Pain

Dexamethasone (Decadron), prednisone, and methylprednisolone (Medrol)

are used for management of acute and chronic cancer pain, pain secondary to spinal cord compression, and inflammatory joint pain syndromes.

Nursing roles for pain

assess, initate, evaluate, advocate

Treatment goals of chronic pain

Control to the extent possible and Focus on enhancing function and quality of life

Another definition of pain

"Unpleasant sensory and emotional experience associated with actual or potential tissue damage." IASP

Definition of pain

"Whatever the person experiencing pain says it is, existing whenever the person says it does." Margo McCaffery

Side effects of Corticosteroids

(especially when given chronically in high doses) hyperglycemia, fluid retention, dyspepsia and GI bleeding, impaired healing, muscle wasting, osteoporosis, adrenal suppression, and susceptibility to infection

Magnitude of pain problem

25 million people experience acute pain from injury or surgery, Chronic pain affects over a million American adults, 60% of cancer patients experience pain during treatment

Routes: Patient-controlled analgesia (PCA)

A dose of opioid is delivered when the patient decides a dose is needed, Patient pushes a button to deliver a bolus dose of opioid IV, Teach patient that they cannot "overdose"

Nonopioid examples

Acetaminophen, aspirin and other salicylates, and NSAIDs (GI bleeding)

Visceral Pain

Activation of nociceptors in the internal organs and lining of the body cavities, Tumor involvement or obstruction, Arises from internal organs such as the intestine and bladder

Opioid

Bind to receptors in the CNS, Inhibition of transmission of nociceptive input , and Activation of descending inhibitory pathways

Common side effects of opioids

Constipation (most common), Nausea/vomiting, Sedation, Respiratory depression, and Pruritus

Combined with nonopioids for moderate pain

Codeine plus acetaminophen (Tylenol #3) and Hydrocodone plus acetaminophen or ibuprofen (Vicoprofen)

Pain reassessment

Critical to reassess at appropriate intervals, guided by Pain severity, Physical and psychosocial condition, Type of intervention, Risks of adverse effects, Institutional policy

Neuropathic pain

Damage to peripheral nerve or CNS

Nociceptive pain

Damage to somatic or visceral tissue

Behavioral manifestations of chronic pain

Decreased physical movement/activity, Fatigue, and Withdrawal from others and social interaction

TENS

Delivery of an electrical current through electrodes on the skin

Adjuvant: Corticosteroids expamles:

Dexamethasone (Decadron), prednisone, and methylprednisolone (Medrol)

Cognitive therapies

Distraction, Hypnosis, Relaxation

Non-opioid

Do not produce tolerance or addiction, Many are OTC, Acetaminophen has analgesic and antipyretic effects, It does not have anti-inflammatory effects

Pain assessment documentation

Documentation is critical to ensure effective communication pain assessment tools

Administration: Scheduling

Focus on prevention or control, Do not wait for severe pain, Constant pain requires around-the-clock administration (not PRN), Fast-acting drugs for breakthrough

Pain treatment principles

Follow principles of assessment, Use a holistic approach, Every patient deserves adequate pain management, Base treatment plan on patient's goals, Use both drug and nondrug therapies, Use multimodal approach when appropriate, and Address pain using an interprofessional approach

(TCAs)

Higher levels of serotonin and norepinephrine in the synapse inhibit the transmission of nociceptive signals in the CNS.

Manifestations reflected in sympathetic nervous system for acute pain

Increased heart rate, respiratory rate, and blood pressure

Pain management strategies

Inquire about strategies used (Effective and ineffective) like prescription drugs, OTCs, nondrug therapies

Addiction

Neurobiologic condition with drive to obtain and take substances for other than prescribed therapeutic value

NMDA receptor antagonist

Ketamine

Nalbuphine, pentazocine, butorphanol

Less respiratory depression, More dysphoria and agitation, Have an analgesic ceiling, Can precipitate withdrawal

Somatic pain

Localized and Arises from bone, joint, muscle, skin, or connective tissue

Example of location

Localized, All over, and Referred or radiated from origin to different site

Pain assessment: Location

Location assists in identifying cause and treatment

Non-drug therapy for pain

Massage, Exercise, TENS or PENS, acupuncture, heat/cold therapy, cognitive therapies

Examples of opioid

Morphine, oxycodone, and codeine

Pruritus

Most common with epidural or intrathecal routes

Examples Mixed agonists-antagonists:

Nalbuphine, pentazocine, butorphanol

Pain assessment: Quality

Nature or characteristics (stabbing, electric shock-like, throbbing)

Tolerance

Need for increased dose to maintain same degree of pain control and Rotate drug if tolerance develops, as increasing dose could result in opioid-induced hyperalgesia (OIH)

Are Tolerance and physical dependence indicators of addiction?

No

Pain mechanisms

Nociception

Pain assessment: Characteristics

Onset, Duration, Factors increasing or relieving pain, Pattern

what is pain

Pain is a complex, multidimensional experience that can cause suffering and decreased quality of life

Chronic pain

Persistent pain, Gradual or sudden onset, Longer than 3-month duration; may start acute but continues past normal recovery time, Cause may be unknown, Does not go away; characterized by periods of waxing and waning, Can be disabling and accompanied by anxiety and depression

Nociception

Physiologic process that communicates tissue damage to the CNS

Signs of respiratory depression

Pinpoint pupils, coma

Morphine, oxycodone, and codeine

Potent, no analgesic ceiling, and have several routes for administration and Often combined with nonopioid analgesic for relief of moderate pain

Pain assessment: Intensity

Reliable measure for determining treatment, Rated using scales (0 to 10)

Withdrawal symptoms

Shakes, seizures, stroke, N/V, anxiety

Description of pain

Subjective: Patient's experience and self-report are essential

Acute pain

Sudden onset, Less than 3 month's time for normal healing to occur, Mild to severe, a precipitating event or illness can be identified, Course of pain decreases over time and goes away as recovery occurs, Pain control with eventual elimination

Example of Nociceptive pain

Surgical incision, broken bone, or arthritis

What does the definition of pain emphasize?

The subjective nature

Benefits of (TCAs)

They are effective for a variety of pain syndromes, especially neuropathic pain syndromes.

Dual mechanism agents (non- habit forming)

Tramadol (Ultram) is a weak mu agonist and also inhibits the reuptake of norepinephrine and serotonin and Tapentadol (Nucynta) works at mu receptors and inhibits norepinephrine reuptake.

Antiseizure drugs

Transdermal lidocaine and α2-adrenergic agonists

Pain assessment: Breakthrough pain

Transient, moderate to severe, Occurs beyond treated pain, and Usually rapid onset and brief duration with variable frequency and intensity

Adjuvant: Antidepressants

Tricyclic antidepressants (TCAs) enhance the descending inhibitory system by preventing the cellular reuptake of serotonin and norepinephrine

Adjuvant analgesics (not originally intended to treat pain)

Tricyclic antidepressants and Serotonin norepinephrine reuptake inhibitors (SNRIs)

Consequences of untreated pain

Unnecessary suffering, Physical and psychosocial dysfunction, Immunosuppression, Sleep disturbances

Adjuvant

Used alone or in conjunction with opioids and nonopioids and Generally developed for other purposes, but also effective for pain

Who was Margo McCaffery?

a nurse and pioneer in pain management.

Adjuvant: Antiseizure drugs

affect both peripheral nerves and the CNS in several ways, including sodium channel modulation, central calcium channel modulation, and changes in excitatory amino acids and other receptors.

MOA of Corticosteroids

are may be related to the ability of corticosteroids to decrease edema and inflammation.

Superficial somatic pain

arises from skin, mucous membranes, and subcutaneous tissues and often is described as sharp, burning, or prickly

Adjuvant: GABA receptor agonists (muscle- relaxer)

baclofen an agonist at of GABA receptors, can interfere with the transmission of nociceptive impulses and is used for muscle spasms and neuropathic pain and It crosses the blood-brain barrier poorly and is much more effective for spasticity when delivered intrathecally

Description of pain of nonverbal patients (autistic, dementia, coma patients)

behaviors aids the assessment of pain such as crying, postures of body

Pain assessment: Associated symptoms

can worsen pain (anxiety, fatigue, depression)

Deep somatic pain

characterized as aching or throbbing and originates in bone, joint, muscle, skin or connective tissue

Examples Visceral nociceptors:

contraction of uterus, gallbladder removal, appendix removal

Nociceptive

everything visceral, organ, anything other than nerves

Examples of Antiseizure drugs

gabapentin (Neurontin), lamotrigine (Lamictal), and pregabalin (Lyrica)

Stretching of viscera nociceptors

hollow viscera in the intestines and bladder that occurs from tumor involvement or obstruction can produce intense cramping pain.

Example of end- of- dose failure

in a patient on transdermal fentanyl (Duragesic patches), the typical duration of action is 72 hours and An increase in pain after 48 hours on the medicine would be characterized as end-of-dose failure

Analgesic ceiling

increasing the dose beyond an upper limit provides no greater analgesia

Hepatotoxicity of Acetaminophen

may result from chronic dosing of more than 3 g/day, acute overdose

Neuropathic Pain Treatment

multimodal (adjuvant, antiseizure, NMDA)

Neuropathic

nerve pain

Three categories of Drug therapy

non-opioid, opioid, adjuvant

Pain assessment: End-of-dose failure

occurs before the duration of pain relief that is expected with a specific analgesic, and failure signals the need for changes in the dose or scheduling of the analgesic

what is the major reason people seek health care

pain

Morphine may cause what?

respiratory depression

Visceral nociceptors

respond to inflammation, stretching, and ischemia.

What is Nociceptive pain Divided into?

somatic and visceral

Somatic pain division

superficial and deep

What does Nociceptive pain respond to?

to opioids and nonopioid medications

Nociception process

transduction, transmission, perception, modulation

Common causes of neuropathic pain

trauma, inflammation, metabolic disease such as diabetes mellitus, infections of the nervous system, tumors, toxins, and neurologic disease such as multiple sclerosis

Classification of pain

underlying pathology (nociceptive and neuropathic) and duration (acute and chronic)

Physical dependence

Normal response to ongoing exposure to pharmacologic agents manifested by withdrawal syndrome when the drug is abruptly decreased

Quality of pain for neuropathic pain

Numbing, hot/burning, shooting, stabbing, or electrical in nature, Sudden, intense, short-lived, or lingering

Examples of neuropathic pain conditions

phantom limb sensation, diabetic neuropathy, and trigeminal neuralgia, shingles, MS, sciatic