms or legs so that the image of a moving, nonaffected limb gives the illusion of normal movement in the affected limb. Mirror therapy exploits the brain’s preference to prioritize visual feedback over somatosensory/proprioceptive feedback concerning limb position. The reflection “tricks” the brain into thinking there are two healthy limbs (Physiopedia, 2022b).

Yoga is a mind-body and exercise practice that helps relieve chronic pain. Yoga has many of the same benefits as mindfulness practice due to the common focus on breath, body, and present-moment awareness. There are different types of yoga, with the most evidence of benefit being shown through Iyengar yoga, hatha yoga, and Viniyoga (DHWA, 2021).

Tai chi and qigong are forms of traditional Chinese exercise that incorporate the concepts of two opposing forces—yin and yang. Both exercises are based on the idea and core principle that increasing energy in the body, known as chi, through gentle and repeated movements can enhance a person’s well-being (Marks, 2022; Winchester Hospital, 2022).

Evaluating the Effectiveness of Interventions

There are multiple outcome measures required to adequately assess the pain experience and how it has been modified by pain management interventions. The outcome of pain management is done by assessing:

  • The degree of analgesic effect in comparison to the patient’s baseline
  • The time to onset of the analgesic effect and the time to maximum reduction in pain intensity
  • The duration of the analgesic effect
  • Measures of physical functioning
  • Measures of emotional functioning
  • Secondary effects related to the treatment
    (Edward, 2021)

Nursing Principles of Pain Management

Many disciplines are involved in managing a patient’s pain, and nurses play a pivotal role in the assessment, monitoring, interpretation, and evaluation of pain. Effective pain management by nurses is fundamental to quality of care and is the first responsibility of the nurse.

Nursing functions of appropriate pain management include:

  • Ensuring the patient or legal representative actively participates in treatment plan and understands available options and potential side effects
  • Educating persons and families in a culturally competent manner regarding pain management
  • Using a standardized scale to periodically assess and document the patient’s pain
  • Developing and implementing a plan of care that prevents and alleviates pain as much as possible
  • Administering medications and treatment as prescribed
  • Initiating nonpharmacologic nursing interventions as indicated
  • Serving as an advocate for the patient
  • Communicating side effects or reports of unrelieved pain to the prescriber and team members
  • Documenting pain assessment, intervention, evaluation, and ongoing changes
    (State of Michigan Department of Community Health, n.d.)
NURSING PRINCIPLES OF PAIN MANAGEMENT USING CONTROLLED SUBSTANCES
  • All persons experiencing pain have a right to pain relief.
  • A person’s report of pain is the optimal standard for all interventions.
  • A comprehensive nursing assessment must be completed, including subjective description of pain, objective data, and identified need for psychosocial/spiritual support.
  • Fear of addiction of opioids and other pain medications should not be a barrier to pain management.
  • Nurses recognize and apply the following concepts when providing care:
    • Tolerance and physical dependence are consequences of sustained use of opioid analgesics and are not symptoms of addiction.
    • Pseudo-addiction is a pattern of drug-seeking behavior by persons with pain who are fearful of receiving inadequate pain management and may be mistaken for addiction.
    • Persons with a history of substance abuse have a right to adequate pain relief even if opioids must be used.
    • An interdisciplinary approach is optimal.
    • Pain management continues even if the person becomes unresponsive.
    (State of Michigan Department of Community Health, n.d.)