By Kevin T. Galloway, BSN, MHA; Chester C. Buckenmaier III, MD; Rollin M. Gallagher, MD, MPH; and Rosemary C. Polomano, PhD, RN, FAAN
An important initial step in pain management is setting goals, which differ for acute and chronic pain. Acute pain management aims to gain rapid, effective control of pain and eliminate further sources of pain. In contrast, management of chronic pain, such as low back pain or polytrauma pain, requires a biopsychosocial approach. The goals of chronic pain treatment include:
- communicating realistic expectations (including the message that freedom from pain isn’t realistic)
- improving the patient’s quality of life
- increasing function and mobility
- reducing the degree to which pain interferes with activities
- relieving associated psychological stressors
- minimizing the risk of opioid misuse, abuse, and addiction, which can be associated with long-term opioid analgesics.
Advances in treating combat-related pain
From the 1800s until recently, morphine was the sole pain-control method used by the military. One of the drug’s benefits, researchers recently found, is that morphine given during early resuscitation and trauma care may reduce the risk of posttraumatic stress disorder in military service members who don’t have serious traumatic brain injury. But in the modern combat environment, morphine has many undesirable—and at times deadly—properties. As the Iraq and Afghanistan conflicts continued and more military service members were treated, the need for alternative pain-management methods became increasingly obvious.
The destructiveness of the weapons used and the severity of combat injuries have been greater in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) than in previous conflicts. Yet nearly 90% of OEF and OIF service members have survived their injuries, compared to a 76% survival rate during the Vietnam War. The higher survival rates stem from improvements in modern battlefield care, including advanced frontline surgical and resuscitation capabilities.
For wounded military patients who are hemodynamically stable and have isolated and uncomplicated orthopedic injuries or extremity wounds, oral transmucosal fentanyl citrate is an advance in acute pain management. This is particularly true in austere combat environments, such as those lacking ventilators, where multiple surgeries must be performed in one operating room, or where multiple patients must be placed on a single monitor. One oral fentanyl dose can provide rapid, sustained pain management for up to 5 hours, generally with only minor adverse effects (itching, nausea, vomiting, and light-headedness).
Austere environments challenge the traditional mindsets and training of surgeons, anesthesiologists, and nurses, who must adapt to environmental conditions and develop innovative anesthetic and analgesic plans as resources are consumed. In these environments, regional anesthesia is more common than general anesthesia, and anesthesia complications can be minimized with training and experience.
Rapid transport of wounded soldiers over great distances by air to increasingly sophisticated trauma-care levels contributes to the higher survival rate. Nonetheless, while rapid air transport to the next level of care is an advance, evacuation flights are crowded, light conditions are low, vibration and noise are high, monitoring resources are constrained, and healthcare personnel are limited. These limitations may contribute to the suboptimal pain relief during air transport reported by some military patients with polytrauma.
Recent advances in treating combat related pain during evacuation flights and postoperatively include regional analgesia via continuous peripheral nerve blocks (CPNB) and patient-controlled analgesia (morphine or hydromorphone). Regional analgesia, which may be administered by certified registered nurse anesthetists, is a preventive strategy that yields improved analgesia, outcomes, and patient satisfaction. Regional analgesia with CPNB also provides pain relief during the frequent trips to the operating room that service members with polytrauma undergo at military treatment facilities and during multiple dressing changes and surgical debridements. Compared to patients who undergo general anesthesia,
those who receive CPNB have less pain, receive less analgesia, suffer less postoperative nausea, and experience fewer anesthesia-related complications. Risks of regional anesthesia include local anesthetic toxicity, nerve injury, and infection from the indwelling catheter.
Ongoing pain management
Optimal pain management requires a comprehensive strategy with a multimodal approach that includes pharmacologic therapy, psychological therapy, physical and occupational therapy, and procedural treatments. (See Multimodal treatments for optimal pain management by clicking the PDF icon above.)
The rationale for multimodal therapy is to improve analgesia by taking advantage of the synergistic action between drugs and the various techniques and delivery approaches that affect different mechanisms in the pain perception-modulation system, or that affect the same mechanism but in different parts of the peripheral nervous system (PNS) or central nervous system (CNS). Synergistic action may allow use of lower dosages and avoid complications of opioid-centered analgesia. A tenet of treating pain patients is that they have a right to have their pain assessed regularly and managed effectively—but they don’t have the right to abuse or violate the terms of their treatment programs.
Multimodal pharmacologic therapy
Many drugs other than opioids are available for treating pain. A rational approach to pharmacologic therapy is to consider a drug’s mechanism of action and the source or type of pain. Multimodal analgesia refers to the use of more than one agent from different pharmacologic analgesic classes that target different mechanisms of CNS or PNS pain. The goals of multimodal analgesia are to:
- improve analgesia quality
- achieve more balanced analgesia
- reduce adverse events.
An example of multimodal pharmacologic therapy is use of an anticonvulsant (such as gabapentin or pregabalin) with an opioid for postoperative neuropathic pain. This combination reduces opioid requirements and adverse effects while providing better pain relief. Another multimodal strategy is to use a single agent with dual mechanisms of action. An example is monotherapy with tramadol or tapentadol; both drugs have mu-opioid receptor agonism and inhibit reuptake of neurotransmitters (primarily serotonin with tramadol and norepinephrine with tapentadol).
Nonpharmacologic strategies for ongoing management of both acute and chronic pain include physical and occupational therapy, procedural techniques, and psychological measures. These strategies aim to restore function and mobility and to reduce psychosocial stressors that contribute to pain. An example of multidisciplinary, multimodal pain management is the treatment of military service members with polytrauma at entry to rehabilitation; all of these patients receive medication (opioids, 58%; nonsteroidal anti-inflammatory drugs [NSAIDs], 50%; anticonvulsants, 20%). Other forms of therapy are individualized and may include physical therapy (40%), occupational therapy (38%), individual psychotherapy (49%), and cognitive behavioral therapy (13%).
Chronic pain management
Intervening early and aggressively in the chronic pain cycle is crucial to favorably influencing pain and quality-of-life outcomes and preventing progression of disabling pain. The Veterans Administration (VA) developed a stepped-care approach to pain management in response to the changing veteran population and in an effort to standardize pain management throughout the VA. This approach became official policy in 2009. (See VA stepped pain-care approach by clicking the PDF icon above.)
Besides using the stepped-care approach, other aspects of managing patients with chronic pain include:
- establishing a collaborative relationship with the patient to promote self-management
- shifting the patient from a biomedical to a biopsychosocial treatment model
- identifying long-term functional goals
- supporting the patient’s efforts to address other life problems.
OEF and OIF veterans have a high frequency of pain of musculoskeletal or connective tissue origin (52%) with significant comorbidities, including mental disorders (48%), nervous-system or sensory-organ diseases (40%), and ill-defined signs and symptoms (46%). The most common pain diagnosis among deployed military service members is low back pain, which may be exacerbated by combat. Although 80% of patients with their first episode of nonspecific low back pain recover within 1 month and another 10% recover within 3 months, the remaining 10% go on to develop chronic pain.
A thorough physical examination and comprehensive history are the most important tools in evaluating low back pain. The physical examination includes a head-to-toe evaluation to determine which areas have structural abnormalities and to evaluate posture, inspect for skin changes (such as color), palpate muscles for knots and tender (trigger) points, assess reflexes, and evaluate range of motion. Patients also undergo neurologic and sensory exams and other special tests. The patient history includes the “5 Ps” of pain assessment—precipitation, pattern, prior treatments, patient beliefs, and predisposition. Diagnostic imaging isn’t necessary unless “red flags” are identified during the exam; imaging may be indicated if pain persists for 3 or more months after appropriate conservative treatment.
The goal of conservative treatment is to enable the patient to perform normal activities as soon as possible. Treatment measures include education and reassurance, brief rest (2 to 3 days), prevention of kinesiophobia (fear of movement) with gradual resumption of minimally painful activities, medications (NSAIDs plus muscle relaxants, which may promote a faster return to activity), and physical therapy.
Rational opioid prescribing
Over the last 30 years, use of opioid analgesics for treating chronic pain has increased. As a result, approximately 10% of American adults with chronic pain have a substance abuse disorder. An estimated 33% to 54% of persons with opioid addiction have chronic pain. This vulnerable population deserves effective pain control, but may require more stringent guidelines for opioid prescribing and monitoring. Brain circuits involved in drug abuse and addiction—reward, motivation, judgment, inhibitory control, and memory consolidation—also are involved in pain processing and perception.
Differentiating addiction, physical dependence, and tolerance
How do addiction, physical dependence, and tolerance differ? According to one definition, addiction is a chronic neurobiologic disease whose development and manifestations are influenced by genetic, psychosocial, and environmental factors. Addiction is characterized by one or more of the following:
- impaired control over drug use
- compulsive use
- continued use despite harm
Physical dependence occurs with regular use of mu-opioid agonists and is to be expected. Serious consequences occur when the opioid is withdrawn abruptly or reversed with an opioid antagonist, such as naloxone. Sudden cessation or reversal can lead to a withdrawal syndrome characterized by physiologic responses, such as agitation, rapid pulse, sweating, and orthostatic hypotension. In rare cases, life-threatening seizures may accompany withdrawal, particularly when the patient also is withdrawing from barbiturates or benzodiazepines (which may be coprescribed in patients with chronic pain, although rarely indicated because of synergistic respiratory depression).
Tolerance refers to decreased response to a constant dose of a drug, or the need for increasing doses to maintain a constant effect.
The goal of rational opioid prescribing is to provide pain relief while preventing the potential adverse outcomes of addiction—but recognizing that physical dependence and tolerance may develop, which may necessitate changes in the treatment plan.
The rising use of opioids to treat chronic pain over the last 30 years is tied to a greater number of opioid prescriptions written by providers with limited training in pain management, psychiatry, or addiction. This trend in both the civilian and military sectors may have contributed to a rise in prescription drug abuse in military, VA, and civilian populations. It has prompted the creation of risk-mitigation strategies and programs to minimize the risk of misuse, abuse, and diversion. Risk-mitigation strategies should be used for patients with a history of opioid addiction who may receive opioids for pain management. Recommended strategies for these patients include:
- prescribing long-acting or time contingent (rather than pain-contingent or as-needed) opioids
- providing small quantities of opioids that necessitate frequent visits to reassess pain and function
- prescribing the minimum dosage that relieves pain and maintains function
- continuing to educate the patient about opioids
- seeking specialists’ opinions and care when indicated by clinical complexity, comorbidities, treatment refractoriness, and higher risk.
When caring for patients who take opioids regularly before surgery, remember that they may require significantly higher opioid doses postoperatively to control pain.
Opioid Renewal Clinic
In 2002-2003, the Opioid Renewal Clinic (ORC) was established at the Philadelphia VA Medical Center to mitigate the risk of opioid misuse, addiction, and diversion. Developed by a nurse practitioner and clinical pharmacist (and supported by a multidisciplinary pain-management team that included an addiction psychiatrist, rheumatologist, neurologist and orthopedist), ORC is modeled on an anticoagulation clinic model. It uses various strategies to mitigate risk, including an opioid treatment agreement (and second-chance agreement), frequent visits, opioid prescribing on a short-term (weekly or biweekly) basis, periodic urine drug testing, pill counts, and comanagement with addiction services.
Several measures demonstrate ORC’s success in reducing the risk of opioid misuse, addiction, and diversion. Most primary-care providers report they’re more comfortable managing patients with chronic pain (89%) and receive fewer complaints from patients regarding pain medications (77%). A 2-year assessment showed use of opioid treatment agreements and urine drug testing increased markedly; emergency department visits decreased by 73% and unscheduled visits to the primary-care provider dropped 60%. In addition, at 1 year, 49% of at-risk ORC patients demonstrated 100% adherence with the program and no aberrant behavior. The ORC has been deemed a best practice by the VA and is being established in various forms throughout the administration and in some civilian settings as well.
National opioid pain care agreement policy
Using a multidisciplinary task force composed of clinicians, ethicists, lawyers, and educational specialists, the VA embarked on a 3-year process to develop a national opioid pain care agreement policy that aimed to standardize and optimize the use of opioid analgesia in pain management. The proposed policy, which takes an informed and shared decision-making approach to risk management, was presented for review in 2009. It recommends routine use of a standardized opioid pain care agreement between provider and patient when chronic opioid therapy is instituted. Patient information resources include a patient guide, which details what the patient needs to know about opioids and pain care in the VA, and a brochure outlining policies and expectations. More recent discussions of this procedure have led to consideration of a standardized informed consent process to replace the opioid pain care agreement policy.
Complementary and alternative medicine for pain management
Complementary and alternative medicine (CAM) encompasses a diverse group of healthcare systems, practices, and products not generally considered part of conventional medicine. The following definitions are useful for understanding CAM terms:
- Complementary medicine is the use of CAM together with conventional medicine.
- Alternative medicine is the use of CAM in place of conventional medicine.
- Integrative medicine refers to a practice that combines conventional and CAM treatments for which evidence of safety and effectiveness exists.
For a summary of CAM techniques commonly used to manage pain, see CAM techniques used in pain management by clicking the PDF icon above.
Nurse’s role in pain management
The Army Pain Management Task Force, chartered by the Army Surgeon General in 2009, emphasizes the need for early and aggressive multimodal therapy for acute pain with coordinated transition of care from one level to the next. (For more information on this Task Force, see “Pain management across the military continuum” in this supplement.) At all levels, care is an interdisciplinary team effort in which nurses play a central role that includes:
- communicating with team members and injured military service members
- educating patients about pain management strategies
- assessing and documenting pain and pain treatments.
Nurses develop unique and sustaining relationships with patients and families, engendering lasting trust that can be instrumental in achieving satisfaction with care and established goals in managing acute or chronic pain. The high survival rate after serious combat injuries in the current conflicts will increase the population of military service members and veterans with acute and chronic pain. Nurses can make a profound contribution to their recovery and return to duty or active civilian life.
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Kevin T. Galloway, is Chief of Staff of the Army Pain Management Task Force of the Office of the Army Surgeon General in Alexandria, Virginia. Chester C. Buckenmaier III is director of the Defense and Veterans Center for Integrative Pain Management and an associate professor at the Uniformed Services University of the Health Sciences in Rockville, Maryland. Rollin M. Gallagher is Deputy National Program Director for Pain Management in the Veterans Affairs Health System at the Philadelphia Veterans Affairs Medical Center in Philadelphia, Pennsylvania; he is also a clinical professor of psychiatry, anesthesiology, and critical care and Director of Pain Policy Research and Primary Care at Penn Pain Medicine at the University of Pennsylvania School of Medicine in Philadelphia. Rosemary C. Polomano is an associate professor of pain practice at the University of Pennsylvania School of Nursing and an associate professor of anesthesiology and critical care (secondary) at the University of Pennsylvania School of Medicine in Philadelphia.