Pain is real, suffering is optional. How you
can safely treat pain... |
Overcome Your Pain by Holly Verenski “Pain is real, suffering is optional” is the motto of the newly formed Pain Committee at Lake Forest Hospital in Lake Forest, Illinois. Although pain is the most common reason for health care visits today, up to 50% of patients report inadequate relief from their pain (Journal of Intravenous Nursing, March/April 2001). Pain is described as the “Fifth Vital Sign” and treatment of pain is finally receiving deserved attention. Pain affects all areas of life: physical, psychological, social and spiritual well-being. Therefore a holistic approach is being adopted by many health care facilities. Why should you suffer needlessly? In the past Health care workers have either failed to accurately assess pain or were not knowledgeable about available alternatives. Doctors have been reluctant to prescribe more than minimal doses of pain medications, fearing that they might overmedicate patients or that patients would become addicted to pain medications. Recent media coverage of misuses of Oxycontin has refueled this fear in doctors and families of persons suffering from pain. We are also at fault for not reporting our pain to our doctors. “Pain is not a badge of courage to be worn,” says Kim Gallagher, RN, who works in home care, “Many people are afraid to report pain because they think it is a sign of weakness.” Others are afraid of the underlying causes (fear of cancer or other diseases). THE NATURE OF PAIN All pain is not created equal. Locations, intensities, and causes vary. Different types of pain require different treatments. Previously pain was classified as either chronic (pain that has been present for a long period of time) or acute (pain of recent or sudden onset and short duration). The new classifications are: Nociceptive, Neuropathic and Mixed pain. There are two types of nociceptive pain: somatic and visceral. Nociceptive pain occurs when trauma or inflammation stimulates our somatic or visceral pain receptors. A paper cut on your hand stimulates the pain receptors on the skin– this is known as Nociceptive Somatic pain. Damage to or inflammation of our organs stimulates their pain receptors causing Nociceptive Visceral pain. Nociceptive somatic pain is often described as localized, aching or throbbing and may be constant or intermittent. Nociceptive visceral pain is described as diffuse, aching, sharp, gnawing, cramping or as a feeling of pressure and it may be referred to a part of the body remote from the organ that is causing the pain (feeling heart attack pain in your jaw for instance). Neuropathic pain arises from lesions or other damage to the nervous system. This damage interferes with how we process sensation. The pain associated with Carpal Tunnel Syndrome is this type. Neuropathic pain can also occur “… when nociceptive pain has been inadequately treated and goes awry”, says Diane Goodman, RN, Co-Chair of the Lake Forest Hospital Pain Committee. Phantom limb pain can be of this type, caused by inadequate management of nociceptive pain following an amputation. Neuropathic pain is usually described as tingling, burning, shooting, or shock-like. The skin in the area may be numb or hypersensitive to touch. Mixed pain includes both neuropathic and nociceptive pain. Following carpal tunnel surgery you may have nociceptive pain from the incision in your hand and neuropathic pain from nerve inflammation. Back pain is often of the mixed variety – nociceptive pain from muscle inflammation, neuropathic pain from ”pinched” nerves. ASSESSMENT: THE FIRST STEP TOWARD RELIEF If you have pain and don’t know why, the first step is to see your doctor to determine the underlying cause. If it is possible to treat the underlying cause this should be done first. Assessment of your pain should be ongoing throughout the treatment. When should you seek a pain assessment? “If your pain interferes with your everyday activities or movements,” says Penny Hiniker, RN, Pain Management Team Leader for Lake Forest Home Health Care. Pain has many factors that can make assessment difficult. A thorough assessment must take into account all factors. Your doctor should consider what pain means to you. The meaning attached to pain varies from person to person and from culture to culture. The effect that pain is having on your emotional, psychological, and spiritual well-being is just as important as its physical effects. To assist your doctor in assessing your pain you should make a list that includes: location(s), what alleviates the pain, what increases the pain, and what you are currently doing to treat your pain. It may be helpful to rate your pain on a scale of one to ten for each location when it is at its strongest and when it is at its weakest. Keeping a pain journal for a week is a useful tool and fairly simple to do. It helps you to keep track of when your pain occurs, how long it takes medicines or other treatments to take effect and how long their effects last. Present these to your doctor at your initial assessment (or your regular check-up) and follow up visits to help determine whether your current regimen could be made more effective or if a new approach should be taken. CHOOSING THE TREATMENT THAT’S RIGHT FOR YOU New studies have shown that uncontrolled pain may impair our immune systems (Journal of Intravenous Nursing, March/April 2001). “Not only does relieving pain make you feel better, it may also help you heal faster,” says Diane Goodman, RN. It is essential that you and your doctor work closely together to achieve the optimal treatment for your pain. The World Health Organization (WHO) has devised a guide to treat pain in a holistic manner. It is known as the WHO ladder and it has three levels for treating pain and its effects on our overall well-being. Initial treatment should always begin at level one. Level one is usually effective in relieving mild to moderate pain. Your doctor may recommend the use of non-opioids and adjuvant medications at this level. Non- opioids include acetaminophen and NSAIDS (Non-Steroidal Anti-Inflammatories). NSAIDS include ibuprofen and naproxen. There is a new class of NSAIDS called Cox-2 inhibitors that have fewer side-effects. These include Celebrex and Vioxx. Adjuvant medications are medications that are not used primarily as pain relievers and include tricyclic antidepressants, steroids, antispasmodics, anticonvulsants and sleep aids. Moderate to severe may persist beyond treatment level one. At level two your doctor may add low dose opioids to your current non- opioid and adjuvant medications. Medicines containing a combination of non-opioid and opioid are commonly used at this stage. Tylenol #3 (acetaminophen and codeine), Percodan (aspirin and oxycodone), and Darvocet (propoxyphene and acetaminophen) are typically used for this purpose. Darvocet, however, should be avoided in the elderly due to its serious side-effects. Its analgesic effects are equal to aspirin or acetaminophen. The usefulness of drugs containing acetaminophen is limited by the maximal daily dose of acetaminophen (4mg). It may also be more effective to use a short-acting opioid separately for pain flare-ups, while continuing to take scheduled doses of non-opioids. When your pain persists in spite of the above treatments level three recommends that your doctor prescribe a long acting opioid as a “background” drug. Your doctor may also increase the dose of your short acting opioids while you continue the use of non-opioids and adjuvant medications. Adding a longer-acting opioid on a scheduled basis and using short acting opioids when pain flares up is often most effective. Working through these levels with your doctor it should be possible to achieve adequate relief of your pain. This doesn’t mean that your pain will be completely absent – especially if your pain has been severe for a long period of time – but your pain should be reduced to a level that you consider tolerable. A level at which it does not affect your enjoyment of life’s daily activities. THE FEAR OF ADDICTION “Less than one percent of people using pain medications for true pain become addicted,” reports Diane Goodman, RN, Co-Chair of the Lake Forest Hospital Pain Committee. This is the message that she wants to spread to doctors, patients and their families. Fear of addiction is one of the biggest barriers to relieving pain through proper use of medications. There have been numerous reports of celebrities becoming addicted to pain medications such as morphine. Recently, misuse of the pain-relieving drug Oxycontin has been in the spotlight. We often have the misguided belief that if we take pain medications, especially in a high dosage, that we run the risk of becoming addicted. Our friends and family frequently reinforce this misguided belief, and worse, our physicians may hold this belief. There is also widespread misunderstanding of what constitutes addiction. Two terms that are often equated with addiction are tolerance and physical dependence. Tolerance means that you adapt to the effects and side-effects of a medication over a period of time and may need to increase the dose to achieve the needed effect. Tolerance to side-effects can be beneficial if the side-effects interfere with taking an effective dose of the medication. Tolerance to the beneficial effects of pain medications in persons with true pain is rare. Physical dependence occurs when your body adapts to the presence of opioid medications in your system. It is made evident by withdrawal symptoms if you suddenly stop taking the medication or quickly reduce the dose (by more than 50%). It is an expected effect of long- term opioid use. To avoid withdrawal symptoms you must work with your doctor to decrease the medication dosages gradually before stopping their use. Physical dependence is NOT a sign you are becoming addicted to a medication. The term substance dependence is used to denote addiction in psychiatric terms. Is it addiction or pseudo addiction? Do you know the difference? There is a fine line between the two and many of us don’t recognize the difference. Addiction and pseudo-addiction to pain medications share common observable characteristics: preoccupation with the use of the medication, hoarding medication, taking more than the prescribed dose, frequently requesting pain medications, and “clock watching” for the next dose. If your family observes these behaviors they may jump to the conclusion that you are becoming addicted. When these behaviors are the result of seeking adequate pain relief they are referred to as pseudo addiction. In addiction, these behaviors often become deviant and destructive and are directed at obtaining medications for their psychological effects – not their pain relieving effects. The destructive behaviors continue despite negative social and economic consequences. Emergency rooms are often faced with the task of determining if a person is seeking pain medications due to an addiction or for relief of true pain. A major hospital in Illinois set up a program that allowed patients three months of treatment with pain medications, increasing the levels at the patient’s request (within medically safe ranges). Since pain measurement is subjective, patients were given the benefit of the doubt. Patients with pseudo-addiction returned to work and to normal functioning again when pain was relieved. Patients who sought pain medications because of addiction did not. They withdrew from society instead. ALTERNATIVES There are alternative methods for treating pain that may be used instead of medications or with them to increase the effectiveness of your pain management plan. Brett Sisler, MSW, counsels people suffering from chronic pain and finds that “even simple relaxation techniques, that anyone can learn and use, are helpful in reducing the severity of pain”. Laura Sykes, P.T. (physical therapist), recommends the use of ice and/or heat to decrease pain - especially in sore muscles. To find out what is best for you, first you need to recognize that pain is interfering in your life and seek a thorough assessment from a doctor who is current on pain treatment methods. And remember that pain is indeed real, but suffering is optional. |