A Systematic Approach to Intense Pain

Management of intense pain does not need to be challenging. If you take a thoughtful approach to addressing the various components that are responsible for the pain experience, you increase your chance of minimizing your patient's discomfort and improving their mobility. Rather than leaving pain management to chance, make an intention to develop a structured approach.

The PreEmpt Pain app will guide you through this systematic approach to pain management with recommendations that are backed by scientific evidence. If you a faced with developing a plan for your patient, you can increase your confidence by taking this proactive approach to pain.

I believe that pain should be treated based on the expected intensity of pain. Here is a list of surgical procedures and medical conditions associated with intense pain. In this way, you are making decisions based on objective evidence of pain severity, rather than relying on the patient's self-report of pain. This allows the most appropriate treatment of pain and improves safety. If you are unsure about the degree of pain associated with your patients' surgical procedure, ask the surgical service.

This is the approach that I use when faced with a patient experiencing a potentially intensive pain situation.

- First-line agents

- Non-pharmacologic treatments

- Adjunctive agents

- Considerations for regional anesthesia techniques or local anesthesia

- Consideration for opioids

- How to manage breakthrough pain

- Share plan with patient / family /

nursing / other providers

- Frequent reassessment

First-line Agents

As expected, these are the analgesics that are the safest and should be considered first for most pain experiences. The first-line agents usually include acetaminophen and the non-steroidal anti-inflammatory agents. With intense pain, consideration should be made for offering these first-line agents scheduled (or around-the-clock ATC) rather than as-needed or PRN. This action may prevent the wide swings in pain intensity and keeps pain at more moderate or lower levels. If opioids are also needed, scheduled first-line agents can minimize the dose needed of opioids and thus decrease opioid side effects, such as sedation, pruritus, nausea.

Acetaminophen can be contraindicated in those with elevated liver function tests, liver disease, or an allergy or other reaction. Acetaminophen is dosed either every 4 or 6 hours and daily doses should not exceed 3,000 mg. NSAIDs such as ibuprofen and ketorolac are contraindicated in renal disease and those with GI conditions such as gastric ulcers. In addition, due to increased risk of bleeding or delayed bone healing, some surgeons prefer that NSAIDs are avoided after surgery. Check with the surgical service as to their thoughts.

Non-Pharmacologic Treatments

As the name suggests, these are non-medicine strategies that can improve the pain experience. The application of ice can act as an anti-inflammatory as it reduces swelling. It can also decrease nerve transmission. Alternatively, the application of heat can improve blood flow and reduce muscle tension which can improve the pain experience. TENS units, diaphragmatic breathing, relaxation, meditation, yoga, and acupuncture / acupressure can actually affect various neurotransmitters in the body responsible for pain relief or may serve to move the body's life energy or qi that is relative to the pain experience.

Some other strategies may serve as a distractor from an individual focusing on their pain by affecting some of the neurotransmitters associated with the pain experience. These non-pharmacologic strategies can be a powerful addition to your pain management toolbox and should not be overlooked despite their simplicity. Some of these strategies are less resource-intensive than others and may be easier to implement in certain circumstances. I will dedicate a separate blog post to this topic in the future.

Adjunctive Agents

Being prepared for side effects of a surgical procedure or medication is a large part of pain management. Some side effects can be more predictable than others related to surgical procedures or a specific characteristic of a patient. In this category, I believe there are four main symptoms that can be managed in a proactive manner to decrease discomfort. These three symptoms are:

- nausea / vomiting

- pruritus

- constipation

Knowing what to expect can put you in the position to prescribe a PRN or as-needed dose of a medication to prevent a symptom from occurring or to treating it at the earliest stage once it does present. Patient dissatisfaction is increased once a symptom appears if one must wait for a prescribing provider to be contacted, for the order to be written, the medication to be obtained, and finally administered to the patient. This is the benefit of proactive pain and symptom management; many of these steps are in place prior to the symptom arising and time is decreased between the onset of symptom and its treatment.

Nausea and vomiting can be the result of a general anesthetic due to the properties of the volatile agent and is most common after the age of 3 years of age up into mid adult-hood (50s - 60s), worse in those individuals who experience motion sickness in a motor vehicle, those who undergo ear, breast, or gynecological surgeries, and in those procedures that might warrant an opioid anesthetic technique or medication. Nausea and vomiting can have the effect of decreasing oral intake and preventing the oral route of medication administration, which might result in prolonged use of intravenous medications and hydration

Pruritus or itching can be a debilitating side effect resulting from an opioid medication or a medical condition. Risk versus benefit of continuing the offending agent must be balanced. On some occasions this warrants discontinuation of the opioid that might be responsible and transitioning to a different one or avoiding them altogether moving forward.

Constipation can be pre-existing or the result of a general anesthetic, surgical procedure, or certain medications. It is important to be proactive in the management of constipation. Discomfort can be minimized by scheduling a stool softener in the immediate postoperative period until bowel habits normalize. Stool softeners can be contraindicated in some procedures or conditions so check with the surgeon regarding his or her preference. The goals should ultimately be a bowel movement every one or two days. Stool should be softer in consistency and straining for a bowel movement is to be avoided. Stool softeners should be held for excessive diarrhea. The presence of constipation can also exacerbate the condition of nausea or vomiting so treatments of these conditions are interrelated.

Considerations for Regional / Local Anesthesia

The possibility of intense pain warrants consideration of more invasive techniques that can improve analgesia without the risk or side effects of opioid administration. Regional or local anesthesia techniques have proven invaluable in this regard. Check out this blogpost I created about regional anesthesia. This is yet another tool that can be offered to patients undergoing a surgical procedure. Often the analgesic effects can last many hours or even days in the case of liposomal bupivacaine. This is yet another step in the WHO Stepladder for pain management.

Consideration for Opioids

While opioids are to be avoided with mild pain and in most cases of moderate pain, they might need to be considered for a short period of time with the presence of conditions associated with intense pain. However, the strategies described above must be implemented concurrently when considering opioids. It may not be reasonable to await the patient's response to the treatments described above; so assure that you have optimized first-line agents, non-pharmacologic strategies, and considered prevention of problematic side effects that could contribute to pain.

A valuable rule is to 'use the gut if it works' which means offer medications by mouth if the patient is allowed and tolerating a regular diet or is not NPO (nil per os). This allows a more physiologic response to pain treatments and encourages improved functioning (rather than receiving the primary opioid medication intravenously. If the patient is NPO or is suffering from persistent nausea or vomiting, then IV opioids might be considered.

If the pain is considered to be intermittent, rather than continuous, it might be reasonable to offer the opioid on a PRN basis (for example every 4 hours) rather than on a continuous schedule. Pain experienced continuously may require administration on a scheduled basis. Of course continuous pulse oximetry should be the standard when individuals are receiving IV opioids.

In some instances, individuals with intense pain may need more control over their pain treatment and patient-controlled analgesia (PCA) may be warranted. For a more in-depth review of PCA, check out this link to my app.

How Will You Manage Breakthrough Pain?

(coming soon to the app)

Breakthrough pain, as the name implies, is pain that 'breaks through' the treatments that you have implemented. There are two common reasons for breakthrough pain:

- end-of-dose failure

- incident pain (associated or initiated by a specific activity)

Breakthrough pain can cause anxiety in your patients and can keep them from being as functional as they need to be to return to normal activity. While expecting that the first-line agents and non-pharmacologic strategies have been implemented, there are some methods you can use to decrease the distress associated with this pain.

1 - Reassurance that some increased pain is expected as once becomes functional

2 - Offer non-pharmacologic strategies such as ice or heat. These can be greatly comforting and are usually safe to use. Occasionally breakthrough pain is a result of tension or muscle spasm; massage can be helpful in this setting. Likewise, distraction from the situation, taking a walk or getting to a different location can be helpful

3 - See if you can find a pattern in the appearance of breakthrough pain

- End-of-dose failure results when the analgesic effect does not seem to last as long

as expected. In that instance, I would optimize my first-line agents, making sure

that both acetaminophen and NSAIDs were offered on a scheduled basis if the

breakthrough episodes are frequent.

- Incident pain presents itself when activity is initiated, such as working with physical

therapy, getting up out of bed. If possible, consider providing a dose of pain

medication 30 minutes prior to this identified activity. If pain is associated with

coughing, for example, instructing the patient to brace themselves holding a pillow

close to the body, can reduce the severity of pain.

4 - Consider consulting a pain management expert if you feel opioids need to be optimized. Assuring that all other strategies are maximized is important but breakthrough pain should not be ignored or taken lightly.

Share The Plan with The Patient

Most important is to communicate with the patient how you plan to manage their pain. Allowing the patient to become involved in the plan will benefit their compliance with the plan, improves trust with the healthcare team, and can lead to improved functioning. Encourage the patient to ask questions they might have.

Check Out the PreEmpt Pain App

Pain management is not often approached in a systematic manner. While pain specialists often have a strategy that works for them, for others, the approach can be 'idiosyncratic', without any particular rhyme or reason. I hope my app helps to address the challenges of developing a pain management plan and provides some guidance for you. Check out the References section that is always being expanded. Do you have a reference that might be helpful for others? Contact me or feel free to drop that into the chat. I'd love to hear what tools have been helpful for you.