On a spiritual level, under- and untreated pain can lead to an increased sense of suffering. For people with a relationship to God or a higher power, that relationship often provides a sense of comfort, strength, and sustenance. When such people find themselves in under- or untreated pain, they may feel that they are being punished, tested, or abandoned by that God or higher power and separated from that source of comfort, strength, and sustenance. As nurses, we do not have the right to create such separation.

Psychologically, under- and untreated pain disrupts concentration, focus, and memory. This is particularly significant when patients are being asked to absorb nurses' teachings or make treatment decisions. Pain can lead to increased distress, despair, depression, hopelessness, anxiety, fear, somatic preoccupation, suicidal ideation, and requests for physician-assisted suicide. It also strips away quality of life, life satisfaction, and any sense of autonomy and control or mastery over one's life.

Socially, pain can prevent one from cultivating and maintaining an informal social support system, and, among the elderly, we know that an informal social support system helps prevent premature and permanent institutionalization. Under- and untreated pain can also lead to a shrinking and collapse of a patient's universe, first limiting the patient to his or her home, then to a couple of rooms, and finally to a single room with a bedside commode. Finally, pain significantly increases caregiver burden. It is far more difficult to care for someone who has pain-related immobility than someone who does not.

Physiologically and functionally, pain can limit or erase one's ability to perform IADLS (instrumental activities of daily living, e.g., cleaning, shopping, and cooking) and even ADLs (activities of daily living, e.g., toileting, dressing, hygiene, eating, transferring, and ambulating). Under- and untreated pain can disrupt one's ability to participate in the rehabilitative process; compromise sleep, appetite, and sexual competence; and create self-care deficits. Further, there is great fatigue and exhaustion attached to chronic pain and falls-both those related to weight-bearing pain, as well as those related to medication-induced instability-are not uncommon. Finally, if pain is severe enough, it can lead to immobility, from which a cascade of difficulties evolve. These can include skin breakdown, constipation, wasting syndrome, pneumonia, and depression.

Additional negative consequences of failing to adequately address pain in our patients include increased dollar costs attached to ED visits and rehospitalizations for pain that is out of control. There are both human and dollar costs related to professional caregivers injuring themselves caring for patients in pain and filing workers' compensation claims. Regulation imposed by state legislators who lack medical training and punishing litigation brought by plaintiff attorneys are the direct consequence of our not having proactively learned and practiced sound pain management. Finally, it is ethically unacceptable for us to fail to acquire the skills to relieve the pain-related suffering of our patients.

So, I applaud and champion you for engaging in this undertaking to better prepare yourself to address pain in your patients, advocate on behalf of those patients, educate patients and families about pain management, share with your colleagues, and create hope in those who have suffered with inadequate pain management.

As you approach pain management, remember that the basic tenet of this work is that pain is whatever the patient says it is, whenever the patient says it is, and wherever the patient says it is. Self-report is the gold standard of pain assessment.

In nursing schools, a crowded curriculum often doesn't allows time to cover the differences between acute pain and chronic pain. Most nursing students learn that pain usually presents with the accompanying physical signs and symptoms of diaphoresis; increased pulse, blood pressure, and respirations; nausea; a sense of being lightheaded; or even syncope. What is left out of this teaching is that these are the physical signs and symptoms of acute pain, not chronic pain. With chronic pain the body strives to restore balance and homeostasis, and it is common to see patients with moderate and even severe chronic pain exhibit none of the above physical signs and symptoms, and in fact, be able to sleep, converse, and even chuckle at an old I Love Lucy show.

Acute pain usually has an identifiable cause, while chronic pain may or may not have an identifiable cause. Acute pain is usually unifactorial (having a single cause) while chronic pain may be unifactorial or multifactorial. Acute pain is of a limited duration (minutes, hours, days, or weeks) while chronic pain is ongoing, that is, of unlimited duration. Acute pain is usually nociceptive (transmitted over intact nerves or nociceptors) while chronic pain can be nociceptive, neuropathic (transmitted over nerves that are disordered or damaged), or a combination of the two, that is, a mixed pain syndrome.

Another tenet of pain management is that it is easier to get on top of pain and prevent it than it is to chase it. This implies that with pain that is constant, as opposed to intermittent, we provide analgesics on an ATC (around the clock) basis, rather than a prn (as needed) basis. When the pain is severe, and we are providing opioids orally, it is important to provide a sustained-release opioid on an ongoing (ATC) basis and to pair it with a short-acting, immediate-release opioid to be given prn for BTP (break-through pain). It is also important to assure that the prn opioid is at a dose that is proportional to the ATC opioid. The rule of thumb for morphine is that the prn morphine dose is equal to one-third of the q 12h dose of the ATC morphine. For example, a patient receiving sustained-release morphine 30 mg po q 12h should have a prn dose of short-acting immediate release morphine of 10 mg po q 3h for BTP while a patient receiving sustained-release morphine 180 mg po q 12h should have a prn dose of short-acting immediate-release morphine of 60 mg po q 3h for BTP.

When the ATC dose is titrated (raised or lowered), the prn dose must also be titrated in an amount that maintains the proportionality between them. The rule of thumb for when to raise the dose of the ATC and prn opioid is that when a patient requires 4 prn doses for BTP in a single day, or requires three prn doses for BTP for two days in a row, both the ATC and prn medications should be increased 25% to 50% in amounts that maintain proportionality between them.

Using these basics, along with an approach of assessing pain, instituting a pain management approach and then reassessing pain to monitor and adjust the pain management approach should go far in relieving the suffering and distress of patients living with pain.

Chapter One
Understanding the New Joint Commission Standards

Pain specialists estimate that at least 90% of patients with pain should experience satisfactory relief.¹ Yet at least 50% of patients needlessly suffer moderate to severe pain despite two decades of efforts to educate health professionals. Clinical practice guidelines for pain management have been available since the mid-1980s from organizations such as the American Pain Society (APS), but they have not been widely followed. Current guidelines from the APS include ones for acute pain and chronic pain, arthritis pain, cancer pain in adults and children, sickle cell pain, pain in the primary care setting, and fibromyalgia pain in adults and children.^1-7

At the beginning of 2000, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) released revised standards for the assessment and management of pain for all patients in health care institutions.⁸ Health care facilities are surveyed for compliance with these standards, and they risk losing accreditation if they cannot demonstrate that processes are in place to assess and manage pain appropriately in all patients. The JCAHO requirement for compliance probably will have the most profound effect on improving pain management of any single event to date.

Nurses have played and will continue to play a critical role in pain management. This chapter will inform nurses about the standards and how they will affect their care of patients with pain.

Why standards are needed

The need for pain management standards arose as the JCAHO recognized mounting evidence that pain is undertreated and that unrelieved pain has the potential for harmful effects. For example, in a study from 1989 to 1993 of more than 9,000 hospitalized, terminally ill patients in five teaching hospitals, 50% of conscious patients who died in the hospital experienced moderate to severe pain at least half of the time.⁹ Researchers studying acute pain in hospitalized patients found that more than half the patients reported severe pain during the previous 24 hours, and about half had moderate to severe pain at the time of the interview.¹⁰

Undertreated pain places patients at risk. Our cultural attitude of "no pain, no gain" has proved to be dangerously wrong. Research now shows that unrelieved pain can inhibit the immune system and even enhance tumor growth. Pain causes increased oxygen demand, respiratory dysfunction, decreased gastrointestinal motility, and confusion. Severe acute pain is a major risk for the development of chronic neuropathic pain.¹¹

Barriers to pain management

While our primary focus will be on the institutional barriers to pain management, it is important to recognize that patients and families also present barriers to pain management. Some patients choose to not report pain because they do not want to "bother" or distract the busy nurses and physicians from their "more important" work of treating the patient's disease. Both patients and families are often afraid of addiction and may therefore not be willing to be appropriately treated with medication that is sufficiently powerful to address their pain. There may also be pathological family dynamics in which some family members take pleasure in the suffering of another. Spiritual beliefs may place a value or even a reward on the endurance of suffering, creating resistance to allowing pain to be treated. Finally, cultural differences in the perception, meaning, reporting, and endurance of pain may present a barrier to pain assessment and pain management.

Physicians and nurses may also create barriers to pain management. They may have gaps in knowledge about pain assessment and pain management and fears of causing addiction or respiratory depression and even hastening death. They also may fear regulatory reprisal for "overprescribing" and be limited by stereotypical thinking about certain types of patients.

A pain care committee is one mechanism for promoting an interdisciplinary approach to improving pain management throughout an institution.^12,13 The committee usually consists of seven to 10 people and includes a nurse educator, an anesthesiologist or a certified registered nurse anesthetist, another physician, a pharmacist, and several staff nurses. Ideally, a pain care committee would also include a pain management specialist (regardless of discipline, i.e., MD, PharmD, RN); a social worker or psychologist; a chaplain; a physical therapist; and a certified nursing assistant. Staff nurses are indispensable because pain assessment and treatment are performed by nurses at the bedside. Their input will help prevent many implementation failures, such as those that may occur when revised documentation forms are first put into use. The pain care committee usually becomes a standing committee because improving pain management is an ongoing need.

The committee begins by identifying the problems in the institution. Surveys such as chart audits and patient interviews may be conducted to determine how well pain is being assessed and treated. Knowledge and attitude surveys are a common method of assessing the educational needs of the staff and helping them become aware of their current level of knowledge related to pain management. Many do not realize that they may have received inaccurate or insufficient education about pain management.

Nurses may use the accompanying "Pain Knowledge and Attitude Survey" (see sidbars) to assess the knowledge of fellow nurses, physicians, and pharmacists about pain and its management. To increase the number of respondents, the survey is brief, and the data can be tabulated quickly and shared with staff immediately. Posters can be used to show the percentage of right and wrong answers along with a brief rationale for the correct answers. Upcoming programs on pain can be promoted at the same time to encourage staff to find out about the new recommendations for pain assessment and management.

Certain common institutional practices have been focal points for pain care committees. For example, the frequent use of meperidine (Demerol) has prompted many committees to educate physicians about alternatives and to establish policies that limit its use for patients who are allergic to or intolerant of all other opioids (as recommended in the APS guidelines).² Many hospitals also have developed policies prohibiting the deceptive use of placebos and restricting their use to approved clinical trials.

The JCAHO standards for pain management apply to all patients in all clinical settings. The following activities, described in a videotape available from the JCAHO, are related to compliance with the standards.¹⁴

1. Recognize the right of patients to appropriate assessment and management of pain. This should be included in the patients' bill of rights and may be posted in the lobby and waiting areas.

Inherent in recognizing the right of a patient to appropriate pain management is the recognition of and respect for the patient's personal beliefs, including spiritual, cultural, and ethnic influences. By working with a patient to set comfort/function goals, providing patient teaching, encouraging a patient to make decisions about care, and accepting the patient's reports of pain, the nurse honors the patient's beliefs.

2. Screen for the existence, nature, and intensity of pain. Many institutions have followed the APS suggestion that pain be considered the fifth vital sign and be recorded with vital signs. (This is not required by the JCAHO.) Some institutions, such as Veterans Affairs, have incorporated this and included pain ratings on the vital sign graphic record. This helps screen for pain in all patients who have their vital signs taken, usually the majority of patients. Another way of screening for pain is to include questions on the nursing admission form, such as "Do you have pain now or have you experienced any pain recently?"

In California, legislation designating pain as the fifth vital sign became law in 2000. As a condition of health care facilities' licensure, pain must be assessed at the time a full set of vital signs is taken and noted in the patient's chart with other vital signs.

Virtually all pain care committees make pain assessment a priority. This involves adoption of a pain rating scale that is appropriate for the majority of patients in the facility. Self-reporting of pain is the single most reliable method of assessing pain intensity, and it is used whenever possible. Vital signs and behavior are never used instead of the patient's self-report, because they are not valid as indicators of pain. If most patients in the institution are cognitively intact adults, the 0-to-10 (0 = no pain, 10 = worst pain) pain rating scale usually is used. To accommodate culturally diverse populations, the pain rating scale can be translated into languages other than English. A 0-to-5 pain rating scale, or "faces" pain rating scale, usually is more appropriate for children as young as 3. Behavioral pain measures must be identified for other populations, such as the cognitively impaired adult, the infant, and the preverbal child. If no behaviors are present, such as in patients who are unconscious or on neuromuscular blocking agents, the presence of pathology or procedures that are usually painful is sufficient to assume pain is present. The acronym "APP" (assume pain is present) may be recorded instead of a pain rating.¹⁵

3. If pain is identified, perform a more comprehensive pain assessment that includes location, quality, onset, frequency, and intensity. These items are self-explanatory, and it is easy to ask the patient about them. Location can be assessed by asking the patient to point to the site of pain on his or her body or on a figure drawing. To assess quality, you may need to give the patient some examples, such as "Is it burning, aching, knife-like, or shooting?"

With this assessment, a comfort/function goal is established by asking the patient what pain level rating would make it easy for him or her to perform specific activities required for recovery or quality of life. For example, a patient who has abdominal surgery may need to use the incentive spirometer to prevent pulmonary complications. The patient would be asked, "What pain rating will make it easy for you to use the incentive spirometer regularly?" The patient may respond that 2 on a scale of 0-10 would be sufficient. The comfort/function goal would be documented as "2/10 to use incentive spirometer." When establishing comfort/function goals, keep in mind that research has shown that pain ratings above 4 significantly interfere with activities and mood.¹⁶ Giving adequate doses of opioids and titrating them to relieve pain without unacceptable adverse effects are among the JCAHO principles of pain management. The need to adjust doses and intervals between doses are determined by the patient's comfort/function goal. For example, if the patient using the incentive spirometer experienced a pain rating of 4, it would indicate the need to increase the dose, provided it is safe to do so.

4. Record the results of assessment in a way that facilitates regular reassessment and follow-up. Documentation forms often need to be revised to include pain assessments and to make them visible so that the need for intervention can be identified quickly. At the very least, the forms should include the comfort/function goal and regular assessment of pain intensity.

5. Determine and ensure staff competency in pain assessment and management. Competency needs to be addressed in the orientation of all new staff and arrangements made for continuing education of all staff. An annual pain conference or a pain awareness week are typical ways of doing this.

6. Establish policies and procedures that support the appropriate prescription of pain medications. The pain care committee is responsible for ensuring that physicians prescribe appropriate analgesics. The committee reviews and revises policies and procedures to assure that all patients receive the best possible pain relief within the realm of safety. This approach is coupled with education of physicians about alternatives to dangerous and ineffective methods of managing pain. As previously mentioned, a policy that restricts meperidine use often is necessary. Revising intravenous patient-controlled analgesia order forms often is a helpful way to guide physicians in the prescription of appropriate drugs and dosages.

7. Educate patients and their families about the importance of effective pain management. On admission, patients should be informed-both by staff and in printed patient information-that effective pain relief is their right, that they should tell staff about unrelieved pain, and that staff will quickly respond. An institution may develop its own written materials and videotapes or may obtain them from pharmaceutical companies. An example is a brochure from Endo Pharmaceuticals, Understanding Your Pain: Using a Pain Rating Scale. The JCAHO supported the development of this brochure, which may be ordered free of charge by calling (800) 462-3636.

8. Address patient needs for symptom management in the discharge planning process. Before discharge, the patient should be assessed for the presence of pain. If pain exists, appropriate arrangements are made, such as prescriptions for analgesics. For ambulatory surgery, contact the patient the evening of discharge ¾ or the day after as blocks may not wear off until 24 hours later or more ¾ to determine the effectiveness of pain management.

9. Include patient outcomes in measuring the effectiveness and appropriateness of pain assessment and management. Ask clinical units to include pain in their quality improvement plans.

The JCAHO revised standards may end up doing more to improve pain management than any single development so far. Progress will be slow, however, and mistakes are inevitable. Those asked to implement the standards may not have received the education they need about principles of pain management. Successful implementation ultimately will depend on the nurse at the bedside. Nurses must recognize that they may need to enhance their basic education about pain management by taking continuing education courses and reading professional journals and clinical practice guidelines. These guidelines help dispel many misconceptions about assessment and treatment of pain. Improving pain management will be a process spanning many years, an effort that will know no end.

Chapter Two
Pain Assessment: Debunking the Myths and Misconceptions

Nurses play a pivotal role in assessment and management of pain. Nurses probably spend more time with patients than any other members of the health care team.¹ A 1990 survey of National League for Nursing-accredited baccalaureate programs found that 48% spent less than four hours on the subject of pain.² Inadequate education of nursing students on pain management is evidenced by 50% to 80% of hospitalized patients, 70% to 90% of patients with advanced cancer, and 45% to 80% of long-term care patients reporting that they suffer with under- and untreated pain.³

Despite limited preparation, nurses are held accountable professionally for their knowledge and understanding of pain management. In 1990 a North Carolina jury awarded $15 million in damages to the family of a man whose final days were filled with unbearable pain because of the decision of a nurse to withhold or reduce pain medication.⁴ In California, the state's Elder and Dependent Adult Abuse statutes are being used to penalize those who fail to provide adequate pain management.

Pain is increasingly being recognized as a priority by both national and international agencies. The World Health Organization (WHO), the American Pain Society (APS), and the National Institutes of Health, to name a few, have all contributed publications, guidelines, or consensus conferences focused on pain.

In the 1990s, the Agency for Health Care Policy and Research (AHCPR) published two sets of clinical guidelines for pain management-one for acute pain and one for cancer pain.^5,6 As described in the previous chapter, JCAHO released revised standards on the assessment and management of pain in 2000. Beginning in 2001, health care facilities are expected to comply with these standards. In addition, many states have formed voluntary statewide networks, cancer pain initiatives, devoted to developing care standards for cancer pain management.

Clearly, awareness of the problem of inadequate pain management is growing. But lack of knowledge is only one reason why patients are undermedicated. Other barriers to the assessment and management of pain include the misconceptions and myths surrounding assessment and treatment.

Definition of pain

A working definition of pain by the IASP (International Association for the Study of Pain) states, "Pain is an unpleasant sensory and emotional experience which we primarily associate with tissue damage or describe in terms of such damage, or both."⁷ However, because pain is completely subjective, a more widely used definition is "Pain is whatever the experiencing person says it is and exists whenever he or she says it does."⁷ The self-report of pain by a patient should be considered sufficient evidence to establish pain as a nursing diagnosis.

The AHCPR guidelines support this with such statements as "The single most reliable indicator of the existence and intensity of pain-and any resultant distress-is the patient's self-report," and "Observations of behavior and vital signs should not be used instead of a self-report unless the patient is unable to communicate."⁵

The cornerstone of an assessment of pain is the acceptance that the pain "belongs" to the patient. The patient, not the health care team or the family, is the authority about the presence of pain. Nurses should accept and respect the patient's report of pain and proceed with interventions to promote relief. This ensures that the patient will not suffer needlessly and helps guarantee a higher quality of care.

Expected pain behaviors

Many nurses have been taught that visible physiologic and behavioral signs will accompany pain and can be used as the basis for objective pain assessment. In the acute pain model, physiologic signs of pain include diaphoresis, elevated blood pressure, tachycardia, tachypnea, dilated pupils, and behaviors such as grimacing and moaning. In reality, physiologic and behavioral adaptation occurs, resulting in periods during which patients with severe pain show no signs of pain. Thus, lack of pain expression does not necessarily mean lack of pain.

Physiologically, the body adapts to pain after a period of time, and vital signs normalize. This return to equilibrium is necessary to prevent physical harm and undue stress on the body. It does not necessarily mean pain has disappeared.

Patients also show a behavioral adaptation to both acute and chronic pain. They may minimize their expressions of pain for a number of reasons. A patient may wish to be seen as a "good patient" or may place a personal or cultural or religious value on a stoic response to pain. The patient may become too exhausted to respond vigorously to pain. Sometimes patients use distraction techniques to focus away from pain.

If a nurse adheres to the acute pain model to guide assessment, there will be times when a patient's behavior and physical signs do not correlate with the patient's report of pain. In other words, patients may even experience severe pain without acting like they are in pain.

Identifiable cause of pain

Another common misconception is that all pain has an identifiable physical cause or that the etiology of the pain can be diagnosed and isolated. We erroneously believe that if there is pain, there is a cause we can find; if we can't find the cause, we inaccurately conclude that there is no pain. All pain is real, regardless of its cause and regardless of whether the cause can be identified.

Many patients who are forced to endure chronic pain become depressed and anxious. The depression and anxiety can be exacerbated if it is difficult to establish a cause for the pain. These patients may begin to question their sanity, fear they will be perceived as malingering, and worry that pain relief will be withheld because the pain is not "real."

These emotional responses may cause some health care providers to think that the pain is psychogenic or all in a patient's head. However, psychogenic pain is extremely rare and cannot be diagnosed merely on lack of ability to find a physical cause.

The pain experience usually includes a physical and a mental component. Just as purely psychogenic pain is very rare, pain that is purely physical (experienced without thoughts or feelings about it) also is extremely rare. While physical and behavioral signs of pain and a diagnosis of its cause are useful, they do not substitute for the patient's report that pain exists.

Pain threshold

The definition of a pain threshold is the point at which a stimulus is perceived as painful. Many health care professionals labor under the misconception that everyone perceives the same pain intensity from like stimuli. However, there is no research to support the theory of a uniform pain threshold.¹ The duration and severity of pain cannot be predicted based on the type of pain stimulus.

Over time, health care workers may develop fairly accurate estimates of the amount of pain patients usually feel as a result of certain painful events such as a bone marrow aspiration. However, it is detrimental to quality patient care to assume that there will be no exceptions. A patient who experiences more pain than expected with a treatment or diagnostic procedure or during a postoperative recovery period should not be labeled as exaggerating pain.

For example, most nurses expect that the most severe pain following surgery will occur in the first 48 hours and will gradually subside. However, in a study of 88 postsurgical patients, 31% reported pain that persisted after the fourth postoperative day.⁹

Patient credibility

The basis for pain assessment is the patient's report of pain, and pain cannot be proved or disproved. As nurses we must sometimes deal with the conflict of believing a patient who seems untrustworthy or whose lifestyle is contrary to our personal belief system, such as the substance abuser. A professional approach to pain does not include the application of personal biases or values.

Because the sensation of pain is totally subjective, it is understandable that nurses might look for clues to support the truthfulness of the patient's report. However, even when a patient's moral code, value system, and lifestyle are unacceptable to us, "no health care professional has the right to deprive a patient of appropriate assessment and treatment [of pain] simply because he or she believes the patient is lying."¹

Pain tolerance

Tolerance may be defined as "the duration or intensity of pain that a person is willing to endure."¹ Pain tolerance, pain perception and the expression of pain are all unique to the individual. A patient's tolerance varies from one situation to another. The patient's emotional state, degree of fatigue, and the value or meaning of pain for that patient can influence individual tolerance to pain.

Many health care professionals believe that the more experience patients have with pain, the greater tolerance of pain they will have. In fact, experience with pain usually is associated with a lower tolerance-and a higher level of anxiety-because the patients learn how severe pain is and how hard it can be to get relief.

Relief from placebos

A placebo may be defined as any treatment or procedure that produces a response in a patient because of its intent and not because of any actual physiologic or therapeutic properties. A patient who responds to a placebo is said to have a positive placebo response. A patient who responds positively to a placebo may be perceived by caregivers as malingering or fabricating the pain.

The use of a placebo is never justified to determine the existence of pain. Since the majority of patients will have some response to a placebo, no conclusion other than that the patient believes in the intent and efficacy of the treatment should be drawn from a placebo response.¹⁰

Legal and ethical considerations exist about the use of placebos without informed consent. While placebos have a place in structured research trials, to use them without a patient's consent and knowledge could seriously damage the nurse-patient relationship and destroy the patient's trust in the health care system if the deception is discovered. Because of the seriousness of this problem, the Oncology Nursing Society has issued a position statement on placebo use. It states that placebos should not be used to assess or manage cancer pain and that nurses should not administer a placebo under these circumstances even if there is a medical order.¹¹

The APS states that placebos should not be used to assess the nature of pain and that "the deceptive use of placebos and the misinterpretation of the placebo response to discredit the patient's pain report are unethical and should be avoided."¹⁰ The American Society of Pain Management Nurses "adamantly opposes the use of placebos in the assessment and treatment of pain in all patients." (For a copy of the ASPMN's position on pain management, call [888] 342-7766, or look online at www.aspmn.org). Nurses in California put their license at risk if they administer a placebo in a deceitful manner. In 1997, the California Board of Registered Nursing stated that to use placebos for the management of pain "would not fulfill informed consent parameters."¹² (For a copy of the BRN's complete pain management policy, go online to and search the site with "pain management policy" as the search term.) In 2001, the BRN filed accusations against registered nurses who administered placebos in a deceitful manner, despite the fact that a physician had written the order.¹³

Dispelling the myths

The acceptance of pain as a subjective experience is difficult for many nurses and health care professionals. Personal opinion, coupled with a lack of education, often incorrectly guides pain assessment.

The assessment and documentation of pain were studied in a series of patient vignettes.¹⁴ In the study, nurses were told to rate the pain of two patients with normal vital signs who were recovering from identical surgical procedures but exhibiting different behavioral expressions of pain. One patient smiled; the other grimaced. The patient-reported number from the pain rating scale was the same in both vignettes, 8 on a scale of 0-10. In both cases, many nurses recorded different, lower numbers than the patients had reported, especially for the smiling patient. This indicated that the nurses erroneously relied on patient behaviors and appearance rather than on the patient's self-report of pain.

Overcoming the myths and misinformation that abound regarding pain assessment and treatment is a challenge. Suggestions for implementing a uniform approach to pain management include:

• Reinforce the fact that pain is subjective.
• Accept and act on the patient's report of pain.
• Provide articles and references to support and document your position. For examples, see the guidelines and position statements of any of the organizations listed in the Appendix.

Improving pain assessment

As you become more aware of the problem of pain, you can improve the assessment and management of pain in your workplace. According to one expert, "The first step to change is demonstrating that a problem exists."¹⁵ Once awareness of pain is enhanced, you can inform physicians, staff, and administrators of the need to address this critical issue.

Do a pain audit, and adopt an ongoing system for pain assessment based on the use of consistent assessment tools, especially a pain rating scale. Assessment of pain is useless unless there is consistent communication and documentation to all members of the health care team regarding assessment, comfort/function goals, interventions, and evaluation. Find a way to document this valuable information.

Summary

One of the greatest challenges in nursing is to ensure patient comfort. All patients are entitled to the best pain relief that can safely be achieved. Yet the problem of pain is pervasive, and the myths and misconceptions surrounding the pain experience and the assessment of pain often preclude adequate comfort and quality care. An understanding of the facts and the correction of misinformation are the first steps in breaking down the barriers to successful pain management.

Chapter Three
Techniques of Pain Assessment

It is the nurse's responsibility to assess pain, to evaluate the findings of the assessment, and to institute a plan of care based on information gathered. However, nurses must be careful not to let their personal opinions or experiences with pain adversely affect their assessments of pain.¹

Everyone has experienced the sensation of pain. The difficulty in measuring someone else's level of pain stems from the subjective or individual nature of the pain experience. Research shows that when clinicians rate a patient's pain rather than asking the patient to rate their own pain with a pain scale, the pain is likely to be underestimated by the clinician, especially with moderate to severe pain.²

As the American Pain Society states, "Pain is always subjective"³ and "The clinician must accept the patient's report of pain."³

A patient's self-report of pain is the most reliable indicator of pain, but many nurses were taught to assess pain by identifying and documenting observable, objective, physical signs of pain such as tachycardia, tachypnea, diaphoresis, dilated pupils, grimacing, and moaning. However, patients may or may not exhibit these signs. Fatigue, for example, may result in minimal behavioral and physiologic responses to pain even when the pain is severe.

If objective signs of pain are present, they may serve as clues to the existence of pain; but the absence of physical signs of pain should never be equated with the lack of pain in a patient who verbally reports its existence.

The effective use of pain rating scales to assess pain, adequate documentation of the assessment, and evaluation of the effectiveness of pain interventions are essential to successful pain management.

Pain assessment

During the assessment process, you will gather information on the existence of pain and its effect on many aspects of the person's life. Since pain is rarely a static process, the assessment process is ongoing, not simply a one-time event. The information obtained in the assessment allows you, the patient, and the physician to formulate a plan of care with goals related to pain management.

Unfortunately, this basic step in managing pain never happens for some patients. A 2001 publication authored jointly by the National Pharmaceutical Council and Joint Commission on Accreditation of Healthcare Organizations identifies the absence of pain assessments and pain relief assessments as the most frequently occurring reason for pain in hospitalized patients.⁴ The assessment of pain need not be time-consuming or overwhelming, but unless an assessment of pain is done, the basis for an accurate nursing care plan for pain management cannot exist.

Assessment tools

A wide variety of pain assessment tools are available. No one "best" assessment form or tool exists.

Adapt the following tools to meet the needs in your clinical setting. The following sections describe an initial pain assessment tool and a pain flow sheet. The essential element in both of these tools is the patient's use of a pain rating scale.

Initial pain assessment tool

This tool is composed of 10 sections. (See Table 2.) When possible, obtain this information directly from the patient. Indicate if the information is gathered from another source, like a spouse or parent. Remember, in some settings, such as ambulatory surgery, not all of this information is necessary. Decide what will be useful to you. Below, find comments that may help guide your use of specific sections of the tool.

Location: Anatomical diagrams are provided to illustrate the location of pain. Many patients have more than one painful site; indicate multiple sites with letters, e.g., A. B. C. Members of some cultural groups may have difficulty localizing their pain; do not demand localization if the patient is unable or unwilling.

The patient may draw the pain sites on the form or trace the locations on his or her body, and you or a family member can mark the figures on the assessment form.

Intensity: The person experiencing pain is the only one capable of accurately rating its intensity.

While it is interesting to ask patients and families to rate the "worst pain gets," we know that patients and families alike tend to overrate pain when asked about it at any point in time other than the present.

Three types of common pain rating scales are the numerical scale, verbal description scale, and the faces scale. In fact, they are often combined. (See Table 3.) Many clinical settings use a 0-10 scale with word descriptors. Institutions should select pain rating scales that are appropriate for their populations, and these should be used consistently for all patients who understand them. When a patient cannot use these scales, another should be selected. Whichever scale is selected to assess pain intensity in a patient, it should be used consistently with that patient.

To use the numerical scale, ask the patient: "On a scale of 0 to 10, with 0 meaning no pain and 10 meaning the worst possible pain, what number would you give your pain right now?"After the patient responds with a numeric response to this question, make sure the patient sees you write down the response, so that he or she feels believed and validated.

The Wong-Baker FACES scale may be used with children as young as 3 years. Elderly patients and those who have difficulty with the 0-10 scale may be able to use this scale. Directions for using the Wong-Baker FACES scale with children and adults are included in Table 3. A caution about using this scale is that some members, especially male members of specific cohorts and cultures, may be reticent to identify with a face that depicts crying, regardless of what is stated in the instructions. Therefore, this scale is a poor choice for use with adult males, as it may lead them to under-report their pain.

Another faces scale for children and adults is now available, called Faces Pain Scale-Revised (FPS-R).⁵ For use with adults, the FPS-R is a better choice than the Wong-Baker FACES, because the face depicting the greatest level of pain is not shown to be crying. It may be viewed at www.painsourcebook.ca and downloaded.

Explain the purpose of the scale to the patient. Emphasize the fact that nurses or caregivers do not automatically know when a patient has pain. Caregivers should ask about pain regularly, but patients must understand that they also need to volunteer information.

For those with limited English, try to obtain appropriate translated scales. (See Reference 2, McCaffery and Pasero, pp. 64-65, 68-73, for foreign language translations of these pain rating scales.) Foreign-language versions of the FPS-R are available for viewing and downloading at www.painsourcebook.ca.

When teaching the pain rating scale, discuss the definition of pain, using examples of ways pain can be described. For example, in addition to using the word pain, many people use adjectives such as aching, hurting, tightness, burning, or tingling.

One of the most important reasons for using a pain rating scale is to set a comfort/function goal with each patient. Comfort means pain rating, and function refers to activities the patients needs to perform, such as coughing and deep breathing postoperatively, or activities of daily living, such as bathing. Select an activity that is important for the patient to perform and one that is also likely to cause the most pain. Ask the patient what pain rating would make it possible for him or her to perform the activity comfortably. For example, one patient might need a pain rating of no more than 2 out of 10 to ambulate, and another patient might need a pain rating of no more than 3 to participate in physical therapy. Document the comfort/function goal and try to maintain this goal as much of the time as possible. Intervention is aimed at keeping the patient at or below the selected pain level.

A patient teaching brochure, Understanding Your Pain: Using a Pain Rating Scale, has been developed in cooperation with the JCAHO, and free copies are available from Endo Pharmaceuticals, (800) 462-3636. If your institution decides to adopt this brochure, Endo will provide a disk for making copies.

Regardless of the type of scale chosen, the advantages of using a scale to assess and document pain intensity are numerous. You and the patient achieve consistency in interpretation and communication; it gives you a better understanding of the patient's pain experience; and it provides a method for you to evaluate the effectiveness of interventions.²

Quality: In this section of the assessment form, patients are asked to describe the type of pain or what the pain feels like to them. We ask this because knowing the quality of the pain helps us choose the most appropriate medication with which to treat it. They may use such words as throbbing, burning, stabbing, tender, or heavy. Some patients may be unaccustomed to thinking about their pain in these terms. One approach is to ask a question such as "What would you have to do to me to make me feel the pain that you have?" to help elicit this information. Another approach is to ask a patient to describe the quality of the pain by having him or her choose from three presented sets of words. Say something along the lines of: "I am going to give you three sets of words and I need to know if any one of these, or more than one of these, describe your pain. Is your pain (a) sharp and stabbing (b) dull, aching, and throbbing and/or (c) burning, electric, tingling, and traveling?"

When assessing pain quality, do not forget to assess whether or not the pain is physical pain, emotional pain, or spiritual pain. One can throw great amounts of morphine at emotional pain (e.g., grief over receiving news that one is terminal or that a limb has been amputated) and/or spiritual pain (e.g., feeling abandoned or punished by God or a higher power) without that pain being diminished or relieved.

Onset, duration, variations, and rhythms: Many patients in pain have variations in their pain experiences over a 24-hour period. In planning care, it is important to assess these fluctuations, to anticipate painful procedures, and to modify activities (when possible) to decrease discomfort. If pain is present 12 or more hours out of 24, around-the-clock scheduling of analgesics may be necessary.

Manner of expressing pain: Information about possible pain behaviors is essential when patients cannot communicate. Family members are a good source for information about typical facial expressions, body posturing, or behaviors that may indicate pain in the nonverbal patient. Pain behaviors may be your only assessment guideline if the patient cannot communicate.

Pain relief: Determine successful pain management strategies already in use, including pharmacologic interventions, nondrug measures like positioning, prayer, heating pads, or cold packs and effective distraction techniques such as listening to music or watching television.

Identifying causes of pain: Identify situations or behaviors that precipitate or promote pain, if possible. Along with determining pain patterns, this information allows you to anticipate particularly painful events and plan interventions to decrease or eliminate discomfort.

Effects of pain: Pain has been described by some patients as an experience that overwhelms them and consumes every aspect of life.¹⁵ Pain can easily affect sleep, appetite, physical mobility, and interpersonal relationships. A complete assessment of pain encompasses the impact of pain on patients and their families.

Other: Ask the patient for any additional information that may be significant to the pain experience. For example, the patient may want to identify the aspects of pain that are most distressing.

Nursing plan: At the completion of the assessment, develop an initial, brief plan for pain management. A successful plan is a cooperative effort between the health care team, the patient, and (in some cases) the family. Reassure the patient that the plan's effectiveness will be continually evaluated and the plan adjusted until an acceptable level of comfort is achieved.

Pain in nonverbal or cognitively impaired patients

While self-report is the gold standard in the assessment of pain, every nurse at times cares for patients who cannot verbally report their pain. These patients may be preverbal, nonverbal, or lack cognitive integrity. The absence of the ability to verbally report pain does not equate with an absence of pain. In these situations, nurses must turn to assessment tools specific to the population for whom they are caring.

There are many such assessment tools, and they primarily rely on behavioral observations. Certainly the "three Gs" -- groaning, guarding, and grimacing -- have been passed down from one nurse to another as indicators that a patient is probably in pain. However, today we have more precise and validated indicators of pain in nonverbal patients.

Pain in neonates and infants can be assessed with instruments such as the FLACC (Face, Legs, Activity, Cry, and Consolability) Scale; the NIPS (Neonatal/Infant Pain Scale); and the CRIES Neonatal Postoperative Pain Scale. Assessment of pain in children more often employs the self-report tools of the Oucher Scale, the Wong-Baker FACES Scale, and the Poker Chip Scale.^7,8

A different set of instruments exists for the assessment of pain in adults lacking cognitive integrity. In 2002, the American Geriatrics Society (AGS) Panel on Persistent Pain in Older Persons created a set of guidelines that list six categories in which common pain behaviors might be observed in cognitively impaired elderly people: facial expression, verbalization/vocalizations, body movements, changes in interpersonal interaction, changes in activity patterns or routines, and mental status changes. Multiple behaviors in each category are defined as possibly indicating pain (See the AGS website, www.americangeriatrics.org ).⁹

Most instruments to assess pain in older adults lacking cognitive integrity are based on or include elements described in the AGS guidelines. A number of these instruments are discussed in the chapter on pain assessment in the second edition of Textbook of Palliative Nursing.¹⁰

The most important point to remember is that an inability to verbally report pain does not equate with an absence of pain. Use the references mentioned in this course to find a tool appropriate to the patient population with whom you work, and use it consistently to assess for pain.

The pain flow sheet

The pain flow sheet (see Table 4), whether on a computer screen or on paper, is one way to document your assessment and ongoing evaluation of pain management interventions. Flow sheets may be appropriate when new analgesics are instituted and evaluated; when close monitoring of patient response is indicated, as with high doses of opioids; or when there has been a significant change in the patient's pain.² Pain assessment and documentation before and after intervention are critical in identifying the safety and effectiveness of the intervention and in improving the management of the patient's pain.

The flow sheet contains columns to record the time, the pain rating, the analgesic administered, the vital signs, plans, comments, and more. For example, it can be adapted to record bowel pattern or the presence of adverse effects such as nausea or itching. To prevent respiratory depression in patients at high risk, such as the postoperative patient with severe pain who is receiving opioids for the first time, sedation levels should be monitored. To minimize duplicate charting, the items on the flow sheet should be incorporated into existing documentation forms.

Flow sheets are especially useful in the home care setting, where patients or caregivers complete and record an ongoing assessment and evaluation for the nurse (who cannot be there 24 hours a day). The flow sheets are easily applied to the care of hospitalized patients, as well, and have been shown to improve pain management.⁷ Placing the flow sheet at the bedside allows anyone who comes in contact with the patient to become familiar with the pain management plan and its effectiveness.

An example of how a flow sheet could be used is provided in Table 5. This flow sheet represents the pain rating of a postoperative patient changing from morphine sulfate s IV to oral medication. The nurse would contact the physician to report that four hours after the patient received the first dose of one Tylenol #3 orally, the patient's pain is rated 6 on a scale of 0-10 and never got below 4. The comfort/function goal for this patient to ambulate is 2 on the 0-10 scale. There were no adverse effects. This documents the need for an increase in the dose of Tylenol #3. Once the new dose is administered, the nurse would continue to evaluate the effectiveness of the new dose on the flow sheet until the goal of 2 is reached.

Summary

The inadequate assessment and treatment of pain are well-documented in the literature and are often due to the lack of recognition that a pain problem exists. Every patient should be assessed for the presence or absence of pain, with an assessment complete enough to determine an appropriate nursing care plan for pain management.

Pain affects every aspect of quality of life. Nurses have the primary responsibility for pain management, and patients have a basic right to maximum comfort and an optimum quality of life.

Chapter Four

Using Analgesics

The problem of undertreatment of acute pain and of prolonged pain in the terminally ill patient has been recognized for almost 30 years.^1,2,3 This undertreatment results in needless suffering of patients and families. It is estimated that 90% of patients with acute pain or the prolonged pain of terminal illness could be made comfortable if analgesics were properly used.⁴

There are a number of ways that undertreatment of pain can occur. Physicians may underprescribe opioids for reasons such as a lack of knowledge about the medications and their proper use, fear of repercussion from medical regulatory boards and the legal system, and societal pressures caused by enhanced awareness of substance abuse problems.

Nurses may administer less than a patient could receive under the physician's order for many of the same reasons. Nurses may also fail to adequately manage patients' pain because of their own biases or attitudes. ^5,6

Finally, some patients do not take or request pain medications when needed. Possible reasons include fear and misunderstanding about opioid analgesia, especially related to addiction and physical dependence.

Concerns about addiction

Physicians, nurses, patients, and families share misconceptions and fears about addiction, physical dependence, tolerance, and the adverse effects of opioid analgesics. Patients and families experience misconceptions and fears about addiction and analgesic adverse effects and often believe that the initiation or increase of strong opiates signals that death is near. These fears and misconceptions mean patients suffer in pain although relief or a greater degree of comfort is possible with the use of analgesics.

Both health professionals and the public fear addiction and sometimes equate it with the legitimate use of opioids for pain relief. The APS defines addiction as a behavioral pattern of compulsive drug use characterized by continued craving for an opioid and the need to use the opioid for effects other than pain relief (or use for nonmedical reasons.)⁷ This means that a patient who takes opioids simply for pain relief is not an addict, no matter how much opioid the patient consumes or how long the patient has been taking opioids.

Patients who take opioids regularly and consistently for a week or longer do, however, often develop physical dependency and tolerance. These are physiological changes that should be expected after repeated administration of opioids although they do not occur in all patients. They should not be equated with addiction. Also, they are not difficult clinical problems to handle.

Physical dependence on opioids is revealed when the opioid is suddenly stopped or an antagonist such as naloxone (Narcan) is given.⁷ This is referred to as "withdrawal" or "abstinence syndrome" and is characterized by anxiety, chills, runny nose, diarrhea, and other symptoms that resemble a mild cold or severe influenza. To avoid signs of withdrawal in a physically dependent patient, decrease the opioid dose slowly over seven to 10 days.

Opioid tolerance is characterized by a decrease in one or more effects of the opioid, such as decreased analgesia, sedation, or respiratory depression. Tolerance to analgesia requires an increase in the opioid dose or a decreased interval between doses.⁷ Tolerance to analgesia appears to stabilize after a few weeks. Stable pain leads to stable doses. Further increases in dose are likely to be due to increased pain. Fortunately, tolerance to respiratory depression continues to increase. Therefore, it is usually safe to administer larger opioid doses to patients who require them because of increased disease, such as often occurs in the terminally ill patient.

Tolerance, physical dependence, and addiction are separate entities. (See Table 6 for a comparison of definitions.) They do not necessarily occur together. Many patients receiving opioids daily for pain relief are physically dependent and tolerant but not addicted.

One of the most frequently cited reasons for undertreating pain is the fear of causing opioid addiction. Health professionals have unrealistic and unfounded fears about causing addiction in patients who receive opioids for pain.

The literature reports that the actual incidence of opioid addiction in patients who were not previously addicted to opioids is very low, yet the fear of addiction persists.^8,9

Another reason for undertreatment of pain is misunderstandings about tolerance, e.g., thinking that we should "save the morphine" until pain becomes severe. A major reason for cancer patients' undermedicating themselves is a fear that the opioids' effectiveness will decrease over time. Fortunately, the morphine-like opioids have no analgesic ceiling; opioid doses can be increased indefinitely to maintain effective analgesia.⁴

Principles of analgesic use

The management of pain is a team effort involving the patient, who feels and reports pain; the physician, who prescribes analgesics; the pharmacist, who prepares and dispenses the analgesics; and the nurse, who administers medications and monitors their effectiveness. A patient's family may be a part of the team, as well. Other disciplines such as physical therapy can be invaluable in managing a patient's pain.

Authorities on pain management suggest that analgesics be used in a preventive approach for patients with prolonged or acute pain.^4,7,10 We explain this to patients by saying something like, "It is easier to get on top of your pain and prevent it, than it is to chase it once it gets hold of you." For any patient who has pain most of the day, a routine, around-the-clock (ATC) dosing schedule is indicated.⁷ Some benefits of a preventive approach are that the patient spends less time in pain, a steady plasma level of analgesic can be maintained, and the patient's anxiety about the return of the pain decreases.¹⁰

Safety in medication administration is a prime tenet of nursing practice. Nurses need to know the initial recommended dosage of a given medication and understand the need to titrate (increase or decrease the dosage) as necessary to achieve the desired pain relief with the fewest adverse effects.^7,10

The increased pain that accompanies advancing disease (such as cancer) means that some patients need to take very high doses of morphine-like opioids to maintain analgesia. However, since patients also develop tolerance to respiratory depression and sedation, higher doses are usually safe.⁷ Morphine-like opioids lack an analgesic ceiling, meaning that pain relief can be obtained by continuing to increase the dose.

The numbers of milligrams given to patients on long-term opioids can be shocking to those who don't understand the gradual process of titration and individualization of dose. For example, some patients require the equivalent of 30,000 to 40,000 milligrams of IV morphine per 24 hours.¹⁶ In summary, the safe and effective way to administer opioids is to watch the patient's response to the medication, not the dose.

Three major classes of analgesics

Nonopioid analgesics

The nonopioids are usually divided into two major groups: acetaminophen, which is in the only drug in that group, and nonsteroidal antiinflammatory drugs (NSAIDs). In contrast to opioids, nonopioids have a ceiling effect for maximum analgesia, i.e., beyond a certain dose no more analgesia can be obtained. Also unlike opioids, use of nonopioids does not result in tolerance to analgesia or physical dependence. Unfortunately, the analgesic effect of nonopioids is often underestimated, and they are underused in situations in which they could prove beneficial. For example, the average dose of aspirin or acetaminophen (650mg PO) provides approximately the same pain relief as 30-60mg of codeine orally.⁷ Dosing guidelines for nonopioid analgesics may be downloaded from the website www.mosby.com/PAIN.

The NSAIDs are cyclooxygenase (COX) inhibitors. Two forms of COX are COX-1 and COX-2. Blocking COX-1 causes adverse effects such as increased bleeding time, gastrointestinal (GI) bleeding, and ulcers. Blocking COX-2 relieves pain.¹²

Based on the COX forms that are inhibited, the NSAIDs are subdivided into two groups: nonselective NSAIDs and selective COX-2s (or coxibs). The nonselective NSAIDs block both COX-1 and COX-2 while the selective COX-2s selectively block COX-2. The result is that selective COX-2 NSAIDs produce less incidence of GI toxicity and cause no increase in bleeding time.¹² Recently, two of the COX-2s (Vioxx and Bextra) were pulled from the market, related to claims involving the potential for severe cardiovascular events being associated with extended use.^13,14 Further, the FDA has requested labeling changes for all NSAIDs.¹⁵ Also, keep in mind that both types of NSAIDs have the potential for renal damage.⁷

The nonselective NSAIDs include aspirin, diflunisal (Dolobid), ibuprofen, ketorolac (Toradol), naproxen, and piroxicam (Feldene). The selective COX-2s include celecoxib (Celebrex), rofecoxib (Vioxx), and valdecoxib (Bextra).¹²

NSAIDs are useful analgesics for most types of acute and chronic pain, including inflammatory conditions (rheumatoid arthritis), musculoskeletal pain, dysmenorrhea, bone metastasis, and postoperative pain. Unless contraindicated, a nonopioid should be considered in all analgesics regimens even if pain is severe enough to require an opioid.⁷

Opioid (narcotic) analgesics

Opioids, formerly called narcotics, relieve pain at the level of the central nervous system by attaching to central and peripheral receptors.⁶ Opioids may be divided into two groups: full agonists (mu agonists or morphine-like drugs) and agonist-antagonists. Those in the agonist-antagonist group, such as pentazocine (Talwin), nalbuphine (Nubain), and butorphanol (Stadol), have a very limited place in pain management because there is a ceiling on their analgesia. Also, their antagonist effect (e.g., naloxone-like effect) is strong enough that it sometimes reverses analgesia when these opioids are given following a dose of a morphine-like drug. The full agonists are the mainstay of opioid analgesia and include morphine, hydromorphone (Dilaudid), meperidine (Demerol), fentanyl, hydrocodone, methadone (Dolophine), oxymorphone (Numorphan), oxycodone (e.g., OxyContin), and codeine.

The duration of analgesia varies from opioid to opioid and within a given opioid by delivery system. For example, oral hydromorphone (Dilaudid) may provide analgesia for only three or four hours while oral methadone may do so for six to 12 hours. An immediate-release oral morphine may provide analgesia for three to four hours while a sustained-release form of the same oral medication (morphine) may provide analgesia for 12 to 24 hours. Therefore, to optimize patient comfort nurses must know how long each pain medication is expected to provide analgesia.

The adverse effects commonly associated with opioid use are respiratory depression, constipation, sedation, nausea, and vomiting. Respiratory depression is a potentially life-threatening adverse effect that can be prevented by monitoring respirations and sedation levels and can be easily treated if it occurs. It is critical to assess for sedation levels and respiratory status when you start opioids on a patient who has moderate to severe pain and has not been receiving opioids regularly. Traditional thinking has been that when an opioid causes the patient to be so sedated that he or she has difficulty staying awake, the dose should be decreased to prevent respiratory depression. However, pain is exhausting. If your patient has been in pain and is exhausted and you provide a relieving dose of analgesic, that patient may slip into a very deep sleep because of the sleep debt that has accumulated and because he or she can. Therefore, while sedation levels should not be ignored, it is far more important to monitor respirations. In so doing, remember that depth and consistent rhythm may be more important than just the number of breaths per minute. The likelihood of respiratory depression decreases the longer the patient has been on opioids because tolerance to respiratory depression develops and information about the patient's response to opioids is known.

The antidote for respiratory depression is naloxone (Narcan) administered intravenously (or IM if necessary). Narcan is a pure opioid antagonist that can reverse both analgesic effects and respiratory depression. Sufficient amounts of Narcan should be given to decrease sedation and increase respirations to an acceptable level without completely reversing analgesia. Giving too much naloxone can also precipitate hypertension and ventricular dysrhythmias. Therefore, dilute 0.4 mg of naloxone in 9 to 10 ml of saline and administer 0.5 ml over two minutes.¹⁰ Because of naloxone's brief duration (compared to opioids), multiple administrations may be necessary.

Be alert to the possibility of respiratory depression when you administer opioids, but remember that clinically significant respiratory depression is relatively rare.

Perhaps the most distressing adverse effect for patients who receive opioids is constipation, and it is the one adverse effect that persists and to which tolerance is not developed. Therefore, always anticipate and prophylacticly treat opioid-related constipation. Any patient who receives an opioid analgesic should be started on a bowel program to prevent constipation.¹⁰ A combined stool softener and mild peristaltic stimulant like Peri-Colace, Doxidan, or Senokot-S taken daily is usually enough to prevent constipation. Stronger stimulants, laxatives, cathartics, or enemas are employed if necessary.

Opioid-induced nausea and vomiting may occur when a regimen is first begun, but often subside after a few days. In acute postoperative pain, nausea may be handled by decreasing the opioid dose and adding ketorolac (Toradol), a parenteral nonopioid analgesic, to prevent pain from increasing. A nonsedating antiemetic, such as ondansetron (Zofran) 8 mg PO or IV, may be used. An antiemetic such as metoclopramide (Reglan) may be used. If pain is chronic and the patient can tolerate it, it is helpful to wait to see whether the nausea subsides or can be controlled with antiemetics before discontinuing or changing opioids.

Other causes of nausea-such as other medications, hypercalcemia, uncontrolled pain, copious sputum, or co-existing medical conditions-may be overlooked. Carefully review signs, symptoms, and the patient's case history before targeting opioids as the cause of nausea.

Sedation is a dose-limiting adverse effect for some patients with chronic pain. Most patients develop a tolerance to sedation after a few days on opioids. Some patients, such as the elderly, may be more sensitive to the sedating effects of these drugs.

Each patient's situation should be reviewed separately to determine the acceptable level of sedation and to assess the potential for harm from decreased sensorium. Some patients choose to endure more discomfort if it means less sedation. If the sedation level is still unacceptable after a few days of adaptation, another opioid can be substituted until a satisfactory one is found, or stimulants such as caffeine or dextroamphetamine (e.g., 5-10 mg PO bid, at roughly 8 AM and 2 PM to avoid night sleeplessness) may be helpful. Finally, methylphenidate (Ritalin) at the same oral dose, and frequently as dextromethylphenidate, can be very effective in patients with sedation or fatigue.

Adjuvant analgesics for neuropathic pain

Adjuvant analgesics are drugs that were not originally indicated for pain but are nonetheless effective analgesics for selected types of pain. These drugs are most often used for chronic pain states and seem to be especially helpful for neuropathic pain such as neuropathy, postherpetic neuralgia, and trigeminal neuralgia. These drugs include:

Tricyclic antidepressants (amitriptyline, nortriptyline, doxepin, imipramine), which have been used successfully to manage dull, aching neuropathic pain (such as peripheral neuropathy) as well as to treat painful states associated with sleep disorders (fibromyalgia).

Anticonvulsants (gabapentin, phenytoin, carbamazepine, clonazepam, valproate), which are sometimes helpful for lancinating neuropathic pain (such as trigeminal neuralgia or phantom pain).

Local anesthetics, which are, of course, used to numb painful areas. They also can be used for analgesia. For example, a 5% lidocaine patch (Lidoderm) may relieve pain when it is applied to painful areas associated with postherpetic neuralgia. A eutectic mixture of local anesthetics (EMLA) may be applied to the skin to decrease the pain of immunizations.¹⁰

First-line treatment for almost all types of neuropathic pain is usually gabapentin and, if the pain is well localized and somewhat superficial (not deep tissue), the Lidoderm patch.¹⁶ Both of these approaches tend to have minimal adverse effects and are relatively easy to dose. Up to four Lidoderm patches may be safely applied to the area that hurts for up to 72 hours while changing them every 12-24 hours.¹⁷ Then the patches probably need to be removed for 12 hours before applying again.

Gabapentin is dosed three times a day, but it may be started at low doses, e.g., 300 mg HS, and escalated every three days (adding doses in the morning and midday) to allow tolerance to the adverse effects of dizziness and sedation to develop. The dose should be increased until pain relief is achieved or adverse effects are unacceptable. The effective dose range is usually 900-2700 mg a day, but some patients require up to 6000 mg a day.¹⁶

Dosing guidelines for adjuvant analgesics may be downloaded from the Internet at www.mosby.com/PAIN.

In the recent past, methadone quickly became the drug of choice for neuropathic pain. It is inexpensive, has high compliance because of being dosed q 12 hours, has no active metabolites, works quickly, can be used from pediatrics to geriatrics, and is effective against both neuropathic and nociceptive pain. It does, however, have a long half-life, which makes it a poor choice for patients who are opiate naïve. It has some stigma attached to it related to its use in patients withdrawing from heroin. Finally, it is confusing to work with because of the varying ratios found for it in conversion tables. However, for patients suffering with neuropathic pain, it is one of the most effective tools in the pain management arsenal.¹⁸

Note that phenothiazines are not included in this discussion. They maybe useful as antiemetics for opioid-induced nausea, but sedation and orthostatic hypotension are limiting adverse effects.⁷ Further, they do not potentiate opioid analgesia, and, except for methotrimeprazine (Levoprome), they do not relieve pain.⁷

The WHO analgesic ladder

Cancer pain relief is one of the priorities of organizations such as the World Health Organization and the APS. The pain-relief method endorsed by the WHO is useful in a variety of pain situations. (See Figure 1.) It involves a progression of management beginning with nonopioids with or without adjuvants and advancing to the addition of opioids (such as codeine) for relief of mild pain. For severe pain, opioids (such as morphine) and possibly nonopioids and adjuvants are recommended.

This method not only guides pain management through the terminal stages of illness, but serves as an excellent reminder in any pain management situation. Better pain control may be achieved through a combination of drugs with differing analgesic actions and adverse effects.

As previously discussed, NSAIDs relieve pain primarily by inhibiting COX-2 while opioids relieve pain by attaching to opioid receptor sites in the brain and spinal cord. Combining an opioid with an NSAID attacks pain in two different ways and reduces the required dose of opioid. Adding an adjuvant further reduces the dose of opioid and relieves pain still another way.

Summary

The successful pharmacologic management of pain involves a team approach. It includes assessing pain, administering appropriate analgesics, adjusting the dose and interval according to patient responses, monitoring and managing adverse effects, and evaluating effectiveness of the treatment plan. How an analgesic is used is probably more important than which one.¹⁰ In the complex health care environment, it is a challenge for health care personnel to maintain a current, accurate understanding of the pharmacology of pain management. In addition, we are faced with many myths and misconceptions about addiction and opioid use that may prevent adequate pain control. Despite the barriers, we must strive for state-of-the-art pain management. The results of comfort, satisfaction, and enhanced quality of life are well worth the effort.

Chapter Five

Pain Management: Equianalgesia

This chapter will attempt to help the clinician understand and use an equianalgesic chart. Equianalgesia, which literally means "equal analgesia," is a term that is used to compare the effectiveness of different opioids in managing pain relief.

An equianalgesic chart on the following pages lists analgesics at doses that are approximately equal to each other in the ability to provide pain relief. That is, all the analgesics at the doses listed are approximately interchangeable. Be aware that different sources identify different ratios in these tables, e.g., what appears as 5:1 in one source may appear as 4:1 or even 3:1 in another. These are not errors, but simply differences based on specific research or clinical experience of the creator or reporter of the table.

The equianalgesic chart enables the clinician to compare the pain relief likely to be achieved by opioids at different doses and via different routes. The lack of this knowledge when a change is made in opioid choice, dose, or route has been linked with the undertreatment of pain.¹

The equianalgesic chart used in this course is based on APS recommendations.² The chart is a guideline for determining the appropriate starting dose of an opioid. After the first dose is administered, the dose and interval of the drug are adjusted to the individual's response. The effectiveness of the medication regimen must be monitored through ongoing pain assessments and the use of pain rating scales.

The equianalgesic chart

The first equianalgesic chart (Table 7) is divided into four columns: analgesics, doses for parenteral routes, doses for PO route, and comments. (In the second equianalgesic chart, Table 8, for oral doses, the parenteral route column is omitted.) In Table 7, the analgesic column lists opioids used to manage moderate to severe pain such as postoperative pain or chronic, cancer-related pain. Morphine is listed first as it is the standard by which all other opioids are compared.² The others are listed alphabetically by generic name. The list includes only analgesics available and approved in the United States. Opioid selection is based on pharmacologic properties and various patient variables.³ Some considerations under pharmacologic properties include presence of active metabolites, half-life, and duration of effect.

The second and third columns list the parenteral (IM, subcutaneous, and IV) doses and PO doses that are approximately equal in their ability to relieve pain. A dash in either column means the drug is not available in the United States by that route. The fourth column lists specific considerations in the use of each drug, such as other routes of administration or special precautions.

Converting parenteral opioids

The IM route is no longer recommended because of unreliable absorption and discomfort for the patient. The IM route is especially undesirable for treatment of chronic pain. Preferred routes include oral or continuous infusion subcutaneously or intravenously. However, we will begin with the IM route since it is the easiest route to learn to convert. Then we will progress to problems involving the IV route.

To change a patient from one opioid to another by the IM or subcutaneous (SC) route of administration, refer to the first column of the equianalgesic chart. Locate the analgesic the patient currently receives and the desired new analgesic. Use the second column to determine the dose of each.

For example:

According to the equianalgesic chart, there are several alternatives to giving a patient meperidine (Demerol) 100mg IM while continuing to achieve approximately the same pain relief. Meperidine 75mg IM is equivalent to 10mg morphine SC or IM, 2mg hydromorphone (Dilaudid) SC or IM, 2mg levorphanol (Levo-Dromoran) SC, and 10mg of methadone SC or IM. (See Example 1.) If the dose of an ordered analgesic is not the same dose that appears in the IM column, you can still calculate the dose by using a ratio. For example, if a child is receiving meperidine 50mg IM and you want to switch to morphine IM, calculate that 50mg is one-half of 100mg and that you will need one-half of any IM dose listed, or about 5mg of morphine IM. The listed parenteral doses are also used to calculate IV doses if you are switching from one opioid analgesic to another via the IV route or switching from IM to IV. Most clinicians consider the total daily doses by the IM, SC, and IV routes to be equivalent. For example, a patient may be changed from repetitive IM injections to a continuous infusion of IV morphine simply by calculating the total daily dose of morphine IM and dividing by 24 for an hourly IV rate. If the patient is receiving morphine 10mg IM q4h, the total daily parenteral dose of morphine is 60mg. That dose is divided by 24 hours for an hourly infusion rate of 2.5 mg/hr IV or SC morphine. To convert from one IV opioid to another IV opioid, follow the directions above for changing from one IM opioid to another. Since bolus or hourly IV doses are likely to be smaller than the IM doses, the use of a ratio or percentage is often necessary.

Converting PO opioids

The PO route (mg) column lists the oral doses of analgesics that are approximately equal to each other in relieving pain. To change from one PO opioid to another, refer to this column. (See Example 3.).

The opioids often given PO to clients with mild to moderate pain are codeine, oxycodone, meperidine, and hydrocodone. The so-called stronger opioids are morphine, hydromorphone, levorphanol, and methadone. Although these drugs are considered more effective, the ability of an opioid to relieve pain largely depends on the dose given. This is the reason to use an equianalgesic chart as a guide.

Many older equianalgesic charts include propoxyphene- (Darvon) and/or propoxyphene-containing compounds, for example, Darvocet or Darvon-N. Propoxyphene is no longer seen as a first-line analgesic: it has only weak analgesic properties, has a metabolite that causes CNS and cardiac toxicity, and should be avoided completely in the elderly, in patients with renal or hepatic impairment, in patients with moderate to severe pain, and in patients with chronic pain.^5,6

Changing opioid routes

Refer to the equianalgesic chart when changing the route of administration from IV or IM to PO. If the route is changed and not the drug, first refer to the IM column, then to the PO column next to it, and determine the ratio between IM and PO administration. A patient receiving meperidine 75mg IM q3h would have to receive 300mg of meperidine PO q3h; a patient receiving morphine 10mg IM q4h would need morphine 30mg PO q4h. The large increase in dosage from IM to PO can be explained by what is known as "first pass effect." Not all of the medication taken PO is absorbed by the stomach and upper gastrointestinal tract. The medication that is absorbed into the bloodstream is carried by the portal vein to the liver, where enzyme induction may cause further metabolism, resulting in further loss of the drug.

Note also that the ratios of IM to PO doses are different for the various opioids. The ratio for hydromorphone is 1:5; for morphine, it is 1:3. The practical application of this information is that it gives the number by which an IM, SC, or IV dose must be multiplied to determine the PO dose that would relieve the same amount of pain. Thus, a parenteral dose of morphine must be multiplied by three to obtain the oral dose that relieves the same amount of pain. (See Example 4.)

Summary

Conversions provide the clinician a basis on which to formulate recommendations for adequate pain relief. The initial calculation of an analgesic dose is an educated guess. Adjusting the dose based on the patient's response is essential for the effective use of analgesics.

Examples of using equianalgesic charts

Example 1:

Robert, an 85-year-old male with renal insufficiency, is receiving meperidine 100mg IM q4h for postoperative pain. He has received this therapy for two days. Your assessment reveals that Robert's pain rating is 3 on a 0-10 scale, and he says this is satisfactory. However, he has uncontrollable tremors in his hands, and his sleep is disturbed frequently by twitching and jerking. These are signs of accumulation of the active metabolite of meperidine, normeperidine, and further accumulation could lead to seizures.² Therefore, it is essential to switch this patient to another morphine-like drug, or mu agonist. Hydromorphone is an excellent choice since it has a shorter half life than morphine and is devoid of any known problematic active metabolites that are likely to accumulate with renal dysfunction. Using the equianalgesic chart, the dose of hydromorphone that will relieve approximately the same amount of pain as meperidine 100mg IM is 2mg IM or SC. An hourly ongoing pain assessment is necessary at first to assure that both the dose and the interval of the new opioid provide adequate pain relief.

Example 2:

John, a 26-year-old male, was admitted to the hospital with multiple fractures and facial trauma sustained in a motor vehicle accident. It is two days after the accident, and he is receiving meperidine (Demerol) 25mg/hour IV. He reports his pain is 2 (0-10 scale). However, he is experiencing nausea that has not been responsive to antiemetics. Unmanageable adverse effects are one reason to switch a patient from one opioid to another. Thus, meperidine IV is discontinued and morphine IV is ordered. Using the equianalgesic chart, you find meperidine listed at 100mg in the parenteral column. The patient is receiving one-quarter of that dose. Thus, the morphine dose that probably will achieve the same analgesia is one-quarter of 10mg-morphine 2.5 mg/hour IV.

Example 3:

Margaret, a 45-year-old female, is taking Tylenol #3 tabs ii PO q 4 hours around the clock. Each Tylenol #3 tablet contains codeine 30mg and acetaminophen 300mg for a total of codeine 60mg and acetaminophen 600mg each dose. The pain is in the right arm related to mastectomy and lymph node dissection and to fibrotic changes following radiation therapy to the area for recurrence in the chest wall. Margaret rates her pain at 7 (0-10 scale). Pain intensity one hour after taking two tablets of Tylenol #3 is reported at 5, but her pain rating goal is 2. Increasing the dose of codeine is likely to produce considerable nausea, especially since she is experiencing some nausea from the present dose. To achieve greater pain relief without unmanageable side effects, choose another opioid such as morphine or oxycodone PO, which are both available in extended release formulation for oral administration. (Acetaminophen can be continued separately.) What dose is required to provide more analgesia? Using morphine, first determine how much morphine would be required for the same analgesia she received from the codeine. Locate codeine in the PO column; note the dose is listed at 200mg. The current dose of 60mg is 30% of 200mg. The dose listed for morphine PO is 30mg, and 30% of that dose is 9mg. Next, determine how much to increase the morphine dose of 9mg to achieve more pain relief. Usually a 33% to 50% increase is recommended for a moderate improvement in pain relief.⁸ Thus, a dose of morphine 12mg or 14mg PO might be tried.

Example 4:

Mary is a 51-year-old female with a diagnosis of adenocarcinoma of the lung with a large mediastinal mass. She experienced dysphagia secondary to the tumor mass and received radiation to the mediastinal mass. Pain was controlled with morphine 4mg SC per hour continuous infusion via an infusion pump, with bolus doses of 1mg every 15 minutes. Two bolus doses have been used for breakthrough pain within the last 24 hours. Pain is reported as 1 (0-10 scale). Radiation therapy successfully reduced tumor bulk, and the patient can now swallow. The physician decides to change from morphine SC to morphine PO. The ratio of SC morphine to oral morphine is 1:3 for around-the-clock dosing based on survey data and clinical experience. The first step is to calculate the total number of milligrams of morphine received SC per 24 hours, including the bolus doses. Morphine 4mg/hour SC times 24 doses per day equals 96 mg/24 hours. Two bolus doses of 1mg each equal 2mg/24 hours. Add 96mg plus 2mg morphine for a total of 98 mg morphine SC per 24 hours. The next step is to convert the SC dose to a PO dose by multiplying the 98 mg times three (ratio of SC to PO is 1:3) to get 294 mg per day. The last step is to divide the 294 mg by the number of doses per 24 hours, i.e., six (immediate release oral morphine is usually effective for approximately four hours) to arrive at approximately 49 mg PO q 4 hours. To convert the patient to extended-release morphine that is administered q12h, the 294 mg is divided by 2, so the patient would receive extended release morphine (e.g., MS Contin) 150 mg q 12h (tablets are available in 15 mg, 30 mg, 60 mg, 100 mg, and 200 mg.)

Chapter Six

Nondrug Pain Relief Measures

Simple pain relief methods include distraction, relaxation, and cutaneous stimulation such as heat, cold, and massage. The nurse plays an important role in initiating nondrug methods. If you do not suggest their use, nondrug therapies probably will not be prescribed by the physician or initiated by the patient. These methods are not intended to replace analgesics, but to enhance their effects.

When initiating nondrug techniques, the greatest obstacle you may encounter is the hesitancy of patients to try them. This often is related to experience: The patient may have used heat or relaxation techniques with no relief. Failure of nondrug approaches may result from trying inappropriate methods for the type of pain or may be related to misinformation about how to use the technique or to lack of skill in using the technique.

Sometimes patients mistakenly believe that even partial success with nondrug methods will result in analgesics being decreased or withheld. Emphasize to patients and families that nondrug methods will be used in addition to analgesics and should be used before pain becomes severe. For example, when a patient first feels pain, an analgesic should be given and the nondrug method employed. The rationale is that while the analgesic is being metabolized, which takes about 20 to 30 minutes, the patient can obtain some pain relief from the nondrug method.

Cutaneous stimulation-Cutaneous stimulation involves stimulating the skin to relieve pain. It includes heat, cold, massage, vibration, counterirritants, and transcutaneous electrical nerve stimulation (TENS). These are especially suited for relief of localized pain.

Heat-hot tub baths, heating pads, or heat packs-promotes relaxation. A chemical pack can be heated in a microwave oven or in boiling water and enclosed in an elastic bandage with Velcro. The patient can remain mobile while wearing it, and the wrap provides some degree of support, which is comforting to the patient.

Cold is often more effective in relieving pain than heat, but is less likely to be used by patients. Because of cold's effectiveness, you should strongly encourage its use even if a patient is reluctant.

Most people (even health care professionals) are taught to use heat rather than cold for joint or muscle pain relief. Basic research in this area is lacking, but there are many clinical reports of thermal therapy assisting in the battle against pain.^1,2 And cold, specifically, is identified as reducing both inflamation and spasm.³

Methods of cold application include ice massage, ice bags, and gel packs. Commercially prepared gel packs are inexpensive, can be reused, and are convenient. One way you can increase a patient's acceptance of cold is to avoi