___________________________________________________ Pain Assessment and Management, 2nd Edition
compared to opioid treatment. They should be given with food to minimize gastrointestinal complications such as ulceration of the gastric mucosa. Other negative effects of NSAID use include adverse events in the cardiovascular, kidney, hepatic, and hematologic systems (Ghlichloo & Gerriets, 2024). Because NSAIDs can interfere with nociceptive input during the pre- and perioperative periods, resulting in diminished perception of postoperative pain (Doleman et al., 2021), pain control may be best achieved through the administra- tion of NSAIDs during the preoperative phase. This strategy minimizes central nervous system sensitization by interfering with the expected cascade of inflammatory mediators that are released when tissue is injured. More recently, Gill and Giuliano (2022) systematically reviewed the literature and found that gabapentenoids with or without acetaminophen were a more effective preemptive analgesic for postoperative pain and reduced supplemental opiate use. Use of a long-acting local anesthetic to sustain pain control through the critical first hours postsurgery is also an effective practice. Finally, a well-defined pharmaceutical regimen over the anticipated normal cycle of postoperative pain can dimin- ish central sensitization. Healthcare practitioners can support clients in their pain management strategies by inquiring if they have remembered to take their medication prior to the treatment session, creating strategies or embedding cues into daily routines to support adherence to medication usage, and educating clients about possible altered response during days when they are not taking their prescribed medication. Combination therapy, which targets a variety of pathways and mechanisms, can be an effective approach (George & Johns, 2020). Prior to the introduction of NSAIDs, a combination of aspirin or acetaminophen with an opioid such as codeine had been the regimen of choice to control moderate to severe pain. NSAIDs used in conjunction with other medications can provide pain relief that is more effective and consistent over the period of the administered dose (Boccella et al., 2023). Use of some combinations can avoid the negative side effects associated with some medications. Clients should always be referred to their physician and pharmacist with questions about potential drug interactions. Other medications, such as anticonvulsants, tricyclic antide- pressants, and steroids, may also modify the peripheral pain stimulus. Antispasmodics, anti-arthritis drugs, and muscle relaxants are given for skeletal and smooth muscle relaxation, which can help decrease the reaction to pain. However, because many clients with chronic pain have comor- bid psychiatric and somatic diagnoses, complications with medication management can arise. Chronic pain was two times more likely to be associated with psychiatric diagnoses in a study by Pereira et al. (2017). The diagnoses Pereira et al. (2017) included were mood disorders, anxiety disorders, attention disorders, and substance use disorders. According to Johnston and Huckins (2022), most individuals with psy-
chiatric conditions are at risk for increased rates of chronic pain. Given multiple diagnoses and medications, medical management of a client’s symptoms requires expert attention. With proper education, a healthcare practitioner can assist in organizing and managing the appropriate medication at the appropriate times. In addition, a practitioner can work with the client on effectively communicating with the physician if they have concerns.
COMPLEMENTARY AND ALTERNATIVE TREATMENTS
The National Institutes of Health’s National Center for Complementary and Integrative Health (NCCIH) funds research on complementary and integrative health interven- tions. The center defines complementary as “non-mainstream practice that is used together with conventional medicine” and alternative as “non-mainstream practice that is used in place of conventional medicine” (NCCIH, 2021). The term integrative health involves bringing conventional and comple- mentary approaches together in a coordinated manner. Often multimodal approaches (conventional and complementary) are emphasized using a variety of combinations. This approach to health and wellness has grown across the United States. Cur- rently, complementary health approaches refer to practices and products that are of nonmainstream origin. Integrative health is the incorporation of the complementary approaches into mainstream health (NCCIH, 2021). Nahin et al. (2024) found that between 2002 and 2022, more adults in the United States started using complementary health approaches (CHAs), especially for managing pain. They iden- tify this increase is likely due several factors, including avail- ability of clinical trials, their inclusion in pain management guidelines, and the push to reduce the use of harmful opioids. During this time, insurance coverage expanded, making it easier for patients to access certain CHAs. Scott et al. (2021) found increased use of meditation, chiroprac- tic, and massage therapy in the 2017 data. The data indicate that meditation and chiropractic approaches are highest among adult between ages 45 and 64. These authors found that there was a need for treatment of low back pain and other similar conditions due to the increasing prevalence of joint/bone disease. There was no significant change in the demographics of CAMs users between 2012 and 2017 (Scott et al., 2021). Motivation for using complementary approaches was found to be the perceived benefits and safety of CAMs, and dissatisfac- tion with conventional medicine to improve health and well- being (Tangkiatkumjai et al., 2020). According to the NCCIH (2021), complementary health approaches are classified by their primary therapeutic input: nutritional (special diets, dietary supplements, herbs); psychological (mindfulness); physical (massage, spinal manipulation); and combination (psychologi- cal and physical [yoga, tai chi, acupuncture, dance art therapy] or psychological and nutritional [mindful eating]). The 10 most common approaches are nutritional products, deep breathing,
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