COURSE PRICE: $39.00
CONTACT HOURS: 6
This course will expire or be updated on or before March 1, 2016.
ABOUT THIS COURSE
You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity.
ACCREDITATION / APPROVAL
Wild Iris Medical Education, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
Wild Iris Medical Education, Inc. (CBRN Provider #12300) is approved as a provider of continuing education for RNs and LVNs by the California Board of Registered Nursing.
This program has been pre-approved by The Commission for Case Manager Certification to provide continuing education credit to CCM® board certified case managers.
Nurse practitioners may apply these contact hours to pharmacy continuing education and prescriptive authorization.
Wild Iris Medical Education, Inc. provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional health care. See our disclosures for more information.
Copyright © 2013 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to provide an overview of the management of pain: its nature, sources, assessment, interventions, documentation, ethical and legal issues, and effects upon various groups of people.
Upon completion of this course, you will be able to:
Pain is a universal human experience and the most common reason people seek medical care. Pain tells us something is wrong in the structure or function of our body and that we need to do something about it. Because pain is such a strong motivator for action, it is considered one of the body’s most important protective mechanisms.
The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (2012). Pain, however, is much more than a physical sensation caused by a single entity. It is subjective and highly individual, a complex mechanism with physical, emotional, and cognitive components.
Pain cannot be objectively measured in the same way as, for example, the chemical content of urine or the oxygen content level of blood. Only the person who is suffering knows how the experience feels. For these reasons, McCaffery defined pain as “whatever the experiencing person says it is and whenever he says it does” (1979). The American Pain Society goes further by stating that it is not the responsibility of clients to prove they are in pain; it is the caregiver’s responsibility to accept the client’s report of pain (2009).
Pain alters the quality of life more than any other health-related problem. It interferes with sleep, mobility, nutrition, thought, sexual activity, emotional well-being, creativity, and self-actualization. Surprisingly, even though pain is such an important obstacle to comfort, it is one of the least understood, most undertreated, and oft-discounted problems of healthcare providers and their clients. For this reason, some nurses and therapists add “comfort” to Maslow’s hierarchy of basic human needs (1968). The American Pain Society goes further, declaring the relief of pain a “basic human right” (2009).
Traditionally, pain has been considered merely a physical symptom of illness or injury, a simple stimulus-response mechanism. Though the historic role of caregivers has been to relieve pain and suffering, there has been little understanding of the complexity of pain and only limited ways to manage it. Recent research shows pain to be a distinct disorder, with physical, emotional, and cognitive components. This view of pain has broadened our understanding of pain and given us new ways to understand its characteristics.
Algesia: Sensitivity to pain.
Breakthrough pain: Transitory increase in pain to a level greater than the client’s well-controlled baseline level.
Hyperalgesia: Excessive sensitivity to pain.
Idiopathic pain: Pain for which there is no identifiable psychological or physical cause.
Intractable pain: Pain that is not relieved by ordinary medical, surgical, and caregiving measures (Mosby’s Dictionary, 2012).
Pain syndrome: A group of symptoms of which pain is the critical element, such as headaches and post-herpetic neuralgia.
Pain threshold: Amount of pain required before individuals feel the pain. The lower the threshold, the less pain they can endure; the higher the threshold, the more pain they can endure.
Pain tolerance: Maximum amount and duration of pain a person can endure. Tolerance varies widely among people and is influenced by emotions and cultural background.
Phantom limb pain syndrome: Pain that occurs in the place of a missing limb after it is removed or as a result of severe damage to the affected nerve plexus due to perceptual disruption in the brain (Mosby’s Dictionary, 2012).
Psychogenic pain: Chronic pain with no identified organic explanation.
Radiating pain: Pain that begins at one place and extends out into nearby tissues.
Referred pain: Pain that is felt at a different location than where tissue was damaged. This phenomenon occurs because pain fibers in the damaged area synapse near fibers from other areas of the body; for example, a myocardial infarction may create referred pain in the left shoulder.
Pain is classified as acute and chronic. Acute pain has an identifiable cause and occurs soon after an injury to tissues in the body, such as bone, skin, or muscle. Acute pain is protective in that it motivates a person to take action immediately. Its onset may be sudden or slow, and its intensity may vary from mild to severe. Acute pain is temporary and subsides as healing takes place. Severe acute pain activates the sympathetic nervous system, causing diaphoresis, increased respiratory and pulse rates, and elevated blood pressure.
Chronic pain lasts beyond an expected healing phase, is non-protective in that it serves no function, and may not have an identifiable cause (Patterson, 2007). When pain goes on for more than six months, it moves from being a “symptom” to a “condition.” Chronic pain afflicts more than 1 in 5 Americans and is one of the most pervasive and thorny medical conditions in the United States. Such pain is described as nonmalignant (noncancerous), malignant (cancerous), and intractable.
The sources (causes) of pain are divided into three main categories: nociceptor, non-nociceptor, and psychogenic.
Nociceptor pain results when tissue damage produces a pain-producing stimulus that sends an electrical impulse across a pain receptor (nociceptor) by way of a nerve fiber to the central nervous system. Nociceptor pain is further divided into visceral and somatic pain.
Non-nociceptor (neuropathic) pain is caused by direct injury to structures of the nervous system.
Psychogenic pain is pain for which there is little or no physical evidence of organic disease or identified injury to tissues in the body. Lack of evidence, however, does not mean clients are malingering or that they are not suffering.
|Source: Adapted with permission from Ignatavicius et al., 1999.|
|Physiologic structures||Organs and linings of body cavities|
|Mechanism||Activation of nociceptors|
|Characteristics||Poorly localized, diffuse, deep, cramping, or splitting|
|Sources of acute pain||Chest tubes, abdominal drains, bladder and intestinal distention|
|Sources of chronic pain syndromes||Pancreatitis, liver metastases, colitis|
|Physiologic structures||Cutaneous: skin and sub-cutaneous tissues
Deep somatic: blood, muscle, blood vessels, connective tissue
|Mechanism||Activation of nociceptors|
|Characteristics||Well-localized, constant, achy|
|Sources of acute pain||Incisional pain, insertion sites of tubes and drains, wound complications, orthopedic procedures, skeletal muscle spasms|
|Sources of chronic pain syndromes||Bony metastases, osteoarthritis, rheumatoid arthritis, low-back pain, peripheral vascular disease|
|Physiologic structures||Nerve fibers, spinal cord, central nervous system|
|Mechanism||Non-nociceptive injury to nervous system structures|
|Characteristics||Generalized along distribution of damaged nervous structures|
|Sources of acute pain||Poorly localized: shooting, burning, fiery, shock-like, sharp, painful numbness|
|Sources of chronic pain syndromes||Nervous tissue injury due to diabetes, HIV, chemotherapy, neuropathies, post-therapeutic neuralgia, trauma, surgery|
|Physiologic structures||No organic structures|
|Characteristics||Variable, often numerous|
|Sources of acute pain||Nonorganic|
|Sources of chronic pain syndromes||Nonorganic psychological factors|
Though a person is not consciously aware of the process, the experience of pain involves a complex sequence of biochemical and electrical events or processes beginning with tissue damage and followed by transduction, transmission, perception, and modulation.
When tissue is damaged, there is an immediate release of inflammatory chemicals called “excitatory neurotransmitters,” such as histamine and bradykinin, a powerful vasodilator. Increased blood in the area causes the injured area to swell, redden, and become tender. The bradykinin stimulates the release of prostaglandins and substance P, a potent neurotransmitter that enhances the movement of impulses across nerve synapses.
Transduction occurs as the energy of the stimulus is converted to electrical energy. Transmission of the stimulus takes place when this energy crosses into a nociceptor at the end of an afferent nerve fiber.
Two types of peripheral nerve fibers conduct painful stimuli: the fast, myelinated A-delta fibers and the very small, slow, unmyelinated C-fibers. A-fibers send sharp, distinct sensations that localize the source of the pain and detect its intensity. C-fibers relay impulses that are poorly localized, burning, and persistent. For example, after burning a finger, a person initially feels a sharp localized pain as a result of A-fiber transmission. Within a few seconds the pain becomes more diffuse and widespread as a result of C-fiber transmission.
Pain stimuli travel quickly to the substantia gelatinosa in the dorsal horn of the spinal cord, where the “gating” mechanism (discussed below) occurs. Pain impulses then cross over to the opposite side of the spinal cord and ascend to the higher centers in the brain via the spinothalamic tracts and on to the thalamus and higher centers of the brain, including the reticular formation, limbic system, and somatosensory cortex. (See figure.)
Neurologic transmission of pain stimuli. (Source: Jason M. Alexander. © 2005, Wild Iris Medical Education.)
When pain stimuli reach the cerebral cortex, the brain interprets the signal; processes information from experiences, knowledge, and cultural associations; and perceives pain. Thus, perception is the awareness of pain. The somatosensory cortex identifies the location and intensity of pain, and the associated cortex determines how an individual interprets its meaning.
Once the brain perceives the pain, the body releases neuromodulators, such as endogenous opioids (endorphins and enkephalins), serotonin, norepinephrine, and gamma aminobutyric acid. These chemicals hinder the transmission of pain and help produce an analgesic, pain-relieving effect. This inhibition of the pain impulse is called “modulation.” The descending paths of the efferent fibers extend from the cortex down to the spinal cord and may influence pain impulses at the level of the spinal cord.
Melzack and Wall proposed the gate-control theory to explain the relationship between pain and the emotions (1996). According to the theory, a gating mechanism occurs when a pain impulse travels to the substantia gelatinosa in the dorsal horn of the spinal cord. There, trigger (T) cells influence the transmission of pain impulses. When their activity is inhibited, the gate closes and impulses are less likely to be transmitted to the brain. This mechanism is controlled by descending nerve fibers from the thalamus and cerebral cortex, areas of the brain that regulate thought and emotions. The gate-control theory helps explain how thoughts and emotions modify the perception of pain and why interventions such as imagery and distraction help relieve it.
The perception of pain is influenced by physiologic, psychological, and cultural factors, all of which caregivers need to consider.
Age affects the way people respond to pain. It influences both the development and decline of the nervous system. Aging affects the whole body, causing many painful degenerative disorders (such as osteoarthritis), secondary injuries (such as skin abrasions and fractures), and a host of common surgical procedures (such as cataract and hip replacement). Age also affects the way families and caregivers respond to complaints of pain.
The following table gives a brief overview of the perception of pain relative to age.
|Pre-term infants||Have anatomical and functional ability to process pain by mid to late gestation; seem to have greater sensitivity to pain than term infants or children|
|Newborn infants||Response to pain is inborn and does not require prior learning; respond to pain with behaviors such as crying, grimacing, moving the body|
|Infants, 1 month||Can metabolize analgesics and anesthesia effectively; can recognize caregiver as comforter|
|Toddlers/preschoolers||Can describe pain, its location and intensity; respond to pain by crying, anger, sadness; may consider pain a punishment; may hold someone accountable for pain and remember experiences in a certain location, such as a clinic|
|School-age children||May try to be brave when facing a painful procedure, may regress to an earlier stage of development, seek understanding of reasons for pain|
|Adolescents||May be slow to acknowledge pain, may consider showing signs of pain a weakness, may regress to earlier stages of development with persistent pain|
|Adults||Fear of pain may prevent some from seeking care, many believe admission of pain is a weakness and inappropriate for age or sex, some consider pain a punishment for moral failure|
|Older adults||May have decreased sensations or perceptions of pain; may consider pain an inevitable part of aging; chronic pain may produce anorexia, lethargy, depression; may not report pain due to fear of expense, possible treatment, and dependency; often describe pain in nonmedical terms such as “hurt” or “ache”; may fear addiction to analgesics; may not want to bother caregivers or be a “bad patient”|
Fatigue decreases coping abilities and heightens the perception of pain. When people are exhausted from physical activity, stress, and lack of sleep, their perception of pain may be heightened and their coping skills diminished. Thus, sleep and rest from physical, emotional, and social demands are important measures to manage pain.
Recent research suggests that sensitivity to and tolerance for pain may be a genetically linked trait (Fincke, 2010). This finding does not negate the need to manage pain adequately, regardless of inherited traits.
Memory of painful experiences, especially experiences that occurred as a very young child, may increase sensitivity and decrease tolerance to pain. For example, even young children remember the pain of an immunization injection at the doctor’s office and henceforth may be afraid to visit the office again.
Research has shown that “severe, unrelieved pain can cause an overwhelming stress response in both pre-term and full-term infants which can lead to serious complications and even death” (Pasero, 2004).
Research suggests that unrelieved acute pain slows postoperative wound healing (McGuire et al., 2006). This evidence is not surprising, given our increasing knowledge of the effect of stress on the human body.
Any factor that interrupts or interferes with normal pain transmission affects the awareness and response of clients to pain and places them at risk for injury. Analgesics, sedatives, and alcohol depress the functioning of the central nervous system. Likewise, rare congenital conditions exist in which an individual cannot feel physical pain.
Some diseases, such as leprosy, damage peripheral nerves, decrease sensitivity to touch and pain, and render sufferers more vulnerable to injury. People with diabetes mellitus can have diabetic neuropathy, which may impair their ability to feel pain. They may injure themselves and be totally unaware of the injury, especially if it is in an area of the body they cannot see, such as the bottom of the feet, sacral area, or back of the head. The same may apply to people with traumatic nerve injuries, such as those with spinal cord damage or postsurgical nerve impairment.
The relationship between pain and fear is convoluted and complex. Fear tends to increase the perception of pain, and pain increases feelings of fear and anxiety. This connection occurs in the brain because painful stimuli activate portions of the limbic system believed to control emotional reactions. People who are seriously injured or critically ill often experience both pain and heightened levels of anxiety due to their feelings of helplessness and lack of control. Healthcare providers need to address both pain and anxiety and use appropriate measures to relieve suffering.
People manage pain and other stressors of life in different ways. Some see themselves as self-sufficient, internally controlled, and independent. As a result, they may deny pain or be slow to admit they are suffering. Others see themselves as insufficient, externally controlled, and dependent on others to treat their pain. Self-sufficient, internally controlled people may do better with patient-controlled analgesia (PCA), whereas dependent, externally controlled individuals may prefer nurse-administered analgesia. No matter what the coping style, it is the responsibility of providers to relieve pain.
Cultural beliefs and values affect the way people respond to pain. As children, people learn what is and is not acceptable behavior when they experience pain. In some cultures, any expression of pain is considered cowardly and shameful. In others, noisy demonstrations of pain are expected and acceptable. The meaning of pain itself may be markedly different in different cultures. Some ethnic groups see pain as a punishment for wrongdoing. Others see pain as a test of faith. Still others view pain as a challenge to be overcome. Recent immigrants to the United States are more likely to view pain from their cultural roots. Regardless of an individual’s language, religion, or situation, caregivers are obliged to respect every person and strive to alleviate pain and suffering.
Because pain management is so important to the provision of quality healthcare, many organizations have developed standards by which professional practice is measured. Four such organizations are the Joint Commission (TJC), the Accreditation Association for Ambulatory Health Care (AAAHC), the American Academy of Pediatrics (AAP), and the American Association of Occupational Therapy (AAOT).
The Joint Commission is an independent organization that accredits and certifies more than 17,000 healthcare organizations and programs in the United States. It evaluates how well these healthcare providers meet published standards of care, including their management of pain. The federal government accepts Joint Commission–accredited facilities as qualified to participate in Medicare and Medicaid reimbursement programs.
Regarding pain management, the Joint Commission Resources states:
Each and every patient has a right to the assessment and management of pain. Hospitals must develop policies and procedures that address the organization’s expectations of pain management in support of their mission and philosophy of care. Patients and their families also need education regarding their role in pain management. Developing a comprehensive and coordinated pain management program can be made easier by accessing good practices. From policies and procedures for the different types of pain (acute, chronic, etc.) to training assistants (including pre- and post-tests) to assessment tools, good practices can assist your organization to provide a comprehensive approach to pain management that meets the intent of the standards and, at the same time, achieves positive outcomes for patient (Joint Commission Resources, 2009).
JOINT COMMISSION STANDARDS OF PAIN MANAGEMENT
To meet the Joint Commission standards, accredited facilities must have policies in place to meet the following requirements:
Standard PC.01.02.07: The hospital assesses and manages the patient’s pain.
Rationale: Identification and treatment of pain is an important component of the plan of care. Patients can expect that their healthcare providers will ask them about whether they have pain. When pain is identified the individual is assessed based on his or her clinical presentation and in accordance with the care, treatment, and services provided by the organization.
Elements of Performance:
Source: Joint Commission, 2013.
The Accreditation Association for Ambulatory Health Care is the outpatient counterpart of the Joint Commission. It uses a similar model of standards, interpretive statements, and facility surveys to assure the quality of care delivered in other-than-hospital settings. As with TJC, AAAHC surveys can be used to qualify facilities to participate in Medicare and Medicaid reimbursement programs.
As part of a facility survey, a nurse and/or a physician surveyor will follow a patient from admission to discharge; this is called “tracer methodology.” The surveyors will note how care providers implement, among other things, the pain-related policies. To be considered in compliance with standards on pain management, AAAHC states: “The organization maintains a written policy with regards to assessment and management of acute pain” (AAAHC, 2012).
The American Academy of Pediatrics is a professional organization dedicated to the health, safety, and well-being of infants, children, adolescents, and young adults. As such, its committees develop guidelines, positions, and programs to support the mission of the organization. The AAP guidelines for pain management conclude with the strategies listed below.
AAP GUIDELINES FOR PAIN MANAGEMENT
Source: American Academy of Pediatrics, 2001.
The AAOT recommends that OTs address the physiological, psychosocial, and environmental components of the pain in the daily lives of individuals.
The caregiving process includes assessment, diagnosis, planning, intervention, and evaluation. To manage pain responsibly, healthcare providers use each step of the process.
Basic to every strategy for managing pain is showing respect for the validity of a client’s experience of pain. To communicate respect, caregivers:
Pain is a red flag. It tells us there is a problem somewhere in the body that is crying out for attention. In fact, pain is such an important indicator of health, its assessment has been called the “fifth vital sign,” joining temperature, pulse, respiration, and blood pressure. Even so, until we know more about a specific pain, we cannot address it. To do this, caregivers must gather information from as many sources as possible, especially the primary source, the person in pain. This investigation includes obtaining a comprehensive pain history, making observations of behaviors, performing an appropriate physical examination, and consulting with other healthcare professionals.
A pain history is obtained from written documents and from interviews with the person in pain, family members, and other caregivers. It asks specific questions about the location, intensity, quality, and history of the pain, as shown in the following box. In some facilities these questions are printed on an assessment form, with space for answers to be recorded beside each question.
A variety of pain scales have been developed for use with adults as well as with children. (See the “Pain Assessment Scales” table later in this course for a list of such scales. See also “Partners Against Pain” in the resources section at the end of this course.)
OBTAINING A PAIN HISTORY
Following are questions a healthcare provider can ask as part of taking a pain history:
Location: Where is your pain? Ask client to point to the area of pain.
Intensity: On a scale of 0 to 10, with 0 representing no pain, how much pain would you say you are experiencing? If your pain were a temperature, how hot would it be (warm, hot, blistering)? If your pain were a sound, how loud would it be (silent, quiet, strident, booming)?
Quality: In your own words, tell me what your pain feels like (worms under the skin, shooting, needle pricking, tingling, stabbing, etc.).
Chronology/pattern: When did the pain start? Does your pain come and go? How often? How long does it last?
Precipitating factors: What triggers the pain, or what makes it worse?
Alleviating factors: What measures have you found that lessen or relieve the pain? What pain medications do you use? How much and how often?
Associated symptoms: Do you have other symptoms before, during, or after your pain begins (dizziness, blurred vision, nausea, shortness of breath)?
Most people who suffer pain usually show it either by verbal complaint or nonverbal behaviors. The following table lists some typical behaviors caregivers may observe when they assess people in pain.
A physical examination is most fruitful when the pain history interview and behavioral observations are conducted at the same time. Because pain may be referred from some other area of the body, the examination should include a full scan from head to toe. A physical examination includes inspection, auscultation, palpation, and percussion.
Inspection includes general and specific observations, beginning when the provider first encounters the patient and notes any obvious sign of pain, such as limping or any unusual posture of the body. A specific inspection involves an examination of the place where there is pain using adequate light and appropriate instruments.
Auscultation involves listening to sounds produced by internal body structures, such as the heart, lungs, and bowels. The provider must be able to block out noises in the environment and sounds emanating from other organs. To help isolate sounds, one can close the eyes and concentrate on one auscultation sound at a time.
Palpation involves using one’s hands to gather information about skin temperature, bodily pulsations, vibrations, internal masses, and tenderness or rigidity of organs and structures. When assessing the abdomen, perform palpation after auscultation because palpation may increase intestinal activity, causing misleading findings such as increased bowel sounds (Mosby, 2009).
Percussion involves tapping the patient’s skin with the one’s fingers or hands to elicit sound, evaluate reflexes, uncover abnormal masses, and detect pain. Tapping produces an audible vibration that helps to reveal the location, size, and density of underlying structures. Sounds are classified as dull, flat, tympanic, resonant, or hyper-resonant, depending on what part of the body one is tapping.
An accurate diagnosis depends on an appropriate assessment that focuses on the exact nature of the pain. The more specific the diagnosis, the more effective interventions can be. The North American Nursing Diagnosis Association (NANDA) has identified two primary diagnoses for pain: acute and chronic.
A complete caregiving diagnosis, however, goes further. After identifying whether the pain is acute or chronic, it adds “related to” to the medical diagnosis. For example, “chronic pain related to osteoarthritis of the left hip.” Then, it adds “manifested by” and lists the various symptoms experienced by the client or signs confirmed by objective data. Thus, a complete diagnosis might be “chronic pain, related to osteoarthritis, manifested by stabbing pain in the left hip with weight-bearing.”
The advantage of clear, specific information is that it leads to more effective interventions. In this case, an appropriate intervention might be an assistive devise such as a cane or walker and referral to a physical therapist or orthopedic surgeon for further evaluation.
During the planning stage, healthcare providers synthesize information from many sources and, together with the clinician, plan appropriate treatment. The goal of these interventions is to relieve pain and facilitate the highest possible level of functioning. Practically speaking, this means identifying what activity the pain is preventing and the best way to achieve a return of function. For instance, in the case study below, Mrs. Low’s hip pain is obstructing her mobility.
Planning interventions means working in partnership with clients and other caregivers to provide specific measures to manage the pain. These interventions may be independent or collaborative. Independent actions fall within the scope of the caregiver’s specialty. Collaborative actions involve cooperative interventions with other members of the healthcare team, such as nurses, physical therapists, occupational therapists, pharmacists, and physicians.
Goal setting involves the identification of attainable objectives and reasonable priorities. Because every person is different, caregivers discuss various alternatives with the client and together set priorities. For example, after consulting an orthopedic surgeon, Mrs. Low may have decided to delay hip replacement surgery and maintain mobility as long as possible with the aid of a cane and analgesic medications.
Effective pain management is carried out by a team of professionals, including physicians, nurses, physical therapists, occupational therapists, and counselors. During surgery, anesthesiologists administer intravenous fluids, anesthetics, and analgesic agents. Physicians prescribe medications and oversee care. Nurses administer analgesics, provide comfort measures, and educate patients. Physical and occupational therapists teach and assist patients to facilitate activities of daily living and reduce pain. Although their practices overlap, each professional evaluates the effectiveness of therapeutic measures and communicates with others on the team. Such an interdisciplinary approach helps alleviate pain and promote healing, using both pharmacologic and nonpharmacologic interventions.
Mrs. Low was finding it increasingly difficult to walk because of the pain in her right hip. Finally, she went to her primary care physician, who ordered x-rays. A radiologist studied the x-rays and wrote a report. When her physician read the report, he referred Mrs. Low to an orthopedic surgeon, who recommended hip replacement surgery. She agreed.
Throughout her surgical treatment and healing, the surgeon oversaw Mrs. Low’s care, managing her pain with analgesics and comfort measures. Nurses cared for her during and after the surgery, and physical therapists helped her walk a few steps the day after surgery and ambulate safely. When she went home, visiting nurses oversaw her care, and Mrs. Low continued therapy until she was walking without pain.
There are two primary groups of pain medications: nonopioids and opioids. A third group of drugs called “adjuvants” or “co-analgesics” address symptoms that often accompany pain, such as insomnia, anxiety, muscle spasm, anorexia, and depression.
Nonopioid analgesics relieve pain by acting on peripheral nerve endings at the injury site to decrease the level of inflammatory mediators. This group of analgesics includes drugs such as acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) such as acetylsalicylic acid (aspirin) and ibuprofen (Motrin).
The specific actions and dosages of these analgesics vary. Generally speaking, however, they have analgesic, antipyretic, and anti-inflammatory effects and are useful for mild to moderate pain. With the exception of acetaminophen, most nonopioids are potent anti-inflammatory agents. These drugs are especially effective when the primary cause of pain is inflammation, as occurs in rheumatoid arthritis and bone cancer.
When tissue is damaged, a series of biochemical events leads to the release of prostaglandin, which causes edema, inflammation, and pain. Two isoenzymes—cyclo-oxygenase-1 (COX-1) and cyclo-oxygenase-2 (COX-2)—play an important part in this biochemical process. Drugs that inhibit their action, especially that of COX-2, reduce prostaglandin production and the inflammation it creates. However, these drugs must be used with caution because the safety of long-term use has not been verified.
The following table lists some common nonopioid analgesics.
|Acetaminophen (Tylenol)||650–975 mg every 4 hours||Used for headaches, osteoarthritis; lacks peripheral anti-inflammatory activity of NSAIDs|
|Aspirin||650–975 mg every 4 hours||Used for headaches, osteoarthritis, general pain; antipyretic; inhibits platelet aggregation, causing bleeding|
|400 mg every 4–6 hours||Used for rheumatoid arthritis; antipyretic, anti-inflammatory; multiple brand names, available as liquid; may cause bleeding|
|Indomethacin (Indocin)||150–200 mg/day||Used for gout; anti-inflammatory, anti-rheumatic|
|Naproxen (Naprosyn)||500 mg initial dose,
then 250 mg every 6–8 hours
|Used for gout, headaches; anti-inflammatory; anti-rheumatic; available in liquid preparation; completely inhibits COX-1 and COX-2; may cause bleeding|
Opioid (narcotic, CNS-acting) analgesics pertain to natural and synthetic chemicals with opium-like effects, though they are not derived from opium. They include such drugs as morphine, codeine, and methadone. These drugs modify the perception of pain and provide a sense of euphoria by binding to specific opiate receptors throughout the central nervous system. Opiate receptors have various names, typically denoted by Greek letters such as mu (μ), kappa (κ), and sigma (σ) (Mosby, 2010).
Opioid analgesics are classified as full agonists, partial agonists, and mixed agonist-antagonists. Full agonists bind to μ receptor sites, block pain impulses, and produce maximum pain control—an “agonist effect.” Full agonists include such drugs as morphine, meperidine (Demerol), fentanyl (Duragesic) patch, oxycodone hydrochloride (OxyContin), and hydromorphine (Dilaudid).
Partial agonists produce a lesser response than full agonists and include such drugs as buprenorphine (Buprenex) and nalbuphine (Nubain). Mixed agonist-antagonist analgesics include such drugs as pentazocine hydrochloride (Talwin) and butorphanol tartrate (Stadol).
An antagonist is a drug that competes with opioid receptor sites. Naloxone hydrochloride (Narcan) is such a drug. It is used for opioid overdoses and physical dependency.
The primary action of opioids (narcotics) is to alleviate moderate to severe pain. Many of the unwanted effects of this class of drugs are related to their actions on systems of the body other than the central nervous system (CNS), causing such effects as constipation and respiratory depression.
The following table lists some common opioid side effects and preventative measures.
|Body System||Adverse Side Effects||Preventative Measures|
|Cardiovascular||Hypotension, palpitations, flushing||Monitor blood pressure and heart rate|
|CNS||Sedation, disorientation, euphoria, dysphoria, light-headedness, lower seizure threshold, tremors||Inform client that tolerance may develop over 3–5 days; administer stimulants as needed|
|Gastrointestinal||Constipation, nausea, vomiting||Offer anti-emetic; change analgesic; increase fluid and fiber intake; increase exercise; administer laxatives|
|Genitourinary||Urinary retention||Catheterize as needed; administer opioid antagonist|
|Integumentary||Itching, rash, wheal formation||Apply cool packs or lotion; administer antihistamine|
|Respiratory||Respiratory depression; aggravation of asthma||Monitor respirations closely; administer opioid antagonist such as naloxone hydrochloride (Narcan)|
Some medications combine nonopioid with opioid analgesics in one tablet to offer two different levels of pain relief—acting both on peripheral nerve endings at the injury site and at the central nervous system level. Acetaminophen with codeine is such a medication.
Adjuvant analgesics (co-analgesics) are drugs that were developed for uses other than pain but have been found to enhance analgesic effects. Caregivers need to remember that these are “helper drugs,” not substitutes for analgesics. Clients in pain still need analgesics.
The following table describes some common adjuvant analgesics.
|Class||Indications and Primary Effects|
|Antidepressants: tricyclics and serotonin, reuptake inhibitors||Neuropathic pain, burning sensation; improves sleep, enhances mood and analgesic effects|
|Anti-epileptic drugs||Neuralgic and neuropathic pain; sharp, prickling, shooting pain|
|Antispasmodic||Reflex sympathetic dystrophy syndrome|
|Anxiolytic drugs: benzodiazepines, buspirone, venlafaxine||Anxiety and sedation|
|Botulinum toxin||Migraine headache|
|Lidocaine||Neuralgic pain and diabetic neuropathic pain|
|Psychostimulants||Offsets sedating side effects and enhances analgesic effects of opioids|
|Steroids||Inflammatory and chronic pain of cancer, malignant spinal cord compression, headaches, arthritis|
Analgesics can be administered by many routes. Each has advantages and disadvantages as well as indications and contraindications. The overriding considerations are effectiveness and safety. The table below lists some of the most common routes for the administration of analgesic drugs.
|Oral (per os = PO)||Preferred route due to lower cost and convenience; may be prepared as powders, capsules, tablets, liquids, or lozenges||Gastrointestinal irritation; inability to swallow; need for more potent analgesic|
|Rectal (R)||Inability to take oral drugs; can be self-administered; longer duration than oral||Anal or rectal lesions, diarrhea, thrombocytopenia|
|Intramuscular (IM)||Acute, short-term pain relief||Need for prolonged pain relief; absorption may be poor; possible muscle or nerve damage; costly|
|Intravenous (IV) bolus||Offers most rapid pain relief (5–15 min) but lasts less than 60 min||Requires IV access; gives only brief pain relief when prolonged relief is needed|
|Continuous intravenous (IV) infusion||Gives constant opioid blood level when other methods are ineffective||Requires infusion pumps with alarms and close monitoring|
|Patient-controlled analgesia (PCA)||Allows predetermined IV bolus of analgesic when client desires pain relief||Requires IV access, client cooperation, close supervision; does not give continuous pain relief|
|Subcutaneous (SC) opioid infusion||Continuous, prolonged parenteral opioids when IV not possible; allows home use||Requires site change every 7 days of 27-gauge butterfly needle; potential site irritation|
|Intraspinal (neuraxial), intrathecal, epidural, subarachnoid, intraventricular||Labor contractions; also intractable pain when client cannot tolerate systemic opioids by other routes||Requires expert insertion of catheter into intended space; attached to infusion pump or implanted reservoir; high risk for infection or dislodgment|
|Regional nerve blocks||Continuous or single dose analgesic for acute and chronic pain; used for trauma, burns, and labor||Requires expert insertion of catheter to specific nerve root; attached to infusion pump or implanted reservoir; high risk for infection or dislodgment|
|Topical (cream-laden anesthetic)||Analgesic for needle sticks, venipuncture, dermatitis, and insect stings||Must be applied 30–60 min in advance of need|
|Transdermal skin patch||Continuous dose of opioid; allows home use||Costly; when body temperature is over 102° F, absorption is accelerated|
|Nasal sprays||Alternative to IV, IM, and oral opioid administration; rapid onset of action||Nasal exudates or mucosal swelling may prevent consistent absorption|
PRINCIPLES FOR THE USE OF ANALGESICS
To guide caregivers, the American Pain Society (2009) identifies thirteen principles regarding the use of analgesics to control pain:
Drug tolerance is a physiologic condition in which humans require larger and larger doses of drugs to provide the same effect as provided by the original dose. Tolerance checks the effect of a drug so that overdose does not occur. For instance, specific liver enzymes that degrade an opioid drug increase in relation to the drug dosage increase. The first sign of tolerance is a decrease in the duration of the analgesic effect. This condition is followed by a decrease in total analgesic effect. Decreasing the time between doses or increasing the dosage may help overcome tolerance. Even so, drug tolerance is not the only reason drugs become less effective. They may be less effective because there is advancing tissue damage, thus greater pain.
Pseudotolerance is the need to increase opioid dosage for reasons other than the physical adaptation of continuous use. Such conditions include drug-to-drug interaction, drug-to-food interaction, increased physical activity, psychological dependence (addiction), and changes in opioid formulation.
Physical dependence is a physiologic adaptation of tissues to the drug. The human body adapts physiologically to the presence of chemicals in the body. Opioid dependence is no different than dependence on steroids, beta blockers, and other drugs taken for extended periods of time. As a result, opioid dependence is not evidence of opioid addiction.
If a person who is physically dependent on opioids abruptly stops using them, withdrawal symptoms occur. These symptoms result from an autonomic nervous system response and may include excessive yawning, nausea and vomiting, hypertension, tachycardia, muscle twitching, diaphoresis, delirium, and convulsions. When opioid analgesics are to be discontinued, physical withdrawal symptoms can be reduced or eliminated by a slow reduction of dose.
Psychological dependence (addiction) is the compulsive use of a substance characterized by a continuous craving for a drug’s nonanalgesic emotional effects. Opioids (narcotics) with an affinity for both μ and σ receptor sites produce euphoria and hallucinations. Thus, these drugs are the most frequently abused opioids. When people take opioids to relieve pain, tolerance and physical dependence may occur, but addiction will not necessarily follow. Psychological dependence is far more complex and involves emotional, social, and cultural issues. Addiction is characterized by one or more of the following behaviors: impaired control over drug use, craving, and compulsive and continued use despite harm (Savage, 2003).
Pseudoaddiction is a term used to describe people who, because of severe, unrelieved pain, focus on finding relief. As a consequence, they seem preoccupied with obtaining opioids. This preoccupation is not truly “drug-seeking” but “relief-seeking.” Their quest for opioids is directly related to inadequate pain relief caused by an inappropriate opioid or inadequate doses spaced too far apart.
(Drug tolerance and dependence is also discussed later in this course under “Pain Management in Individuals with Substance Use Disorders” and “Palliative and Hospice Care.”)
WORLD HEALTH ORGANIZATION PAIN MANAGEMENT LADDER
Because of widespread misconceptions about treatment of chronic pain and addiction, the World Health Organization (WHO) recommends a three-step pain relief ladder based on the intensity of pain.
To prevent undertreatment of malignant cancer pain, some authorities recommend a different approach. They begin the treatment of malignant cancer pain with strong opioids, providing immediate relief, then slowly reduce the type and dosage until pain relief is achieved at a lower level.
Source: WHO, 2013.
A placebo, sometimes called a “sugar pill,” is an inactive substance prescribed as if it were an effective dose of a medication even though the clinician believes it has no specific pharmacologic effect upon the condition being treated. Research has found that placebos produce hoped-for results in 30% to 50% of the people who take them (Thompson, 2000).
Nevertheless, because it may involve deception and the patient’s right to autonomy, the clinical use of placebos is a controversial issue. The ethical code of the American Medical Association addresses the use of placebos as follows:
Physicians may use placebos for diagnosis or treatment only if the patient is informed of and agrees to its use. A placebo may still be effective if the patient knows it will be used but cannot identify it and does not know the precise timing of its use. A physician should enlist the patient’s cooperation by explaining that a better understanding of the medical condition could be achieved by evaluating the effects of different medications, including the placebo. The physician need neither identify the placebo nor seek specific consent before its administration. In this way, the physician respects the patient’s autonomy and fosters a trusting relationship, while the patient still may benefit from the placebo effect (AMA, 2007).
Although there are myriad drugs to relieve pain, all have some risk and cost. Fortunately, there are many nonpharmacologic interventions to reduce pain, especially when used in conjunction with pharmacologic measures. Described as physical and cognitive-behavioral interventions, many of these approaches are noninvasive, low-risk, inexpensive, easily performed and taught, and within the legal scope of practice of healthcare professionals. Physical interventions give comfort, increase mobility, and alter physiologic responses. Cognitive-behavioral interventions alter the perception of pain, reduce fear, give a greater sense of control, and are called holistic care.
Comfort measures such as clean and smooth sheets, soft and supportive pillows, warm blankets, and a soothing environment have been used by caregivers throughout history to relieve pain and suffering. These measures may be difficult to provide in the noisy, mechanized healthcare facilities of today. Nonetheless, they are important to the mental and physical well-being of patients.
Position change and movement are well-known pain-relieving interventions. Moving the body, even a small amount, relieves muscle spasm and provides a degree of pain relief. So important is movement of the body to health, an entire profession has developed specializing in physical therapy. Other caregivers, however, need not wait for a specialist to offer such important pain-relieving interventions.
Massage relieves muscle spasm, improves circulation, and provides cutaneous stimulation. While there are many different massage techniques, they all involve rubbing the skin in various patterns and degrees of pressure. Once considered an expected part of basic care, backrubs offer an important noninvasive way to relieve pain and provide comfort.
Applications of hot and cold are effective pain-relieving measures when used appropriately. Heat decreases muscle spasm and increases blood flow to an area. Cold decreases blood flow, edema, and inflammation and may decrease muscle spasm and pain. Many devices are available to provide hot and cold, including electric heating pads, patches, and ice packs. Soaks and baths relieve muscle spasm and are important measures to provide comfort.
Adaptive devices are pieces of equipment that assist clients in carrying out the activities of daily living with reduced pain and greater ease. For example, larger handles on tools can help lessen joint pain in the hands. Longer handles on garden spades can allow people to work in the garden with less lower back pain. Occupational therapists specialize in assessing client needs and identifying such adaptive devices to reduce pain and facilitate function.
Transcutaneous electrical nerve stimulation (TENS) provides a continuous, mild electric current via 2 to 4 electrodes placed on the skin near a painful site. The stimulator is a small, battery-operated device worn by the client. Experienced as a tingling sensation, TENS works by stimulating large nerve fibers to close the “gate” in the spinal cord. It also may stimulate endorphin production. TENS may be used for acute postoperative pain or for chronic conditions such as low back pain, phantom limb pain, and neuralgia.
Surgical interventions may be recommended when severe pain persists despite medical treatment. If pain is due to a known condition, such as osteoarthritis of a joint, joint replacement surgery may be offered. When specific interventions are not available and conservative measures do not relieve pain, surgical interruption of pain pathways may be undertaken. Rhizotomy and cordotomy are two such procedures.
In a rhizotomy the surgeon isolates the nerve roots as they enter the spinal cord and delivers neurolytic chemicals, heat, extreme cold, or radio frequency (RF) impulses or performs a laminectomy. This destroys the nerves’ ability to transmit pain signals to the brain. With RF rhizotomy, nerves will regenerate and pain relief lasts for only 6–24 months in most patients. A cordotomy is more extensive than a rhizotomy, involving resection of the spinothalamic tract. Both procedures can cause permanent loss of pain and thermal sensations and may cause paralysis due to motor nerve damage.
Relaxation exercises are useful ways to reduce anxiety, decrease muscle tension, and lower blood pressure and heart rate. They induce a state of altered consciousness and give individuals a sense of control and peace of mind. Meditation, yoga, and other such interventions may effectively relieve pain. Recent studies found that “mindfulness meditation training significantly reduce[d] pain unpleasantness by 57% and pain intensity ratings by 40% when compared to rest” (Zeidan et al., 2011).
One such exercise involves controlled breathing. A coach speaks in a calm, clear voice, suggesting the subject begin by breathing slowly and diaphragmatically, allowing the abdomen to rise slowly and the chest to expand fully. Then, the coach suggests the subject locate an area of muscle tension, contract the muscles in that area, and then relax them. As the subject relaxes, pain perception and anxiety diminish.
Guided imagery is similar to relaxation exercises in that a coach leads subjects in a calm, clear voice, often beginning with a relaxation exercise. The coach then suggests subjects imagine themselves in some peaceful place where they experience various sensory pleasures such as the warmth of the sun, the sound of ocean waves, and the smell of salt water. The purpose of the exercise is to provide an experience of relaxation and relief from stress and pain.
Distraction diverts the attention of individuals away from painful stimuli. When people focus on something that gives pleasure, they are less likely to feel acute pain. This phenomenon occurs because the reticular activating system briefly inhibits the awareness of pain. Distraction works best for short acute pain, such as a needle stick. Such things as listening to music, watching an intense scene on television, or describing something of special interest may temporarily distract a person from pain. Distraction, however, does not work for chronic, long-term, or severe acute pain.
To relieve their pain, an increasing number of people in the United States are turning to theories and practices outside the realm of conventional Western medicine. To address this trend, in 1991 the U.S. Congress passed legislation to establish an office within the National Institutes of Health to investigate and evaluate unconventional medical practices. In 1998, the agency became the National Center for Complementary and Alternative Medicine (NCCAM). The mission of NCCAM is to “define, through rigorous scientific investigation, the usefulness and safety of complementary and alternative medicine interventions and their roles in improving health and healthcare” (NCCAM, 2012a).
In this context, complementary describes practices used in conjunction with or to supplement conventional medical treatments and alternative means those practices used independently or in place of conventional medicine. Practitioners of such techniques and practices often use the term holistic because they view health and illness as affecting the whole person—body, mind, and spirit.
The major categories of complementary and alternative medicine are:
Biologic. Plants have been used to treat human ailments throughout history. Their therapeutic effects are due to the chemical compounds they contain. Such chemicals may be administered to patients by giving some part of a plant or by extracting or synthesizing the essential chemical. When prepared in a purified form, the dose of known active ingredients is more precise than it can be from a plant. Some common drugs originally derived from plants are: digitalis, found in the foxglove plant; atropine, a tropane alkaloid extracted from nightshades; and morphine, one of the most abundant and potent opiate analgesic drugs, derived from the poppy.
Energy Fields. Energy field healing measures are based on theories about unseen forces in the human body. For example, acupuncture is based on an ancient Chinese theory that two opposing forces, yin and yang, move along meridians in the body and when these forces are out of balance, pain and illness result. There are at least 350 acupuncture points by which energy flows are accessible. The theory posits that by stimulating these points with very fine needles, energy flows can be rebalanced and pain relieved.
Recent research addressed the pain-relieving differences between traditional acupuncture and stimulated approaches. NCCAM found that “the study provides the most robust evidence to date that acupuncture is more than just a placebo and is a reasonable referral option for patients with chronic pain” (2012b).
Manipulative/Body-Based. Manipulative/body-based measures focus on the relationship between the body’s structure and its functioning. In chiropractic treatment, the most widely known interventions are adjustments to the spine or other parts of the body with the goal of correcting alignment problems and supporting the body’s natural ability to heal itself. Side effects and risks depend on the type of manipulative treatment. Research has examined the effects of various approaches, how they work, and the conditions for which they may be most helpful (NCCAM, 2012c).
Osteopathy is a medical specialty that combines traditional and nontraditional medicine and includes the use of manipulative/body-based techniques. Doctors of Osteopathy (DOs) are also licensed to perform surgery and prescribe drugs.
Mind-Body. These measures actively employ the mental capacity of individuals to manage chronic pain. They include such things as biofeedback and hypnosis. Biofeedback uses an electric device to gather information about physical responses and report them back to clients. The information goes to the biofeedback machine by way of electrode sensors placed on the person’s skin. The machine displays information as visual signals on a monitor. As clients watch the signals, they learn to control their responses.
Another example, Mindfulness-Based Stress Reduction (MBSR) started in the United States in the Stress Reduction Clinic at the University of Massachusetts Medical Center in 1979 and is now offered in over 200 medical centers around the world. Research studies have found that MBSR can contribute to decreased drug use, increased activity levels, and greater feelings of well-being.
Hypnosis creates a trancelike state that resembles normal sleep during which perception and memory are altered, resulting in increased responsiveness to suggestion. The Nursing Interventions Classification (NIC) defines hypnosis as “assisting patients to achieve a state of attentive, focused concentration with suspension of some peripheral awareness to create changes in sensation, thoughts, or behavior” (Bulechek et al., 2012).
Evaluation is one of the most critical phases of the caregiving process. It tells us the degree to which an intervention achieved an expected outcome. If the expected outcome is pain reduction, evaluation tells us if the intervention did, in fact, reduce pain and if so, how much and at what cost in time, treasure, and long-term effects.
To find out, we gather data from the best source of information, the client, or the second-best source, the client’s caregivers. To be of value, the information must address the aspects of pain that were noted before the intervention, including the location, intensity, quality, and duration of the pain. In addition, data is gathered about adverse effects of an intervention, such as an allergic reaction, hypotension, or respiratory depression.
Such feedback is essential if we are to revise the plan of care to make it more effective. A positive evaluation means that an intervention was successful and probably should be continued. A negative evaluation means that an intervention was not satisfactory and should be changed. Hence the adage “negative feedback makes for change.”
Communication about pain and the response of clients to pain-relieving interventions is facilitated by accurate and thorough documentation. This communication needs to be conveyed from caregiver to caregiver. Various tools have been devised to facilitate this communication, including pain-flow sheets, running diaries, and bedside computer charting, called “point-of-care.”
When communicating information about pain, it is important to describe the time and exact nature of an intervention, including details such as an analgesic, dose, level of pain before and after the intervention, and adverse effects, such as respiratory depression. The more specific a report, the more effective the care.
Because pain is a potent motivator for change, people who suffer are vulnerable to all manner of fake gadgets and magical cures. It is the responsibility of healthcare professionals to give patients accurate information and to teach them about medications, devices, physical activities, and psychological strategies in clear, understandable ways. Such teaching empowers those who suffer and demonstrates genuine concern, accurate empathy, nonpossessive warmth, and respect.
Unbelievable as it may seem, only recently has the medical profession taken seriously the pain and suffering of infants and children. Not long ago, newborn infants were circumcised without anesthesia or analgesia, and seriously injured children were given pain medication “as needed.” Happily, such undertreatment of pain in children is changing. Better assessment tools, new pharmaceuticals, and innovative delivery systems are contributing to these advances.
Research has shown that neonates and infants do feel and remember pain. In fact, by 6 months of age, when children are taken to places where they previously experienced pain, they demonstrate anticipatory fear (Pasero, 2004). One study measured the long-term effect of newborn circumcision without analgesia on behavioral response to immunizations. When pain was measured by observable indicators such as facial expression, length of crying, and body movement, 4- to 6-month-old infants circumcised without analgesia had higher pain scores than those circumcised with analgesia (Anand et al., 2007).
Other research found some children so traumatized by past injections that were intended to relieve pain that they were afraid to admit having present pain (Stevens, 1999). These and other studies have corrected many misconceptions about pain in infants and children, as described in the table below.
|Preterm infants are less sensitive to pain than term infants and older children due to an immature nervous system.||Preterm infants have the anatomical and functional ability to process pain and an even greater sensitivity to pain than term infants.|
|Infants and children have a diminished perception of pain and no memory of its occurrence.||Perception of pain is present with the first insult, requires no prior experience, and is remembered.|
|Infants are incapable of expressing pain.||Although infants cannot verbalize pain, they give physical signs and behavioral cues.|
|Pain in infants cannot be assessed accurately.||Behavioral cues and physiologic signs of pain can be reliably and validly assessed; facial expressions are the most valid indicators.|
|Anesthetics and analgesics cannot be given to neonates and infants because of an immature ability to eliminate drugs.||Infants older than 1 month metabolize drugs in the same way as older infants and children.|
|Opioids are too dangerous to give to infants and children because of the risk of addiction and other adverse effects.||Adverse effects of opioids and nonopioids can be minimized by careful monitoring and drug titration.|
|Infants and children tolerate pain well and become accustomed to pain.||Pain is pain, whether it occurs in an infant, child, or adult.|
|Postoperatively, children should not receive the next analgesic dose until they show obvious signs of pain.||Opioids are most effective if administered as a continuous infusion rather than “as needed,” thus avoiding the need of children to complain.|
|Infants and children cry or complain at the slightest discomfort even when they are not in pain.||Often children are afraid to complain of pain because their fear of an injection is greater than their pain.|
To manage pain effectively, healthcare professionals need to be able to communicate with children and adolescents. Such interaction must be appropriate to age and stage of development. The following table describes some approaches that can be used to refine the caregiver’s interactions with children and, at the same time, model effective communication skills for family members.
|Age and Stage||Approaches and Communication Modes|
|Source: Cohen, 2005.|
Because infants and very young children may not be able to tell us they are in pain, caregivers must use other means to gather information about their distress. Acute pain initiates a response known as the general adaptation syndrome (GAS). This begins with the sympathetic nervous system, causing initial physiologic signs such as tachycardia, rapid respirations, hypertension, pupil dilation, pallor, and increased perspiration—the alarm reaction.
As the stress response continues, the body adapts physiologically in the resistance stage, and vital signs return to near normal and perspiration decreases. For this reason, measurement of vital signs is not a reliable indication of pain in children. Other means must be used to gather this information. Eventually, when severe, prolonged pain goes unrelieved, the body enters the exhaustion stage, causing release of catecholamines, cortisol, aldosterone, and other corticosteroids and decreased insulin, which leads to hyperglycemia.
Long before pain pushes infants and children to the exhaustion stage, they show behavioral signs in developmental and age-appropriate behavioral responses. The table below summarizes some common responses of infants and children to pain.
|Age||Behavioral Response||Verbal Response|
|Source: Adapted from Ball et al., 2011.|
|Generalized body movement, facial grimacing, chin quivering, refusal to drink or eat||Crying|
|Disturbed sleep, irritability, reflex withdrawal to stimulus||Crying|
|Disturbed sleep, aggressive behavior, localized withdrawal||Crying, screaming, unable to describe intensity of pain|
|Low frustration level, active physical resistance, strikes out when hurt||Able to identify location, intensity, and characteristics of pain|
|Resists passively, holds body rigidly, emotional withdrawal, plea bargains for relief of pain||Able to identify location, intensity, and characteristics of pain|
|May regress with stress and anxiety, pretend not to hurt to project bravery, perform poorly in school||Able to describe location, intensity, and characteristics in detail, including psychic pain|
|Controls behavior to be socially acceptable, may perform poorly in school, irritable, unable to concentrate||Detailed, able to give a more complete description of pain and its meaning|
The assessment of pain in children should include gathering all the same details as with adults, namely the location, intensity, quality, chronology, pattern, precipitating events, alleviating actions, and accompanying symptoms. Information about these factors is gained by means of a pain history, physical examination, observations, and various pain assessment scales. Occupational therapists also assess the functional activities of children as they play with toys or with other children in order to determine what adaptations need to be made to the environment or activities to decrease a child’s level of pain.
Debby is a right-handed 8-year-old. She is confined to a bed in a noisy, busy pediatric unit, awaiting the results of an x-ray of her injured right arm. To distract her from her pain, an attendant gives her a package of crayons and a pad of paper, and Debby is trying to draw with her left hand. It doesn’t work, so she puts a crayon in her right-hand fingers and tries again to draw. The cast is heavy and the pain too great. Frustrated and hurting, she throws the crayons and the paper on the floor and cries out, “It just hurts too much!”
Obviously, crayons and a pad of paper were not the right toys at this time, in this environment, under these circumstances. John, an OT working in the unit, explains to the attendant that Debby needs a quiet, age-appropriate, low-energy activity that will distract her from her discomfort, such as a storybook read by her mother. Better yet, it may be time for her pain medicine and for Debby to sit in her mother’s lap and just be held.
In today’s information age, healthcare providers have ready access to earlier medical and surgical events in the life of infants and children. However, details about their pain, effective pain-relieving measures, and the family’s customary approach to pain may not be included in the record. This information may be gathered in a pain history, using tools such as the questionnaire shown below.
|Child||Parent or Caregiver|
|Can you tell me what you are feeling? Where does it hurt?||What word or words does your child use in regard to pain?|
|Have you ever had a pain (hurt, owie, ouch, etc.) before?||What painful experiences has your child had before?|
|When you have a hurt, whom do you tell?||Does your child tell you or others when in pain?|
|What do you want others to do for you when you hurt?||How do you know when your child is in pain?|
|What do you do for yourself when you are hurting?||How does your child usually react to pain?|
|What helps the most to take away your hurt?||What works best to decrease or take away your child’s pain?|
|Is there something special you want me to know about you when you hurt? If so, what is it?||Is there something special you want me to know about your child and pain? If so, what is it?|
Complaints and signs of pain in children need to be taken seriously and investigated immediately. The physical examination should include inspection, palpation, percussion, and auscultation:
Although procedural and postoperative pain is anticipated, unexpected intense pain should be assessed immediately, particularly if it is accompanied by altered vital signs. Such pain may signal serious complications, such as internal bleeding, hematoma, constricting bandages, allergic reaction, infection, or even wound dehiscence.
Because infants and children are dependent on the adults in their lives and in many ways are molded by them, observation of interactions between children and family members informs caregivers about how children respond to pain. Children who have been punished or shamed for crying may not report pain and may suffer in silence. Others who had been neglected or ignored may have found the only way to get attention was to cry; thus, they may need affection more than pain medicine.
Children are in a state of constant change—physically, mentally, and emotionally. For this reason, pain assessment strategies are more effective it they are adapted to chronological age, developmental level, functional status, cognitive ability, and emotional status. Although a complete pain assessment includes many variables, the most common one in hospitalized children is intensity. Thus, most assessment scales focus on that issue. The table below lists some well-known assessment scales according to the age and developmental level of children.
|Age Group||Name of Scale||Description of Scale|
|Preterm (28–36 weeks’ gestation)||Premature Infant Pain Profile (PIPP)||Assessor observes for 5 to 30 seconds on various pain indicators, including physiologic signs; gestational age affects scoring (Pasero, 2002a).|
|Preterm–6 weeks||Neonatal Infant Pain Scale (NIPS)||Assessor scores infant on six criteria: crying, facial expression, breathing pattern, arm movement, leg movement, state of arousal (Lawrence et al., 1993).|
|Neonatal facial responses||Illustration of a neonate in pain.|
|Birth–6 weeks||CRIES Neonatal Post-Op Pain Scale||Assessor scores infant’s crying, requiring oxygen, increased vital signs, expression, sleeplessness as 0 to 10; severe pain = 10 (Pasero, 2002a).|
|Birth–3 years||Netherlands Comfort Scale||Assessor scores 0 to 5: child’s alertness, agitation, respirations, crying, physical movement, muscle tone, facial tension; severe pain = 35 (Van Dijk & Tibboel, 2005).|
|2 months–7 years||FLACC Behavioral Pain Assessment Scale||Assessor observes child for 1 to 5 minutes, then scores face, legs, activity, crying, consolability as 0 to 10; severe pain = 10 (Pasero, 2002b).|
|3–6 years||Finger Span Scale||Assessor uses span of index finger and thumb to indicate degree of pain. Asks, “How big is your pain?” (Merkel, 2002).|
|3–7 years||Oucher Scale (photographs)||Photos of 3 children of different skin color in 6 levels of pain, from no pain to severe pain (Ball et al., 2011).|
|Poker chips||Assessor uses piles of poker chip, from 1 to 5; asks “How much is your pain?” (Ball et al., 2011).|
|4–16 years||Wong-Baker FACES Pain Scale||Illustration of 6 faces, from smiling to crying, (0, 2, 4, 6, 8, 10) (Wong-Baker, 2012)|
|9 to 18 years||Number Scale||Assessor asks child, “On a scale of 0 to 10, with 10 being the most, how much is your pain?”|
The North American Nursing Diagnosis Association (NANDA) has identified two primary diagnoses for pain: acute and chronic. Acute pain is sudden and of short duration (less than 6 months). It includes the pain caused by surgical and medical procedures and by trauma and burns. The diagnosis of pain in a child with burns might be “acute pain related to tissue damage manifested by continuous, searing pain.” Chronic pain lasts for 6 months or longer and is generally associated with a prolonged disease process. The diagnosis of pain in a child with juvenile rheumatoid arthritis might be “chronic pain related to inflammation of right knee, manifested by aching pain.”
During the planning stage, healthcare professionals synthesize the information they have gained from the pain history, physical examination, and assessment and plan appropriate interventions. The goals of interventions are to relieve pain both physically and emotionally, reduce complications, and facilitate a return of function. Of course, there may be many other diagnoses, such as anxiety and a risk of infection, each of which includes specific interventions and expected outcomes.
As with adults, there are both pharmacologic and nonpharmacologic interventions for pain in children. Pharmacologic interventions include nonopioids, opioids, and adjuvant drugs. Nonpharmacologic interventions include physical and cognitive-behavioral measures. While drugs used to alleviate pain in adults may be prescribed for infants and children, they must be in preparations that are appropriate to the development of the child, such as a liquid rather than a tablet, and they must be in safe and effective dosages relative to the body weight of the child.
As new analgesics gain FDA approval, manufacturers publish suggested dosages according to body weights. Often equianalgesic doses are calculated for children and adults who weigh more or less than 50 kilograms (110 pounds). As a cautionary measure, many physicians prescribe potent drugs in smaller-than-recommended initial doses.
Pain relief for children should be continuous, not sporadic or “as needed.” When analgesics are given “as needed,” greater amounts of analgesics are required to restore pain control. The preferred routes of administration are intravenous for acute pain and oral as the child recovers. Continuous infusion analgesia eliminates the highs and lows of pain control and is recommended to maintain constant drug levels, particularly in children with severe, persistent pain. If oral preparations are prescribed, they should be scheduled to reduce the likelihood of breakthrough pain and the expectation of its return.
Patient-controlled analgesia (PCA), such as intravenous morphine, can be used for children 5 years of age or older. The healthcare provider programs a computerized pump to deliver a fixed dose of analgesic at certain intervals, controlled by the child. After initial pain control has been achieved, the child can press a button to receive a smaller analgesic dose for episodic pain relief. In addition, the PCA monitor can be set to infuse analgesics continuously, thus preventing pain during sleep. As the child’s pain lessens, the PCA is discontinued and oral analgesics are prescribed.
Regional nerve blocks and continuous epidural infusions of analgesics via the lumbar or caudal space are being used with increasing frequency in children. In these procedures only small doses are required to achieve pain relief because a high concentration is delivered to opioid receptor sites. Though these methods of pain control require specialized knowledge, they are increasingly popular because they avoid many adverse effects of opioids on other body systems.
Because pain is a subjective experience, influenced by the emotions, stress, sleep, activity, and even nutrition, it can be controlled by a variety of interventions. Fortunately, children respond well to nonpharmacologic pain-reduction measures, especially when they are used in conjunction with appropriate pharmacologic interventions. Some of these interventions are: comforting, distraction, relaxation, hypnosis, imagery, applications of hot and cold, massage, and transcutaneous electrical nerve stimulation (TENS).
Comforting is one of the most important nondrug measures to relieve pain. The enfolding arms of a parent or caregiver around a frightened child provide far more than physical warmth. They give the child basic needs important to survival, such as safety, security, acceptance, and recognition. In fact, studies show that infants who do not receive adequate amounts of touch fail to thrive, even when they are fed and otherwise cared for (Polan et al., 1991). As a consequence, healthcare professionals encourage parents to participate in the care of children in pain. If parents are not available, surrogates may be found to provide this valuable intervention.
Distraction is a useful way to divert a child’s attention away from a painful event, such as a needle stick. Focusing on something of pleasure, such as listening to music, watching an intense scene on television, or listening to a gripping story may temporarily distract a child from pain or reduce the amount of analgesic required to eliminate pain. Distraction works best for short acute pain, not for severe or chronic pain.
Relaxation, hypnosis, and imagery are especially effective pain relieving measures for children when they are used in conjunction with analgesics. Because children have an active imagination, unhampered by learned responses, they are able to disassociate from present reality to imaginary scenes and situations. These measures are especially useful when children must undergo repeated painful procedures.
Applications of hot and cold have been used for centuries to dull the pain of an acute injury and treat painful muscle spasms. Young athletes are well-acquainted with the use of cold to contract blood vessels, reduce inflammation, and numb peripheral nerves, and with heat to decrease muscle spasms and increases blood flow. People of every age find warm baths comforting and pain relieving.
Massage and touch stimulate the skin and comfort individuals of every age, even tiny pre-term infants. These measures give both children and adults the nonpossessive warmth and unconditional positive regard so needed when people are suffering and frightened.
Transcutaneous electrical nerve stimulation (TENS) delivers small amounts of electrical stimulation to the skin by electrodes. This stimulation may interfere with the transmission of pain from the peripheral nerves to the spinal cord. TENS is used for both acute and chronic pain in children of school age and older.
As with adults, pain relieving interventions for children are judged by their effectiveness and the severity of adverse effects. Such evaluation must be continuous, hour by hour, and day by day. To effect change, evaluation must be documented and communicated to those who provide ongoing care. If pain is not relieved adequately or if adverse effects occur, caregivers need to take corrective action. Children of any age should not have to suffer pain.
All people deserve pain management of the highest quality, including those who sustain injuries, undergo invasive procedures, give birth, or suffer from painful diseases. Some folks, however, are especially vulnerable because they have conditions that complicate pain management. These include disorders of aging, cognitive and mental condition, substance use disorders, headaches, and neuropathic syndromes.
By all standards of measurement, the relief of pain is inadequate in older adults. Yet, this sorry picture of pain management in older adults need not continue. With educational programs for older adults, their caregivers, and especially healthcare professionals, needless suffering can be reduced.
Unrelieved pain is so common among older adults that it is accepted as inevitable and cynically described as “better than the alternative” (i.e., death). Research has shown that:
Financial constraints add to the problems of pain in the aged. Even when some of the newer sustained-release nonopioid and adjuvant drugs are prescribed, older adults may not be able to afford them. According to a survey of 2,038 adults by Consumer Reports, 16% said they had not filled prescriptions, 13% had taken expired drugs, 12% skipped doses, 8% split pills, and 4% shared a prescription with someone else to save money (Mann, 2011). In addition, pharmacies often limit the number of doses of opioid they will dispense per prescription, a policy that increases the cost to sufferers. In many states, Medicaid, the managed healthcare program for the poor, will not pay for more effective and more costly analgesics.
Fear of addiction and the side effects of analgesics, especially opioids, keep many older adults from taking medications sufficient to relieve their pain. As a result, they take smaller doses than are prescribed or they wait until the pain is unbearable before they “give in” and take an analgesic, reducing its effectiveness.
Age-related pharmacokinetics—the absorption, excretion, and action of drugs—differs significantly from one individual to the next, particularly in an ever-enlarging population of people over 85 years of age, the so-called “old-old.” Though their physical stamina varies widely, many of these folks are frail, cared for in long-term care facilities, and at risk for both under- and over-treatment with drugs. For this reason, pain management requires particular attention at every step of the caregiving process.
Older adults often have difficulty hearing, speaking, and seeing. These sensory and cognitive deficits may be due to the normal aging process or common disorders such as cataracts, cerebrovascular accident, and dementia. Because of these deficits, seniors need time to gather their thoughts and express their needs. Caregivers should listen carefully and speak slowly, distinctly, and loudly enough to be heard and understood. They may want to ask family members or personal caregivers about the body language of a particular individual who is suffering pain.
The following table lists some typical nonverbal indicators of pain and comfort.
|Body Language||Indications of Pain||Indications of Comfort|
|Source: Adapted from Perkins, 2002.|
|Behavior||Rocking, fidgeting, squirming, agitation, decreased socialization, crossing and uncrossing legs||Enjoys and participates in activities, positive responses to interaction and touch|
|Breathing||Labored, irregular, noisy||Effortless, even, quiet|
|Extremities||Resistant to repositioning, knees pulled up, stiffened joints, clenched fists, wringing hands||Cuddled up or stretched out in restful position, joints relaxed, hands open|
|Face||Scowling, clenched jaw, stern or frightened look||Placid expression, smile, relaxed jaw|
|Mood||Cranky, sad, irritable, combative, confused||Cheerful, pleasant, serene|
|Sleep||May increase due to exhaustion or decrease due to frequent wakening||Restful and untroubled through the night|
|Verbalizations||Moaning, groaning, monotone, muttering, screaming, screeching||Agreeable responses, singing to self, humming, quiet|
Pain assessment in older adults and persons with cognitive-mental disorders includes all the same factors as pain assessment in other adults and children, but with special considerations.
Because older adults suffer many chronic conditions, they may experience pain in more than one area of the body at the same time. To gather accurate data, healthcare professionals inquire about the specific location of pain, asking clients to touch the place or places that hurt. Some facilities provide line-drawing illustrations of the body, front and back, so that clients can indicate specifically areas where they feel pain.
A variety of scales are used to assess pain intensity in older adults, including numerical (0 to 10), descriptive (none-mild-moderate-severe-very severe), FACES (smiling to scowling), and vertically oriented (4-inch vertical line drawn on paper with “severe pain” at the top and “no pain” at the bottom) (D’Arcy, 2009). Regardless of the scale that is used, individuals need to understand their meaning.
When a caregiver breezes into a client’s room and demands, “What is your pain number?” the older adult may not understand what is being asked. Instead, the caregiver should say, “I want to find out about the pain in your [name the specific area]. On a scale of 0 to 10, with 0 being no pain and 10 being severe pain, what number would you say you are feeling in your [name the specific area] right now?”
Older adults often have their own terms to describe the quality of their pain. They may call throbbing pain “jumping” or sharp pain “stabbing or poking.” It may be helpful to ask the person to liken their pain to a familiar experience, such as the vibration of an electric motor or the pricking of a needle.
Most adults remember what they were doing when they first felt acute pain, such as “I was walking down the front steps.” However, chronic pain creeps up on people. They may not remember when or how it began. To alleviate pain, people often try home remedies first, such as a shot of whiskey, an herbal preparation recommended by a neighbor, or an over-the-counter medication advertised on television. For this reason it is useful to ask what remedies they have tried and which ones were most helpful.
It is important to learn what other-than-pain symptoms older adults are experiencing, such as dizziness, blurred vision, urinary incontinence or retention, diarrhea, and constipation. These symptoms may be due to prescription drugs, home remedies, drug interactions, or other disorders. All such symptoms should be reported, documented, and investigated.
All of the adult nonpharmacologic and pharmacologic interventions discussed in this course can be used for older adults. However, adverse effects of analgesic drugs are of special concern because of age-related changes in the body. In older adults, these adverse effects may occur with markedly different drug dosages than in younger people. Particular attention should be paid to adverse effects on renal and hepatic function, metabolism, and clearance of analgesics, for example:
Evaluation and documentation about interventions for pain are vital to the well-being of older adults because they tell us about both beneficial and adverse effects of interventions. Beneficial effects include such things as relieving pain, reducing anxiety, and increasing mobility. Adverse effects include such things as respiratory depression, mental confusion, and constipation. The latter are of particular concern because they endanger the well-being of older adults. Thus, caregivers monitor the effects of interventions and take corrective action when needed.
JOINT COMMISSION RECOMMENDATIONS
The Joint Commission (TJC) published specific recommendations for healthcare providers to manage pain in older adults. In essence, they suggested the following actions:
Source: TJC, 2000, 2012.
Cognitive and mental conditions may be apparent at birth or develop at any age thereafter. The causes of these conditions may be metabolic, toxic, structural, or infectious. Regardless of age or the cause of their condition, everyone with such conditions experiences real physical pain and deserves adequate and appropriate relief.
Respect and communication are vital. Nowadays, persons who have been cognitively impaired since childhood are often better equipped to tell healthcare professionals about their pain than people who have become impaired later in life. For instance, hearing-disabled children are taught signing (sign language) as part of their basic education. Adults with cognitive conditions seldom receive such instruction. Even so, healthcare providers can learn some signs and teach them to clients and family members.
Many strategies used with children are effective with cognitive and mentally impaired adults, including:
Pain management for individuals with substance use disorders (SUDs) is a serious concern because the drugs that relieve pain are the very ones that are misused. Individuals who suffer high levels of pain from traumatic injuries or painful chronic diseases such as pancreatitis and cancers are more likely to develop higher drug tolerance and physical dependency. Furthermore, drug craving is strongly associated with emotional and physical stress, yet the stress of unrelieved pain may contribute to substance use disorder (Koob & Kreek, 2007).
To better address the complex issues of pain management for people with SUDs, the American Society for Pain Management Nursing (ASPMN, 2012) published a position paper which:
UNIVERSAL PRECAUTIONS IN PAIN MEDICINE
To guide healthcare professionals who prescribe and administer Schedule II medication (drugs with high abuse potential), the ASPMN suggests the following universal precautions:
The National Institute on Drug Abuse offers similar guidance for clinicians involved in screening pain patients for substance use disorder risk factors (see “Resources” at the end of this course).
The ASPMN has published caregiving recommendations for patients with persistent pain, based on the risk of developing SUD. Risk is identified as low, moderate, and high (Gourlay et al., 2008).
Patients may be safely managed in primary care settings; monitor every 12 months.
Patients may be managed in primary care settings; monitor every 6 months.
Patients pose significant risk to themselves; require a specialist in addiction, pain management, and frequent monitoring.
Recommendations for patients at each risk level are provided in the ASPMN Position Statement (ASPMN, 2012). A brief summary of these recommendations follows.
Headaches are a special kind of pain that interferes with thought, creative endeavor, activity, and comfortable living. They have been classified as primary, secondary, and other. Primary headaches include migraine, cluster, and tension headaches. Secondary headaches include intracranial, extracranial, and systemic disorders such as encephalitis, glaucoma, and hypertension. Others include cranial neuralgias and facial pain.
Diagnosis requires information about the frequency, duration, location, severity, moderating factors, associated signs and symptoms, and special studies to identify their cause. Because secondary headaches are caused by underlying disorders, interventions require identification and treatment of the causative disorder.
In 1981, the International Headache Society (IHS) was founded to help people whose lives are affected by headaches. Their journal, Cephalalgia, provides an international forum for original research papers about headaches. In 2004, the society published the second International Classification of Headache Disorders (ICHD-2) , listing diagnostic criteria for headaches based on current clinical and laboratory observations (IHS, 2012).
Migraine headaches cause intense pain, often throbbing, which begins in and around the eye and spreads to one or both sides of the head and lasts 4–72 hours. More common in women beginning between the ages of 10 to 40, migraine headaches are often accompanied by anorexia, nausea, vomiting, photophobia, and phonophobia.
There are two types of migraine headaches: those with an aura of altered visual perceptions (15%) and those without an aura (85%). There is no evidence of underlying disease and the pathophysiology is not fully understood, though estrogen seems to be a significant trigger and explains the higher incidence in women (Merck Manual, 2011).
Migraines are believed to stem from a variety of triggers—such as allergens, bright light, and estrogen—that activate the trigeminal-vascular system, releasing neuropeptides. These neuropeptides increase trigeminal nerve activity, intensify the pain, and sensitize sensory neurons in the caudal brainstem and upper cervical spinal tract. As a result, normally nonpainful stimuli, such as light, noise, and touch, may cause severe, disabling pain (Frazel, 2004).
Interventions for migraines depend on the symptoms and frequency of their occurrence. These treatments are classified as prophylactic, abortive, and analgesic. For example, a prophylactic intervention may be to ingest a prescribed beta-blocker to lower blood pressure when hypertension accompanies migraines. An abortive measure may be to go to a dark, quiet environment at the first sign of a headache. An analgesic measure may be to ingest an analgesic. Complementary and alternative medical (CAM) interventions such as meditation and acupuncture may give relief.
Cluster headaches last 15 or more minutes and are severe, unilateral, and occur up to 8 times a day. They are associated with at least one of the following symptoms: facial sweating, stuffy nose, red eye, tearing, ptosis (drooping eyelids), and miosis (contraction of the muscle of the iris). Cluster headaches are triggered by barometric pressure change and alcohol ingestion and are more common in men.
Diagnosis is based on presenting symptoms and excluding intracranial pathology. As with migraine headaches, interventions for cluster headaches may be prophylactic (preventative, such as abstaining from alcohol), abortive (stopping the pain before it becomes more severe, such as taking an antihistamine), or analgesic (ingesting pain-relieving drugs such as hydrocodone//acetaminophen) (Merck Manual, 2011).
Sometimes called “muscle tension headaches”, these disorders are associated with stress and anxiety and are characterized by a tightening quality of pain without nausea or vomiting. They may last for 30 minutes to 7 or more days and are nonpulsating, bilateral, mild to moderate in intensity, and not aggravated by activity or exertion. They are thought to be a state of cranial hyperalgesia, aggravated by anxiety, and believed to be caused by mood disorders and sleep dysfunction.
Tension headaches are treated with nonopioid medications such as aspirin and acetaminophen and stress reduction measures such as meditation and physical exercise. Antidepressant and antianxiety medications may be effective. Because migraines are associated with tension headaches, treatment may overlap.
Secondary headaches are symptoms of other disorders. They may be intracranial, extracranial, or systemic. Intracranial disorders include such things as stroke, subdural hematoma, meningitis, brain abscess, and obstructive hydrocephalus. Extracranial conditions include such conditions as optic neuritis, glaucoma, dental, cervical spine, sinusitis, and mandibular joint disorders. Systemic ailments include hypertension, hypoxia, anemia, viremia, and caffeine withdrawal.
Treatment of secondary headaches involves addressing the underlying cause. For example, meningitis is treated with antibiotics and temporal arthritis with corticosteroids. Subdural hematomas and tumors within the inflexible bones of the adult skull increase intracranial pressure, cause pain, and usually are treated surgically.
So-called rebound headaches are a relatively common systemic ailment. They are believed to be caused by caffeine or other vasoconstrictors to which the body becomes tolerant. When the effects of caffeine wear off, blood vessels dilate, intracranial pressure increases, and a dull, generalized headache results. By gradually reducing caffeine or the offending drug, the body gradually adapts and headaches disappear (Merck Manual, 2011).
After direct injury to the central nervous system (CNS) or peripheral nervous system, pain may continue and become chronic. The cause of this pain is not fully understood but is believed to involve reorganization of central pain pathways in the brain related to its perception. This group of pain syndromes includes reflex sympathetic dystrophy, phantom pain, root avulsions, and polyneuropathy due to spinal surgery, mastectomy, and amputation. Sufferers complain of tingling, burning, and stinging sensations severe enough to interfere with thought, action, and sleep.
Medical diagnosis and treatment involve:
Pain management for these clients involves all the steps of the caregiving process, especially assessing their psychological status. This is important because people with chronic pain often feel helpless, hopeless, and worthless—feelings associated with depression and suicide. It is essential to encourage creative endeavor, instill hope, and affirm the person’s worth.
To many people, the word cancer means pain and death. Sadly, there is much to support this point of view. One study found that 30% of clients experience pain at the time of diagnosis, 30%–50% experience pain while undergoing therapy, and 70%–90% experience pain as cancer advances and overcomes their defenses (Portenoy & Lesage, 1999). Since then, even more pain-relieving treatments have been developed. To achieve the goal of providing adequate pain relief for people with cancer, healthcare providers seek to understand the causes and types of cancer pain, its impact on a patient’s life, and effective strategies to manage the pain.
Cancer pain is complex, interactive, and ever changing. It comes from two general sources: the cancer itself and its various treatments. As cancer cells invade healthy tissue, visceral and somatic nociceptors sense tissue damage and send pain impulses to the brain. Such pain may be localized at the cancer site or referred to a remote area. Not only do sensory impulses inform the person of tissue injury, they initiate the release of neuromodulators that produce localized inflammation, generating more pain. As nervous tissue is infiltrated by tumor growth or damaged by its treatment, neuropathic pain results, often persisting long after the initial insult.
In addition to physical pain, people with cancer and their families experience the emotional pain of anticipatory grief and the stress and fear of cancer and its treatment. Thus, cancer causes many kinds of pain: nociceptor, neuropathic, psychogenic, and secondary:
Pain caused by cancer depends on the site and extent of growth. Often, tumors produce clusters of symptoms, or syndromes. The table below lists some common cancer pain syndromes and a description of the typical pain they create.
|Peripheral nerve syndromes||Constant, burning pain with dysesthesia in area of sensory loss; radiating, often unilateral|
|Cranial neuropathies||Severe head pain with cranial nerve dysfunction; metastasis to skull base and leptomeningeal area|
|Vertebra of spine||Constant dull, aching pain; may be relieved by standing or exacerbated by recumbency|
|Bone: metastatic or primary||Aching, deep, intense pain, usually worse at night; pain may be referred; associated muscle spasm and stabbing pain with nerve involvement|
|Viscera||Pain in related area: pancreatic pain is relentless, boring, mid-epigastric, radiating through to the mid-back|
|Plexopathies||Cervical plexus||Aching and diffuse in shoulder girdle and radiating|
|Lumbosacral plexus||Aching, pressure-like, may be referred to abdomen, buttocks, lower back, or legs|
|Brachial plexus (Pancoast’s syndrome)||Heaviness and tightness in upper arm, radiating pain|
Modern medicine treats cancer with potent chemicals, radiation, and surgery, each of which can cause pain. These treatments destroy healthy cells as well as cancer cells, and their side effects may cause pain. Some side effects include incisional pain from surgery, emesis from chemotherapy, and stomatitis from radiation. Sweeder (2002) estimated that 20%–25% of cancer clients’ pain is directly related to its treatment. The following table lists some common syndromes that result from treatment modalities, associated pain, and its complications.
|Typical Pain and Complications|
|Postoperative Pain Syndromes||Incision pain; sharp and burning|
|Mastectomy||Tight, constricting, burning in back of arm, axilla, over chest; worse on movement; tingling in distribution of peripheral nerves; loss of sensation|
|Axillary lymphectomy||Numbness and aching due to edema|
|Thoracotomy||Referred pain to arm and chest, sensory loss around scar; reflex sympathetic dystrophy may develop|
|Amputation||Phantom pain in place of missing limb or body part|
|Radical neck dissection||Tight burning sensation and numbness or prickly sensation in the neck; dysesthesia in area of sensory loss|
|Oophorectomy||Surgical menopause, hot flashes|
|Post-radiation Pain Syndromes||Aching pain, similar to postoperative and tumor pain; radiation may cause new neurogenic tumors and soft-tissue fibrosis|
|Myelopathy||Aching or shooting pain in certain muscles|
|Necrosis of bone||Aching, prickling; may be localized or referred|
|Mucositis and stomatitis||Ulcers of the mucus membrane; raw, burning sensation; eating and drinking made painful|
|Post-chemotherapy Pain Syndromes||Some drugs (vesicants) seriously damage tissue if they leak outside blood vessels (extravasation); most cause nausea and vomiting|
|Mucositis and stomatitis||Painful ulcers of the mucous membrane most common, especially from methotrexate, doxorubicin, daunorubicin, bleomycin, etoposide, fluorouracil, and dactinomycin; appears about 10 days after beginning of treatment; pain on eating or drinking|
|Aseptic necrosis of the bone||Jaw pain; intermittent calf pain and/or prickling in hands or feet|
|Painful polyneuropathy||May feel pain in several places at once|
|Steroid pseudorheumatism||Aching pain in joints|
|Chemical menopause for estrogen-positive breast cancer||Hot flashes from tamoxifen, an anti-estrogen|
|Pain due to tests and devices||Sharp, piercing pain from needle sticks; abdominal distention from cleansing enemas and colonoscopies; discomfort from exposure; squeezing from machines; burning from extravasation of IV drugs|
Cancer pain is more than a physical symptom. It is a reminder of one’s mortality and a harbinger of death. It may interfere with normal routines, degrade the quality of life, and rob one of rest, creativity, joy, and peace. Cancer pain adds anxiety and stress to its sufferers and to their friends and family. For this reason, professional caregivers:
The management of cancer-related pain is complicated when sufferers have pre-existing chronic pain, a history of substance abuse, or are failing and near death. For this reason accurate assessment is essential, especially of “new pain.” Caregivers may find the acronym OLDCART a useful tool as they gather information about the person’s pain:
L Location (possibly multiple sites)
D Duration (how long it lasts and whether it is constant or intermittent)
C Character (sharp, shooting, dull, aching, cramping, squeezing)
A Aggravating factors (moving, walking, sitting, turning, chewing, breathing, urinating, defecating, swallowing)
R Relieving factors (activities or drugs that make pain better or worse)
T Treatment (drug or nondrug interventions) (Bednash & Ferrell, 2002)
Cancer pain is treated with both pharmacologic and nonpharmacologic therapies. Pharmacologic remedies include nonopioid analgesics, opioid analgesics, and co-analgesics/adjuvants. Nonpharmacologic therapies include surgical, complementary, and alternative measures. Unlike postoperative or post-trauma pain, cancer pain may go on for months and years. Thus, ongoing assessment and intervention is required. Many healthcare facilities specialize in cancer pain treatment, such as the Cancer Treatment Center of America (CTCA) (see “Resources” at the end of this course).
Palliative care is the active, total care of clients with a goal of providing comfort rather than cure. Such care addresses pain control, symptom management, and social, emotional, spiritual, and financial concerns of people, regardless of age, prognosis, or length of time the care is needed. Hospice care is palliative care given at the end of life. Medicare provides hospice benefits when two physicians certify a patient has less than 6 months to live if his or her disease follows its usual course. However, community agencies provide palliative care to the sick and dying regardless of prognosis.
PAIN MANAGEMENT GUIDELINES FOR END-OF-LIFE CARE
To provide better care for individuals who are suffering at the end of life, Paice and Fine (2001) suggest the following guidelines:
Many people roll their eyes and change the subject when they hear the word ethics, viewing it as too controversial or too complex to discuss freely. Nonetheless, ethics is a significant concern of thinking, caring persons who manage the care of people in pain.
Ethics is the branch of philosophy concerned with the rightness or wrongness of human behavior and the goodness or badness of its effects. Ethics assumes that people have the ability to make choices about their behavior. Prescriptive ethics offers advice about how people should decide what is good or bad behavior. It does this from two very different perspectives: teleological and deontological.
Bioethics is the application of ethics to matters of human life. As scientific knowledge expands and healthcare providers have greater control over pain and pain relief, life and death, it is vital that caregivers address issues of right and wrong behavior.
Over the years, five ethical principles have emerged as especially applicable to healthcare providers and can be seen as related to pain management. They include: respect for human life and dignity, beneficence, autonomy, honesty, and justice.
Respect for human life and dignity is one of the most basic of ethical principles. It requires that “individuals be treated as equal to every other individual and that special justification is required for interference with an individual’s own purposes, privacy, and behavior” (Rawls, 1971). When applied to pain management, respect for human life and dignity means caregivers:
Beneficence means doing good to benefit others. For caregivers, beneficence means more than providing technically competent care. It means acting in ways that demonstrate genuineness, empathy, nonpossessive warmth, support, and nurturance. In fact, the central task of caregivers—the very essence—is doing good for others. When applied to pain management, beneficence means caregivers:
Autonomy is the right of self-determination, independence, and freedom. It is the personal right of individuals to absorb information, comprehend it, make a choice, and carry out their choice. Caregivers demonstrate the principle of autonomy when they provide accurate information to clients, help them comprehend it, and respect the decisions they make as a result of their understanding. When applied to pain management, autonomy means caregivers:
Honesty means communicating the truth in word and deed. Even when caregivers must convey unwelcome information about an illness, injury, or treatment option, they must do so truthfully. Withholding information from clients is appropriate only when they are minor children or adults who require a legal guardian. When applied to pain management, the ethical principle of honesty means caregivers:
Justice implies fairness and equality. It requires impartial treatment of clients. Like other ethical principles, justice is based on respect for human life and dignity. The traditional image of justice is a blindfolded woman with a scale, weighing an issue on the basis of objective evidence and judicial precepts. Justice means that scarce resources are distributed equally, using the same criteria for everyone. When applied to pain management, the ethical principle of justice means caregivers:
A dilemma is a perplexing problem that requires a choice between conflicting alternatives. An ethical dilemma is a moral problem that requires a choice between optional actions, each of which is based on an ethical principle. For example, a caregiver weighs whether to fully disclose the risks of a proposed treatment for pain, honoring the ethical principle of autonomy, or to withhold such information to reduce the client’s anxiety, honoring the ethical principle of beneficence. Healthcare professionals are faced with many such dilemmas.
Resolution of ethical dilemmas requires evaluation of all the facts of the case, consultation with concerned parties, and appraisal of the decision-makers’ ethical stance (whether it is teleological, considering end results, or deontological, obeying fixed laws of behavior).
Nowadays, ethical dilemmas in healthcare facilities arise more frequently because modern medicine can keep hearts and lungs functioning much longer than thinking brains. To help resolve these perplexing issues, many institutions appoint ethics committees made up of healthcare professionals, ethicists, lawyers, and clergy. The task of these committees is to help decision-makers resolve ethical dilemmas using a process such as the following:
Codes of ethics are formal statements that set standards of ethical behavior for groups of people. In fact, one of the hallmarks of a profession is a code of ethics to which its members subscribe. For instance, the American Nurses Association’s (ANA), the American Physical Therapy Association, and the American Occupational Therapy Association (AOTA) all make explicit the goals and values of their professions and provide guidance for practitioners to meet those standards by publishing codes of ethics for their members.
In 1971, in response to the growing misuse and abuse of drugs in the 1960s, Congress passed the Comprehensive Drug Abuse, Prevention, and Control Act. Known as the Controlled Substance Act, the legislation is of particular concern to healthcare professionals concerned with the management of pain. The act created a schedule of controlled substances, ranking them according to their potential for abuse. Specifically, it identified five categories or schedules of drugs, from those with the highest abuse potential (C-I) to those with the lowest abuse potential (C-V), as shown in the table below.
|Category/Schedule||Abuse Potential||Dispensing Restrictions||Examples|
|C-I||High, possible severe psychological and physical dependency; no approved medical use||Only with approved protocol||Heroin, marijuana, LSD, mescaline, peyote, psilocybin, methaqualone|
|C-II||High, possible severe physical or psychological dependency||Written prescription only (if phoned in, written prescription required within 24 hours), no prescription refills, container warning, label required||Codeine, cocaine, hydromorphone, morphine meperidine, methadone, oxycodone, secobarbital, pentobarbital, amphetamine, methylphenidate|
|C-III||Less than C-II drugs, moderate to low physical or high psychological dependency||Written or oral prescription that expires in 6 months, no more than 5 refills in 6 months, container warning label required||Combination drugs containing hydrocodone, codeine, morphine, dihydrocodeine, oxycodone, paregoric; non-narcotic compounds of pentazocine, propoxyphene|
|C-IV||Less than C-III, limited physical or psychological dependency||Written or oral prescription that expires in 6 months, no more than 5 refills in 6 months, container warning label required||Barbital, phenobarbital, chloral hydrate, meprobamate, fenfluramine, benzodiazepines, pentazocine|
|C-V||Less than C-IV, limited physical or psychological dependency||Written prescription or over-the-counter, varies with state law||Medications containing limited amounts of opioids; used for relief of coughs or diarrhea|
Of special concern in the management of pain are laws that authorize the medicinal and recreational use of marijuana (cannabis). The active chemicals in cannabis, called cannabinoids, have been studied extensively in laboratories and clinics for relief of pain, nausea and vomiting, anxiety, and loss of appetite. Two cannabinoids (dronabinol and nabilone) are approved by the U.S. Food and Drug Administration for the prevention or treatment of chemotherapy-related nausea and vomiting (National Cancer Institute, 2013).
Because of vigorous enforcement of the Controlled Substance Act by the federal Drug Enforcement Administration (DEA) and harsh penalties imposed on individuals who use the herb, an increasing number of states have passed laws regulating marijuana within their borders. These legislative acts permit some use, possession, and cultivation of marijuana for medicinal purposes, and though they differ, most require a physician’s diagnosis and prescription, registration of the user, and limitation of the amount of marijuana a person may grow or possess.
Pain is a universal human experience, the strongest motivator for an individual to seek medical care, and one of the body’s most important protective mechanisms. Pain alters the quality of life more than any other health-related problem, interfering with sleep, mobility, thought, emotional well-being, sexual activity, and creativity. Yet, pain is one of the least understood, most under-treated, and oft-discounted problems faced by healthcare providers. For these reasons, it behooves all caregivers to manage pain more consistently and effectively and to support research to improve pain management.
American Pain Society
American Society for Pain Management Nursing
Cancer Treatment Centers of America: Pain management
International Headache Society (IHS)
National Institutes of Health Pain Consortium
National Institute on Drug Abuse (NIDA): Screening pain patients
Partners Against Pain: Pain management tools
Accreditation Association for Ambulatory Health Care (AAAHC). (2012). 2012 Accreditation handbook including Medicare requirements for ambulatory surgery centers (ASCs). Skokie, IL: author.
American Academy of Pediatrics (AAP). (2001). Assessment and management of acute pain in infants, children, and adolescents. Pediatrics, 108(3), 793–797.
American Medical Association (AMA). (2007). AMA Code of Medical Ethics: opinion 8.083 - placebo use in clinical practice. Retrieved February 2012 from http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion8083.page
American Pain Society. (2009). Principles of analgesic use in the treatment of acute and cancer pain (6th ed.). Glenview, IL: American Pain Society.
American Society for Pain Management Nursing (ASPMN). (2012). Position statement: pain management in patients with substance use disorders. Pain Management Nursing, 13(3), 169–183. Retrieved December 2012 from http://www.aspmn.org/Organization/documents/PainManagementinPatientswithSubstanceAbuseDisorders.pdf.
Anand KJS, Stevens BJ, & McGrath, PJ. (2007). Pain in neonates and infants: pain research and clinical management series, (3rd ed.). New York: Elsevier.
Anand KJS, Stevens BJ, & McGrath, PJ. (1997). Long-term effects of pain in neonates and infants. In T Jensen, et al. (Eds.), Proceedings of the Eighth World Congress on Pain: progress in pain research and management, 881–892. Seattle: IASP Press.
Ball J, Binder R, & Cohen KJ. (2011). Pediatric nursing: caring for children (5th ed.). New York: Prentice Hall.
Bednash G & Ferrell BR. (2002). Pain and symptom management in end-of-life care. Sacramento: CME.
Bulechek G, Butcher H, Dochterman J, Wagner C. (2012). Nursing interventions classification (NIC) (6th ed.). St. Louis: Mosby.
Cohen, NJ. (2005). Impact of language development on the psychosocial and emotional development of young children. Retrieved December 2012 from http://www.child-encyclopedia.com/pages/pdf/cohenANGxp.pdf.
D’Arcy Y. (2009). Overturning barriers to pain relief in older adults. Nursing2009, 10, 32–39.
Davis G, Hiemenz M, White T. (2002). Barriers to managing the chronic pain of older adults with arthritis. Image: Journal of Nursing Scholarship, 34(2), 121–126.
DiLuzio JA & Spillane E. (2002). Holistic nursing practice: is it right for you? RN, 65(8), 32–34.
Ferri RS & Sofer D. (2004). News: pain management in older adults. Journal of Nursing, 104(2), 19.
Fincke A. (2010). Genetic influences on pain perception and treatment. Practical Pain Management, 10(1). Retrieved November 2012 from http://www.practicalpainmanagement.com/resources/genetic-influences-pain-perception-treatment.
Frazel J. (2004). Optimize migraine management in primary care. Nurse Practitioner, 29(4), 23.
Gourlay DL & Heit HA. (2008) Pain and addiction: managing risk through comprehensive care. Journal of Addictive Diseases, 27, 23–30. Retrieved January 2012 from http://www.tandfonline.com/doi/full/10.1080/10550880802122570.
Gourlay DL, Heit HA, Almahrezi A. (2005). Universal precautions in pain medicine. Pain Med, 6(2), 107–12. Retrieved February 2013 from http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4637.2005.05031.x/full.
Haylock PJ & Curtiss CP. (1997). Cancer doesn’t have to hurt. Alameda, CA: Hunter House.
Ignatavicius DD, Workman ML, Michler MA. (1999). Pain and symptom management in Medical-surgical nursing: across the healthcare continuum (3rd ed.). Philadelphia: W. B. Saunders.
International Association for the Study of Pain. (2012). IASP taxonomy: pain terms. Retrieved January 2013 from http://www.iasp-pain.org/Content/NavigationMenu/GeneralResourceLinks/PainDefinitions/default.htm.
International Headache Society (IHS). (2004). IHS Classification ICHD-II. Retrieved December 2012 from http://ihs-classification.org/en/02_klassifikation/01_inhalt/.
Joint Commission (TJC). (2013). Hospital accreditation standards (HAS) Oakbrook Terrace, IL: Author.
Joint Commission (TJC). (2012). Facts about pain management. Retrieved December 2012 from http://www.jointcommission.org/pain_managment.
Joint Commission on Accreditation of Healthcare Organizations (TJC). (2000). Pain assessment and management. Oakbrook Terrace, IL: Author.
Joint Commission Resources. (2009). Pain management. Retrieved November 2009 from http://www.jcrinc.com/JCR-Good-Practices-Database-for-Hospitals/JCR-Good-Practice-Examples-of-Survey-Complian/Pain-Manage/.
Jost T. (2000). Medicare and Medicaid financing of pain management. Journal of Pain, 1(3), 183–194.
Koob GF & Kreek MJ. (2007). Stress, dysregulation of drug reward pathways, and the transition to drug dependency. American Journal of Psychiatry, 164(8). Retrieved December 2012 from http://ajp.psychiatryonline.org/article.aspx?articleid=98729.
Lawrence J, et al. (1993). The development of a tool to assess neonatal pain. Neonatal Network 12(6), 61.
Mann D. (2011). Many skip doses of Rx drugs to save money. WebMDHealth News. Retrieved January 2013 from http://www.medicinenet.com/script/main/art.asp?articlekey=149843.
Maslow AH. (1968). Toward a psychology of being (2nd ed.). New York: D. Van Nostrand.
McCaffery M. (1979). Nursing management of the client with pain (2nd ed.). Philadelphia: Lippincott.
McGuire L, et al. (2006). Pain and wound healing in surgical patients. Annals of Behavioral Medicine, 31(2), 165–172.
Melzack R & Wall PD. (1996). The challenge of pain. New York: Penguin Group.
Merck Manual of Diagnosis and Therapy (19th ed.). (2011). West Point, PA: Merck & Co., Inc.
Merkel S. (2002). Pain assessment in infants and young children: the finger span scale. American Journal of Nursing, 102(11), 55–56.
Mosby’s Dictionary of Medicine, Nursing & Health Professions (9th ed.). (2012). St. Louis: Mosby Elsevier.
Mosby’s Expert 10-minute Physical Examinations (3rd ed.). (2009).St. Louis: Mosby Elsevier.
Mosby’s Nursing Drug Reference (23rd ed.). (2010). St. Louis: Mosby Elsevier.
National Center for Complementary and Alternative Medicine (NCCAM). (2012a). Mission: important events in NCCAM history. Retrieved December 2012 from http://www.nih.gov/about/almanac/organization/NCCAM.htm.
National Center for Complementary and Alternative Medicine (NCCAM). (2012b). Acupuncture may be helpful for chronic pain: a meta-analysis. Retrieved December 2012 from http://nccam.nih.gov/research/results/spotlight/091012.
National Center for Complementary and Alternative Medicine (NCCAM). (2012c). Chiropractic: an introduction. Retrieved December 2012 from http://nccam.nih.gov/health/chiropractic/introduction.htm.
National Cancer Institute (NCI). (2013). Cannabis and cannabinoids (PDQ). Retrieved January 2013 from http://cancer.gov/cancertopics/pdq/cam/cannabis/patient/.
National Cancer Institute (NCI). (2012). Pain control: support for people with cancer. Retrieved December 2012 from http://www.cancer.gov/cancertopics/coping/paincontrol/page5.
Paice JA & Fine BR. (2001). Pain at the end of life. In B. Ferrell and N. Coyle (Eds.), Textbook of Palliative Medicine, 76–90). Oxford: Oxford University Press.
Pasero C. (2004). Pain relief for neonates. American Journal of Nursing, 104(5), 44–47.
Pasero C. (2002a). Pain assessment in infants and young children: neonates. American Journal of Nursing, 102(8), 61–64.
Pasero C. (2002b). Pain assessment in infants and young children: premature infant pain profile. American Journal of Nursing, 102(9), 105–106.
Patterson K. (2007). Help for where it hurts. Heal: Living Well after Cancer, 1(2), 24–31.
Perkins EM. (2002). Less morphine, or more? RN, 65(11), 51–54.
Polan HJ, Kaplan MD, Kessler DB, Shindledecker R, Newmark, M, Sterm DN, Ward MJ. (1991). Psychopathology in mothers of children with failure to thrive. Infant Mental Health Journal, 12(1), 55–64.
Portenoy R & Lesage P. (1999). Management of cancer pain. Lancet, 353, 1695–1700.
Rawls J. (1971). The theory of justice. Cambridge: Harvard University Press.
Savage SR. (2003). Principles of pain management in the addicted patient. In AW Graham, TK Schultz, MF May-Smith, RR Ries, BB Wilford (Eds.), Principles of addiction medicine (3rd ed.), 1405–1416. Chevy Chase, MD: American Society of Addiction Medicine.
Stevens B. (1999). Pain in infants. In C Pasero & M McCaffery (Eds.), Pain: clinical manual (2nd ed.), 626–73. St. Louis: Mosby.
Sweeder J. (2002). Educating clinicians on effective pain management. Pain Clinic, 4(1), 11–19.
Thompson W. (2000). Placebos: a review of the placebo response. American Journal of Gastroenterology, 95(7), 1637.
Van Dijk M & Tibboel D. (2012). Update on pain assessment in sick neonates and infants. Pediatric Clinical North America, 59(5), 1167–81.
Wong-Baker FACES Foundation. (2012). Wong-Baker Foundation. Retrieved December 2012 from http://www.wongbakerfaces.org/.
World Health Organization (WHO). (2013). WHO’s pain ladder. Retrieved February 2013 from http://www.who.int/cancer/palliative/painladder/en/.
Zeidan F, et al. (2011). Brain mechanisms supporting the modulation of pain by mindfulness meditation. Journal of Neuroscience, 31(14), 5540–5548.
Providing accredited healthcare continuing education since 1998