Perceptions, Problems, and Solutions

By Michelle Christensen

Pain Management

Objectives The post-surgical nursing staff will be able to analyze

how complementary pain management measures for post-surgical patients could be used in conjunction with pharmaceutical measures to manage pain on the unit.

The post-surgical nursing staff will be able to compare and contrast three current (with in the last five years) evidence based best practices for complementary pain management measures for post-surgical patients.

The post-surgical nursing staff will be able to compare and contrast current measures being used on unit to deter opiate abuse with current (within the past five year) evidence based best practices.

Perceptions Pain is a unique disliked experience and is perceived by

each patient in a different way.

What effects perceptions of pain?

As T. Jackson Et AL, states “ the interpersonal context of taking medication, expectations, or other verbal and nonverbal factors” can all play an important role in how the patient perceives their pain and relief of pain.

One study showed that the environment, healthcare professionals presence, and medical equipment played a role in how a patient perceived pain. This study goes on to discuss the use of pharmaceuticals in patients expectations for pain relief. In the study patients are given a strong pain reliever there after they are given a placebo to reduce their pain. In the study it was found that patients expected the medication to work as it did initially and thus it did and the placebo reduced the patients pain just as the initial dose did.

What does this mean?

Evidence suggests that during the initial pain

assessment it is important to determine what the

patients expectations for pain relief are. This

would include inquiring about;

What the patient would do to relieve pain at

home, what percent of pain relief the patient

expects to experience, and what measures the

patient expects to receive to reduce their pain.

Two proven pain relieving interventions include

pharmaceutical measures as discussed and

complementary therapies.

Complementary therapies

aka CAM therapiesBackground

Complementary therapies are “health care approaches with a history of use or origins outside of mainstream medicine.”

In the United States complementary therapies are often used in addition to conventional medical treatment, but can also be used alone.

There have been a reported 1800 CAM therapies! This makes it vital for healthcare professionals to have a basic understanding of what CAM therapies are.

Opioids or pharmaceutical measures should be used when non opioid therapy is not effective alone.

Categories of CAM therapies Whole medical systems- Some practices do not fit

into other categories and would include things such

as homeopathy and naturopathy which take a more

holistic approach to care.

Mind-body medicine- These are the most widely used

CAM therapies today. They use the mind to effects

the bodies function.

Biologically based practices-substances generally

found in nature such as herbs.

Manipulative and body-based practices- Apply

Pressure to manipulate or move one or more body

parts.

Energy medicine-These therapies use

electromagnetic fields or biofield energies thought to

originate from the body.

Risks

Kramlich confirms these therapies do not come with out risk.

“Concerns with some of the energy therapies include inaccurate

diagnoses of conditions by practitioners and safety issues

associated with the manipulative therapies

Biologics-Such products may be disruptive to normal

physiological processes, such as coagulation and glucose

regulation, and interactions with conventional medications may

produce devastating effects.

Some concerns about manipulative therapies include delay or

avoidance in seeking conventional care and aggravation of

existing conditions

What are They?Within these categories there are different therapies that

can be utilized such as;

Aromatherapy

Acupuncture

Herbal medicine

Massage therapy

Visualization (guided Imagery)

Yoga

Music therapy

Reflexology

Spinal manipulation

Some misconceptions

Many people believe that complementary

therapies are a joke and that people don’t want to

use them.>>>>This is not true in fact according to

the National institutes of health 40% of adults and

12% of adolescents reported using CAM

therapies. For a reported spending of 34 billion

dollars!

All CAM therapies are all safe and anyone can

use them because they aren’t medical

treatments. False there are several CAM

therapies that require a licensed professional to

perform them, for example chiropractic services.

Benefits of Using Cam Therapy

Although there are risks involved with CAM

therapy careful considerations and accurate

patient history can eliminate many of these risks.

One benefit of CAM therapies for your unit is the

evidence that CAM therapies can reduce pain

perceptions and or eliminate pain.

Lets Discuss how to use CAM therapies

in Conjunction with pharmaceutical

measures.

Potential Problems with Pain

management

It’s no secret that opiate abuse is a serious and

potential risk when treating patients for acute and

chronic pain.

Opiate abuse is on the rise and according to the

Centers for disease control they have“ identified

prescription drug abuse and overdose as one of the

top five health threats for 2014”.

Opiate addictions are becoming one of the top leading

reasons that many people are seeking drug

rehabilitation.

The institute for clinical systems improvement

performed a retrospective cohort study showing that

patients who received a prescription for opioids within

seven days of surgery were 44% more likely to result

in long term opioid use within one year.

Minnesota DHS I would now like to discuss a video I watched

produced by the Minnesota Department of Health

about opiate addiction called Heroin at home.

What does the Heroin Epidemic have to do with

the Opiate epidemic?

https://www.youtube.com/watch?v=nXAu_pWg0s

s

According to the Minnesota Department of Health

the united states has 5% of worlds population but

consumes 80% of the worlds opiates.

Signs of an addiction Larger than expected amounts of opiates to control

pain.

Patient may report allergies or unwanted side effects

to many other opiates in order to gain access to the

desired drug of choice. For example a patient may

report GI upset with oral oxycodone, but reports that

they do not have the same issue with IV dilaudid.

Patient requests specific pain medications possibly

stating that others do not work for them.

Symptoms of withdrawal when opiates are not given

may arise. Such as; Low energy, irritability, yawning,

teary eyes, muscle aches/pains, hot and cold sweats,

abdominal pains, and or N/V.

DSM-V substance use disorder

Criteria

The drug is taken in larger amounts and over longer periods of time than intended

There is a persistent desire or unsuccessful attempts to cut down or control use

A great deal of time is spent in activities to obtain, use or recover from the effects.

Craving or a strong desire for the substance

Tolerance: a need for increased amounts to achieve the desired effects

Withdrawal: A syndrome developing after cessation characteristic to the specific substance.

Solutions

what can we do?

Assessing a patients opiate exposure can aide in determining a patients risk for opiate abuse. As it has been shown that those exposed to opiates more so then those not have a higher risk for developing abuse. Also if a patient has history of street drug use they are more likely of opiate addiction. Overall an in depth risk assessment prior to opioid administration is beneficial in the reduction of opioid abuse.

Use clinical judgment and effective communication with your healthcare team to determine whether a patient truly needs opioid therapy and if so how much is needed. Implementation of an algorithm to aide in opiate administration could also be beneficial.

Solution cont… Let your postoperative patients know in advance there

is and endpoint to their surgical pain.

Explain the risks of opiate use and encourage the patient to be involved with their care.

Encourage prescribing providers to check the prescription monitoring website prior to administration to determine current narcotic prescriptions with in the last year.

Remind your patients to discard any unused pain medication and to not save for future pains as this is considered drug abuse.

The FDA is also currently working on an opioid abuse deterrent pain medication that if made could help control pain while reducing the risk for opioid addiction!

Case Study Your patient rates there a pain at a 2 on a 0-10 scale where 0

is no pain and 10 is the worst pain. The patient has had a

total knee replacement and is post op day 3. This rating is

given after having an hour of physical therapy. The patient

describes the pain as dull and aching and states it gets

worse with exercise and activity. Which would be the most

appropriate action.

A. Do nothing the pain rating is not high enough

B. Give the patient 10mg of Oxycodone P.O as ordered

C. Give the patient Tylenol 650mg P.O as ordered and assist the

patient with guided imagery.

D. Give the patient 5mg of Oxycodone P.O as ordered and assist

the patient with guided imagery.

Case StudyYou are the primary RN for a patient who has been admitted with

severe abdominal pain. X rays, ultrasounds, and other diagnostic studies are finding no cause for the pain. You have been given orders for 5 to 10mg of oxycodone q4hours P.O as needed. The patient has taken 10mg of oxycodone and is still rating their pain at a 10 on a 0-10 scale with 10 being the worst possible. You request an order for IV dilaudid .5mg to 1mg q 1-2 hours as needed. After receiving the order you give the patient .5mg of dilaudid. The patient continues to rate pain at a 10 despite IV medication. You administer the other .5mg of Dilaudid IV and the patient rates pain has decreased and is now rating pain at a 9. You have also tried several other complementary therapies such as guided imagery, music therapy, and aromatherapy with no results. Despite best efforts the patient continues to call every 10 to 15 minutes about pain. You notify the provider that you are concerned about your patient as nothing is helping. The provider decides to do exploratory studies and again finds nothing. You begin to wonder if the patient has a history of opioid abuse and share this with the provider they are suspecting the same thing. What would be the best way to gather further information to determine the patients history with narcotic pain medications?

Case Study cont…. A. Next time the patient calls for pain medication notify them that

you are concerned that they have been taking way to many pain

meds and this is a classic sign of opioid abuse, also letting them

know that they need to tell you the truth.

After administering the patients pain medication you begin

talking with them about them about the current epidemic with

pain medications telling them how much you are disgusted with it

and then ask them if they have ever had any issues with opioid

abuse.

You enter the patients room letting them know that you are

concerned about there increasing needs for increased dosing of

narcotic pain medications. In a matter of fact approach you let

them know that you are concerned there might be an issue with

opioid abuse.

Case study This same patient tells you that they do have a problem with

opioid abuse and have had an addiction to narcotics for 5

years now. They state they heard about tolerance with the

drugs after using for a period of time, but that their pain is

real. They state that they generally take 50mg of oxycodone

a day recreationally. What is your response to this situation

A. Let the patient know that tolerance is very likely and that you

believe their pain is real. While letting them know you will have to

notify the provider in order to determine a more effective

approach to their treatment.

B. Let the patient know that because they have an addiction to

pain medication you can not give them narcotics any longer

despite their complaints of pain.

Leave the patients room immediately and notify the provider.

Questions???

References

Acute Pain Assessment and Opioid Prescribing Protocol. (2014). Quality Improvement Support, 1-44.

Cobaugh, D., Gainor, C., Gaston, C., Kwong, T., Magnani, B., Painter, J., & Krenzelok, E. (2014). The opioid abuse and misuse epidemic: Implications for pharmacists in hospitals and health systems. Am J Health-Syst Pharm, 71, 1539-1551.

General Internal Medicine in Minnesota. (2015, January 1). Retrieved April 12, 2015, from http://www.mayoclinic.org/departments-centers/general-internal-medicine/minnesota/overview/specialty-groups/complementary-integrative-medicine

Jackson, T., Iezzi, T., Nagasaka, T., Fritch, A., & Gunderson, J. (2002). Does the mere presence of over-the-counter pain medication affect pain perception? Some preliminary findings. Psychology, Health & Medicine, 215-222.

Kramlich, D. (2014). Introduction to Complementary, Alternative, and Traditional Therapies. Critical Care Nurse, 34(6), 50-56.

https://www.youtube.com/watch?v=nXAu_pWg0ss