Unless managed aggressively, acute pain (defined as pain lasting a few seconds to about 3 months) may progress to chronic or persistent pain. This progression stems from central sensitization (sometimes called wind-up syndrome), in which increased sensitivity to unrelieved pain makes neurons more excitable, leading to central nervous system changes. Continuous stimulation of peripheral nerves activates group C nerve fibers, causing a progressively increasing electrical response and hyperexcitability. This can result in chronic pain syndrome.

As healthcare professionals, we need to manage our patients’ acute pain effectively to help prevent hospital readmissions necessitated by pain and to prevent chronic pain syndrome. To do this, we need to separate the facts about pain from the myths. This article dispels pain myths using actual cases (names have been changed) and discusses best practices for patients with pain.

Pain myth #1: Standard analgesic dosages are effective for all postoperative patients

A 48-year-old female (we’ll call her Susan) is admitted for intractable back pain. Her pain rating is 9 on a 0-to-10 scale. Comorbidities include degenerative hip disease of the right side and multiple sclerosis. She has had more than 10 previous surgeries and many episodes of unrelieved pain. For 10 years, she took up to six hydrocodone/acetaminophen tablets daily. She also has an undiagnosed anxiety disorder.

When a magnetic resonance imaging (MRI) scan reveals a new disc herniation at the site of a previous laminectomy, the physician prescribes conservative treatment, including a lumbar epidural steroid injection, oral steroids, I.V. opioids, and physical therapy. Nonetheless, Susan’s pain persists and grows even worse.

The physician then recommends a microdiscectomy. After the procedure, Susan’s postoperative course is managed via patient-controlled analgesia (PCA) with hydromorphone I.V. 0.3 mg every 8 minutes, with a 10-minute lockout for the first 24 hours, until she can tolerate oral fluids. Her pain rating on PCA therapy is 3 on a 0-to-10 scale (3/10), and she’s reluctant to have the PCA discontinued. However, she begins to receive extended-release oral morphine 30 mg every 12 hours. To reduce the amount of opioids, the healthcare team initiates a multimodal pain-management regimen, which includes the muscle relaxant baclofen 10 mg P.O. every 8 hours, two lidocaine (Lidoderm^®) patches applied to intact skin (12 hours, 12 hours off), and the anxiolytic hydroxyzine 50 mg P.O. every 6 hours as needed.

As this case study shows, standard analgesic dosages may not be effective in postoperative patients. Susan had persistent (chronic) pain for many years caused by multiple sclerosis and degenerative hip disease. Although her persistent pain previously had been fairly well controlled, her healthcare team is now challenged by her acute postoperative pain. Her history of chronic pain may necessitate higher-than-standard analgesic dosages to control postoperative pain.

Although medication is the mainstay of acute pain management, nonpharmacologic options should be tried as well to ease discomfort. Before a nonpharmacologic method begins, explain to the patient how the technique works based on the gate control theory of pain. This theory proposes that all pain sensations pass through a “gating” or control mechanism in the dorsal horn of the spinal cord. When more small nerve fibers than large nerve fibers are stimulated, the gate opens and pain impulses travel to the brain, where pain is perceived. Complementary and alternative techniques (such as relaxation and distraction) cause stimulation of more large nerve fibers, which is thought to cause the gate to close. Taking the time to explain the rationale in simple language shows patients you care and want to ease their discomfort.

On day 3, Susan rates her pain as 6/10 and experiences muscle spasms in her paraspinal muscles. Her muscle relaxant is changed to tizanidine 4 mg P.O. every 8 hours as needed. Multimodal therapy includes ice applied to the surgical site for 20 minutes every 4 hours and physical therapy assistive devices (a grabber and a walker).

Susan’s pain is more challenging to manage than many other patients’, partly because of her history of multiple surgeries, opioid tolerance, and undiagnosed anxiety disorder.

Multimodal management allows a decrease in Susan’s opioid dosage. She tolerates tizanidine better than baclofen, so she’s now more able to participate in physical therapy. She states, “I was always so anxious about my pain. Now my anxiety is lessened, and I don’t need anxiety medication because my pain is controlled.” At discharge, she reports a pain rating of 3/10 and thanks the nursing staff for the high-quality care they provided.

Pain myth #2: Older adults shouldn’t receive chronic opioid therapy

An 88-year-old female who’s not a native English speaker is brought to the emergency department by her husband. The electronic medical record indicates that Pradnaya has had multiple readmissions due to compression fractures and pain. During the intake process, she is unable to rate her pain when the nurse asks her to, but the nurse assumes she’s experiencing pain based on her compression fractures and her obvious moaning. When moved to the table machine for an MRI, Pradnaya just cries and moans. Her husband reports she stopped taking her prescribed hydrocodone/acetaminophen because it caused constipation and she hated using it. He states, “We don’t want her to take it any more.”

Medication refusal is common in older adults. If patients keep refusing pain medication, they’ll begin to decline due to physical dysfunction. If your patient refuses pain medication, realize there may be more to the story. Perhaps he or she can’t afford the medication, doesn’t understand how to take it, or (like Pradnaya) can’t tolerate the side effects.

So what are best practices for a patient like Pradnaya? To address the language barrier, use an interpreter to interview her and find out why she stopped taking her pain medication. In Pradnaya’s case, the interpreter confirmed that it was constipation.

Through the interpreter, Pradnaya and her husband receive education on the purpose of pain medication as well as treatment and prevention of side effects. In the hierarchy of pain assessment, self-report is the gold standard. But with a patient like Pradnaya who’s unable to self-report, caregivers should keep in mind that she has a pathologic condition that can be expected to cause pain. The physician decides to prescribe a 24-hour analgesic trial of around-the-clock oxycodone 5 mg P.O. every 6 hours to determine if it reduces her pain and improves physical function.

Opioids aren’t contraindicated for older adults, but they should be started at a low dosage and titrated upward slowly. Many older adults have multiple comorbidities that can result in more serious adverse effects. Prevention and treatment of opioid-induced constipation is managed mainly by the bedside nurse and should begin when the opioid is started. Nurses must be proactive about bowel function in all patients taking opioids. Patients don’t build a tolerance to this side effect, which significantly affects overall health.

The nurse is able to find a pain rating scale (0-10) in Pradnaya’s native language. After 24 hours of oxycodone therapy, Pradnaya rates her pain as 2/10. To help prevent constipation, the nurse starts her on senna (a nonprescription laxative) and docusate sodium (a nonprescription stool softener) twice daily. After several days, her constipation resolves. On discharge, she rates her pain as 3/10 with activity. She verbalizes to her husband that she will adhere to the drug regimen.

The dangers of labeling patients as drug seeking

Some healthcare professionals may label certain patients who come in frequently as “drug seeking”. But we need to ask ourselves how such labeling advances the patient’s care. Does it truly promote the nurse’s role as patient advocate? When a coworker refers to a patient this way, do you stop and discuss the problems that can result from patient labeling—or do you bypass the discussion because you’re busy and wish to avoid what’s likely to be an uncomfortable conversation? Addressing patient labeling and misconceptions is crucial to providing the best possible care.

Because we’re human, we may find it hard to care for challenging patients. If you find yourself not believing or trusting a patient, speak with your manager. Consider asking that the patient’s care be transferred to another nurse for that shift; although not an ideal solution, this gives the patient a better chance of getting the best care possible. Then further reflect on why you don’t believe or trust the patient, and think about how you can resolve your feelings in the future. Your manager should be happy to support you.

Best practices in pain management

When appropriate, healthcare givers should use multimodal approaches to pain management. Multimodal analgesia combines different classes of medications that fight pain through different mechanisms, which can make pain management more effective. Some medications add analgesic effects; others work synergistically. The patient can receive lower dosages of each medication and experience fewer adverse effects.

Pharmacologic management of acute pain may include:

• opioids
• nonopioid drugs, such as I.V. or oral acetaminophen, I.V. ketorolac, or oral nonsteroidal anti-inflammatory drugs (NSAIDs)
• adjuvants, such as muscle relaxants, anticonvulsants, and anti­an­xiety agents. (See Common nonopioid drugs used for acute pain by clicking the PDF icon above.)

Commonly used opioids include morphine, hydromorphone, and fentanyl. Oral or I.V. administration (or both) are recommended. Codeine isn’t recommended because of genetic variances in how this drug is metabolized and absorbed. Several pharmaceutical companies are working to develop tests or markers that allow healthcare professionals to identify the most effective analgesics for individual patients. (See Common opioids used for acute pain by clicking the PDF icon above.)

Here are some other best practices for pain management:

• Advocate for pain management for all patients.
• Assess pain regularly using an appropriate pain scale.
• Make pain “visible” in the hospital setting. For instance, advocate for a hospital-wide campaign so patients, families, and visitors can see that pain control is a priority.
• Avoid labeling and judging patients.
• Ask the patient, “Is there anything we can do to make you more comfortable?”
• Treat pain early instead of waiting for it to become more severe.
• Consider the patient’s age, culture, religion, and socioeconomic status when developing a pain-management plan.
• Assume pain is present. To evaluate analgesic effectiveness, use a 24- to 48-hour around-the-clock analgesic trial for patients with obvious pain.
• Beware of the risk of acetaminophen toxicity. Keep the total daily dosage below 4,000 mg—even lower for older adults.
• Give the lowest dosages of NSAIDs possible for the shortest duration to avoid complications, such as peptic ulcers, GI bleeding, and cardiovascular disease.
• Assist prescribers in choosing an appropriate analgesic for your patient’s pain level—for example, nonopioids or tramadol for mild pain; oxycodone or hydro­codone for moderate pain; or morphine, oxycodone, hydromorphone, or fentanyl for severe pain.
• If possible, give only one opioid—preferably a long-acting opioid and a short-acting formulation of the same opioid (if one is available). This will simplify the regimen.
• Administer adjuvant analgesics, such as anticonvulsants, muscle relaxants, and antispasmodics, as appropriate.
• Use nonpharmacologic interventions as needed to enhance pain relief.
• Regularly evaluate the effectiveness of the pain-management plan.

Nurse’s role

According to Ann Schreier, past president of the American Society for Pain Management Nursing, “Every nurse is a pain-management nurse.” In acute-care settings, nurses should empower and educate patients and families about pain and its management. Make pain management be a high priority. Urge your organization’s leaders
to make pain more “visible”—for instance, with appropriate signs, whiteboards, TV monitors, and handouts of the Pain Care Bill of Rights (from the American Pain Foundation). Many hospitals have created pain-awareness campaigns that feature “pain teams” and pain-resource nurse programs.

Our messaging should incorporate appropriate and positive communications, such as “What can we do to make you more comfortable?” As nurses, we know never to promise patients that a medication or other treatment will take away all of their pain. But if we can treat pain before it gets severe, help make it more tolerable, and increase patient functioning, we’re giving the best care we can.

References

American Pain Society. Pain: Current Understanding of Assessment, Management, and Treatments.

Glenview, IL: American Pain Society; 2001.
www.americanpainsociety.org/education/content/enduringmaterials.html. Accessed May 21, 2014.

American Society of Pain Management Nursing. Core Curriculum for Pain Management Nursing. 2nd ed. Dubuque, IA: Hunt Publishing; 2012.

Helfand M, Freeman M. Assessment and management of acute pain in adult medical inpatients: a systematic review. Pain Med. 2009;10(7):1183-99.

Herr K, Coyne PJ, Key T, et al. Pain assessment in the nonverbal patient: position statement with clinical  practice recommendations. Pain Manag Nurs. 2006;7(2):44-52.

Madadi P, Ciszkowski C, Gaedigk A, et al. Genetic transmission of cytochrome p450 2D6 (CYP2D6)  ultrarapid metabolism: implications for breastfeeding women taking codeine. Curr Drug Saf.  2011;6(1):36-9.

Pasero C, McCaffery M. Pain Assessment and Pharmacologic Management. Elsevier-Mosby: St. Louis, MO: 2010.

Lora McGuire is a clinical educator at Presence St. Joseph Medical Center in Joliet, Illinois. Pam Bolyanatz is an inpatient pain-management nurse practitioner at Cadence Health Delnor Hospital in Geneva, Illinois.