Management of Pain Management of Pain Author: Ayda G. Nambayan, DSN, RN, St. Jude Children’s Research Hospital Content Reviewed by: Nursing Education Department, International Outreach Program, St. Jude Children’s Research Hospital Wren Kennedy, RN, MSN, PNP/O, St. Jude Children’s Research Hospital Cure4Kids Release Date: 1 September 2006 Children of all ages deserve compassionate and effective pain treatment. - World Health Organization It is a common belief that if a child or adolescent has cancer, he or she must be in pain. Although this statement is not necessarily true, if and when the child or adolescent has pain, concerted efforts should be made to reduce or eliminate the pain whenever possible. As a population group, pediatric patients in general are at risk of undertreatment of pain; undertreatment is due perhaps to several reasons related to age and assessment. Not only should the nurse be mindful of the presence of pain, but also parents should be encouraged to discuss the issue of pain with the health care providers. Studies have shown that anxiety, fear and even phobias can develop as a result of painful experiences long before children can express them. The goal of pain management is to provide each child or adolescent with the dose of analgesic medication that prevents the recurrence of pain before the next dose is administered; thus, the patient remains pain-free (McGrath, 1996). Health care providers must be educated and provide information to patients and families regarding the appropriate medical use of analgesic agents. The treatment plan for pain is usually based upon the following factors: The patient’s age, The patient’s overall health and medical history, which should include the results of an assessment of the presence, of persistent and breakthrough pain and their effects on function, The type and extent of the cancer, A diagnostic evaluation of signs and symptoms associated with common presentations of cancer pain and syndromes, A patient’s tolerance of specific medications, procedures and therapies, The parents’ opinions and preferences, The outcomes of the psychosocial assessment. Several professional groups (A – 1) have developed recommendations, assessment and management guidelines and treatment algorithms that are designed for clinical use. Module 9 - Document 7 Page 1 of 18 Management of Pain Although the recommendations (A – 2) are good roadmaps, 2 key principles should be emphasized in planning and implementing strategies of pain management: the regimen should be individualized, and the administration or implementation of the regimen should be optimized. Individualizing the Regimen There is not a standard dose of pain medication that will work for all children and adolescents. It is important that the needs of the patient be considered when the dosages of pain medication are determined. Individualizing the pain treatment plan (A – 3) begins with a comprehensive pain assessment. To date, there are many different formulations of pain medications. Their creative use in a logical manner and according to the specific patient needs is becoming accepted practice. Information gathered during the assessment will help clinicians develop a strategy in which pharmacologic and nonpharmacologic approaches are used to manage pain. For example, instead of the oral route for administration of pain medication, a transdermal route may be used to treat the patient who has mucositis, dislikes swallowing pills or has had bad experiences with the taste of oral medications. The health care professional should use information gathered during the assessment about the culture and beliefs of the patient and the family. For example, Chinese patients traditionally take medications as a single dose and may not continue taking the medication around the clock if they feel well. They may also be confused by the use of controlled-release pain medications. The medication dose should be titrated according to the desired effect (the absence of pain with minimal side effects). Because individual patients may respond differently to the same analgesic medications and dose, the amount and dose intervals must be titrated to optimize the balance between analgesia and side effects. Understanding the unique needs of each child or adolescent is essential in providing appropriate pain interventions. Careful consideration of the patient’s situation provides individualized pain treatment and its associated nursing care – thus, the patient’s quality of life will be improved. Optimizing Administration The rule regarding optimization of administration is to provide sufficient analgesic(s) to continuously relieve the pain, if possible. A preventive approach may entail administering analgesic medications (or starting imaging activities) before the pain occurs or increases. To maintain the optimum level of pain relief, analgesic administration should be scheduled to prevent pain recurrence. Examples include giving the pain medication several minutes before a painful procedure such as dressing changes and around-the-clock administration of analgesics if the pain is present most of the day. Another example is using timed- or continuous- release formulations for patients with persistent pain Another way that clinicians can optimize administration is to be creative with the meaning of “PRN” (as needed) analgesics. Nurses have been taught to administer PRN medications only when a patient requests them; however, current clinical practice guidelines recommend the proactive use of analgesics as around-the-clock rather than PRN medications to prevent pain Module 9 - Document 7 Page 2 of 18 Management of Pain from becoming severe. Thus, PRN analgesics should be given if the pain assessment indicates the need for the analgesic (presence of breakthrough pain), even if the patient has not yet requested it. Because young children and infants have lower pain thresholds and poor central modulation, they will often require sedation or general anesthesia to undergo procedures (such as bone marrow aspiration) that adults often undergo with minimal or no analgesia. Older children and adolescents may be given opioids or nonopioid analgesics before they undergo such procedures; however, ample time for the analgesic(s) to reach its peak concentration should be allowed before the painful procedures are performed. Pharmacologic Management of Pain Effective doses of analgesics (A – 4) should be used to treat pain; the selection of the appropriate analgesic should depend upon its indications for use, side effects, needs of the individual patient, dosing and titration. A good guideline that is commonly used in clinical practice is the World Health Organization (WHO) Analgesic/Pain Ladder (A – 5). Nonopioid analgesics (A – 6) are a class of pharmacologic agents that can effectively treat mild to moderate pain and are often used in combination with an opioid analgesic to control pain caused by bone metastasis and other types of severe pain. The main types of nonopioid analgesics are as follows: acetaminophen (Tylenol®), which is usually the drug of choice for children with mild to moderate pain; aspirin (ASA), although it is not commonly used in patients with cancer because of its antiplatelet activity; other nonsteroidal anti-inflammatory drugs, which have analgesic, antipyretic and anti-inflammatory effects, inhibit cyclo-oxygenases 1 and 2 (COX1 and COX2) and prevent synthesis of prostaglandins. Opioids (A – 7) are a second class of pharmacologic agents used to treat pain. Their mechanism of action depends upon their ability to bind to specific opioid receptors in the central nervous system (CNS). The primary CNS receptors are mu (μ) and kappa (ĸ). Opioids are also capable of altering the perception of and emotional responses to pain because of the wide distribution of the opioid receptors in the CNS. Opioids are classified as agonists, partial agonists and agonist- antagonists. Agonist opioids bind to the opioid receptors to activate them and stimulate the maximum response mediated by the individual receptors. Partial agonists bind to the receptors, but their binding produces only a partial response. Agonist-antagonist opioids cause mixed effects – these compounds act as an agonist at one type of opioid receptor and as a competitive antagonist at another. Module 9 - Document 7 Page 3 of 18 Management of Pain Adjuvant drugs (A – 8), a third class of pharmacologic agent used to treat pain, are medications used in combination with analgesics to enhance pain relief or to treat symptoms that exacerbate pain. In some instances, adjuvant drugs may be used alone to treat specifically identified pain. Medications in this category include the following. Anticonvulsants, antidepressants, anesthetics and antidysrhythmics are commonly used to treat neuropathic pain and are often used in combination with an opioid. Antihistamines have analgesic properties as well as anxiolytic and sedative effects, which are often helpful for patients who need to rest. Corticosteroids are beneficial to the treatment of cancer pain originating in a fairly restricted area such as an intracranial or pelvic region or an area along a nerve root. Corticosteroids suppress the release of prostaglandins; thus, inflammation is inhibited, and subsequently pressure within the confined area or along the nerve is relieved. Psychostimulants potentiate opioid analgesia and increase alertness or reduce persistent opioid-induced sedation in some patients. Clonidine (Catapres; Duraclon) is used