Pain: Symptom management and alternative therapiesKAREN FOREN LAKE, PHD, RNC, CNP

MICHIGAN NURSES ASSOCIATION

Pain: Symptom management and alternative therapies

This continuing nursing education activity is worth 2.0 contact hours.

New reapplication requirements from the Michigan State Board of Nursing state

that nurses must have 2.0 credits of continuing education in pain symptom and

management. (This is an increase from the previous requirement of one credit.)

These two credits must be renewed every two years.

Disclosure to ParticipantsSuccessful Completion of this Continuing Nursing Education Activity In order to receive full contact-hour credit for this CNE activity, you must:

Carefully read the entire self study module. Complete the evaluation form and post-test and indicate responses on the answer sheet. Submission instructions and links to

the post test and evaluation are on the last page of this self study. This CE is FREE for MNA members and $20 for non-members. Participants who achieve a minimum passing score of 80% will receive a certificate awarding 2.0 contact hours. Certificates will

be mailed within six weeks of receipt of evaluation and post-test. Participants who do not achieve a passing score will have the option to retake the test at no additional cost.

Conflicts of Interest A conflict of interest occurs when an individual has an opportunity to affect educational content about health-care products or

services of a commercial company with which she/he has a financial relationship. The planners and presenters of this Continuing Nursing Education activity have disclosed no relevant financial relationships

with any commercial companies pertaining to this activity.

Non-Endorsement of Products The Michigan Nurses Association’s accredited-provider/approver status refers only to continuing nursing education activities and does not imply that there is real or implied endorsement by of any product, service, or company referred to in this activity nor of any company subsidizing costs related to the activity.

Michigan Nurses Association is accredited as a provider of continuing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Objectives

Discuss the historical aspects and beliefs about pain and its management.

Describe how these views have changed to our current beliefs.

Define the basic types of pain.

Define the nurse’s role in pain symptom recognition and management.

Discuss the opioid addiction problem.

Discuss several methods of non-pharmacological pain management.

A little history about pain and its management

Pain is the oldest medical problem known to mankind.

Pain management has always been intertwined with religious beliefs:

The earliest known nurses were monks whose mission was to alleviate the suffering of people. Later, most nurses were nuns associated with a religious order.

However, pain was also thought of as a sacred obligation of self-sacrifice and necessary to strengthen faith.

The alleviation of pain (particularly in childbirth) was thought of as a violation of God’s law.

History of pain management

In the 1600s, European physicians began to use opium to alleviate pain.

Later, a mixture of opium and sherry called laudanum was popular.

In the 1800s, physicians recognized the need to relieve pain during and after surgery. The emergence of sedative gases such as ether became widely utilized for pain.

Queen Victoria was the first well-known woman to demand pain medication during childbirth. She was given chloroform for several of her eight deliveries.

How pain occurs – the theory then

Scientists have long studied pain and developed theories about its perception by humans.

In the 1800s they theorized that pain arose primarily from damaged tissue.

They also believed that pain signals are carried to the brain by the spinal cord where they are interpreted.

How pain occurs – the theory now

In the 1960s neuroscientists began studying the dynamics of pain in new ways.

They now believe that the perception of pain arises from information from a variety of sources, including injured tissue.

That perception of pain can be modified by emotional and behavioral information, thus forming the basis for the use of non-pharmacological methods of pain management.

Pain definitions

Pain – an unpleasant sensory and emotional experience.

Acute pain – pain that is brief and responsive to intervention.

Chronic pain – ongoing/recurrent pain that may be unresponsive to some interventions.

Intractable pain – pain in which the cause cannot be removed or treated (such as cancer).

The latest trend in pain management

The bio-psycho-social approach is a comprehensive pain management plan that addresses all aspects of the individual.

The bio part includes treating the underlying pathology or root cause of pain.

The psycho part addresses anxiety, fear and depression that can accompany pain.

The social component includes addressing the patient’s ability to work, function in daily life, and maintain friendships.

What is the nurse’s role in pain management?

Historically, nursing’s primary goal was to alleviate suffering in patients.

Nurses now have a legal, moral and ethical responsibility to assess and manage pain in their patients.

Nurses are usually the healthcare professional most involved in ongoing implementation and evaluation of pain alleviation.

What is the nurse’s role in pain management?, continued

The management of pain for nurses involves:

Communication and collaboration between the patient, their family, and other members of the healthcare team.

Provision of a balanced approach to pain management which addresses the potential for abuse but does not deny the patient the management necessary.

Promoting a level of pain management that incorporates pharmacological and non-pharmacological methods of pain control.

Scope of practice for nurses

The nurse is accountable for the assessment and documentationof pain.

The nurse is responsible for implementing pain management.

The nurse is responsible for the integration of multimodal approaches to pain.

Scope of practice for nurses, continued

The nurse has the authority to adjust medication within the dosage range as specified by the prescriber.

When pain is not controlled, the nurse is responsible for reporting these findings to the prescriber, advocating for an optimal pain management plan and documenting such.

When implementing the above, the nurse must be sensitive to cultural and religious considerations of the patient.

Conducting a pain assessment

Location of pain;

Cause of pain;

Intensity of pain;

Anything that exacerbates the pain;

The patient’s interpretation of the pain and how it impacts daily function and quality of life.

Note: At one point, pain was considered as as assessment tool along with the four other vital signs: body temperature, pulse rate, respiration rate and blood pressure. However, JCAHO and other organizations have recommended against using pain as the “fifth vital sign.”

Nursing assessment of pain (continued)

Should include the use of an appropriate, evidence-based pain assessment scale such as:

Wong-Baker FACES Pain Rating Scale;

0-10 Numeric Pain Rating Scale;

Where is your pain? Human body diagram;

Pain Quality Assessment Scale (PQAS);

Or a combination of the above.

Assessment of pain in special needs individuals

Consider using a specialized assessment scale for group with special needs:

Children;

Those with language barriers;

Older adults with cognitive impairment;

Visually impaired patients.

Re-assessment of pain

Re-assessment of pain should take place in an appropriate amount of time for the treatment used (i.e., if the patient was given an IM injection of a narcotic, pain relief would be expected quickly).

Re-assessment should include whether the pain was relievedand to what extent.

It should also include any other physiological or psychological effects (such as increased blood pressure, or sleeping).

The opioid epidemic

In the past 20 years, opioid abuse and addiction in the U.S. has quadrupled.

Deaths from opioids have also multiplied.

Many addictions began as a effort by the patient to control chronic pain.

Some patients have had a relapse of addiction following a short interval of opioid use.

Pain definitions related to pharmacological treatment

Substance abuse – a pattern of using substances that results in impairment of the ability to fulfill obligations at work, school, or home.

Physical dependence – a physiological adaptation to a substance, characterized by withdrawal symptoms when the substance is stopped. Note: physical dependence alone is not addiction.

Pain definitions related to pharmacological methods

Tolerance – the physiological adaptation to a substance that then requires increasing the dose to achieve the same effect. Note: tolerance alone is not addiction.

Addiction – a combination of behavioral and physiological symptoms in which the individual continues using the substance despite the risk of harm.

The federal plan to address the opioid epidemic

The CDC is recommending that primary care doctors create a safer, more effective course for dealing with chronic pain.

They recommend prescribing painkillers only after non-addictive painkillers and alternative methods have failed.

For short-term pain, the CDC recommends limiting opioids to a three-day course.

The FDA is recommending limiting the refills available on opioid prescriptions.

Prescribers are encouraged to use a Automated Prescription System (MAPS in Michigan) to track prescription usage of patients.

Nursing’s role in managing the opioid epidemic

The Joint Commission has recommended that nurses be responsible for acquiring and maintaining current knowledge, skills, and abilities to practice in accordance with accepted standards of care for pain management.

That knowledge should include the current and federal state laws for the prescription, dispensing, administration and destruction of controlled substances.

It should also include the use of pharmacological and non-pharmacological modalities of pain management.

Nursing’s role in managing the opioid epidemic

Beyond assessment and re-assessment of pain, nurses should explore what options the patient has to relieve pain.

Nurses should be aware of the pharmacological methods and side effects of opioids.

Nurses should be well-informed about non-pharmacological methods of pain management.

Nurses should assess whether the patient can carry out some non-pharmacologic methods (such as yoga or acupuncture).

Nurses should, in consultation with the physician, be able to develop a well-rounded plan of pain management that is tailored to the individual.

Non-pharmacological methods of pain management

Can be used with pharmacological methods if necessary.

Should be customized because they are usually more time-consuming and require placing the patient in a more active role.

Some methods use psychological means, while others are physically based.

Some methods require the skills of an advanced practitioner in that method (such as acupuncture).

Non-pharmacological pain management therapies to be used in the hospital

Beds – often overlooked as a pain control strategy. Nurses can recommend that the physician order an alternate type of mattress.

Bedding – needs to be smooth and unwrinkled. Pillows help stabilize the patient’s position.

Splinting – stabilizing an incision during episodes of coughing.

Positioning – alternating the patient’s position in bed can be helpful. Make sure the body is well-aligned, and that the over-bed table and the call light are well within reach.

Non-pharmacological pain management therapies to be used in the hospital (continued)

Heat – heat application reduces muscle spasms and relaxes smooth muscle. Heat can be applied through the use of moist hot packs, warm blankets or assisting the patient to bathe or shower.

Cold – cold also reduces muscle spasms and edema. It has a longer lasting effect than heat. Cold can be applied through the use of ice packs, ice cubes or cool, moist washcloths.

Massage – massage decreases muscle tension and can increase endorphins. It helps to bring about mental and physical relaxation. Nurses can offer the patient a back or neck rub anytime, as well as incorporating into routine care (such as bedtime).

Psychological pain management methods to teach to patients

Distraction – distraction is helpful in directing the patient’s focus away from the pain. Distraction is often taught in childbirth preparation classes. Types of distractions include listening to music, engaging in conversation or watching television.

Music therapy – this approach teaches the person to perform or listen to music as a distraction from pain. It has been shown to help with many types of pain, including cancer pain.

Psychological pain management methods to teach to patients (continued)

Meditation – works by focusing the mind on a specific word or phrase in order to quiet it. It also includes acceptance (but not dwelling on) of thoughts that enter the mind and “float by.” It can be learned quickly and practiced anywhere, for a few minutes or more.

Guided imagery – as taught by an expert, guided imagery helps to direct one’s thoughts to specific images. It has been shown to help with headaches, osteoarthritis and other conditions.

Combined psychological and physical methods

Controlled breathing – increases oxygenation and the elimination of CO2. This is another technique often taught in childbirth preparation classes, but can be used anywhere. Regular practice of controlled breathing is necessary for full benefit.

Muscle relaxation therapy – another method often used in childbirth, muscle relaxation can be taught to anyone for any type of pain or stress. It involves systematically tensing and then relaxing muscle groups in the body.

Physically-based pain management therapies that may be recommended (upon discharge)

Orthopedic manipulation – the moving of muscles and joints through stretching, pressure and resistance may be recommended by the physician. Although it has been viewed with suspicion in the past, OM is becoming much more accepted and recommended.

Physical therapy – involves the use of specialized movements to strengthen the body and decrease pain. Performed by a professional, who then teaches the patient what to do at home.

Physically-based pain management therapies that may be recommended following discharge (continued)

Yoga – a discipline that combines breath control, meditation and specific body positions, there is good evidence that yoga helps with chronic pain caused by fibromyalgia and arthritis.

Tai Chi – a slow, flowing ancient Chinese practice that take the body though a number of continuous movements.

Exercise – patients should be encouraged to exercise regularly once discharged. Exercise reduces fatigue, builds strength, and improves mobility.

Non-pharmacological pain management therapies that may be recommended

Talk Therapy – chronic pain and depression often co-exist, and depression can lower a patient’s pain threshold. Therapy can be particularly helpful, especially cognitive behavioral therapy.

Hypnosis – has often been looked at with skepticism, but studies have shown that it can have a positive effect on reducing many types of pain.

Acupuncture – another method that is becoming more accepted. Studies have shown that it can decrease pain caused by fibromyalgia, back and sports injuries, and arthritis.

Nutritional pain management therapies that may be recommended

Although often met with skepticism, supplements and vitamins have been found to help with certain types of pain:

Fish oil – may reduce pain associated with swelling.

Capsaicin – which is derived from chili peppers may help with arthritis and diabetic nerve pain.

Glucosamine – has been long touted to help relieve joint pain.

A word of warning – some supplements are not safe. Gingko biloba and ginseng have been found to thin the blood and increase bleeding.

Large doses of vitamin B6 can cause nerve damage.

Lifestyle changes for pain management

As with all illnesses and disorders, a healthy lifestyle should be recommended.

This includes weight management, nutritious foods, and exercise.

Smoking and the use of street drugs and alcohol should be discouraged.

A regular sleep routine and schedule should be encouraged.

It should be reinforced that patients are responsible for their health, and they should see a doctor regularly.

Medical marijuana

Medical marijuana has been a controversial topic recently. However, there is evidence that marijuana can help with certain types of discomfort. It may help with nerve pain and can relieve nausea associated with chemotherapy. It can also relax the patient and help with sleep.

The use of medical marijuana is legal in Michigan, provided it is prescribed by a physician for any one of a variety of conditions:

The patient may possess no more than 2 ½ oz. of marijuana at a time.

The patient may home-cultivate marijuana with no more than 12 plants.

The patient must possess a legitimate card for medical marijuana use.

Other nursing considerations for dealing with pain management

Active listening – conveys support and trust in the patient. It allows the patient to discuss any matter with the nurse, thereby reducing stress.

Believing the patient – patients reaction to pain differs greatly. Believing the presence and level of pain in the patient is important to build a rapport.

Consideration of culture – cultures vary in how their members perceive and react to pain. Some cultures encourage vocalization that may seem excessive to others. Other cultures encourage quiet and tolerance of pain.The nurse needs to be sensitive to how the patient’s culture may affect their pain expression.

References

CDC (2016). CDC urges doctors to curb prescribing painkillers. Accessed 3/16/2106 from http:www.foxnews.com/health

Baker, D. (2017). History of Joint Commission’s pain standards. JAMA; 2/23/16

Hansen, G., & Streltzer, J. (2005). The psychology of pain. Emergency Medicine Clinics of North America; 23: 339-348

Keller, A. (2016). What every nurse needs to know about pain management. Accessed 3/16/2017 from http://dailynurse.com

Khazoom, L. (2009). Drug-free remedies for chronic pain. AARP: The Magazine; Jan. & Feb

References (continued)

Mahoney, D. (2016). Nurses’ role in improving the pain management culture. Industry Edge; 8: 1-2

Meldrum, M. (2003). Medical biology: History of pain management. JAMA; 290: 2470

National Initiative on pain control. Pain assessment scales. Accessed 3/16/2017 from http://www.nipic/pain.assessment.

Oregon State Board of Nursing (2015). The nurse’s role in pain management. Interpretive Statement;1-6

Wood, S. (2008). Assessment of pain. Nursing Times; 9.1-9

Post-test information

This CE is FREE for MNA members and $20 for non-members.

POST-TEST DIRECTIONS Complete the evaluation and post-test response form and make your payment online by clicking HERE. OR Download and complete the evaluation and post-test response PDF FORM and send to:

By mail: Michigan Nurses Association, 2310 Jolly Oak Road, Okemos, MI 48864 By fax: 517-349-5818

AWARDING OF CE

Participants who achieve a minimum passing score of 80% will receive a certificate awarding 2.0 contact hours. Certificates will be mailed within six weeks of receipt of evaluation and post-test. Participants who do not achieve a passing score will have the option to retake the test at no additional cost.

Michigan Nurses Association is accredited as a provider of continuing education by the American Nurses Credentialing Center’s Commission on Accreditation