Can Pain Be Prevented?

[Lane Therrell FNP, MSN, RN, NP]

It's easy to become so involved in the routine of assessing pain and administering pain medications, that we forget about the big picture of pain management. The public health crisis known as The Opioid Epidemic inspired me to do some extra reading on pain, and as a result, I am integrating a new-to-me way of thinking about pain management in my nursing practice: Pain can be prevented (at least to some extent).

According to the Association of Rehabilitation Nurses, part of the official role of a rehab nurse involves preventing pain, in addition to identifying and alleviating it. Indeed, some types of pain and certain pain triggers can be prevented. What that means to me as a nurse practitioner in primary care, is that by preventing some of the conditions and circumstances which can trigger or exacerbate pain, I can, by extension, prevent pain.

Of course, this does not mean all pain can be prevented. And, despite the encouragement nurses have received since the 1980s to alleviate all pain at all costs (see Joy Eastridge's excellent allnurses.com article, "Accidental Pill Pusher"), we actually would not want to eliminate all physiological pain across the board because pain can be a valuable indicator, alerting us to the body's condition.

Although the need for 1-10 scales and pain medications including narcotics, will never go away, I'm convinced that by considering preventive strategies when managing pain, nurses in all roles can set patients up for a far more comfortable existence, involving fewer and less addictive, pain medications. For example, some forms of acute pain can be prevented by anticipatory guidance, such as emphasizing safety practices to reduce injuries and falls. Chronic pain, while arguably more difficult to prevent, can still be approached proactively.

Dehydration

When I began thinking about the possibilities for proactive pain management in nursing practice, preventing dehydration was the first thing that came to mind. Dehydration is a great place to start because not only can dehydration influence a patient's experience of pain, it can be prevented, at least to some extent, and it is something nurses routinely monitor. How much pain can we prevent if we begin to address dehydration in terms of pain prevention? This would be a great topic for a research project. Meanwhile, below are my initial thoughts on some things we can do to prevent dehydration, and by extension, help prevent pain.

Several considerations can help us think differently about dehydration and motivate us to prevent it in the name of pain prevention:

1) Many patients, more than we think, are at risk for dehydration;

2) fluid balance measures may mask dehydration;

3) dehydration contributes both directly and indirectly to pain.

Helping Those at Risk for Dehydration

First, Consider how many individuals are at risk for dehydration every moment of every day-diabetics, athletes, elders, people taking diuretic medication, and more. That's a lot of people. Consider the number of patients who take prescription diuretics for blood pressure control. Taking a diuretic means the patient should be drinking more water, not less. Yet, I often hear from my ambulatory patients who take diuretics that they choose to drink less water because they want to avoid "running to the bathroom all the time."

We can help these patients evaluate their water-drinking habits and understand the longer-term costs of chronic dehydration. Beyond refilling the patient's bedside water container and encouraging the patient to drink it, help the patient make plans to drink more water at home, every day, and commit to doing so. I find that it is often helpful to demonstrate the ideal amount of water that should be consumed daily by show-and-tell. One well known basic guideline for determining fluid intake states that the patient's weight in pounds divided by 2 is the minimum number of ounces per day that the patient should be drinking. When patients visualize this volume, they invariably respond with amazement, "That's a lot!" It gets their attention, and the image stays with them.

Next, every nurse is educated about the crucial importance of fluid balance, yet proper hydration involves so much more than the bottom line of input versus output. When we think of dehydration only in terms of fluid balance instead of specifically addressing the body's need for pure water, we get fooled into thinking they are properly hydrated when in fact they are not. We are generally taught that fluid is fluid, but the fact remains that some of our most beloved fluids tea, coffee, soda, contain caffeine which has a diuretic effect.Think about it: if we are counting fluids that are caffeinated, we are getting a false sense of the patient's actual hydration level. It is important to understand the value of pure water vs other fluids, and encourage actual water intake as opposed to intake of other fluids, which may contain salt, sugar, and caffeine which will affect (and likely inhibit) the body's assimilation and processing of plain water.

We can prevent dehydration by honoring the value of plain water. Instead of simply thinking of the ratio of fluid input to fluid output as an exercise in monitoring bodily functions, we can also think about what kind of fluid the patient is regularly consuming and how it may be affecting the patient's experience of pain. There is no substitute for pure fresh water-the body knows what to do with it.

Finally, dehydration can trigger pain both directly and indirectly. Dehydration headaches, for example, can be a very real and direct cause of pain. Scientists believe this happens when a lack of sufficient fluid causes a decrease in brain volume and the shrinking tissue activates meningeal pain receptors. It stands to reason, then, that adequate hydration can help prevent this type of pain. Dehydration can also exacerbate constipation, which is not only one of the most unpleasant, and often painful, side effects of opioid pain medication, but can also occur due to reduced physical activity.

Drink More Water

Encouraging patients to drink more water by connecting the dots for them about how dehydration is contributing to their discomfort can help. In cases where I have recommended that my patient drink warm water first thing in the morning on an empty stomach to stimulate peristalsis, the patient has enjoyed good results. In my experience, the more water a patient at risk for constipation can drink, the less severe his symptoms will be.

Some pain can be prevented, and one way to start is by preventing dehydration to prevent pain. This article has explored several practical ways to proactively prevent pain by thinking approaching dehydration proactively. No doubt, there are many ways to not only prevent dehydration but to prevent pain. I firmly believe nurses at all levels of practice can contribute in a meaningful way to managing pain effectively while reducing the need for opioid medications-just by thinking a little differently about some of the things we are already doing. The notion that pain can be prevented is a useful concept for finding new ways of approaching pain management in light of the current opioid crisis- especially for managing chronic pain.

Questions for discussion:

• How does your view of pain change when you think in terms of proactively preventing it rather than reactively treating it?
  
• What other possible ways to prevent pain can you think of in addition to those listed in this article?
  

Sources and Resources:

Accidental Pill Pusher

https://allnurses.com/general-nursing-discussion/accidental-pill-pusher-1131809.html

Aging and Preventive Health

Aging and Preventive Health

American Chronic Pain Association - September is Pain Awareness Month

American Chronic Pain Association - September is Pain Awareness Month

Are You Drinking Enough Water

Drinking Enough Water to Prevent Dehydration

Back Pain Prevention

Back pain - Symptoms and causes - Mayo Clinic

Dehydration Headache: Know the Causes, Signs, and Treatments

Dehydration Headache: Know the Causes, Signs, and Treatments - University Health News

Hydration Assessment

Hydration Assessment

Prevent Dehydration with Nursing Interventions

Prevent dehydration with nursing interventions - www.hcpro.com

Resource Guide to Chronic Pain Management

American Chronic Pain Association - Resource Guide to Chronic Pain Management

The Opioid Epidemic: A Crisis Years in the Making

https://www.nytimes.com/2017/10/26/us/opioid-crisis-public-health-emergency.html

The Role of the Rehabilitation Nurse in Pain Management

http://www.rehabnurse.org/pubs/role/Role-Pain-Management-Rehab-Nurse.html

[Triddin]

I feel like I am missing the connection you've made between dehydration and the pain experience. This is the first I have heard of the connection and would appreciate some studies to see how you've made that connection and it doesn't seem like any of the resources you've point to that connection either

[traumaRUs, MSN, APRN]

I found this fascinating so investigated a little further:

Being Dehydrated Increases Pain Sensitivity

Dehydration Headaches

[J.Adderton, BSN, MSN]

I work in rehabilitation and preventing or minimizing pain is a priority for optimal functioning and quality of life. A few strategies implemented include:

- Thorough pain assessments and exploring root cause of pain

- Consistent and timely re-evaluation of pain management techniques implemented

- Proper positioning and body mechanics

- Use of lidocaine patches and therapeutic rubs

-Adjunct therapist including gabapentin

- Heat and ice therapies

I am sure many others....

[blondy2061h, MSN, RN]

It makes sense. When I have a migraine or muscle aches one of the first things I try is chugging water.

[Guest805836]

In the context of my anesthesia nursing studies I am following a class on pain management this year (in France, nurse anesthesists are specialised in anesthesia, but also pain managment, emergency care and intensive care). One of the things of which I was insufficiently aware during my initial nursing studies (which are.... a bit of a time ago!) was the impact of acute pain on developping chronic pain, neuropathy. So I'd say one of the important things to drive home is how important it is to have good quality pain managment in acutely painful situations (post-op comes to mind), no toughing it out ! Educating patients towards managing their post-op pain, especially if they are going to be out of the hospital very soon is critical.

Also, another thing that has been a bit of an eye opener was how little neuropathic pain was accurately diagnosed and treated (I only learned about the DN4 during this class; how come I'd never heard of it before ??).

[Tommy5677]

Last year I suffered a severe orthopedic injury. So severe in fact that it required a trauma ortho surgeon and 3 1/2 hours of surgery to repair it. I ended up with a plate and 12 screws. Can I even begin to talk about the level of pain I endured? After the nerve block wore off, I received 48mg of morphine post op in a PCA in about 14 hours. Then I was sent home on oxycodone. He knew I was going to require so much that he left out the acetaminophen. The Rx was 1-2 every 6h prn. At one point I even took three which was a big mistake because it resulted in horrible thoughts. At one point I felt that my face was in a permanent snarl, like that of a rabid dog. It was harrowing, to say the least. I was fine at two.

After about two weeks I stopped it altogether and decided to suffer. Again, think about untouchable bone pain after having 12 holes drilled into it. Why did I choose to stop? Because of severe constipation. It was so bad that I worried about impaction.

After Hallucinating and severe constipation it's hard for me to even imagine dependence on that drug. Could I have gone there had I continued? Possibly. Not likely.

Thanks to God and a brilliant surgeon, I'm now 100% pain free and no addiction. I'm one of the lucky ones, I guess. I guess I'm the opposite of the above scenario.

[Guest805836]

Then I was sent home on oxycodone. He knew I was going to require so much that he left out the acetaminophen.

And yet, paracetamol + opioid = synergy (the sum of the two is greater than the effect of one + the effect of the other), so it would probably have been interesting to include it despite you needing the opoids.

After about two weeks I stopped it altogether and decided to suffer. Again, think about untouchable bone pain after having 12 holes drilled into it. Why did I choose to stop? Because of severe constipation. It was so bad that I worried about impaction.

And that is why an opioid prescription alone isn't great : patient education about pain management is also about managing the side effects of the medications (and if there is one classic one it is constipation from opioids !). So you stopped a prescription before it was due (?) because of side effects and probably were in a great deal of pain, with the risks for chronicisation that entails.

I am glad you are pain free now, here's to you making a great recovery :)

[BookishBelle]

Very interesting and helpful article! When my sister was diagnosed with colon cancer one of the things that would help manage her pain was indeed water. She bought herself a large water canteen and set the goal to finish it 3 times a day. It helped with aches, headaches and constipation.

As another simple remedy, the Sitz bath needs more praise! One of her most irritating pains was from an anal fissure. Constantly having either constipation or diarrhea while on the chemo didn't allow it the space to heal well. The Sitz bath helped the pain and the anticipation of pain she would feel. Sometimes she would start to cry knowing that she had to defecate and how much it would hurt (despite using stool softeners) but it was bearable once she got the Sitz bath. I also thought it was amazing postpartum. Not sure if they are used in hospitals any more?

[Tommy5677]

I was told to start Miralax with the oxy, which was totally inadequate. I started Dulcolax and ultimately ended up taking magnesium citrate which did nothing. Even Fleet enemas were inadequate. I felt after all that, that I had little choice but to stop the oxy.

[djmatte, ADN, MSN, RN, NP]

In the context of my anesthesia nursing studies I am following a class on pain management this year (in France, nurse anesthesists are specialised in anesthesia, but also pain managment, emergency care and intensive care). One of the things of which I was insufficiently aware during my initial nursing studies (which are.... a bit of a time ago!) was the impact of acute pain on developping chronic pain, neuropathy. So I'd say one of the important things to drive home is how important it is to have good quality pain managment in acutely painful situations (post-op comes to mind), no toughing it out ! Educating patients towards managing their post-op pain, especially if they are going to be out of the hospital very soon is critical.

Also, another thing that has been a bit of an eye opener was how little neuropathic pain was accurately diagnosed and treated (I only learned about the DN4 during this class; how come I'd never heard of it before ??).

I find this interesting because it has always been my impression that places like Europe focus more on "toughing out" acute pain versus inoculating it from us. Hence the significantly lower number of actual opiate abuse over there. They have a general mindset that pain is normal, expected, and allows the body an opportunity to fight it.

My pain perspective is different here working as a Acute Pain RN. We have established protocols for a range of pain patients by approaching it multimodally. Our theory is for every percentage you knock pain down from alternative therapies, that is a few less opiates that may be needed during acute post-op situations or during pain crises. We use NSAIDS where we can, gabapentin, acetaminophen, and mag regularly for the majority of our patients and in some cases before surgery. We also employ epidurals, nerve blocks, and a long range of nerve catheters for everything from peri-vertebral to nerves that impact orthopedic procedures. The biggest necessity IMO is to ensure the patient has the ability to get functional as soon as possible so they can improve what they intake, rebuilding/maintaining muscle strength, and ensuring adequate lung function.

[Guest805836]

I find this interesting because it has always been my impression that places like Europe focus more on "toughing out" acute pain versus inoculating it from us. Hence the significantly lower number of actual opiate abuse over there. They have a general mindset that pain is normal, expected, and allows the body an opportunity to fight it.

And we found out the hard way that seems to not be a great way to do that either (chronic pain epidemic in our waters....).

Our theory is for every percentage you knock pain down from alternative therapies, that is a few less opiates that may be needed during acute post-op situations or during pain crises.

Yep, we're more about that now. Also, non medicated interventions (cold / heat / TENS....).