THE INTERDISCIPLINARY NATURE OF MANAGING PAIN

The most important member of the interdisciplinary team is the person with pain—the patient. Other team members can include:

• Significant others (family, friends, etc.)
• Physicians, physician assistants, and nurse practitioners
• Nurses
• Psychologists
• Physical therapists
• Occupational therapists
• Recreational therapists
• Vocational counselors
• Pharmacists
• Nutritionists/dietitians
• Social workers
• Support staff
• Volunteers

Role of the Nurse

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 STANDARDS OF CARE

Standards of care for nurses in the management of pain include, but are not limited to:

• Acknowledging and accepting the patient’s pain
• Identifying the most likely source of the pain
• Assessing pain at regular intervals, including each new complaint of pain, utilizing a pain assessment tool
• Assessing barriers to effective pain management
• Reporting the patient’s level of pain and developing a plan of care that includes interdisciplinary input
• Aggressively treating side effects such as nausea, vomiting, constipation, etc.
• Educating patient, family, and significant others on:
• Their role in the pain management plan and expected outcomes
• Detrimental effects of unrelieved pain
• Overcoming barriers to effective pain management
• Evaluating effectiveness of strategies and nursing interventions
• Documenting and reporting the interventions, patient responses, outcomes
• Advocating for the patient and family for effective pain management
  (MD BON, n.d.)

PATIENT EDUCATION AND OPIOID MEDICATIONS

Nurses have an important role to play in educating patients about the proper use of opioid medications. The following information should be included in the education provided to patients who are receiving opioids as well as to their caregivers:

• Take opioids as prescribed.
• In case of a missed dose or if the pain is not managed by the recommended doses:
• If pain is not managed, talk with the healthcare team and do not take extra doses.
• If a dose is missed, take it as soon as possible; however, if it is almost time for the next dose, skip the missed dose and go back on schedule.
• Do not double doses.
• For slow-release medication, if more than four hours late, do not take it.
• Oral capsules may be opened and mixed with cool foods, but extended-release medication should not be opened, crushed, broken, or chewed.
• It can be dangerous to use CNS depressants, including sedatives, alcohol, or illicit drugs, when taking opioid medications.
• Due to the addictive nature of opioids, discontinuation should be accomplished by tapering the drug’s dose with the assistance of one’s primary care provider.
• Opioids slow peristalsis and can lead to constipation; adequate fluid and fiber intake will facilitate the passage of stool.
• Opioids can impact one’s ability to drive or operate machinery and affect one’s balance, increasing the risk for falls.
• Death due to respiratory depression is a potential side effect.
• Drugs should never be shared.
• To avoid diversion, opioids should be locked in a secure location.
• Unused opioids should be disposed of safely (see table below).
  (Jackson, 2020)

FDA’s “FLUSH LIST” OF MEDICATIONS FOR DISPOSAL BY FLUSHING

Drug Name	Examples
(U.S. FDA, 2020)
Drugs That Contain Opioids
Any drug that contains the word buprenorphine	Belbuca, Buavail, Butrans, Suboxone, Subutex, Zubsolv
Any drug that contains the word fentanyl	Abstral, Actiq, Duragesic, Fentora, Onsolis
Any drug that contains the words hydrocodone or benzhydrocodone	Apadaz, Hysingla ER, Norco, Reprexain, Vicodin, Vicodin ES, Vicodin HP, Vicoprofen, Zohydro ER
Any drug that contains the word hydromorphone	Exalgo
Any drug that contains the word meperidine	Demerol
Any drug that contains the word methadone	Dolophine, Methadose
Any drug that contains the word morphine	Arymo Er, Avinza, Embeda, Kadian, Morphabond ER, MS Contin, Oramorph SR
Any drug that contains the word oxycodone	Codoxy, Combunox, Oxadydo (formerly Oxecta), Oxycet, Oxycontin, Percocet, Percodan, Roxicet, Roxicodone, Roxilox, Roxybond, Targiniq ER, Troxyca ER, Tylox, Xartemis XR, Xtampza ER
Any drug that contains the word oxymorphone	Opana, Opana ER
Any drug that contains the word tapentadol	Nucynta, Nucynta ER
Drugs That Do Not Contain Opioids
Any drug that contains the terms sodium oxybate or sodium oxybates	Xyrem, Xywav
Diazepam rectal gel	Diastat, Diastat Acudial
Methylphenidate transdermal system	Daytrana

ANA POSITION STATEMENT ON PAIN MANAGEMENT

The American Nurses Association Position Statement (2018) on the nurse’s role and ethical responsibility in the management of pain states that:

• Nurses have an ethical responsibility to provide clinically excellent care to relieve pain. Clinically excellent pain management considers clinical indications, mutual identification of goals for pain management, and ongoing reassessment with the patient of the effectiveness of pain control efforts.
• Nurses use the nursing process to guide actions to improve pain management and should ensure that each patient experiencing pain has an individualized pain management plan with appropriate monitoring to avoid undertreatment, overtreatment, or addiction.
• Nurses provide respectful, individualized nursing interventions to all patients experiencing pain regardless of the person’s personal characteristics, values, or beliefs.
• Nurses consider that multimodal and interprofessional approaches are necessary to achieve effective pain relief.
• Nurses use pain management modalities that are evidence-based. Lack of knowledge and understanding of best practices for assessing and optimally managing pain constrain the nurse’s ability to effectively minimize pain.
• Nurses have an obligation to assess and address factors within themselves and their practice environments that constrain ability and willingness to relieve pain and the suffering it causes.
• Nurses advocate for policies to assure access to all effective modalities. Nurses have a duty to advocate for improved parity in coverage for all effective pain relief modalities

Role of the Occupational Therapist

The role of the occupational therapist within an integrative pain management program focuses on function in daily living and takes a holistic and comprehensive approach to evaluate structural, physiologic, psychological, environmental, and personal factors that influence the experience of pain. The information obtained by patient evaluation is then used in the application of self-management strategies, functional activities, hands-on techniques, and specific exercises to improve function and participation.

OCCUPATIONAL THERAPY INTERVENTIONS

Depending on the area impacted by chronic pain, the occupational therapist provides the following interventions:

Physical mobility:

• Adaptive equipment selection and training
• Positioning equipment and strategies
• Functional mobility training (e.g., static positioning, dynamic movement, transfers, lifting and bending techniques)

Activities of daily living/self-care:

• Neuromuscular re-education
• Nerve mobilization
• Functional range of motion and strengthening exercises
• Activity pacing and energy conservation strategies
• Ergonomic and body mechanics training
• Fall prevention and safety
• Home evaluation

Instrumental activities of daily living:

• Adaptive equipment selection and training
• Transportation training, including comprehensive driver evaluations and driver rehabilitation

Health management:

• Patient education and disease self-management training, including trigger identification, symptom tracking, and pain flare-up planning
• Pain coping strategies, including physical modalities, complementary and alternative pain coping strategies, sensory strategies, self-regulation, and mobilization
• Pain and assertive communication training
• Medication management
• Eating routine strategies to avoid dietary pain triggers and improve energy management
• Establishing sustainable physical activities
• Time management strategies

Rest and sleep:

• Sleep hygiene and positioning strategies
• Cognitive behavioral therapy for insomnia
• Energy conservation and fatigue management

Education and work:

• Academic and work accommodations
• Ergonomic and body mechanics training
• Sensory strategies to monitor environmental triggers or exacerbating factors
• Advocacy and self-advocacy training
• Assertive communication training
• Community reintegration, including gradual re-entry plans
• Activity pacing and energy
• Environmental modifications
• Community and online resources exploration
• Compensatory cognitive strategies

Play, leisure, and social participation:

• Strategies to prevent social isolation
• Assertive communication strategies
• Personal values and interests exploration

(Reeves et al., 2022)

Role of the Physical Therapist

Physical therapy is one of the most important nonpharmacologic measures to be considered in the management of pain. The physical therapist evaluates the patient with pain in order to:

• Determine the identity of the pain mechanism(s) to guide treatment
• Identify physical and psychosocial factors impacting pain so they can be addressed
• Assess the impact of pain on physical and psychosocial function
• Select appropriate goals
• Determine whether the patient requires referral to other healthcare providers

The goals of physical therapy include the reduction of pain, restoration of function, improved mobility, prevention or limitation of permanent physical disabilities, and encouragement of self-management through the use of physical, cognitive, and behavioral approaches to help reduce the impact of pain and disability (Sullivan et al., 2019).

PHYSICAL THERAPY INTERVENTIONS

When physical therapists work with patients who are experiencing pain, tests and measures are utilized to determine the causes of pain and to assess its intensity, quality, physical characteristics, and progression. Patients are also evaluated for risk factors for pain in order to prevent future pain issues. These factors may include disease history, cognitive and psychological factors, negative beliefs, and sedentary lifestyle.

Once contributors to the pain are identified, the therapist works with the patient to design an evidence-based management program with goals that are specific, measurable, achievable, relevant, and time-framed.

The physical therapist then implements the management program, which includes active approaches and passive approaches as indicated. These approaches include:

• Education about pain and how to manage pain, working with the patient toward regaining the ability to perform normal activities of daily living.
• Strengthening and flexibility exercises to improve movement with less pain. A graded exercise program may be instituted that gradually increases according to abilities. Exercises help to improve movement and coordination, reduce stress and strain on the body, and decrease pain.
• Manual therapies using hands-on techniques to manipulate or mobilize tight joint structures and soft tissues. Manual therapy may help increase range of motion, improve tissue quality, and reduce pain. Such therapies may include peripheral joint mobilization, myofascial mobilization, spinal mobilization, soft tissue mobilization, and therapeutic massage.
• Instruction in proper postural awareness and body mechanics, in order to help patients use their body more efficiently.
• Physical agents, which may include electrotherapies.

The therapist educates and supports the patient to adopt active rather than solely passive pain-management strategies that are meaningful to the patient and achievable, using motivational strategies and adherence techniques to support compliance.

Physical therapists include cognitive and behavioral approaches that support improved functional movement and pain outcomes, along with self-management strategies, as a key component of the management plan (IASP, 2021c).

MODALITIES

Modalities physical therapists may employ in pain management include:

• Thermotherapy
• Dry heat
• Hot packs
• Paraffin baths
• Tecar therapy
• Cryotherapy
• Ice packs
• Ice spray
• Immersion
• Ice massage
• Cryokinetics
• Biofeedback
• Manual therapies
• Massage
• Connective tissue massage
• Therapeutic massage
• Manipulation/mobilization
• Dry needling
• Soft tissue mobilization
• Spinal and peripheral joint mobilization
• Neural tissue mobilization
• Passive range of motion
• Electric stimulation
• Electric stimulation for tissue repair (ESTR)
• Functional electrical stimulation (FES)
• High-voltage pulsed current (HVPC)
• Neuromuscular electrical stimulation (NMES)
• Transcutaneous electrical nerve stimulation (TENS)
• Electrotherapeutic delivery of medications
• Iontophoresis
• Hydrotherapy
• Contrast bath
• Pools
• Pulsatile lavage
• Whirlpool tanks
• Acoustic
• Ultrasound
• Phonophoresis
• Traction devices
• Intermittent
• Positional
• Sustained
• Light therapy
  • Laser (low level and high power)
  • Ultraviolet
  • Infrared and near infrared
  • Cold laser therapy
  (Physiopedia, 2021)