Learning Objectives
By the end of this section, you will be able to:
- Differentiate among types of pharmacological methods of pain management
- Describe the nurse’s role in educating patients about pharmacological pain management therapies
Pain management can involve pharmacological and nonpharmacological therapies. Therapy that involves drugs or medications is called pharmacological therapy. This section explores pharmacological methods for pain management and the nurse’s role in educating patients on pharmacological pain management therapies.
Types of Pharmacological Pain Management
A pain medication may be classified as an analgesic, a medication used to prevent or treat pain, or an adjuvant, a medication that has an independent analgesic effect but also an additive analgesic property when administered with an opioid; an adjuvant is also called a coanalgesic. Examples of adjuvants are antidepressants and anticonvulsants. They are used for depression and seizure control, respectively, but are also administered to enhance the effects of pain medications. Analgesics may be further classified as opioids or nonopioids. An opioid is a class of drugs derived from opium, a chemical sourced from poppy plants. A nonopioid is a medication that is not an opioid.
When administering analgesics, start with the medication that has the fewest side effects, in the smallest dose possible, via the least invasive route. The World Health Organization (WHO) developed a pain ladder (Figure 7.3) that was originally used to guide pain control for cancer patients; it applies to all types of pain, however, and has since been expanded to distinguish between increasing and decreasing pain intensity. Nonopioids should typically be the first choice to control pain, because they typically have fewer side effects than opioids and are less likely to result in addiction. If pain persists or increases, then opioids may be added as additional therapies in combination with nonopioids and adjuvant therapies. For pain that is severe and expected to decrease over time, opioids, nonopioids, and adjuvants may be given first, with adjuvants and opioids being removed from the regimen over time so the patient is eventually taking just the nonopioid medications.
Interdisciplinary Plan of Care
Pain Management from a Physical Therapy Perspective
Physical therapy (PT) is a key intervention for physical rehabilitation, but patients often report an increase in pain severity during their therapy sessions. To maximize the patient’s participation in physical therapy exercises, pharmacological pain management therapies may be administered thirty to sixty minutes before the therapy session. Physical therapists will often notify the patient’s nurse of an upcoming session and request the pain be premedicated prior to treatment. The therapy session will then begin thirty to sixty minutes later once the pain medication has taken effect.
Analgesic medications, including opioids and nonopioids, can prevent or treat pain. Nonopioids typically treat mild to moderate pain, and patients tolerate them well. Opioids are used to treat moderate to severe pain.
Analgesic Medications: Nonopioids
Nonopioid analgesics include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). Acetaminophen is used to treat mild pain and is typically safe for all age groups. Because it may be administered via several routes, including orally, rectally, and intravenously, it may be a good choice for those unable to take oral medications. Use it sparingly in patients with liver failure, because hepatotoxicity (severe liver damage) is a potential side effect. Thus, it is important to carefully monitor the daily intake of acetaminophen. Older adults should take no more than 3,200 mg in a twenty-four-hour time frame, whereas healthy younger adults should take no more than 4,000 mg; patients with alcohol use disorder should take no more than 2,000 mg. It is important to include all sources of acetaminophen in the daily totals, including amounts of the medication found in combination medications. For example, Percocet 5/325 contains 5 mg of oxycodone and 325 mg of acetaminophen. If the patient were to take one tablet of Percocet, the 325 mg of acetaminophen would count toward their daily intake of acetaminophen. It is also important to ensure that combination medications are not administered too close to another time for administering acetaminophen. For example, if 500 mg of acetaminophen is ordered every four to six hours for fever and Percocet 5/325 is ordered every four to six hours for pain, the nurse must recognize that both medications contain acetaminophen and carefully consider how much acetaminophen is administered within the four-to-six-hour time frame, as well as be aware of the total dosage amount of acetaminophen administered within the twenty-four-hour period.
Nonsteroidal anti-inflammatories treat mild to moderate pain or inflammation; they may also be used in combination with opioids to treat severe pain. Examples of NSAIDs include ibuprofen, naproxen, and ketorolac. Ibuprofen is typically prescribed every six to eight hours and is safe for individuals 6 months of age and older. Naproxen is typically prescribed two to three times per day and is longer-acting than ibuprofen. Ketorolac is used for short-term treatment (up to five days) of moderate to severe pain in adults. It is the last line of nonopioids before opioids are prescribed and can be used to treat breakthrough pain for patients already taking opioids. Use a reduced dose of ketorolac for patients aged 65 and older because of the risks of stomach or intestinal problems; swelling of the face, feet, or lower legs; and sudden decrease in urine production. Side effects of NSAIDs can include dyspepsia, nausea, and vomiting. To reduce the risk of these side effects occurring, administer NSAIDs with food. Most NSAIDs also increase the risk of heart attack, stroke, and heart failure, particularly if taken in large doses or over prolonged periods of time, except for aspirin, which in low doses can decrease the risk of a second heart attack in people who have already had one. For some people, NSAIDs may also cause gastrointestinal bleeding, particularly if administered in combination with warfarin or corticosteroids, and renal failure.
Life-Stage Context
Use of NSAIDs and Acetaminophen in Older Adults
Use NSAIDs and acetaminophen cautiously in older adults. These patients may have difficulty with the first-pass effect in the liver and are slower metabolizers than younger patients, putting them at risk for greater side effects and adverse effects. Adverse reactions associated with these analgesic medications include gastrointestinal, cardiovascular, renal, and hematologic side effects. Prescribing these medications to older adults requires consideration of individual patient risk factors, benefits and risks of the medication, and patient education. In addition, these patients should be carefully monitored for effectiveness and side effects.
Analgesic Medications: Opioids
Opioids treat moderate to severe pain by blocking the release of neurotransmitters involved in sending pain signals. Opioids may be administered via a variety of routes, including oral, intramuscular, intravenous, subcutaneous, rectal, and transdermal. Typically, oral opioids, such as codeine, hydrocodone, and oxycodone, are used to treat moderate pain. Stronger opioids, such as fentanyl, hydromorphone, and morphine, may be used to treat more severe pain. Morphine is commonly used for cancer and end-of-life pain because it is not associated with a ceiling effect, the point at which the effect of a drug plateaus, so that increasing the dose will not increase the effect. Because morphine does not have a ceiling effect, increasing the dose will result in an increased effect of the medication.
Although opioids are very effective at managing pain, they can be highly addictive and must be used with caution. Of the potential adverse effects of opioids, the most serious is respiratory depression. Monitor patients receiving opioids for decreased respiratory rate, oxygen saturation, and heart rate. Patients at greatest risk for respiratory depression are those taking opioids for the first time, people receiving an increased dose of opioids, or individuals taking benzodiazepines or other sedatives, including alcohol, concurrently with opioids. Opioid-induced respiratory depression is treated with naloxone Figure 7.4, which immediately reverses all analgesic effects.
Link to Learning
The American Medical Association has created a video that demonstrates how to administer naloxone to a patient.
Monitor patients taking opioids for less severe side effects as well, such as constipation, nausea and vomiting, urinary retention, and itching. Opioids slow peristalsis and increase reabsorption of fluid into the large intestines, thereby slowing the passing of stool and removing the fluid from the stool so that it becomes concrete-like. It is important for the nurse to assess bowel functioning and encourage fluid and fiber intake and ambulation throughout the course of opioid treatments. The provider will also typically prescribe a bowel management program that includes a stool softener (such as docusate) and a stimulant laxative (such as sennoside, bisacodyl, or milk of magnesia). If patients experience nausea and vomiting, antiemetics (such as prochlorperazine or ondansetron) may be prescribed. If patients experience urinary retention, they may require urinary catheterization, but this should not be used long-term. Antihistamines (such as diphenhydramine) may treat itching, but they may cause drowsiness and exacerbate the potential for opioid-induced respiratory depression.
The concept of patient-controlled analgesia (PCA) entails the patient self-administering opioid medications—including morphine, hydromorphone, and fentanyl—using a programmed pump. The medication syringe is locked inside a computerized pump that is attached to the patient’s intravenous (IV) line. The lock ensures the medication cannot be accessed or tampered with. The programming of the pump is also locked to ensure the medication is infused at the intended rate and volume.
The patient self-administers doses of the medication on an as-needed basis by pressing a button. The patient may deliver a dose of medication according to a preset number of minutes or doses per hour (lockout interval). If these criteria are met, the PCA button lights up, signaling to the patient that they can administer a dose when needed. If the button is not lit up, the patient can still press it, but a dose of the medication will not be delivered. Some pumps deliver a continuous amount of medication, with the patient able to self-deliver additional doses as needed. Additionally, the provider may order a loading dose, or bolus, administered during initiation of the PCA.
PCAs may only be used for patients who are alert, oriented, and can independently press the button. Because small doses of opioids are administered frequently, it is important to monitor patients for oversedation and respiratory depression. Education for patients and their visitors is an important part of using a PCA. To reduce the risk of these adverse events, the patient and all caregivers should understand that no one should press the PCA button except for the patient. Nurses should also ensure that the PCA button and call light are easily within the patient’s reach, along with any other interventions designated by the institution for patients who have a high fall risk (such as bed in low position, bed alarm on, high-fall-risk armband, red socks), because patients on PCAs are at a high risk for falling.
Considering the potential for harm if a medication error were to occur with a PCA, both the incoming and outgoing nurses during shift change should confirm pump settings. Each nurse should independently double-check to ensure the correct drug, concentration, doses (loading dose, PCA demand dose, continuous dose), and lockout interval. Two nurses are also needed when providing a bolus, changing any of the settings, and replacing the medication syringe to double-check for errors.
When a patient is on a PCA, it is important to monitor their vital signs to identify potential signs of respiratory depression, such as decreased respiratory rate, oxygen saturation, and heart rate. The nurse should follow their organization’s protocols for administering PCA medications, including frequency of vital signs. Typically, baseline vital signs should be taken prior to beginning the PCA, for a certain period of time after beginning the administration, and then every two hours for the duration of the PCA. The nurse should also perform a pain and sedation assessment using scales, such as the Richmond agitation sedation scale (RASS) or the Pasero opioid-induced sedation scale. Additionally, the volume infused should be captured as intake fluid, according to the protocols.
Link to Learning
Visit this site to see a PCA documentation checklist from Kaweah Health. Nurses are responsible for documenting PCA use.
Prior to initiating a PCA, document the patient’s vital signs, PCA settings, and dual verification of the initial setup. Typically, the patient’s pain level, alertness, respiratory rate, and oxygen saturation will be monitored every fifteen minutes after the initial setup, then every hour for four hours, followed by every two hours for the duration of the PCA; however, always follow the frequency of monitoring established in the institutional policy. The nurse must also document the volume of medication administered, which may be documented every four hours, at the end of every shift, or according to the institutional policy. The medication administered via the PCA is generally an opioid or narcotic, so it is the responsibility of the nurse to account for the amount used and correctly dispose if necessary.
Link to Learning
Watch this video for a step-by-step demonstration of how to set up a PCA on the Alaris PCA pump module.
Coanalgesic Medications
Coanalgesics are medications that have analgesic effects but their primary indication is not pain relief. For example, antidepressants are used to treat depression but they may also be used to treat chronic pain and pain-related symptoms, such as sleep problems and muscle spasms. Anxiolytics are primarily used to treat anxiety, but they may also treat chronic pain and pain-related anxiety and help to relax muscles. Anticonvulsants are used to treat seizures because they block pain receptors, but they may also be used to treat certain types of neuropathic pain. Corticosteroids are used to reduce inflammation, but they also reduce neuropathic pain by lessening signals from injured nerves.
Nursing Responsibility for Patient Education
It is the nurse’s responsibility to properly educate patients on pharmacological pain interventions. Education should be culturally sensitive and linguistically appropriate for the patient. When providing culturally sensitive and linguistically appropriate education, nurses help the patient to understand the treatment plan, improve adherence to the plan, alleviate fears, set realistic expectations, discuss concerns, and build a relationship based on mutual respect—all of which will improve health, well-being, and patient outcomes.
Education should begin at treatment initiation and continue throughout the course of therapy. To be most effective, the approach should be tailored to the individual patient’s needs. Consider the primary language spoken by the patient, as well as the patient’s culture, age, cognitive function, and health literacy level. It is important to use simple language, define technical terms, ask open-ended questions, and provide visual materials, such as demonstrations, videos, pictures, or handouts.
Patients should be informed that pain management is a patient right. It is important to stay ahead of the pain by not waiting until the pain is severe before taking medications. Once the pain becomes severe, it will be much more difficult to control the pain and may require stronger pain medications to manage the pain. The nurse should also help patients understand the typical progression of pain medications according to the pain ladder. It is important for the patient to understand the need for starting with nonopioids before adding opioids and finally adjuvants to the pain medication regime. Patients with acute pain that is severe in nature, such as surgical pain, should know that opioids may be used to treat the initial pain but that the goal is to transition from intravenous opioids to oral opioids and eventually to nonopioids.
Patients should also be instructed of the need to use the smallest dose possible to achieve the intended pain goal. For example, if the provider has ordered one to two tablets every four to six hours upon discharge, then best practice is to advise the patient to start with one tablet, reassess their pain, and then take the other tablet if needed. It is much easier to add more pain medication, as needed. Patients should be told not to take more than the prescribed dose, as well as the risks of doing so.
Link to Learning
Read this position statement on the ethical responsibility to manage pain and the suffering it causes from the American Nurses Association.
The first time a medication is administered, the patient should be educated on the medication name, dose, route, and frequency at which they should take the medication. It is important to note if the medication should be taken at a certain time of day, if they should take the medication with food, and any other instructions for administering the medication. It is also important to review how to store the medication, including how to keep medications safely away from children by keeping them out of reach or locked up.
Any time a medication is given, patients should be educated on the potential medication side effects, as well as when to report side effects. With opioids, instruct patients on the risks for constipation, respiratory depression, and addiction. It is important for the patient to understand that the medication may make them drowsy. They should be told not to drink alcohol, drive or operate heavy machinery, or take medications that the prescriber is not aware of while taking opioid medications.
Patients will sometimes have misconceptions about pain management that need to be addressed. It is important to assess the patient’s understanding of pain management and to address any misconceptions. For instance, a patient may not want to take opioids for fear of becoming dependent on them. Although it is true that opioids may lead to dependency with long-term use, it is important for the patient to understand the benefits of short-term use and the plan that will be followed to ensure they are tapered off opioids as quickly as possible.