Draft:Common practices in pain management

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Common Practices in Pain Management with an Emphasis on the Role of Opioids

Pain management is a topic of interest to many patient advocates. The ethical challenge typically noted is the use of pain control to manage human suffering in comparison to the alternative of death. Dr. Ross Albert states (2017) that pain is the most common symptom in the last month of life. Pain not only includes physical symptoms but social, psychological, and spiritual components of distress. Pain can be denoted into a two-tier system of understanding. The first tier of pain comprehension is the physical reaction to the pain, this aspect is immediate and presents as a reflex. The second tier is the emotional component of the trauma where the interpretation of pain takes place in the cortex. [1] Sedation for anxiety near death is a common treatment modality and should be considered if indicators of death are pronounced (Albert, 2017). Most patients, if given the choice, choose to die outside the intuition of the hospital. Surveys by Broglio and Cole (n.d.) suggested patients prefer to die at home, although only 25% are able do so. Pain management has been the instrumental in achieving the outcome of being able to die at home. Opioid drug therapy has been the leading treatment modality for patients dyeing from terminal diseases. The three most prescribed drugs for pain management are morphine, midazolam, and haloperidol. These medications are most commonly used in the setting of palliative care, which is the treatment of serious illness with the end goal being symptom relieve. According to Anniek Masman , Monique van Dijk, Dick Tibboel, Frans Baar, and Ron Mathot (2015), pain medication doses did significantly increase on the day of death. Although, the route of administration was changed due to physiological changes in the patient that made subcutaneous administration more effective route. [1][4]

History[edit]

In 1896, Herbert Snow created a drug cocktail of morphine and cocaine that relieved pain in patients that were dying of a terminal disease. The analgesic cocktail was later refined by physicians at the Royal Brompton Hospital in London, England. The “Brompton” cocktail consisted of pain suppressants (opioids), cocaine (stimulant), ethyl alcohol (anti-anxiety), and thorazine(anti-nausea). However, with the advancement of the science behind pain, the “Brompton” cocktail is rarely used today. [5]

Current Issues[edit]

A common problem in pain management is pain assessment. Assessment of pain includes location, quality, duration, onset, intensity, and other factors. Physicians’ concerns involving the use of opiates for pain relief is related to their use of opiates for their patients. According to Hunter, Groninger, and Vijayan (2014), physicians feel uncertain about managing opiates for pain control and the ambiguous procedures to be followed. Hunter, Groninger, and Vijayan state physicians should look for facial grimace, tachycardia, tachypnea, and restlessness for judgement on pain intensity. The article states that a log of pain analgesic use and pain intensity should assess the effectiveness of the current interventions. In pain assessment, the Wong-Baker Faces of Pain Rating Scale are most commonly used in clinical settings. Hunter states how special attention must be given to patients with cognitive impairment from disease or pharmacotherapy, noting on the use of validated pain assessment scales for patients who fit into this category. The pain management techniques advocate the use of acetaminophen and nonsteroidal anti-inflammatory drugs (NSAID) as a first line treatment of pain control. The next tier treatment modality when acetaminophen and nonsteroidal anti-inflammatory drugs are ineffective at pain management is opioids. Hunter Groninger and Jaya Vijayan note that the greatest concern with opioid use is addiction and respiratory depression. Additional concerns of opioid induced impaction bring cautions to at risk populations that may have medication induced compromised peristalsis. [6] Groninger and Vijayan state that concerns over opioid use limit the use of these drugs during pain management. In addition, concerns with opioid use in terminal patients includes metabolites that may accumulate with morphine, oxycodone, codeine, and hydromorphone with specific attention given to renal and/or hepatic dysfunction. Common practice dictates that opioid treatments should be rotated for reasons of cognitive decline, impaired swallowing, organ dysfunction, and to increased tolerance to the current opioid. Alternatives to neuropathic pain include antidepressants, anticonvulsant, and sodium channel blocking medications. An adverse effect of using opioids comes with the presentation of opioid-induced hyperalgesia which is characterized by increased sensitivity to pain despite high doses of opioids. [6] When assessing pain, it is utmost priority to understand the cause of the pain in order to treat appropriately. As more patients are surviving cancer, pain management has become a critical part of treatment modality. Ballantyne (2003), states that pain can occur from peripheral neuropathies due to radiation, chemotherapy, and tumor erosion. Additional sources of pain originate from radiation fibrosis, chronic postsurgical incisional pain, phantom pain, arthropathies and musculoskeletal pain due to changes in posture, and visceral pain from tumor infiltrates. Previous practices include liberal use of opioids in terminal cancer patients because terminal patients will expire before the opioid addiction becomes a concern.

Ballantyne states that addiction is primarily a concern with long term pain management. In non-terminal patients, opioid use should be assessed regularly for pain intensity, goal achievement, functional status, toxicology, and functional status. Ballantyne states a standard approach for management of chronic pain with opioids.


  1. Conduct a comprehensive medical history and examination as part of the pain evaluation
  2. Nonopioid and nonmedical approaches should be tried before opioid therapy is started. Failure of nonopioid
  3. Fully explain the likely benefits and adverse effects of opioid therapy before beginning therapy
  4. Use adjunctive treatments, medical and non-medical, whenever possible
  5. Agree upon treatment goals between the physician and the patient
  6. Use a single physician and a single pharmacy whenever possible
  7. Follow up regularly, including assessments of effectiveness of treatment and signs of abuse.
  8. Ending opioid treatment if goals are not met
  9. Carefully document all assessments and treatment plans and their rationale and progress.


Moreover, regular follow up should include formal assessment of pain, goal achievement, functional status, quality of life, and toxicology screening. The author notes that at high opioid doses, toxicolic results are seen that also effect neuronal, hormonal, and immune systems. Ballantyne speaks about how pain associated with cancer is often linked with neuropathy and may respond well to tricyclic antidepressants or anticonvulsants. It is a general goal of therapy for chronic pain to improve functionality whereas with terminal illness it is pain relief. The author notes in the assessment of pain that quality-of-life questionnaires can be helpful, and second opioids may be added if pain control is not sufficient. [2]

In an article from Practical Pain Management, authors Kathleen Broglio and Barry Eliot Cole discuss pain management and treatment modalities to consider. Broglio and Cole operationalizes the definition of pain in a more accurate way by assessing pain outcome. According to the article, pain steals both the quality and satisfaction of the patients’ remaining life, contributing to anxiety, depression, despair, loss of self-efficacy, and interferes with medical decision making. Broglio and Cole state that pain should be assessed by location, duration, onset, characteristics, severity, provoking factors, and associated signs and symptoms. The article recommends using pain assessment in advanced dementia (PAINAID), Behavioral Pain Scale (BPS), and Critical Care Pain Observation Tool (CPOT) for assessment of patients who have undergone cognitive decline. The author notes that using nonopioid medications off label may prove more beneficial for terminal patients, but opioids are still the standard for pain relief due to their potency, mild sedation, anxiolytic, and ability to be administered by multiple routes. [4]

Biopsychosocial Model to pain relief[edit]

Addiction is a major concern with the use of opioids in pain management. Considering the high abuse potential that opioids have, prescription opioids should be conserved for use in the final step in pain management. When assessing for the risk-benefit use of opioids, consideration must be given to the dosage to achieve pain relieve. At or above 100 mg/day opioids become toxic to the body and alternative pain control measures must be taken. Pain management often takes the form of achieving a goal for pain relief. It is important to note that the elimination of pain is not necessary but achieving diminished pain to enhance functionality and quality of life is a more achievable and valuable goal. Patients may present with fear avoidance to activities that may illicit pain. This demonstrates the importance of biopsychosocial model in that having social support can alleviate the feeling of being alone and the associated depression and anxiety. Cognitive behavioral therapy in combination with pharmacological interventions can produce 80% pain relief. Current treatment modalities for addiction include informed consent, a contract for pain relief, and monitoring for adhesion to schedule. Drug screen profiles that can detect usage serve as a deterrent for illicit sale and misuse of the prescribe opioids.Many health care providers use adjunctive therapy in combination with non-steroidal pain management. Healthcare providers believe that physical therapy is an essential component to pain management in that the fear avoidance of pain eliciting movements contributes to the continuation of the pain leading to secondary disabilities. Physical therapy helps to elevate those fears by confronting the area of pain. Following current treatment modality, it is essential in the contract for treatment that the patient understands that pain management does not mean freedom from pain but rather a limitation of pain that allows for function in the patient’s daily life. When tolerance occurs, a subtle progressive weaning may be practiced bringing the patient back down to the use of non-opioid pain medication. An additional treatment modality for the development of tolerance of opioids is to decrease the opioid prescription and add the non-opioid medication.

Kaye et al (2014), state that their barriers to effective pain management in the elderly population. He notes that elderly men and women represent the fastest growing population in the world. It is estimated by 2040 that the elderly population will grow from 40 million to 80 million in the United States. Kaye reports that 25% to 50% of community elders report pain and as much as 80% report pain in nursing homes. Kaye notes that without adequate treatment of pain, elders may develop functional impairment and decreased quality of life as well as sleep disturbances, depression, anxiety, decreased socialization, cognitive dysfunction, polypharmacy, malnutrition, and increased healthcare costs. Other barriers to effective pain management not otherwise noted are co-existing diseases, contaminate medications, cognitive impairments, decreased communicative abilities, and the high costs of medications. The article revealed that elderly patients underreport pain because they believe that it is a normal part of aging. The article mentions assessing for function during activities of daily living, balance, and gait. The terminology of pain in the elderly is often dictated by common words such as “hurting”, “burning”, and “aching” when referring to the patient’s problem. As part of normal aging there is a consistent reduction in organ functioning. As a result, pain that is incurred should be treated in a manner that is consistent with the origins of the pain. Central nervous system atrophy in the substania nigra is implicit in pain due to the unproportionate amount of glial cells, decreased efficiency in the synapse, and an overall down regulation of the receptors. Pharmaceutic changes are present with the elderly in that there is an increase in body fat, decrease in total body water, and decrease muscle mass. Pharmacodynamic changes occur in the geriatric population that present with increased sensitivity to benzodiazepines, opioids, and psychotropic drugs. Poor medical compliance prevents physicians from providing effective pain management. Factors associated with ineffective pain management include physician-patient communication, cost of care, ethnic and cultural beliefs, drug and dosage form, and insurance coverage. Pain management modality arrives in 4 modes.


  1. Pharmacotherapy
  2. Physical Rehabilitation
  3. Psychological Support
  4. Interventional Procedures


Non-opioid pharmacological adjuncts include acetaminophen which is considered the first initial line of treatment, nonselective NSAIDs and COX-2 selective inhibitors. The next line of pharmacological therapy is the administration of opioids in patients that have moderate to serve pain, pain related functional impairment, and diminished quality of life. The article also addresses that breakthrough pain should be anticipated, assessed, and prevented using short acting immediate release opioids which is a variance in the typical treatment modality that consists of treatment with non-opioid adjuncts to lessen the tolerance to the opioid. The article noted that other adjuvant treatments may be appropriate for neuropathic pain including tertiary tricyclic antidepressants such as amitriptyline, imipramine, and doxepin which the primary mechanism of action is the nor-epinephrine receptor site. Long term systematic corticosteroids may yield positive results with patients who had pain associated inflammatory disorders. Patients with localized nonneuropathic pain would be good candidates for topical analgesics or non-steroidal anti-inflammatory drug (NSAIDS). Physical therapy allows mobilization of the patient preventing secondary disabilities, decrease pain perception using a multidisciplinary approach in treating deficits in function, adaption to the disability, and promoting overall wellness. Therapeutic exercises can be used to improve range of motion exercises, flexibility, and prevent contractors. Treatment modalities include passive and active, active-assisted, resistance exercises, flexibility exercises, and aerobic conditioning. Devices used in therapy include the rowing machine, ergometers, and treadmills. Physical modalities include cold, heat, massage, ultrasound and transcutaneous electrical nerve stimulation (TENS). Transcutaneous electrical nerve stimulation utilizes small pads that are applied to an area where pain originates from and pass electrical current through the area to stimulate the perfusion, improved healing, and restoration of proper nerve signaling. Heat therapy will yield vasodilation and increase oxygen supply and nutrients to the area while eliminating carbon dioxide and metabolic wastes. Acupuncture has been shown to beneficial for the patient in that it stimulates the production of endorphins. Cognitive behavioral therapy utilizes biofeedback to adjust to the pain signals and apply relaxation techniques such as breathing exercises, guided imagery, and graded activation. However, cognitive impairment can hinder the ability to benefit from cognitive behavioral therapy. Interventional modalities focus on the invasive treatments used for pain management. Among the treatments include intraspinal opioid therapy that minimizes the systemic side effects. The current “Gate Theory” proposes that pain is a balance of small and large neural fiber influences the sensation of pain. It is the closing of the gate to large fibers that limits pain. Radiofrequency ablation has shown to be affective in some patients, but the results are mixed. [7]




References [1] [2] [3] [4] [5] [6] [7]





Jerod Nerad 16:28, 13 November 2018 (UTC)

  1. ^ Albert, R. (2017). End-of-Life Care: Managing Common Symptoms. American Academy of Family Physicians
  2. ^ Ballantyne, J (2003). Chronic Pain Following Treatment for Cancer: The Role of Opioids. The Oncologist.8:567-575
  3. ^ Baar, F., Dijk, M., Masman, A. , Mathot, R., and Tibboel, D., (2015). Medication use during end-of-life care in a palliative care center. Internal Journal of Clinical Pharmacology. 37: 767-775 DOI: 10.1007/s11096-015-0094-3
  4. ^ Broglio, K and Cole, B (N.D.). Pain Management and terminal Illness. (8)4
  5. ^ Clark, D. (2014, August 1). Retrieved from: http://endoflifestudies.academicblogs.co.uk/the-brompton-cocktail 19th-century-origins-to-20th- century-demise/
  6. ^ Groninger, H. & Vijayan, J. (2014). Pharmacologic Management of Pain at the End of Life. American Academy of family Physicians.90 (1):26- 32
  7. ^ Kaye, A., Baluch, A., Kaye, R., Niaz, R., Kaye A., Liu H., and Fox C. (2014). Geriatric Pain Management Pharmacological and Non-pharmacological Considerations. Psychology and Neuroscience. 7,1,15-26 DOI: 10.3922/j.psns.2014.1.04