Assessment and Multimodal Management of Pain
AN INTEGRATIVE APPROACH
We would like to dedicate this work to all people who experience pain and the clinicians who care for them; and to all who have contributed to the field of pain management through their passion and tireless efforts in research, education, leadership, and advocacy.
Meera K. Shah, PharmD, AAHIVP
Clinical Pharmacist
Hepatology and Infectious Disease
University of Kansas Health Systems
Kansas City, Kansas
Tara C. Shaw, RN, MSN
Assistant Professor
Nursing
Goldfarb School of Nursing at Barnes Jewish College St. Louis, Missouri
Paula Denise Silver, BS Biology, PharmD
Medical Instructor
Medical Assisting/LPN/RN
ECPI University: School of Health Science Newport News, Virginia
Linda Wilson, PhD, RN, CPAN, CAPA, BC, CNE, CHSE, CHSE-A, ANEF, FAAN
Assistant Dean for Special Projects, Simulation and CNE
Accreditation
College of Nursing and Health Professions
Drexel University Philadelphia, Pennsylvania
Robin Ye
Registered Pharmacist–State of Illinois Doctor of Pharmacy (PharmD)
Board Certified Pharmacotherapy Specialist (BCPS); Basic Life Support (BLS)
Clinical Pharmacist
Inpatient Pharmacy
NorthShore University HealthSystem–Glenbrook Hospital Glenview, Illinois
Adjunct Associate Professor of Pharmacy Practice & Pain Management
Albany College of Pharmacy & Health Sciences Albany, New York
Carla R. Jungquist, PhD, ANP-BC, FAAN Assistant Professor School of Nursing University at Buffalo Buffalo, New York
Courtney Kominek, PharmD Clinical Pharmacy Specialist-Pain Management Pharmacy
Harry S. Truman Memorial Veterans’ Hospital Columbia, Missouri
Susan O’Conner-Von, PhD, RN-BC, CHPPN, CNE
Associate Professor School of Nursing University of Minnesota Minneapolis, Minnesota Director of Graduate Studies Center for Spirituality and Healing University of Minnesota Minneapolis, Minnesota
Shalvi B. Parikh, MBBS Former Research Assistant Department of Anesthesia Division of Pain Medicine Westchester Medical Center Valhalla, New York
Christine Peltier, DNP, RN-BC, FNP-BC Nurse Practitioner M-Health, Fairview Minneapolis, Minnesota
Thien C. Pham, AS, BS, PharmD Clinical Pharmacy Specialist-Pain Management Pharmacy
VA Long Beach Healthcare System Long Beach, California
Eva Pittman, MSN, RN-BC LEAN Strategies Coach LEAN Strategies Department
New Hanover Regional Medical Center Wilmington, North Carolina
Mena Raouf, PharmD, BCPS
Clinical Pharmacy Programs Coordinator–Pain
Management
Kaiser Permanente Federal Way, Washington
Nitin K. Sekhri, MD Medical Director of Pain Management
Anesthesiology
Westchester Medical Center
Valhalla, New York
Assistant Professor
Anesthesiology
New York Medical College
Valhalla, New York
Erica L. Wegrzyn, BS, PharmD Clinical Pharmacy Specialist, Pain Management
Stratton VA Medical Center
Albany, New York
Adjunct Faculty
Western New England University College of Pharmacy
Springfield, Massachusetts
Albany College of Pharmacy & Health Sciences Albany, New York
Elsa Wuhrman, DNP, FNP,BC
Nurse Practitioner and Assistant Professor of Nursing at CUIMC
Pain Management/Anesthesiology
Columbia University Irving Medical Center
New York, New York
Clinical Scenario Contributors
Cindy Kerwick
Denise Kuhn
Brian Quinlan
7 Pain Assessment of Patients Who Cannot Self-Report Pain, 120
Debra Drew and Ann Quinlan-Colwell
Pain Assessment of Patients Who Cannot Self-Report Pain, 120
Pain Assessment in Critically Ill Adults Who Cannot Self-Report Pain, 124
Patients With Delirium Who Cannot Self-Report Pain, 125
Patients With Dementia Who Cannot Self-Report Pain, 125
The Checklist of Nonverbal Pain Indicators (CNPI), 129
Patients With Intellectual Disabilities Who Cannot Self-Report Pain, 129
Patients at the End of Life Who Cannot Self-Report Pain, 131
Newer Trends in Pain Assessment for Patients Who Cannot Self-Report Pain, 131 Cautions, 132
Key Points, 132
Case Scenario, 132 References, 133
8 Assessment of Factors Affecting Pain and Affected by Pain, 136
Ann Quinlan-Colwell
Sleep, 136
Anxiety and Depression, 146
Family Assessment, 158
Financial Assessment, 158
Key Points, 158
Case Scenario, 159 References, 159
9 Basic Concepts Involved with Administration of Analgesic Medications, 163
Maureen F. Cooney and Ann Quinlan-Colwell
Patient Considerations, 163
Route Selection, 167
Analgesic Dosing Considerations, 181
Key Points, 190
Case Scenario, 191 References, 191
10 Nonopioid Analgesic Medications, 195
Meredith W. Crumb, Timothy J. Atkinson, and Maureen F. Cooney
Aspirin and Nonsteroidal Antiinflammatory Drugs, 195
Multimodal Use of Nonopioid Analgesics, 214
Key Points, 215
Case Scenario, 215 References, 216
11 Opioid Analgesics, 222
Maureen F. Cooney, Mena Raouf, Jeffrey J. Bettinger, Erica L. Wegrzyn, and Jeffrey Fudin
Section 1, 223
Opioid Pharmacology, 223
Opioid Receptors, 224
Factors Affecting Drug Response, 226
Opioid Classes, 232
Key Points, 236
Section 2, 236
Opioid Selection, 236
Key Points, 269
Section 3, 269
Opioid Dosing Practices, 269
Tapering and Discontinuing Opioid Therapy, 287
Key Points, 289
Case Scenario, 289 References, 291
12 Common Unintended Effects of Opioids, 303
Ann Quinlan-Colwell and Maureen F. Cooney
Constipation, 306
Xerostomia (Dry Mouth), 311
Opioid-Induced Nausea and Vomiting, 312 Pruritus, 314
Urinary Retention, 319
Hypogonadism, 321
Sedation, 323
Myoclonus, 325
Opioid-Induced Hyperalgesia, 326
Physical Dependence on Opioids, 327
Opioid Tolerance, 328
Immune Suppressing Effect of Opioids, 328
Key Points, 329
Case Scenario, 329
References, 329
13 Preventing Opioid-Induced Advancing Sedation and Respiratory Depression, 337
Carla R. Jungquist and Ann Quinlan-Colwell
Opioids and Respiratory Function, 338
Advancing Sedation and Opioid-Induced Respiratory Depression, 338
Identification of the Risk Factors, 339
Associated Pharmacologic Factors, 342
Strategizing to Improve Safety for Patients at Risk, 347
Assessing the Patient for Risk, 347
Procedures for Intermittent Nursing Assessment for All Patients on Opioids: Level of Sedation, 348
Procedures for Intermittent Nursing Assessment for All Patients on Opioids: Respiratory Status, 351 Interventions After Assessment, 353 Summary, 353
Key Points, 353
Case Scenario, 354
Acknowledgments, 354
References, 354
14 Opioid Use Disorder, 360
Ann Quinlan-Colwell and Maureen F. Cooney
Substance Use Disorder and Opioid Use Disorder, 361
Caring for Patients With Pain and Opioid Use Disorder, 363
Treatment of Opioid Use Disorder, 365
Pain and Opioid Use Disorder: Acute Care Setting, 369
Strategies to Reduce Risk, 376
Key Points, 377
Case Scenario, 379
References, 379
15 Coanalgesic Medications, 384
Courtney Kominek and Maureen F. Cooney
Medication Selection, 386
Gabapentinoids, 389
Antidepressants, 394
Alpha-Adrenergic Receptor Agonists, 398
Corticosteroids, 401
N-Methyl-d-Aspartate Receptor Antagonists, 403
Sodium Channel Blockers: Lidocaine and Mexiletine, 409
Muscle Relaxants, 412
Dronabinol, Nabilone, and Cannabidiol, 416
Other Coanalgesic Medications, 418
Key Points, 418
Case Scenario, 419
References, 419
16 Topical Analgesics for the Management of Acute and Chronic Pain, 429
Elsa Wuhrman, Maureen F. Cooney, and Thien C. Pham
Benefits of Topical Analgesics, 429
Types of Topical Analgesics, 431
Compound Analgesics, 441
Key Points, 443
Case Scenario, 443 References, 444
17 Patient-Controlled Analgesia, 447
Ann Quinlan-Colwell
General Concepts, 447
Optimize Safety Within the Patient-Controlled Analgesia Process, 449
Prescription Components, 455
Routes of Administration, 458
Patient Assessment and Monitoring to Optimize Safety, 462
Evaluating Equipment to Optimize Patient Safety, 464
Authorized Agent–Controlled Analgesia, 465
Key Points, 468
Case Scenario, 468 References, 468
18 Regional Analgesia, Local Infiltration, and Pain Management, 474
Maureen F. Cooney, Christine Peltier, and Ann Quinlan-Colwell
Neuraxial Analgesia, 475
Regional Analgesia, 510
Regional Analgesia Infusion Systems, 518
Local Infiltration Analgesia, 520
Additional Analgesic Procedures Involving Use of Local Anesthetics, 524
Key Points, 525
Case Scenario, 526
References, 526
19 Interventional Approaches, 533
Nitin K. Sekhri, Emily Davis, Ann Quinlan-Colwell, and Maureen F. Cooney
Anatomy of the Central Nervous System, 533
Spinal Pain, 533
Diagnostic Imaging, 537
Spinal Injections, 538
Implantable Therapies, 543
Key Points, 554
Case Scenario, 554
Acknowledgement, 555
References, 555
20 Exercise and Movement, 560
Ann Quinlan-Colwell
Fear of Pain With Movement, 561
Exercise-Induced Hypoalgesia, 564
Movement, 564
Dance Movement Therapy, 565
Exercise, 566
Tai Chi, 569
Yoga, 570
Physical Therapy, 571
Patient Education for All Exercise and Movement, 576
Key Points, 576
Case Scenario, 576
References, 578
21 Distraction and Relaxation, 586
Michele Erich, Ann Quinlan-Colwell, and Susan O’Conner-Von
Distraction, 586
Relaxation, 591
Progressive Muscle Relaxation, 594
Music Therapy, 596
Animal-Assisted Therapy, 600
Guided Imagery, 603
Autogenic Training, 604
Key Points, 605
Case Scenario, 605
References, 606
22 Cognitive-Behavioral and Psychotherapeutic Interventions as Components of Multimodal Analgesic Pain Management, 613
Geralyn Datz and Ann Quinlan-Colwell
Integrative, Interdisciplinary, and Multimodal Pain Treatment, 613
Interdisciplinary Pain Rehabilitation or Functional Restoration Programs, 615
Cognitive-Behavioral Therapy, 617
Evidence Supporting Cognitive-Behavioral Therapy for Pain Management, 622
The Activating Event Belief Consequence Model, 624
Acceptance and Commitment Therapy, 625
Biofeedback (Applied Psychophysiology), 626
Mindfulness-Based Stress Management and Mindfulness-Based Cognitive Therapy, 627
Psychoeducation, 630
Key Points, 631
Case Scenario, 631
References, 631
23 Energy Healing Therapies or Biofield Therapies as Components of Multimodal Analgesic Pain Management, 636
Ann Quinlan-Colwell and Susan O’Conner-Von
Reiki, 637
Therapeutic Touch, 638
Healing Touch, 642
Acupuncture, 642
Auricular Acupuncture, 644
Acupressure, 647
Key Points, 648
Case Scenario, 648
References, 648
24 Manual Therapies for Pain Management, 652
Ann Quinlan-Colwell
Manual Therapy, 652
Osteopathy, Osteopathy Manual Medicine, or
Osteopathic Manipulative Therapy, 653
Craniosacral Therapy, 654
Massage Therapy, 655
Reflexology, 659
Chiropractic Practice, 664
Myofascial Trigger Point Therapy, 666
Muscle Energy Technique, 667
Fascial Distortion Model, 667
Key Points, 668
Case Scenario, 668
Acknowledgments, 668
References, 668
25 Spirituality as a Component of Multimodal Pain Management, 673
Susan O’Conner-Von and Ann Quinlan-Colwell
Spirituality, 673
Prayer, 674
Meditation, 675
General Cautions and Precautions Regarding Meditation, 682
Key Points, 683
Case Scenario, 683
References, 684
26 Natural Products: Supplements, Botanicals,
Vitamins, and Minerals as a Component of Multimodal Pain Management, 687
Ann Quinlan-Colwell
Dietary Supplements, 688
Botanicals and Herbs, 688
Pharmaconutrients: Nutritional Modulators of Pain, 702
Supplements, 707
Vitamins, 716
Key Points, 723
Case Scenario, 723
References, 723
27 Additional Nonpharmacologic Interventions as Components of Multimodal Pain Management, 738
Ann Quinlan-Colwell
Aromatherapy, 739
Caring, Empathy, and Compassion by Caregivers, 742
Crossing Hands and/or Arms Over the Midline, 743
Dietary Choices, 745
Environmental Modifications, 747
Hypnosis, 749
Mirror Therapy or Mirror Visual Feedback Therapy, 751
Obesity and Weight Management, 754
Static Magnet Therapy, 756
Temperature Modalities, 756
Alternating or Contrasting Temperature Therapy, 759
Valsalva Maneuver, 760
Key Points, 761
Case Scenario, 761
References, 762
28 Improving Institutional Commitment for Effective Multimodal Pain Management, 770
Ann Quinlan-Colwell, Sue Ballato, Greg Scott Firestone, and Eva Pittman
Organizational Commitment to Quality and Pain Management, 770
Organizational Initiatives to Support Quality of Safe and Effective Multimodal Pain Management, 772
Quality Improvement, 781
Clinical Nursing Efforts to Support Organizational Initiatives, 787
Education of Clinicians, 789
Future Opportunities for Improvement, 790
Key Points, 790
Case Scenario, 792 References, 792
Appendix: Terminology, 797
Index, 830
Assessment and Multimodal Management of Pain
AN INTEGRATIVE APPROACH
In this introductory chapter, an overview is presented, including brief description of the evolution of pain being understood as a complex multidimensional experience, the importance of assessing pain, and why an integrative approach of managing pain with multimodal analgesia is the safest and most effective way to support people to best control pain.
Incidence and Prevalence of Pain
Pain is primarily a universal experience occurring among humans and other animals. Even rodents with somatosensory cortex lesions who experienced asomaesthesia, or the inability to recognize physical sensations, experienced pain at least through the inflammatory process even when they were not able to process the sensations somatosensorily (Uhelski, Davis, & Fuchs, 2012). The small number of people who are diagnosed with a true painlessness disorder either have a Mendelian genetic trait or an abnormal development of pain receptor neurons (Nahorski, Chen, & Woods, 2015a; Nahorski, et al., 2015b). Although acute pain is a protective response to trauma or inflammation, when unrelieved it is harmful and can evolve into chronic pain (Chapman & Vierck, 2017).
In 1982, Khatami & Rush wrote: “Chronic pain is a perplexing problem that costs billions of dollars annually in the United States alone. It affects family relations, job performance, emotional well-being, and even the doctor-patient relationship” (Khatami & Rush, 1982, p. 45). Unfortunately, these words are surprisingly still accurate as a description of chronic pain 35 years later. For many reasons, despite the universality of the pain experience, it is not
possible to obtain accurate data on the incidence and prevalence of pain. The challenges of collecting such data include the subjective nature of pain, numerous definitions of pain, methodologic issues, and infrequent research involving epidemiologic studies of pain (Henschke, Kamper, & Maher, 2015). This is complicated by different people not only experiencing pain differently but also understanding it and describing it differently. The same challenges exist for collecting data regarding acute pain. However, this is complicated by acute pain having a more elusive nature, which results in most acute pain data being reported only for postoperative and trauma pain (Rzewuska, Ferreira, McLachlan, Machado, & Maher, 2015).
In a 2015 National Institutes of Health (NIH) report, it was estimated that 126 million adults in the United States experienced pain at some point during the previous 3 months, with 25.3 million (11.2%) reporting chronic daily pain (Nahin, 2015). In addition, in 2015, chronic pain was again described as causing clinical, social, and financial challenges, with an estimated cost of more than $34 billion annually in Australia and between $560 and $635 billion annually in the United States (Henschke et al., 2015). These figures do not include the loss of productivity incurred by people living with pain (Dale & Stacey, 2016). The following year, it was estimated that approximately half of people in Europe experienced at least one episode of pain, with a 19% prevalence of chronic pain (Macfarlane, 2016).
The situation regarding acute pain is similar, with more than 80% of people reporting pain after surgery and approximately 75% reporting moderate, severe, or extreme pain (Chou et al., 2016). Approximately half of all patients report inadequately controlled postoperative pain (Polomano, Dunwoody, Krenzischek, & Rathmell, 2008). Despite many publications about acute pain after surgery, rigorous research is needed to ascertain the prevalence and evidence to support guidelines and recommendations for safe and effective multimodal management (Gordon, et al., 2016).
There is increasing awareness that unrelieved acute pain results in chronic pain (Choinière, et al., 2014). This is estimated to be as prevalent as 30% after some surgical procedures (e.g., herniorrhaphy, thoracotomy, limb amputation, mastectomy) (Lovich-Sapola, Smith, & Brandt, 2015). Additional research is needed to better understand the extent to which acute pain is experienced and to more fully understand the evolution of acute pain to chronic pain and how to prevent that from occurring after both surgical and trauma pain situations (Bendayan, RamírezMaestre, Ferrer, López, & Esteve, 2017; Chapman & Vierck, 2017; Lovich-Sapola et al., 2015; Shipton, 2014).
Historical Perspective of Multimodal Pain Management
The work of anesthesiologist John Bonica, who is considered the father of modern pain management, was instrumental in the development and advancement of multidisciplinary
Fig. 1.1 | Drawing by Louis La Forge based on Descartes’ description of Treatise of Man (1664). (Out of copyright.)
pain management (Tompkins, Hobelmann, & Compton, 2017). Bonica, while working with injured soldiers in World War II, recognized that despite the use of regional anesthetic techniques, many of the soldiers did not have adequate pain relief and developed chronic pain (Tompkins et al., 2017). He reached out to colleagues in the fields of psychiatry, neurology, and orthopedics and noted that when his patients were seen by consultants from those specialties, pain and functional outcomes improved. In the 1950’s based upon his experiences, Bonica developed the first multidisciplinary pain clinic, which was opened in Tacoma, Washington, and relocated to the University of Washington in Seattle in the 1960s (Loeser, 2017). The treatment included multidisciplinary and integrative interventions such as physical therapy, occupational therapy, and a variety of psychologic and cognitive approaches (Gatchel, McGeary, McGeary, & Lippe, 2014; Parris, & Johnson, 2014) (see Chapters 20, 21, 22). Pharmacologic approaches were also provided, but contrary to usual practice, scheduled medication administration, rather than as-needed (prn) dosing, was employed (Tompkins et al., 2017). The patients in the multidisciplinary clinic had significant improvements in outcomes, including return to employment. Studies of patient outcomes in the multidisciplinary clinic compared to single discipline treatment, usual medical care, or no treatment, showed improved outcomes were an effect of the coordinated biopsychosocial approach to care provided in the multidisciplinary setting (Tompkins et al., 2017). As study results were disseminated, multidisciplinary programs were developed throughout the country and many of Bonica’s integrative approaches to pain management were adopted (Tompkins et al., 2017).
Multidisciplinary pain clinics continued into the 1990s. Although this type of clinic still exists, the following factors contributed to the decline in the use of this approach in the United States (Tompkins et al., 2017)
• Changes in insurance reimbursement practices from bundled services to a fee-for-service model resulted in financial losses in multidisciplinary clinics.
• The introduction of managed care changed payment structures and carved out, or stopped, reimbursement for services such as physical therapy if the service was provided in the multidisciplinary clinic.
• Academic medical centers, which often provided multidisciplinary pain clinics, closed the clinics because of financial losses associated with managed care.
• The growth of anesthesia-based pain fellowship training programs increased the focus on procedurebased care rather than multidisciplinary care.
Growth in Pain Research
Bonica was a major contributor to the development of pain research and progress in the field of pain management in the latter half of the 20th century (Loeser, 2017). He published numerous studies that demonstrated the
extent, severity, and impact of pain on a worldwide level. Bonica’s work was instrumental in the formation of the American Pain Society (APS) and the IASP. His efforts encouraged a new focus on the study of pain, and over the years new pain theories were published, scientific inquiry into the field of pain expanded, and significant growth in the understanding of pain processes and pathways occurred. The identification of peripheral and central pain pathways led to great interest in pharmaceutical research and the development of different classes of analgesic agents such as the nonsteroidal antiinflammatory medications (Tompkins et al., 2017).
Early National Efforts to Address Pain
As scientific efforts to improve understanding and treatment of pain evolved, there was growth in awareness of continued undertreatment of pain as a health care problem. This awareness led to an initiative by the NIH to form a consensus development conference to address the issues and challenges associated with the need for an integration of approaches to pain management (NIH, 1986). Expert health professionals, including biomedical researchers, physicians, dentists, psychologists, nurses, and others, along with representatives of the general public, were brought together on May 19 to 21, 1986 to address the following questions (NIH, 1986):
• In what way should pain be assessed?
• In what ways should medications be used in an integrated pain management approach?
• How should nonpharmacologic approaches be used in an integrated pain management approach?
• What role does the nurse have in an integrated pain management approach?
• What are the future directions for pain management research?
As an outcome of the conference, participants reached consensus in response to these questions (NIH, 1986). It was agreed that pain is an important and complex phenomenon, and accurate pain assessment facilitates classification of pain and establishment of treatment objectives. It was also recognized that the management of pain is challenging, because although pain may be well assessed, many variables and barriers, including personal attitudes and lack of knowledge of health care providers, may interfere with adequate treatment. The pivotal role of the nurse in the assessment and management of pain was recognized. Agreement was reached that the nursing role in pain management was expected to increase with an integrated approach involving the multidisciplinary health care team is necessary.
The importance of both pharmacologic and nonpharmacologic therapies in treating different types of pain was identified, and it became evident that no single modality is appropriate for the treatment of most people in pain. The experts concluded the treatment of pain and the assessment
