ElsevierElsevier: Saunders, Mosby, Churchill Livingstone, Butterworth-Heinemann
Pain Clinical Manual


PAIN CLINICAL MANUAL 2ND EDITION

Margo McCaffery RN MS FAAN; Chris Pasero RN MSNc


TABLE OF CONTENTS


  • PAIN MANAGEMENT: Problems and Progress 1 Continuing Undertreatment of Pain 2
    Continuing Barriers to Pain Management 3

    The system: Lack of accountability 3
    Health care professionals 4
    The patient and family 10
    Signs of Progress 10
    Increase in pain facilities 10
    Creation of acute pain services 11
    Growth of professional organizations that focus on pain 11
    Growth of state cancer pain initiatives 11
    Certification for pain specialists 11
    Recognition of the rights of people with pain 13

  • BASIC MECHANISMS UNDERLYING THE CAUSES AND EFFECTS OF PAIN 15 Definitions of Pain 16
    Types of Pain 17

    Treatment approaches, 18
    Anatomy and Physiology of Pain 18
    Nociceptive pain 18
    Neuropathic pain 23
    Harmful Effects of Unrelieved Pain: Impact of Aggressive Pain Management 23
    Endocrine and metabolic system 23
    Cardiovascular system 25
    Respiratory system 26
    Genitourinary system 27
    Gastrointestinal system 27
    Musculoskeletal system 28
    Cognitive function 28
    Immune system 29
    Developmental effects 30
    Future pain 30
    Quality of life 31


  • ASSESSMENT: Underlying Complexities, Misconceptions, and Practical Tools 35 Underlying Complexities of Pain Assessment 36
    Failure to assess pain 36
    Failure to accept patient's report of pain 38
    Failure to act on the patient's report of pain 39
    Focus of the chapter 39
    Misconceptions That Hamper Assessment and Treatment of Patients Who Report Pain 39
    Authority about pain: Patient versus caregivers/family 39
    Pain threshold: Uniform versus variable 42
    Pain tolerance: High versus low 42
    Behavioral and physiologic responses to pain: Acute pain model versus adaptation 43
    Patients' knowledge of clinician's expectations of pain behaviors 44
    Cause of pain: Known versus unknown cause 46
    Addiction: Seeking drugs versus seeking pain relief 50
    Definitions and likelihood of occurrence 50
    Pain relief from placebos 54
    Implications for clinical practice 56
    Assessment Tools 58
    Tools for initial pain assessment, 58
    Pain rating scales, 62
    Neuropathic pain scale, 75
    Assessment of breakthrough pain 75
    Flow sheets 78
    Communication strategies, 84
    Challenges in Pain Assessment 89
    Patients who deny pain or refuse pain relief 89
    Patients with impaired communication 92
    Cultural considerations 98
    Conclusion 99

  • OVERVIEW OF THREE GROUPS OF ANALGESICS 103 Pain Mechanisms Affected by Each Analgesic Group 108
    Clinical Considerations for Use of Each of the Three Analgesic Groups 108

    Nonopioids: Acetaminophen and NSAIDs, 108
    Opioids 110
    Adjuvant analgesics 112
    What is not analgesic? 113
    Comparison of Characteristics of the Three Analgesic Groups 113
    Combining Analgesics 115

    Rationale 115
    WHO analgesic ladder for cancer pain relief 115
    Multimodal, continuous analgesia: Balanced analgesia 119
    Key Principles of Analgesic Therapy 121
    Individualizing the regimen 121
    Optimize administration 122
    Guidelines for Implementing Pharmacologic Pain
    Management 123
    Assessment of analgesic history 123
    Patient/family teaching 123
    Nurse's role 125

  • NONOPIOIDS: Acetaminophen and Nonsteroidal Antiinflammatory Drugs (NSAIDs) 129 Mechanisms Underlying Analgesia of Acetaminophen and NSAIDs 130
    Acetaminophen 130
    NSAIDs 130
    Principles of Administration of Nonopioid Analgesics 130
    Indications for administration of
    acetaminophen or NSAIDs 131
    Side effects of acetaminophen and NSAIDs 134
    Individualizing the selection of nonopioid
    analgesics 138
    Choice of starting dose and dose titration 141
    Special circumstances 142
    Perioperative NSAID use 144
    Nonprescription Nonopioids 148
    Buffered aspirin 149
    Caffeine 149
    Antihistamines 150
    Overdose 150
    Acetaminophen 151
    Aspirin and other salicylates 152
    Other NSAIDs 152
    Patient/Family Teaching Tools 152

  • OPIOID ANALGESICS 161 Basic Physiology and Pharmacology
    of Opioid Analgesics 165

    Groups of opioids 165
    Underlying mechanisms of opioid analgesia and side effects 165
    Pharmacologic concepts, 166
    Key Concepts in Analgesic Therapy 174
    Balanced analgesia 174
    Around the clock (ATC) dosing 175
    PRN dosing 175
    Patient-controlled Analgesia 175
    Guidelines for Opioid Analgesic Administration 177
    Opioid drug selection 178
    Routes of administration 194
    Selecting an analgesic and route of administration 239
    Selecting a starting opioid dose 240
    Dose titration 246
    Patient-controlled analgesia (PCA) 248
    Switching to another opioid analgesic 253
    Switching from epidural to IV opioid analgesia 257
    Switching from IV to oral opioid analgesia 258
    Switching from one opioid and route to another opioid and route 259
    Switching from multiple opioids and routes to one opioid and route 259
    Initiating epidural analgesia in opioid-tolerant patients 260
    Managing side effects 261
    Tapering and cessation of therapy 270
    Unwarranted Withholding of Opioids 271
    Long-term opioid treatment for chronic nonmalignant pain 271
    Opioids during weaning from mechanical ventilation, 271
    Managing pain in the terminally ill 272
    Documenting Pain Management 272
    Patient and Family Teaching 272

  • ADJUVANT ANALGESICS 300 General Considerations 303
    Drug selection, 304
    Dosing, 304
    Variability in response, 304
    Polypharmacy 304
    Positioning of treatment 304
    Multipurpose Adjuvant Analgesics for Chronic Pain 306
    Antidepressant drugs 306
    Corticosteroids 311
    Alpha2-adrenergic agonists 313
    Other drugs with nonspecific analgesic effects 314
    Adjuvant Analgesics for Chronic Continuous Neuropathic Pain 317
    Antidepressants 317
    Oral and parenteral (systemic) local anesthetics 317
    Adjuvant Analgesics for Chronic Lancinating ("Shooting") Neuropathic Pain 320
    Anticonvulsant drugs 321
    Baclofen (GABA agonist) 324 Adjuvant Analgesics for Chronic Bone Pain 324
    Calcitonin 325
    Bisphosphonates 325
    Radiopharmaceuticals 326
    Other drugs for bone pain 326
    Adjuvant Analgesics for Malignant Bowel Obstruction 326
    Anticholinergic drugs 327
    Octreotide 327
    Corticosteroids 327
    Adjuvant Analgesics for Chronic Musculoskeletal Pain 327
    Muscle relaxants 328
    Benzodiazepines 328
    Adjuvant Analgesics for Refractory Cases of Neuropathic Pain 328
    N-Methyl-D-Aspartate (NMDA) receptor blockers: Dextromethorphan and ketamine 328
    Calcitonin 330
    Other drugs for sympathetically maintained pain 330
    Topical analgesics 331
    Adjuvant Analgesics of Limited Usefulness 332
    Neuroleptics 332
    Antihistamines 334
    Cannabinoids 334
    Alcohol (ethanol) 334
    Benzodiazepines 335
    Role of Adjuvant Analgesics in Acute Pain and Crescendo Pain 335
    Clonidine 336
    Ketamine 336
    Parenteral lidocaine 338
    Adenosine 339
    IV phenytoin 339
    Dextroamphetamine 339
    Corticosteroids 339
    Use of Adjuvant Analgesics in Children 340
    Conclusions 340
    Patient Information 340

  • PROCEDURAL PAIN MANAGEMENT 362 Barriers to Effective Procedural Pain Management 363
    Determining the Need for Procedural Pain Management 363
    Goals of Procedural Pain Management 365
    Informed Consent and Patient Teaching 365
    Procedural information 366
    Temporal information 366
    Sensory information 366
    Assessment of Procedural Pain 366
    Pharmacologic Approaches to Procedural Pain 367
    Local anesthetics 367
    Opioid analgesics 378
    Nonsteroidal antiinflammatory drugs (NSAIDs) 380
    Benzodiazepines 381
    Barbiturates 381
    Chloral hydrate 386
    General anesthetics used for analgesia and sedation 386
    Nondrug Approaches to Procedural Pain 389
    Cognitive-behavioral methods 389
    Cutaneous stimulation 390
    Comments on Selected Procedures 390
    Reducing back pain after angiography 391
    Reducing the discomfort of IM injections 391
    Atraumatic suturing of lacerations 395

  • PRACTICAL NONDRUG APPROACHES TO PAIN 399 Role of Nondrug Pain Treatments 400
    Rationale for use: Benefits and limitations 400
    Avoid abuse of nondrug pain treatments 402
    Considerations in selecting and using nondrug pain treatments 403
    Cutaneous Stimulation 405
    Superficial heating and cooling 406
    Vibration 411
    Distraction 412
    Indications for distraction 413
    Characteristics of effective distraction strategies 414
    Specific structured distraction strategies 414
    Relaxation 417
    Research evidence of relaxation as a method of pain management 418
    Indications for use of relaxation 418
    Characteristics of effective relaxation techniques 419
    Specific relaxation techniques: Active patient involvement 419
    Specific relaxation techniques: The patient as passive recipient 420
    Nondrug Approaches to Pain Management for Children 421
    Integrating Nondrug Pain Treatment Into Clinical Practice 421

  • SUBSTANCE ABUSE 428 Addiction 430
    Models of addiction 431
    Drugs of abuse 432
    What is addiction? 433
    Phenomenology of addiction 436
    Treatments for Addiction 440
    Characteristics of drug treatment 440
    Models of treatment 441
    Commonalties across treatment models 446
    Making drug treatment referrals 446
    Relieving Pain in the Context of Addiction 450
    Sources of overlap between pain and addiction 452
    Clinical management of patients with pain and addiction 453
    Challenges Faced 462

  • CHRONIC NONMALIGNANT PAIN 467 Misconceptions 471
    Scope of the Problem 471

    Definition of chronic nonmalignant pain 471
    Conditions, prevalence, and cost of chronic
    nonmalignant pain 471
    Treatment challenges 472
    Purpose and Limitations of Chapter 473
    Clinical Settings Providing Care 473
    Acute care settings and emergency departments 473
    Psychiatric settings 475
    Dual diagnostic and addiction treatment centers 477
    Assessment of Chronic Nonmalignant Pain 477
    Elements of the assessment 477
    Assessment of suicidal risk 487
    Rehabilitative Treatment Goals 487
    Communicating and coordinating treatment 488
    Setting realistic patient goals 490
    Patient Care Guidelines for General
    Clinical Practice 490

    Respect for the individual 491
    Avoiding mislabeling appropriate opioid use 492
    No placebos for treatment 492
    Reevaluating at each admission 492
    Acute versus chronic pain treatment 493
    Education as a therapeutic tool 494
    Medication management 494
    Psychosocial considerations 499
    Physical rehabilitation 503
    Long-term planning and measuring outcomes 505
    Advanced Pain Management Techniques 505
    Referral to a Pain Management Program 513
    Chronic Nonmalignant Pain Resources for Patients/Clinicians 516
    Organizations 516
    Books 518
    Relaxation audiotapes 518
    Pain and related symptom assessment instruments 519
    Common personality assessment instruments 519
    References for Further Assessment/Psychometric Tests 520

  • SELECTED PAIN PROBLEMS 522 SECTION 1: Quick Guides to
    Selected Pain Problems 523
    Arthritis: Osteoarthritis and
    Rheumatoid Arthritis 523
    Burn Pain 527
    Cancer-Related Pain 531
    Ehlers-Danlos Syndrome 543
    Fibromyalgia Syndrome 545
    Headache 550
    Herpes Zoster and Postherpetic
    Neuralgia 561
    HIV-Related Pain 564
    Myofascial Pain Syndrome 568
    Osteoporosis 572
    Painful Peripheral Neuropathies 576
    Pancreatitis 579
    Reflex Sympathetic
    Dystrophy/Causalgia 581
    Sickle Cell Disease—Related Pain 585
    Temporomandibular Dysfunction 588
    Wound Pain 592

    SECTION 2: Brief Descriptions
    of Selected Pain Problems 595
    Ankylosing Spondylitis 595
    Arachnoiditis 596
    Chronic Fatigue Syndrome/Chronic Fatigue Immune Deficiency Syndrome 597
    Crohn's Disease 597
    Hemophilia 598
    Low Back Pain 599
    Lyme Disease 600
    Mucositis 601
    Multiple Sclerosis 602
    Phantom Limb Pain 603
    Postmastectomy Pain 604
    Postpolio Syndrome 604
    Postthoracotomy Pain 605
    Spinal Cord Injury 606

  • PREGNANCY, CHILDBIRTH, POSTPARTUM, AND BREAST FEEDING: Use of Analgesics 608 Pain Management During Pregnancy 609
    Maternal-placental-fetal drug transfer 610
    Analgesic use during pregnancy 611
    Pain related to or affected by pregnancy 615
    Pain unrelated to pregnancy 616
    Substance abuse during pregnancy 616
    Pain Management During Childbirth 617
    Incidence and factors influencing childbirth pain and suffering 617
    Patterns of labor pain 617
    Use of nondrug methods during childbirth 617
    Use of opioid analgesics during childbirth 618
    Use of local anesthetics during childbirth 618
    Use of benzodiazepines during childbirth 618
    Parenteral pain relief during childbirth 619
    Regional techniques for pain relief during childbirth 619
    Controversies related to analgesic/anesthetic use during childbirth 621
    Pain Management During the Postpartum Period 621
    Pain from uterine contractions 622
    Episiotomy pain 622
    Breast and nipple pain 622
    PostÐcesarean section pain 622
    Analgesic Use During Breast Feeding 623
    Acetaminophen and NSAIDs 623
    Opioid analgesics 623
    Adjuvant analgesics 623

  • PAIN IN INFANTS 626 Overview 628 Definition of pain in infants 628
    Undertreatment of pain 628
    Consequences of pain 631
    Sources and settings of pain 635
    Pain Assessment in Infants 639
    Assessment versus measurement 639
    Infant pain measurement approaches 640
    Unidimensional pain measures 641
    Multidimensional pain measures 642
    Management of Pain in Infants 651
    Pharmacologic pain management 652
    Nonpharmacologic pain management 658
    Roles of Health Care Professionals and Parents in the Management of Pain in Infants 661
    Roles of health care professionals 661
    Roles of parents 668
    Resources for Health Care Professionals and Parents 668

  • PAIN IN THE ELDERLY 674 Age Classifications for the Elderly 677
    Common Types of Pain in the Elderly 677

    Acute pain 677
    Cancer pain 678
    Chronic nonmalignant pain 679
    Settings in Which the Elderly Receive Care 679
    Acute care hospital 679
    Multidisciplinary pain care programs 680
    Hospice 681
    Long-term care facilities 681
    Home care 683
    Support Groups and Resources 686
    Pain Assessment in the Elderly 686
    Pain assessment in cognitively impaired elders 686
    Analgesic Use in the Elderly 687
    Physiologic changes influencing analgesic therapy 687
    Selected analgesics 689
    Issues related to analgesic use in the elderly 698
    Nondrug Pain Relief 700
    Transcutaneous electrical nerve stimulation 700
    Caring for Complex Elderly Patients 700
    Elders who are frail and debilitated 700
    Elders who are cognitively impaired or confused 701
    Elders with memory difficulties 705
    Elders who misuse alcohol 705
    Elder Abuse 706

  • BUILDING INSTITUTIONAL COMMITMENT TO IMPROVING PAIN MANAGEMENT 711 Institutional Barriers to Effective Pain Management 713
    Continuous Quality Improvement 713
    Applying continuous quality improvement to pain management 715
    Building Institutional Commitment to Improving Pain Management 715
    Establishing a pain care committee 715
    Establishing the need for change in pain management practices 720
    Committee responsibilities 730
    Other Strategies for Building Institutional Commitment to Improving Pain Management 738
    Administrative rules 738
    Clinical pathways 738
    Pain services 739
    Role model programs 740
    Pain resource nurse programs 742
    Nurse-based PCA programs 742

    APPENDICES 745

    Pain Resources on the Internet 745
    Written Agreements Relative to Prescribing Opioid Analgesics 751
    Terminology 756


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