1. Other Pain Issues and Strategies to Manage Pain

2. Placebos Never use placebos ◦Unethical ◦Creates an environment of distrust  Causes the patient to feel foolish  Can result in disruptive behavior from the patient ◦Can result in litigation ◦Can result in harm

3. Other Pain Strategies There are many “adjuncts” to pain management Pain does not have to be relieved with narcotics “opioids” alone Find out from the patient what has controlled pain episodes in the past

4. Complementary Therapies Cold or hot packs treatment Find out what has been effective before Does not need a physician order Can be delegated to a nursing assistant Massage Relieves muscle tension Does require an order from the prescriber May be covered by insurance

5. Complementary Therapies Acupuncture ◦Invasive ◦Needs an order from the prescriber ◦Cannot be done in many situations Aromatherapy ◦Can be done by anyone at any time ◦Cost effective ◦Promotes total relaxation

6. Complementary Therapies Imagery ◦Completed by the patient (self) ◦Assisted by trained staff (guided) ◦Patient thinks about a favorite time, place, or event ◦Talk with patient about the images and why these provide comfort ◦Instruct patient to use slowed deep breaths while using imagery

7. Complementary Therapies Distraction ◦Allows patient to focus on something else while experiencing pain episode ◦Can be anything meaningful to the patient  Television  Puzzles  Video games (especially for children)  Knitting or needlework

8. Complementary Therapies Music therapy ◦Some facilities have trained Music Therapists ◦Provide musical intervention during painful episodes ◦May also provide radios, CD’s, or portable listening devices to record or play back songs ◦Patient may also use their own music or portable listening devices ◦Some may also prefer to sing out loud

9. Non-Opioids NSAIDs ◦For control of inflammation ◦Needs to be given consistently for chronic pain ◦Watch renal function ◦Watch for stomach irritation  Heart burn  Bloody stools  Nausea

10. Non-Opioids Acetaminophen ◦Some anti-inflammatory properties ◦Also works on mu receptors ◦Watch liver function  If chronic liver disease present, no more than 2 grams total in 24 hours  If no liver issues, no more than 3 grams in 24 hours in the home setting  If no liver issues, no more than 4 grams in 24 hours in all settings  Be careful-acetaminophen is in many other medications!

11. Non-Opioids Muscle relaxants ◦Calm smooth and skeletal muscle irritation ◦Can cause sedation  No driving or operating machinery  Can cause liver issues  Should not be used more than 3 times a day  Space doses out over consistent time frame

12. Non-Opioids Anticonvulsants ◦Work on brain chemistry and receptors ◦Used mostly for nerve pain ◦Watch therapeutic drug levels ◦Do have a maximum daily dose

13. Non-Opioids Nervous system sedatives ◦Decrease neural transmission ◦Reduces pain perception ◦Also cause sedation so same rules apply ◦Watch for changes in level of consciousness and perception ◦Watch for suicidal thoughts

14. Antidepressants Also work on brain chemistry Reduces pain perception Risk of suicide Can change mood and behaviors Have therapeutic drug levels Needs close monitoring for the first few months of therapy

15. Opioids Long acting – DO NOT CRUSH OR ALTER ◦Longer action ◦Longer peak time ◦Dose can be escalated to control pain ◦Work on the mu receptors in the brain  Morphine Extended Release (MS Contin, Kadian, Oramorph)  Hydromorphone Extended Release (Exalgo)  Oxycodone Extended Release (OxyContin) ◦ Increased risk for abuse and dependency ◦ Most commonly abused long acting narcotic All may be given rectally (pr)

16. Opioids Short acting Also work on mu receptors ◦Many drugs  Morphine sulfate instant release (MSIR)  Oxycodone HCl instant release (OxyIR, Oxy, Roxi)  Hydromorphone (Dilaudid)  Acetaminophen w/oxycodone (Percocet)  Acetaminophen w/hydrocodone (Vicodin, Lortab, Narco) Many forms and routes ◦Tablets and liquids ◦Subq, IM, IV, Intraspinal

17. Opioids Used for acute pain episodes or breakthrough pain Oral is preferred route If and/or when used with long acting: ◦Notify prescriber if more than 4 doses are used in a 24 hour period ◦Should be same drug component as long acting drug ◦Short acting dose should be 25% of long acting dose

18. Side effects Assess for pruritis (itching) ◦Most commonly seen with morphine injections ◦Related to the preservative and not the drug ◦Treat w/diphenhydramine (benadryl) or famotidine (pepcid) Assess effectiveness of the medication ◦If oral, reassess pain in an hour ◦If subQ, IM or IV, reassess in 30 minutes ◦If oral dose was given and not effective, administer parenteral dose of medication

19. Narcotics Assess patient bowel function ◦Patient should be on bowel regimen (stool softeners and fiber bulking agents) ◦Ensure adequate hydration Assess pulmonary status Assess for oversedation ◦It is okay to sleep after medication is given-it means the body is finally able to rest because the pain is getting controlled Assess urinary function ◦Narcotics can cause urinary retention

20. Concerns Know the difference between addiction, dependency, and tolerance If concerned, discuss with patient Bring valid concerns to the attention of the prescriber Obtain pain management consult if available ◦Pain nurse ◦Pharmacist

21. Pain Remember pain is subjective No room for judgment Untreated pain is a medical emergency Watch for clues of untreated pain Never assume nothing else can be done- patients do not have to live with pain Make sure pain management goals are realistic Document pain interventions