Pain Assessment and Management, 2nd Edition _ _________________________________________________
PHARMACOLOGY Commonly used medications for chronic pain management include the following (Queremel Milani & Davis, 2022; Vorvick, 2021): • Nonopioid analgesic agents • Acetaminophen • Nonsteroidal anti-inflammatory drugs (NSAIDs)— ibuprofen, ketoprofen, naproxen, sodium • Antidepressants—tricyclics, serotonin and norepinephrine reuptake inhibitors • Antiepileptic medications—gabapentin, pregabalin, oxcarbazepine • Local anesthetics—lidocaine • Opioid agents—codeine, fentanyl, hydrocodone, hydromorphone, meperidine, morphine, oxycodone, tramadol The types and amounts of medication are dependent upon pain severity, pre- or post-surgery status, and comorbidities. Groenewald et al. (2022) found opioids to be the only form of pain management used by 4.4% (95% CI, 3.8%-5.1%) of adults with chronic pain. Prescription opioid use was more common among those over the age of 45, having insurance, and with lower education levels and a lower annual income. These authors report that 54.7% (95% CI, 53.1%-56.3%) used only nonopioid pain management techniques, and 10.7% (95% CI, 9.9%-11.6%) used a combination of opioid and nonopioid techniques. Bandara et al. (2022) studied privately insured individuals with chronic non-cancer pain (CNCP) between 2012 and 2019. These authors found the number of individuals prescribed opioids decreased from 49.7% to 30.5%, p < 0.01. They found that nonopioid pain medication prescriptions remained consistent at approximately 66.7% to 66.4%, p < 0.01. The number of prescriptions, the morphine milligrams per day, the days supplied were all found to be lower than previous studies. Antidepressants (selective serotonin reuptake inhibitors [SSRIs], serotonin-norepinephrine reup- take inhibitors, anticonvulsants [SNRIs], tricyclics), muscle relaxants, 5HT1 agonists, NSAIDs, miscellaneous analgesics, ketamine, caffeine, topical agents, and COX-2 inhibitors were all used for management of pain. In 2022, the CDC released updated guidelines for prescribing opioids. The recommen- dations continue to include that nonpharmacologic therapy and nonopioid pharmacologic therapy is the first method to treat chronic pain. Opioids should be considered only if the expected benefits for pain and function outweigh the risks (Dowell et al., 2022). Although NSAIDs such as aspirin and ibuprofen are used twice as often when compared to opioids (Atkinson & Fudin, 2020). NSAIDs are being prescribed for both acute and chronic pain; however, inappropriate use of these substances is widespread. da Costa et al. (2021) found that NSAIDs were most effective for pain and function in patients with osteoarthritis when
MECHANISMS OF PAIN RELIEF There are many influences on the ability to adapt to chronic pain. Meints et al. (2019) found that when clients have a higher level of catastrophizing, they will likely perceive a higher level of pain. The effect of a client’s belief on pain is related to the placebo effect, which can be described as health improvements that are directly linked to the placebo’s psychological or bio- logical mechanisms, like expectations or learned associations (Mitsikostas et al., 2020). A meta-analysis found nonsteroidal anti-inflammatory drugs (NSAIDs) had a significant reduc- tion in chronic pain scores when compared to nonsteroidal opioid drugs (Shetty et al., 2024). The results were found to be comparative to those given a placebo. There is still much to be discovered about the power of placebo effects, but what is important for practitioners working in pain management to consider is the connection between the mind and the body (Kaptchuk et al., 2020). Practitioners should include in their clients’ management plans what the clients themselves believe might help their pain. An open-minded health professional can do much to help clients manage their pain. Certain areas of the brain are important in processing painful sensations, which can lead to different experiences of pain. New technologies are helping scientists better understand how brain circuits and specific cells are involved in pain perception, especially in chronic pain conditions (Tan & Kuner, 2021). These new insights show that specific parts of the brain play a direct role in creating and controlling pain. Understanding how these brain mechanisms work may open up new ways to treat pain more effectively. THERAPEUTIC INTERVENTION METHODS Methods of therapeutic intervention include removing the pain source, decreasing the pain stimuli, blocking the pain pathway, decreasing perception, modifying interpretation, and decreasing the reaction. Good practitioners stay vigilant to how their intervention techniques are affecting the client throughout the treatment session. The source of pain can be addressed by relieving skeletal or muscle pressure through stretching, exercise, and massage. Practitioners can be instrumental in instructing clients on how to progressively improve flexibility and strength through spe- cific exercises and by using soft tissue mobilization, myofascial release techniques, and massage. Several modalities, including heat, ultrasound, transcutaneous electrical nerve stimulation (TENS), and electrical stimulation, can be used to manage pain with varied results (Allen et al., 2023). In addition, basic comfort needs may be met by ensuring that the client has vis- ited the restroom in a timely fashion and has thirst, hunger, fatigue, loneliness, and boredom under control. Information given in a way the client comprehends can relieve anxiety and consequently modify interpretation of the pain.
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