pain pointers

Whats your game plan for defeating pain?

YVONNE DARCY, CRNP, CNS, MS Nurse Practitioner/Pain and Palliative Care Outcomes Manager Suburban Hospital Bethesda, Md.

PAIN IS THE MOST common reason that people seek medical care. However, too many of them fail to nd relief despite the vast array of pain medications, advanced technology, and expert guidelines available today. When it comes to defeating pain, health care providers are like a football coach at game time: They must know the opposition, understand the available players on the bench, and develop a game plan. In this article, Ill discuss recent advances in drug delivery systems and strategies that may relieve your patients pain and help keep them in the game.

Whos on the bench?

Pain control options have increased as researchers discover how the body uses natural substances, such as serotonin and epinephrine, to transmit and block pain impulses. We can now target the affected physiologic area or specic pain-causing process. Although morphine remains the gold standard, new developments in nonsteroidal anti-inammatory drugs (NSAIDs) that can provide analgesia with fewer gastrointestinal adverse effects, such as cyclooxygenase (COX)-inhibiting nitric oxide donator drugs, are promising. Currently, celecoxib (Celebrex), a COX-2 NSAID, can be used for pre- and postoperative pain. Lets take a look at the currently available methods of drug delivery. Extended-release medications offer more options for pain management. New products on the market include: I Opana, a 12-hour oral form of oxymorphone that has immediate release for breakthrough pain. The injectable form, Numorphan, can be used for postoperative pain. I Kadian and Avinza, two forms of extended-release morphine that have been developed for 24-hour, oncea-day dosing. These oral capsules contain morphine suspended in tiny spheres. As the capsules pass through the intestine, the medication is gradually pushed out of the spheres by digestive uids and taken up by the patients vascular system. Fentanyl transdermal patches provide 72hour pain relief by releasing small amounts of fentanyl for vascular uptake. This is useful for patients who cant ingest oral medications

Get ready to tackle your patients pain.

The opposition
Lets start with a quick review of the three pain types: I Acute pain follows an injury and should end after healing; it serves only to warn the body that its been injured. Allowed to persist, pain can become chronic. Current recommendations encourage health care providers to treat acute pain aggressively and to avoid deferring analgesia, even without a diagnosis. I Chronic or persistent pain lasts beyond the normal healing period. Previously dened as pain that lasts longer than 3 to 6 months, the new denition is more exible. Surprisingly widespread, chronic pain includes low back pain, arthritis, and bromyalgia. I Neuropathic pain is chronic pain caused by nerve damage; for example, diabetic neuropathy, low back pain with radicular components, postmastectomy pain syndrome, and postherpetic and trigeminal neuralgia.

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or who need long-term systemic pain relief. Because the patch needs up to 12 hours to start working and may not reach its full effect for about 48 hours, additional pain medication may be needed. If so, monitor your patient for sedation. Be sure to warn patients who require 24-hour pain medication not to take more than one extended-release medication at a time (see What you need to know about fentanyl transdermal patches). Topical lidocaine patches, typically used to relieve local pain, can also help patients with neuropathic pain syndromes. The soft, annel-like, transdermal patch, which has a lidocaine-impregnated gel layer, is worn over the painful area for 12 hours a day. The patch reduces the amount of substance P, a pain-promoting substance produced at the pain site. Buccal swabs are only approved for breakthrough pain in opioid-tolerant adults with cancer. A patient is considered opioidtolerant if hes taking at least 60 mg of morphine per day, 50 mcg of transdermal fentanyl per hour, or an equivalent dose of another opioid for a week or longer. As the Actiq (oral transmucosal fentanyl) a small ball of medication on a stickis rubbed inside the cheek, the medication is absorbed in much the same way as sublingual nitroglycerin. This rapid uptake and onset gives faster relief from breakthrough pain than an oral elixir or tablet. As with any opioid, carefully monitor your patient for such adverse reactions as sedation. The patient-controlled analgesia (PCA) pump is now routinely used for treating acute pain. The latest pumps incorporate touch screen programming and bar coding. A PCA pump can track pain medication as it leaves the pharmacy and can identify the patient who receives the medication and the nurse who delivers it. Using a handheld computer, you can collect information from the patients ID band and PCA pump and wirelessly download data to a central pain assessment station. The fentanyl iontophoretic transdermal system (IONSYS) attaches to the patients upper arm with an adhesive backing. When your patient pushes a button attached to the credit card-sized device, the medication is delivered into the tissue by an electrical current (iontophoresis). A recent study found the IONSYS to be as effective as a morphine PCA pump for controlling moderate to severe postoperative pain.

Got game?
Now lets put this information together with specic pain types and develop strategies to relieve your patients pain.

Acute pain
Besides the PCA pump, you can use an epidural catheter, a patient-controlled epidural analgesia (PCEA) pump, or a peripheral nerve catheter to help manage your patients acute pain. I An epidural catheter is useful for patients whove had major abdominal or orthopedic surgeries. The catheter is inserted into the patients epidural space at the spinal level

What you need to know about fentanyl transdermal patches

Keep these facts in mind when a fentanyl transdermal patch is prescribed for your patient.

Risk factors
Fentanyl is a powerful schedule II opioid that has a serious potential for abuse, which may be increased because of its high content in the patch. Patients are at high risk for severe respiratory depression leading to fatal overdose.

Indications
Use a fentanyl transdermal patch for patients who: need extended, continuous opioid administration are opioid-tolerant have chronic pain that hasnt responded to other treatments.

Contraindications
Dont use a fentanyl transdermal patch if the patient: isnt opioid-tolerant needs opioid analgesia for a short period of time or for postoperative pain has mild or intermittent pain.

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of the nerves serving the incision site. Most epidural solutions contain a local anesthetic and an opioid. When delivered in this way, very small amounts of pain medication can provide excellent pain relief. I The PCEA pump improves pain relief and lowers the risk of adverse reactions. Because the patient can give himself a bolus dose to control dynamic pain, the continuous rate can be lower. Remember, education is key: Before surgery, teach your patients how to use PCA and PCEA devices so they can actively participate in their pain control. I The peripheral nerve catheter delivers local anesthetic directly to the nerve sheath. One variation is a soaker-type catheter inserted along a surgical incision to numb the area. This local relief can reduce the need for opioids and allow your patients to resume activity sooner. space uid and the skill required to maneuver in such a small area. I The implanted pump delivers morphine into the intrathecal space of patients who are unable to obtain relief with other therapies. This is useful for cancer pain or resistant, persistent pain syndromes. The pump, which can run a continuous or varied rate of pain medication with the help of a computer chip, is placed subcutaneously in the patients abdomen. Patients with implanted systems, such as the nerve stimulator or morphine pump, may also need oral pain medication to control breakthrough pain.

Patient still in pain? Its OK weve got options!

Neuropathic pain
Neuropathic pain may not fully respond to opioids and it often requires additional medications, such as the anticonvulsant agents gabapentin (Neurontin) and pregabelin (Lyrica). Topical lidocaine patches can also help patients with neuropathic pain, as part of a regimen that may include opioids, anticonvulsants, or antidepressants.

Chronic pain
For chronic pain that doesnt respond to oral medication, implanted systems for spinal cord stimulation and implanted intrathecal morphine pumps can improve functional abilities, even if they dont address the underlying condition. I The spinal cord stimulator is indicated for patients with chronic neuropathic pain syndromes. One or more stimulator leads are implanted in the epidural space adjacent to the nerves that enervate the affected body area. The leads emit a mild electrical current that makes the body feel less pain. Although the stimulator cant cure the pain, it can make it more tolerable. I Radiofrequency lesioning is a newer technique that involves inserting a thermal-tipped needle into the area of the nerve root serving the painful area. The heated needle tip cauterizes the nerve root. Relatively painless, this is an outpatient procedure. I Epiduroscopy involves inserting a small, exible beroptic catheter into the epidural space. A small device attached to the epiduroscope removes scar tissue from nerve roots, decreasing pain. This process is limited by the lack of clarity in the epidural
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Touchdown!
The art and science of pain management has made amazing progress over the last 30 years. New medications and advanced drug delivery systems and strategies have improved pain management and quality of life for patients. Imagine what the next 30 years will bring! I

Learn more about it

American Academy of Pain Management. http://www.aa painmanage.org. Accessed September 6, 2006. American Chronic Pain Association. http://www.theacpa. org. Accessed September 6, 2006. American Pain Foundation. http://www.painfoundation. org. Accessed September 6, 2006. American Pain Society. http://www.ampainsoc.org. Accessed September 6, 2006. Block B, et al. Efcacy of postoperative epidural analgesia: A meta-analysis. JAMA. 290(18):2455-2463, November 12, 2003. DArcy Y. Conquering pain. Nursing2005. 35(3):37-41, March 2005. DArcy Y. Using regional blockade for adjunct pain relief. Nursing2004. 34(11):74-75, November 2004. Viscusi ER, et al. Patient-controlled transdermal fentanyl hydrochloride versus intravenous morphine pump for postoperative pain: A randomized controlled trial. JAMA. 291(11):1333-1341, March 17, 2004.