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