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Pain Management in Five Easy Pieces

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Jerome Stone RN has 33 years experience and specializes in Research, ICU, hospice, pain management.

5 Articles; 14,422 Profile Views; 20 Posts

While scores of patients in the hospital environment experience some degree of pain, for many of us the topic of pain and pain management is (pardon the pun) an uncomfortable experience. In order to treat the pain in our patients' experience, we need to come to terms with our own views about pain; our biases, fears, and misinformation on this important topic. And we need to learn how to bring our mind, compassionately in focus, to the art of pain management.

Which of the following is your biggest concern around pain management?

  1. 1. Which of the following is your biggest concern around pain management?

    • Knowing which medication to give
    • Fears of overdosing my patient
    • Fears that I'll give too little medication
    • Concerns that my patient may be drug-seeking
    • Not knowing the side-effects of the medications I'm giving
    • I can't stand pain so having patients in pain is stressful to me
    • I'm completely comfortable with pain management

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Pain Management in Five Easy Pieces
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Without pain, there would be no suffering, without suffering we would never learn from our mistakes. To make it right, pain and suffering is the key to all windows, without it, there is no way of life. - Angelina Jolie

On a Scale from 1 - 10, What's Your Comfort Level With Pain?

How comfortable are you with pain? Does it depend on whether it's your own pain or someone else's? Would you like to find comfort in pain...or at least in pain management?

For many of us, pain is something to be avoided, whether it's our own pain or the pain of another. When confronted with this most daunting physical experience, we'd rather turn and run...or at least walk quickly, in the other direction.

What would your nursing practice (and life) look like if you were able to engage with pain in the same way that you engage with anything else that you're familiar and comfortable with? Would you feel more secure in your job if treating your patients' pain was as simple as one, two three?

What's amazing to me is that there are so many very competent and capable nurses who treat pain as if it's an emergency. And when pain feels like an emergency, we either fear the subject of pain management or are unclear on how to deal with it.

Pain Cuts Close to Our Fears

Pain cuts close to our own humanity and frailty; on a very deep level, we never wish it on ourselves (who would?) and in the darkness of our mind, we're "...glad that it's them and not me."

Because of pain's proximity to our own fears of it, we may find ourselves unable to surmount our limitations, and manage pain by administering the drugs without first understanding its essence and nature. And because it affects us on such a basic level, we may find ourselves unable to surmount our own limitations in learning how to alleviate this pervasive expression of human suffering.

If anything that I've said so far feels familiar to you...no worries! There are some very basic tools that you can begin to use now that will help you to manage not only the pain of your patients, but your own pain as well.

Comfort in Pain

A very brief, and very personal note here: I am a "chronic pain sufferer" of many years, except that I don't really suffer that much. This doesn't mean that I don't experience the sensation of pain, nor that life wouldn't be easier if I didn't have it as a guest in all aspects of my life. I just mean that the pain doesn't result in my suffering from it. Huh?

First off, I consider pain management to be one of my strengths. At one point I managed the care of over 3500 pain patients and have worked in enough end-of-life settings to become comfortable with terminal pain. So, I'm able to negotiate the landscape of pain with a certain degree of comfort (was that a bad use of words?)

In order for us to treat those with pain, we need to check our inventory of ideas and opinions about pain; how do we deal with our own pain? How do we deal with our patients who are in pain? Have we formulated ideas or biases about pain and its management?

And, like many others, do we fear pain? All of these questions are important to address if we're going to be able to show up, present, to treat those who need us.

The Bright (and darker) Side of Pain Medications

Part of the difficulty around pain management isn't really about its management but about its acceptance by both patients as well as their families. The use of opiates is still a charged subject, especially in the older population.

There are many people who believe that the use of opiates, even for post-operative pain, will result in addiction. Old myths of the past about pain "junkies" still prevail among our patient population and educating people about the appropriate use of medications is important to gaining acceptance of their use for pain.

What's sad about this is that so few people, including some nurses, aren't aware that pain is the best antidote to pain medication so that as our pain decreases, so will our need for the medication. Automatic addiction really isn't the problem; it's the belief that this is the case that needs attention and treatment.

In recent history, because of the misunderstanding about pain and its treatment, there were prevalent beliefs among the medical and nursing communities that patients who needed large amounts of pain medication were "drug seeking" or falsely representing their pain. Due to these misconceptions, thousands of people went under-medicated and suffered needlessly. Then, in 1995, the President of the American Pain Society, Dr. James Campbell, coined the term "fifth vital sign", suggesting that "quality care means that pain is measured and treated".

Even though pain's recognition as a "vital sign" has resulted in increased treatment and vigilance in attending to those in pain, there continues to be ongoing debate about whether it's truly a "vital sign" since it cannot be measured and is subjective.

And now, the pendulum has swung to the opposite extreme; perhaps as much an overreaction to our past failings to treat pain, more narcotic prescriptions are being filled than at any other time in US history. According to the American Society of Interventional Pain Physicians , "Americans, constituting only 4.6% of the world's population, have been consuming 80% of the global opioid supply, and 99% of the global hydrocodone supply, as well as two-thirds of the world's illegal drugs." Wow! So, what do we do?

Five Easy Pieces to Pain Management

There are what I call the "five easy pieces" to pain management and they make up key points to remember in learning how to effectively manage your patients' pain. They're not end-all guidelines in the treatment of pain, but they're a great place to start and will give you the tools that you need to be able to treat pain effectively now. I encourage you to learn all that you can about pain management; there's not a lot to it once you make the commitment to learn it.

1. Pain is a subjective experience.

The experience of pain lies within the mind and body of the beholder. As such, it is determined by an individual's cultural beliefs, religious beliefs, previous experience with pain, and even their genetic predisposition. To know exactly what your patient is experiencing, or - for that matter - to know what anyone is experiencing, is simply impossible. At times this element of pain management can be exasperating. You may have one patient who labels their pain as "5 out of 10" and is in obvious distress, while your other patient calmly lies in bed watching TV, stating that their pain is a "10." What do you do? Treat the pain. How? Do so in measured steps and observe the patient to determine how effective your efforts are. And, know that there will be people who, simply because of their relationship with pain, require a lot of medication even when they appear to be free from distress. And there will be those who you need to persuade to take pain medication because their vital signs, as well as their inability to participate in ADLs, is impaired due to their pain. Finally; knowing that pain is subjective can help you to remain compassionate in your care, preventing you from falling into judgment or questioning your care.

2. Know thyself.

Let's face it, our attitudes about pain are going to inform our treatment for it, just like our attitudes about anything affect how we live our lives. If we have a fear of pain, or an ability to stand a lot of pain, it will affect our expectations of your patients. Learning how to deal with pain on a personal level, and understanding that we're all different (see # 1) will help you to treat others with more compassion and come from less of a personally biased point of view.

3. Learn the basics of pain management.

Learning about opiates, anti-anxiety medications, and sleep medications doesn't take a lot of time. In addition, it's also good to know your anti-inflammatory medications since their concurrent administration can augment your pain regimen. If you look online, you can find numerous sites that have equianalgesic charts, including ones that you can download or purchase and that you can keep in your pocket. These charts offer you comparisons of equal doses between different medications, mostly opiates; hence the equianalgesic title. Learning this information doesn't take a lot of time and can save you bouts of anxiety when you're unsure of how to medicate your patient.

4. Learn the body language of pain.

Our patients will tell us a lot about their pain...even when they're not saying anything. Obviously, changes in vital signs can tell us a lot about what's going on, but there are other ways. Pain speaks in a variety of ways, in facial expressions, how a person moves, range of motion of the limbs, even in the language that our patients use. Become familiar with the embodiment of pain, it will help you to help your patients.

5. Learn how to meditate.

Seriously? Ongoing research into meditation has proven - without a doubt - that meditation can have a positive effect in mediating the experience of pain. In fact, Dr. Fadel Zeidan, a researcher at Wake Forest has conducted research showing that meditation can actually decrease the amount of morphine necessary to alleviate pain. So, why should you learn to meditate? If you know how to meditate and learn how to use your mind to lessen your experience of pain, imagine what you can teach your patients that can help them to also deal with their pain. Additionally, and we'll go into this is future articles, there are many more benefits of meditation that can help you in your nursing practice as well as in your daily life.

So Now What?

To summarize, the best things that you can do to serve your patients are to start with the "five easy pieces." By learning more about how to manage pain and by engaging your own beliefs about pain, you can show up for your patients with more clarity about what they're going through. And by learning to work with pain in your mind and in your own life, you can engage this "...key to all windows..." as an educated advocate to your patients, as well as a nurse who has more comfort in the face of pain.

A Final Note to Nurses Everywhere

As nurses, we tend to hold ourselves to high standards...sometimes unreasonably high. In fact, much has been written about nursing and perfectionism, stress and burnout. So when I write an article like this one, that offers techniques and solutions to a common challenge that nurses encounter, I have to remember that there will be those of us who will struggle with statements like, "Know thyself," and, "Learn to meditate." Therefore, let me encourage all of us to be kind in how we go about creating change in our nursing practice and in our lives in general. A gradual path is just as beneficial as a rapid one and usually leads to a more integrated approach to change. Be kind to yourself. You're a nurse, and you rock!!

https://www.asipp.org/documents/ASIPPFactSheet101111.pdf, The American Society of Interventional Pain Physicians (ASIPP) Fact Sheet

Fadel Zeidan, Ph.D. - Wake Forest School of Medicine

Perfectionism and Depression: Vulnerabilities Nurses Need to Understand Melrose, S. Perfectionism and Depression: Vulnerabilities Nurses Need to Understand. Nurs Res Pract. 2011; 2011: 858497. Published online 2011 May 29.

I've been an RN for over 30 years. I am an author, blogger, and keynote speaker. My site is: www.mindingthebedside.com

5 Articles; 14,422 Profile Views; 20 Posts

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KatieMI has 6 years experience as a BSN, MSN, RN and specializes in ICU, LTACH, Internal Medicine.

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Awesome piece. But, as usual...

As we all probably know, the current trend in healthcare is all about customer service. That makes questions like "what is your comfort level with pain?" impossible to ask, alternatives such ad NSAIDs not available, and many nursing techniques such as teaching meditation, guided relaxation, feedback, guided imaginary, etc. not usable as they all work much slower than hydromorphone IV and thus potentially produce low Press Ganey scores. Adding to that, the techniques above are much less useful for patients with opioid-induced pain, and in my place we have close to 100% of such patients. Teaching pain relieving non-pharm techniques takes a lot of time, which ordinary floor nurse never has. Using these techniques requires significant effort from the patient, as he has to overcome his fears, the knowledge of the fact that easy help is available, and almost inevitable failure of the first attempts.

From the population I work with (chronically critically sick patients), about half of those who are able to communicate express fears of dependency from opioids and want to "try something else" if they are directly asked about it. That happens at the point when these people already spent 2 or 3 weeks in acute care where they got their pills and shots after their first whim. After being taught "pain 101" ( gate theory of pain, pain perception, guided relaxation, sometimes "warm/cold" technique for diagnosed neuropatic pain, meditation) over 2 or 3 days, approximately half of them attempts using these techniques. Of the above, half (so, about 25%) comes to some sort of success in terms of not being "on the clock" callers and tolerating PT/OT without getting stoned beforehead. The rest says "I will think about this, and I want something for my pain right now, gimme my good shot".

In addition, the only one pain clinic which practices holistic-oriented pain management for the whole state is not taking any insurance at all. One (and working) course of treatment there for FBM (acupuncture, massage, wraps, hot/cold, diet consult, sleep consult, etc.) is around $5000 paid out of pocket.

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mmc51264 has 8 years experience as a ADN, BSN, MSN, RN and specializes in orthopedic; Informatics, diabetes.

2,807 Posts; 39,387 Profile Views

I work in ortho where pain is usually issue #1. we have many pts. that have chronic pain issues and are used to taking more than what is usually prescribed/ordered. We also have a Pain Team to help us. I really do not think it should be a huge issue about drug seeking. The short time people are in the hospital is not going to make or break them. We sometimes have to go through bags if we suspect some is double dipping (rare) but in the end we have to address the real pain they have and NOT have them going into withdrawl while under our care.

I have had pts come in that have been taking 90 mg of oxycontin TID and 20-40 (or more!) of oxycodone. Then add a traumatic fx to the mix. We have started (about a year now) using ketamine, which os supposed to reset pain receptors. We may also start using lidocaine drips for the hard to manage. We have to believe that their pain is what they say it is. If I feel differently, I speak to docs and they make those decisions.

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thevez has 1 years experience and specializes in Rehabilitation,Critical Care.

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One of my best way to distract people in pain when transferring them is breathing. People forget to breathe when they are in pain thus all the mind focuses on is the pain. My patients would say, I don't feel as much in pain when I breathe more as I am moving. It is a hard habit to learn though so I educate the everyday , every shift so they can learn it.

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brownbook has 35 years experience.

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I think I have it easy.....I work out patient surgery.....patients are only there one to two house and go home. They are on continuous pulse ox and B/P monitoring. Our pain medications are on a check box standard orders form anesthesia fills out. Anesthesia is in the clinic all day so any issues, concerns, are immediately addressed by them.

So it is easy for me to say I am comfortable with patients pain and medicating them......I am certain I would not be so nonchalant if I worked a busy med/surg floor!

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