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

Nonopioids

opioids
5 lb. lobster ! ! !
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
Sympathetically-
maintained pain
 Associated with
dysregulation of
autonomic nervous
system
Eg. reflex sympathetic
dystrophy
Administration Routes
Flexibility of routes
enables

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
Let’s Do A

Corticosteroids Quick
Review

Transmission (step 2)

opioids
 4 steps to physiologic pain:

 Transduction
1. Conversation of stimuli to action potential
2. Occurs at level of peripheral nerve (free
endings or nocioceptors)
3. Causes release of chemicals into area
around peripheral afferent nociceptor or
PAN
Some will excite/sensitize PAN
 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
 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
 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
 Assessed adequately,
and as a consequence
 Not treated adequately

 Pain assessment tools

may need adaptation
for elders
 Special populations & pain
Cognitively impaired
 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

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
 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

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.