Articles: Pain and Suffering
What’s new in pain management?
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record summaries that provide details about pain symptoms
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to understanding treatment.
Effective
management of pain has a direct impact on the quality of
an injured person’s life. The rule of thumb is to
“start slow, go slow” by using the weakest drugs
that will be effective, and then moving up the ladder to
find the drugs which will make the patient comfortable.
New 2007 Joint Commission on Accreditation of Healthcare
Organizations National Patient Safety Goals were released
in June 2006. One of the goals has a bearing on informing
the patient of all medications being taken. “A complete
list of the patient’s medications is communicated
to the next provider of service when a patient is referred
or transferred to another setting, service, practitioner
or level of care within or outside the organization. The
complete list of medications is also provided to the patient
on discharge from the facility.”
What’s
out: Demerol
Demerol (Meperidine) was once commonly used for
pain control, particularly after surgery to relieve moderate
to severe pain. Demerol can be given orally, subcutaneously,
intramuscularly or intravenously. It was often used in combination
with Vistaril or Phenergan to enhance its effects. A common
order is 75 mgs every 4 hours. This order is inadequate
because Demerol provides pain reduction for only 2.5 –
3.5 hours. A dose of 75 mgs every 4 hours is equivalent
to only 5 – 7.5 mgs of Morphine. To obtain the same
amount of relief as that provided by 10 mgs of Morphine,
physicians would need to prescribe 100-150 mgs of Demerol
every 3 hours. [1] Demerol should not be used when kidney
function is impaired, as it is excreted by the kidneys.
Seizures, increased intracranial pressure, respiratory depression,
confusion and irritability may result from its use. The
frequency with which prescribers have requested that Demerol
be given to patients has substantially declined in recent
years. It is no longer the pain reliever of choice, although
it may be used to reduce shivering in a postoperative patient.
What’s
new:
In addition to Methadone, which has an extended
effect with a half life of 24 - 48 hours, other new medications
are effective for once-a-day dosing. New extended release
products on the market include Hydromorph Contin, a 12 hour
extended release form of Dilaudid/hydromorphone. Kadian
and Avinza are two forms of extended release morphine, and
may be used for 24 hour dosing. [2] Both Fentanyl and Lidocaine
can be delivered by patch. The Fentanyl patches take up
to 48 hours to reach full effect and are changed every 72
hours. Lidocaine patches are applied over the painful area
for 12 hours a day.
A Fentanyl
patient controlled transdermal system consists of a credit-card
sized system with an adhesive backing that is applied to
the patient’s upper arm. The patient pushes a button
attached to the device. The medication is delivered into
the tissues. The device can deliver 80 doses or last 24
hours, whichever comes first. This method of pain relief
has proven to be as effective as Morphine PCA pumps for
postoperative pain control. Spinal cord stimulators are
used in patients with chronic neuropathic pain that do not
respond to medication. Leads are implanted in the epidural
space next to the nerves that affect the body area in pain.
The leads emit a mild current that makes the patient feel
less pain. The morphine pump is another device that is implanted.
This device can deliver Morphine into the intrathecal space
to reduce pain. The pump is placed in the abdomen and can
be programmed from the outside. Additional medication may
be needed to supplement the Morphine within the pump. [3]
Depending
on how the physician orders the medication, doses of narcotics
may be given in addition to or instead of a continuously
running infusion of narcotics. These additional doses given
on demand are usually limited to 1 mg of the narcotic in
the pump. The pump is programmed to limit the number of
additional doses which the patient can receive, so as to
not exceed safe hourly limits of the narcotic. New pumps
have touch screens and bar coding, which can be used to
track pain medications as they leave the pharmacy, but also
to identify the patient who receives the medication and
the nurse who puts it in the pump. A hand held computer
can be used to collect information from the patient’s
identification band and the pump. Infrared technology allows
the data to be wirelessly downloaded to a central station
where pain assessment and medication can be monitored. [4]
Concerns
have been identified in the last few years about the hazards
of PCA by proxy, that is allowing nurses and family members
to activate the PCA pump on behalf of the patient. Overdoses
of medication have occurred due to this practice, which
is now being discouraged. Careful PCA pump programming and
patient selection, as well as vigilant monitoring for the
patient’s responses to medication are essential to
provide a safe delivery of pain relief. There have been
tragic instances of overdoses delivered through PCA pumps,
resulting in respiratory arrest and brain damage.
A PCEA
(patient controlled epidural analgesia) pump is one that
delivers pain medication into the patient’s epidural
space. Dilaudid, Morphine, or Fentanyl are used along with
a local anesthetic such as Buprivacaine or Ropivacaine.
The epidural method of pain medication administration should
be done only by clinicians who are skilled in its use and
when careful monitoring of the patient can be provided.
Joint
Commission on Accreditation of Healthcare Organizations
standards place emphasis on ongoing recording of pain levels
using a scale that is appropriate to the developmental stage
and communication abilities of the patient. Increasingly,
medical records contain this information.
Using
data in the medical record, methods of conveying pain to
a fact finder include: presenting a sample of words used
by the patient to describe pain (sharp, excruciating, constant,
shooting), creating a calendar using symbols for each dose
of pain medication given in the acute care setting, and
using candy such as M&Ms to represent each dose of pain
medication.
References
1. Agency for Healthcare Policy and Research, Acute
Pain Management: Operative or Medical Procedures and Trauma,
US Department of Health and Human Services, Rockville, MD,
1992.
2. D’Arcy, Y. “Conquering pain: Have you tried
these new techniques?” Nursing 2005, pgs 36-41, March
2005.
3. Id.
4. Id.
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