Dr.Proxy

THE NATURE AND EXPERIENCE OF PAIN

Pain is a universal human experience and the most common reason people seek medical care. Pain tells us something is wrong in the structure or function of our body and that we need to do something about it. Because pain is such a strong motivator for action, it is considered one of the body's most important protective mechanisms.

Definitions of Pain

The International Association for the Study of Pain defined pain as "an unpleasant, subjective, sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage" (1979). Pain, however, is much more than a physical sensation caused by a single entity. It is subjective and highly individual, a complex mechanism with physical, emotional, and cognitive components.
Pain cannot be objectively measured in the same way as, for example, the chemical content of urine or the oxygen content level of blood. Only the person who is suffering knows how the experience feels. For these reasons, McCaffery defined pain as "whatever the experiencing person says it is and whenever he says it does" (1979). The American Pain Society goes further by stating that it is "not the responsibility of clients to prove they are in pain; it is the nurse's responsibility to accept the client's report of pain" (2005).
Pain alters the quality of life more than any other health-related problem. It interferes with sleep, mobility, nutrition, thought, sexual activity, emotional well-being, creativity, and self-actualization. Surprisingly, even though pain is such an important obstacle to comfort, it is one of the least understood, most undertreated, and oft-discounted problems of healthcare providers and their clients. For this reason, some nurses and therapists add comfort to Maslow's hierarchy of basic human needs (1968). The American Pain Society goes further, declaring the relief of pain a "basic human right" (2005).
Traditionally, pain was considered merely a physical symptom of illness or injury, a simple stimulus-response mechanism. Though the historic role of nurses and therapists has been to relieve pain and suffering, there has been little understanding of the complexity of pain and only limited ways to manage it. Recent research shows pain to be a distinct disorder, with physical, emotional, and cognitive components. This view of pain has broadened our understanding of pain and given us new ways to understand its characteristics.

Types of Pain

Pain is classified as acute and chronic. Acute pain has an identifiable cause and occurs soon after an injury to tissues in the body, such as bone, skin, or muscle. Acute pain is protective in that it motivates a person to take action. Its onset may be sudden or slow, and its intensity may vary from mild to severe. Acute pain is temporary and subsides as healing takes place. Severe acute pain activates the sympathetic nervous system, causing diaphoresis, increased respiratory and pulse rates, and elevated blood pressure.
Chronic pain lasts beyond an expected healing phase, is non-protective in that it serves no function, and may not have an identifiable cause (Patterson, 2007). When pain goes on more than 6 months, it moves from being a "symptom" to a "condition." Chronic pain afflicts more than 1 in 5 Americans and is one of the most pervasive and thorny medical conditions in the United States. Such pain is described as nonmalignant (noncancerous), malignant (cancerous), and intractable.

• Nonmalignant, noncancerous chronic pain typically accompanies such conditions as osteoarthritis and peripheral neuropathy. The lack of purpose and uncertainty of duration of such pain may lead to depression, fatigue, insomnia, anorexia, apathy, learned helplessness, and other psychosocial consequences. If it is severe, chronic pain—like prolonged stress—activates the parasympathetic nervous system, resulting in muscle tension, decreased heart rate and blood pressure, and failure of body defenses.
• Malignant, cancerous chronic pain may be due to tumor progression, invasive procedures, infection, toxicities of treatment, and physical limitations. Such pain may be felt at the tumor site or some distance from it. Since clients with cancer may experience both chronic and acute pain, caregivers need to investigate immediately any new pain in these clients.
• Intractable chronic pain is pain from any cause that is resistant to medical, surgical, and nursing measures. Persistent and ongoing, intractable chronic pain may be psychogenic in nature (Mosby's Dictionary, 2009).

Sources of Pain

 

The sources of pain are divided into three main categories: nociceptor, non-nociceptor, and psychogenic.
Nociceptor pain results when tissue damage produces a pain-producing stimulus that sends an electrical impulse across a pain receptor (nociceptor) by way of a nerve fiber to the central nervous system. Nociceptor pain is further divided into visceral and somatic pain.

• Visceral pain results from stimulation of nociceptors in the abdominal cavity and thorax.
• Somatic pain is divided into deep somatic and cutaneous pain. Deep somatic pain arises from bones, tendons, nerves, and blood vessels. Cutaneous pain originates in the skin or subcutaneous tissue. Some body tissues, such as the brain and lung, have no nociceptors, and some tissues have many.

Non-nociceptor (neuropathic) pain is caused by direct injury to structures of the nervous system.
Psychogenic pain is pain for which there is little or no physical evidence of organic disease or identified injury to tissues in the body. Lack of evidence, however, does not mean clients are malingering or that they are not suffering.

PHYSIOLOGIC SOURCES OF PAIN

Source: Adapted with permission from Ignatavicius et al., 1999.
Nociceptor: Visceral
Physiologic structures	Organs and linings of body cavities
Mechanism	Activation of nociceptors
Characteristics	Poorly localized, diffuse, deep, cramping or splitting
Sources of acute pain	Chest tubes, abdominal tube drains, bladder and intestinal distention
Sources of chronic pain syndromes	Pancreatitis, liver metastases, colitis
Nociceptor: Somatic
Physiologic structures	Cutaneous: skin and sub-cutaneous tissues Deep somatic: blood, muscle, blood vessels, connective tissue
Mechanism	Activation of nociceptors
Characteristics	Well-localized, constant and achy
Sources of acute pain	Incisional pain, insertion sites of tubes and drains, wound complications, orthopedic procedures, skeletal muscle spasms
Sources of chronic pain syndromes	Bony metastases, osteoarthritis, rheumatoid arthritis, low-back pain, peripheral vascular disease
Non-nociceptor: Neuropathic
Physiologic structures	Nerve fibers, spinal cord, and central nervous system
Mechanism	Non-nociceptive injury to nervous system structures
Characteristics	Generalized along distribution of damaged nervous structures
Sources of acute pain	Poorly localized: shooting, burning, fiery, shock-like, sharp, painful numbness
Sources of chronic pain syndromes	Nervous tissue injury due to diabetes, HIV, chemotherapy, neuropathies, postherpetic neuralgia, trauma, surgery
Psychogenic
Physiologic structures	No organic structures
Mechanism	Emotional
Characteristics	Variable, often numerous
Sources of acute pain	Nonorganic
Sources of chronic pain syndromes	Nonorganic psychological factors

Physiology of Pain

Though a person is not consciously aware of the process, the experience of pain involves a complex sequence of biochemical and electrical events or processes beginning with tissue damage and followed by transduction, transmission, perception, and modulation.

TISSUE DAMAGE

When tissue is damaged, there is an immediate release of inflammatory chemicals called excitatory neurotransmitters, such as histamine and bradykinin, a powerful vasodilator. Increased blood in the area causes the injured area to swell, redden, and become tender. The bradykinin stimulates the release of prostaglandins and substance P, a potent neurotransmitter that enhances the movement of impulses across nerve synapses.

TRANSDUCTION AND TRANSMISSION

Transduction occurs as the energy of the stimulus is converted to electrical energy. Transmission of the stimulus takes place when this energy crosses into a nociceptor at the end of an afferent nerve fiber. Two types of peripheral nerve fibers conduct painful stimuli: the fast, myelinated A-delta fibers and the very small, slow, unmyelinated C-fibers. A-fibers send sharp, distinct sensations that localize the source of the pain and detect its intensity. C-fibers relay impulses that are poorly localized, burning, and persistent. For example, after burning a finger, a person initially feels a sharp localized pain as a result of A-fiber transmission. Within a few seconds the pain becomes more diffuse and widespread as a result of C-fiber transmission.
Pain stimuli travel quickly to the substantia gelatinosa in the dorsal horn of the spinal cord, where the "gating" mechanism (discussed below) occurs. Pain impulses then cross over to the opposite side of the spinal cord and ascend to the higher centers in the brain via the spinothalamic tracts and on to the thalamus and higher centers of the brain, including the reticular formation, limbic system, and somatosensory cortex. (See figure.)

PERCEPTION

When pain stimuli reach the cerebral cortex, the brain interprets the signal; processes information from experiences, knowledge, and cultural associations; and perceives pain. Thus, perception is the awareness of pain. The somatosensory cortex identifies the location and intensity of pain, and the associated cortex determines how an individual interprets its meaning.

MODULATION

Once the brain perceives the pain, the body releases neuromodulators, such as endogenous opioids (endorphins and enkephalins), serotonin, norepinephrine, and gamma aminobutyric acid. These chemicals hinder the transmission of pain and help produce an analgesic, pain-relieving effect. This inhibition of the pain impulse is called modulation. The descending paths of the efferent fibers extend from the cortex down to the spinal cord and may influence pain impulses at the level of the spinal cord.

GATE-CONTROL THEORY

Melzack and Wall proposed the gate-control theory to explain the relationship between pain and the emotions (1982). According to the theory, a gating mechanism occurs when a pain impulse travels to the substantia gelatinosa in the dorsal horn of the spinal cord. There, trigger (T) cells influence the transmission of pain impulses. When their activity is inhibited, the gate closes and impulses are less likely to be transmitted to the brain. This mechanism is controlled by descending nerve fibers from the thalamus and cerebral cortex, areas of the brain that regulate thought and emotions. The gate-control theory helps explain how thoughts and emotions modify the perception of pain and why interventions, such as imagery and distraction, help relieve it.

Factors That Influence Pain

The perception of pain is influenced by physiologic, psychological, and cultural factors, all of which caregivers need to consider.

PHYSIOLOGICAL FACTORS

Age

Age affects the way people respond to pain. It influences both the development and decline of the nervous system. Aging affects the whole body, causing many painful degenerative disorders (such as osteoarthritis), secondary injuries (such as skin abrasions and fractures), and a host of common surgical procedures (such as cataract and hip replacement). Age also affects the way families and caregivers respond to complaints of pain. The following table gives a brief overview of the perception of pain relative to age. (The management of pain in children and older adults will be discussed in greater depth later in this course.)

AGE AND THE PERCEPTION OF PAIN

Age	Pain Perception
Pre-term infants	Have anatomical and functional ability to process pain by mid to late gestation; seem to have greater sensitivity to pain than term infants or children
Newborn infants	Response to pain is inborn and does not require prior learning; respond to pain with behaviors such as crying, grimacing, moving body
Infants, 1 month	Can metabolize analgesics and anesthesia effectively; can recognize caregiver as comforter
Toddlers/Preschoolers	Can describe pain, its location and intensity; respond to pain by crying, anger, sadness; may consider pain a punishment; may hold someone accountable for pain and remember experiences in a certain location, such as a clinic
School-age children	May try to be brave when facing a painful procedure; may regress to an earlier stage of development; seek understanding of reasons for pain
Adolescents	May be slow to acknowledge pain; may consider showing signs of pain a weakness; may regress to earlier stages of development with persistent pain
Adults	Fear of pain may prevent some from seeking care; may believe admission of pain is a weakness and inappropriate for age or sex; may consider pain a punishment for moral failure
Older adults	May have decreased sensations or perceptions of pain; may consider pain an inevitable part of aging; chronic pain may produce anorexia, lethargy, depression; may not report pain due to fear of expense, possible treatment, dependency; often describe pain in nonmedical terms such as "hurt" or "ache"; may fear addiction to analgesics; may not want to bother nurses or be a "bad patient"

Fatigue

Fatigue decreases coping abilities and heightens the perception of pain. When people are exhausted from physical activity, stress, and lack of sleep, their perception of pain may be heightened and their coping skills diminished. Thus, sleep and rest from physical, emotional, and social demands are important measures to manage pain more effectively.

Genetic Makeup

Recent research suggests that sensitivity to and tolerance for pain may a genetically linked trait (Ruda et al., 2000). This finding does not negate the need to manage pain adequately, regardless of inherited traits.

Memory

Memory of painful experiences, especially experiences that occurred as a very young child, may increase sensitivity and decrease tolerance to pain. For example, even young children remember the pain of an immunization at the doctor's office and henceforth may be afraid to visit the doctor again.

Stress Response

Research has shown that "severe, unrelieved pain can cause an overwhelming stress response in both pre-term and full-term infants which can lead to serious complications and even death" (Pasero, 2004). In recent years, post-traumatic stress syndrome has been the subject of extensive research, both as to its cause and its treatment (Hamilton, 2008).

Healing

Recent research suggests that unrelieved acute pain slows postoperative wound healing (McGuire, 2006). This evidence is not surprising, given our increasing knowledge of the effect of stress on the human body.

Neurologic Function

Any factor that interrupts or interferes with normal pain transmission affects the awareness and response of clients to pain and places them at risk for injury. Analgesics, sedatives, and alcohol depress the functioning of the central nervous system. Some diseases, such as leprosy, damage peripheral nerves, decrease sensitivity to touch and pain, and render sufferers more vulnerable to injury.

PSYCHOLOGICAL FACTORS

Fear and Anxiety

The relationship between pain and fear is convoluted and complex. Fear tends to increase the perception of pain, and pain increases feelings of fear and anxiety. This connection occurs in the brain because painful stimuli activate portions of the limbic system believed to control emotional reactions. People who are seriously injured or critically ill often experience both pain and heightened levels of anxiety due to their feelings of helplessness and lack of control. Caregivers need to address both pain and anxiety and use all appropriate measures to relieve suffering.

Coping

People manage pain and other stressors of life in different ways. Some see themselves as self-sufficient, internally controlled, and independent. As a result, they may deny pain or be slow to admit they are suffering. Others see themselves as insufficient, externally controlled, and dependent on others to treat their pain. Self-sufficient, internally controlled people may do better with patient-controlled analgesia (PCA), whereas dependent, externally controlled individuals may prefer nurse-administered analgesia. No matter what the coping style, it is the responsibility of caregivers to relieve pain.

CULTURAL FACTORS

Cultural beliefs and values affect the way people respond to pain. As children they learn what is and what is not acceptable behavior when experiencing pain. In some cultures, any expression of pain is considered cowardly and shameful. In others, noisy demonstrations of pain are expected and acceptable. The meaning of pain itself may be markedly different in different cultures. Some ethnic groups see pain as a punishment for wrongdoing. Others see pain as a test of faith. And still others view pain as a challenge to be overcome. Recent immigrants to America are more likely to view pain from their cultural roots. Regardless of an individual's language, religion, or situation, nurses and therapists respect every person and strive to alleviate pain and suffering.

STANDARDS AND GUIDELINES FOR PAIN MANAGEMENT

Because pain management is so important to the provision of quality healthcare, many organizations have developed standards by which professional practice is measured. Two such organizations are the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and American Academy of Pediatrics (AAP).

Joint Commission

The Joint Commission is an independent organization that accredits and certifies more than 17,000 healthcare organizations and programs in the United States. It evaluates how well these healthcare providers meet published standards of care, including their management of pain. The federal government accepts Joint Commission–accredited facilities as qualified to participate in Medicare and Medicaid reimbursement programs.
Regarding pain management, the Joint Commission Resources states: "Each and every patient has a right to the assessment and management of pain. Hospitals must develop policies and procedures which address the organization's expectations of pain management in support of their mission and philosophy of care. Patients and their families also need education regarding their role in pain management. Developing a comprehensive and coordinated pain management program can be made easier by accessing good practices. From policies and procedures for the different types of pain (acute, chronic, etc.) to training assistants (including pre- and post-tests) to assessment tools, good practices can assist your organization to provide a comprehensive approach to pain management that meets the intent of the standards and, at the same time, achieves positive outcomes for patient." (Joint Commission Resources, Inc., 2009). The JCAHO Standards of Pain Management are listed below.

American Academy of Pediatrics

The American Academy of Pediatrics is a professional organization dedicated to the health, safety, and well-being of infants, children, adolescents, and young adults. As such, its committees develop guidelines, positions, and programs to support the mission of the organization. The AAP guidelines for pain management conclude with the strategies listed below.

PAIN AND THE NURSING PROCESS

The nursing process includes assessment, diagnosis, planning, intervention, and evaluation. To manage pain responsibly, nurses use each step of the nursing process.
Basic to every strategy for managing pain is showing respect for the validity of a client's experience of pain. To communicate respect, nurses:

• Acknowledge pain and take action to manage it.
• Give accurate information to reduce anxiety and facilitate relief of pain.
• Reduce environmental stressors that add to the experience of pain.
• Encourage disclosure of feelings and fears.
• Provide privacy and maintain confidentiality.

Assessing Pain

Pain is a red flag. It tells us there is a problem somewhere in the body that is crying out for attention. In fact, pain is such an important indicator of health, its assessment has been called the "fifth vital sign," joining temperature, pulse, respiration, and blood pressure. Even so, until we know more about a specific pain, we cannot fix it. To do this, nurses and therapists must gather information from as many sources as possible, especially the primary source, the person in pain. This investigation includes obtaining a comprehensive pain history, making observations of behaviors, performing an appropriate physical examination, and consulting with other healthcare professionals.

PAIN HISTORY

A pain history is obtained from written documents and from interviews with the person in pain, family members, and other caregivers. It asks specific questions about the location, intensity, quality, and history of the pain, as shown in the following box. In some facilities these questions are printed on an assessment form, with space for answers to be recorded beside each question. Later sections of this course discuss the assessment of pain in children and special populations.

BEHAVIORAL OBSERVATIONS

Most people who suffer pain usually show it either by verbal complaint or nonverbal behaviors. The following table lists some typical behaviors nurses may observe when they assess people in pain.

NONVERBAL BEHAVIORS INDICATING PAIN

Facial Expressions	Vocalizations	Body Movement	Social Interaction
Clenched teeth Wrinkled forehead Biting lips Scowling Closing eyes tightly Widely opened eyes or mouth	Crying Moaning Gasping Groaning Grunting	Restlessness Protective body movement Muscle tension Immobility Pacing Rhythmic movement	Silence Withdrawal Reduced attention span Focus on pain relief measures

PHYSICAL EXAMINATION

When clients complain of pain or show it by their behavior, health professionals need to take action to find the cause. Assessment is most effective if the pain history interview and behavioral observations are conducted at the same time as the physical examination. For example, if a client complains of acute pain on the sole of a foot, the nurse or therapist visually examines the foot for unusual signs, observes the person for behavioral cues of pain, and asks about the onset, intensity, quality, and pattern of the pain and what makes it worse or better. If the cause is not identified immediately, the client is referred for further assessment.

Diagnosing Pain

An accurate diagnosis depends on an appropriate assessment that focuses on the exact nature of the pain. The more specific the diagnosis, the more effective interventions can be. The North American Nursing Diagnosis Association (NANDA) has identified two primary diagnoses for pain: acute and chronic. A complete nursing diagnosis, however, goes further. After identifying whether the pain is acute or chronic, it adds "related to" the medical diagnosis. For example, "chronic pain related to osteoarthritis of the left hip." Then, it adds "manifested by" and lists the various symptoms experienced by the client or signs confirmed by objective data. Thus, a complete diagnosis might be "chronic pain, related to osteoarthritis, manifested by stabbing pain in the left hip with weight-bearing."
The advantage of clear, specific information is that it leads to more effective interventions. In this case, an appropriate intervention might be an assistive devise such as a cane or walker and referral to an orthopedic surgeon for further evaluation.

Planning and Goal Setting

During the planning stage, nurses and therapists synthesize information from many sources and, together with the physician, plan appropriate interventions. The goal of these interventions is to relieve pain and facilitate the highest possible level of functioning. Practically speaking, this means identifying what activity the pain is preventing and the best way to achieve a return of function. For the client described above with chronic hip pain, the activity the pain is preventing is mobility.
Planning interventions means working in partnership with clients and physicians to provide specific measures to manage the pain. These interventions may be independent or collaborative. Independent nursing actions fall within the scope of nursing practice and include controlling the environment, giving emotional support, and providing comfort. Collaborative nursing actions involve cooperative interventions with other members of the healthcare team, such as physical therapists, pharmacists, and physicians.
Goal setting involves the identification of attainable objectives and reasonable priorities. Because every person is different, the nurse or therapist discusses various alternatives with the client, and together they set priorities. For example, after consulting an orthopedic surgeon, the person with osteoarthritis may decide to delay hip replacement surgery and maintain mobility as long as possible with the aid of a cane and analgesics for pain.

Interventions

PHARMACOLOGIC INTERVENTIONS

There are two primary groups of pain medications: nonopioids and opioids. A third group of drugs called adjuvants or co-analgesics address symptoms that often accompany pain, such as insomnia, anxiety, muscle spasm, anorexia, and depression.

Nonopioid Analgesics

Nonopioid analgesics relieve pain by acting on peripheral nerve endings at the injury site to decrease the level of inflammatory mediators. This group of analgesics includes drugs such as acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) such as acetylsalicylic acid (aspirin) and ibuprofen (Motrin). The specific actions and dosages of these analgesics vary. Generally speaking, however, they have analgesic, antipyretic, and anti-inflammatory effects and are useful for mild to moderate pain.
With the exception of acetaminophen, most nonopioids are potent anti-inflammatory agents. These drugs are especially effective when the primary cause of pain is inflammation, as occurs in rheumatoid arthritis and bone cancer. When tissue is damaged, a series of biochemical events leads to the release of prostaglandin, which causes edema, inflammation, and pain. Two isoenzymes—cyclo-oxygenase-1 (COX-1) and cyclo-oxygenase-2 (COX-2)—play an important part in this biochemical process. Drugs that inhibit their action, especially that of COX-2, reduce prostaglandin production and the inflammation it creates. However, these drugs must be used with caution because the safety of long-term use has not been verified. The following table lists some common nonopioid analgesics.

COMMON NONOPIOID ANALGESICS

Drug	Adult Dose	Considerations
Acetaminophen (Tylenol)	650–975 mg q 4 hr	Used for headaches, osteoarthritis; lacks peripheral anti-inflammatory activity of NSAIDs
Aspirin	650–975 mg q 4 hr	Used for headaches, osteoarthritis, general pain; antipyretic; inhibits platelet aggregation, causing bleeding
Ibuprofen (Motrin)	400 mg q 4–6 hr	Used for osteoarthritis; antipyretic; multiple brand names; available as liquid
Indomethacin (Indocin)	150–200 mg/day	Used for gout; anti-inflammatory; anti-rheumatic
Naproxen (Naprosyn)	500 mg initial dose, then 250 mg q 6–8 hr	Used for gout, headaches; anti-inflammatory; anti-rheumatic; available in liquid preparation

Opioid Analgesics

Opioid (narcotic, CNS-acting) analgesics are derivatives of opium and include such drugs as morphine, codeine, and methadone. These drugs modify the perception of pain and provide a sense of euphoria by binding to specific opiate receptors throughout the central nervous system. Opiate receptors have various names, typically denoted by Greek letters such as mu (μ), kappa (κ), and sigma (σ). Many of the characteristics of particular opioids relate to the receptor to which they bind. For example, morphine binds to m receptors and follow m receptor control.
Opioid analgesics are classified as full agonists, partial agonists, and mixed agonist-antagonists. Full agonists bind to μ receptor sites, block pain impulses, and produce maximum pain control—an "agonist effect." Full agonists include such drugs as morphine (Kadian, Avinza, Rylomine intranasal), meperidine (Demerol), fentanyl (Duragesic patch, Fentanyl oralets), oxycodone hydrochloride (OxyContin), and hydromorphine (Dilaudid).
Partial agonists produce a lesser response than full agonists and include such drugs as buprenorphine (Buprenex) and nalbuphine (Nubain). Mixed agonist-antagonist analgesics include such drugs as pentazocine hydrochloride (Talwin) and butorphanol tartrate (Stadol). An antagonist is a drug that competes with opioid receptor sites. Naloxone hydrochloride (Narcan) is such a drug. It is used for opioid overdoses and physical dependency.
The primary action of opioids (narcotics) is to alleviate moderate to severe pain. Many of the unwanted effects of this class of drugs are related to their actions on systems of the body other than the central nervous system (CNS), causing such effects as constipation and respiratory depression. The following table lists some common opioid side effects and preventative measures.

OPIOID ADVERSE EFFECTS AND PREVENTIVE MEASURES

Body System	Adverse Side Effects	Preventative Measures
Cardiovascular	Hypotension, palpitations, flushing	Monitor blood pressure and heart rate
CNS	Sedation, disorientation, euphoria, dysphoria, light-headedness, lower seizure threshold, tremors	Inform client that tolerance may develop over 3–5 days; administer stimulants as needed
Gastrointestinal	Constipation, nausea, vomiting	Offer anti-emetic; change analgesic; increase fluid and fiber intake; increase exercise; administer laxatives
Genitourinary	Urinary retention	Catheterize as needed; administer opioid antagonist
Integumentary	Itching, rash, wheal formation	Apply cool packs or lotion; administer antihistamine
Respiratory	Respiratory depression; aggravation of asthma	Monitor respirations closely; administer opioid antagonist such as naloxone hydrochloride (Narcan)

Some medications combine nonopioid with opioid analgesics in one tablet to offer two different levels of pain relief—acting both on peripheral nerve endings at the injury site and at the level of the central nervous system. Acetaminophen with codeine is such a medication.

Drug Tolerance and Dependence

Drug tolerance is a physiologic condition in which humans require larger and larger doses of drugs to provide the same effect as provided by the original dose. The first sign of tolerance is a decrease in the duration of the analgesic effect. This condition is followed by a decrease in total analgesic effect. Decreasing the time between doses or increasing the dosage may help overcome tolerance. Even so, drug tolerance is not the only reason drugs become less effective. They may be less effective because there is advancing tissue damage, thus greater pain.
Pseudotolerance is the need to increase opioid dosage for reasons other than the physical adaptation of continuous use. These other needs include drug-to-drug interaction, drug-to-food interaction, increased physical activity, psychological dependence (addiction), and changes in opioid formulation.
Physical dependence is a physiologic adaptation of tissues to the drug. If a person who is physically dependent on opioids abruptly stops using them, withdrawal symptoms occur. These symptoms result from an autonomic nervous system response and may include excessive yawning, nausea and vomiting, hypertension, tachycardia, muscle twitching, diaphoresis, delirium, and convulsions. When opioid analgesics are to be discontinued, physical withdrawal symptoms can be reduced or eliminated by a slow reduction of dose.
Psychological dependence (addiction) is the compulsive use of a substance characterized by a continuous craving for a drug's nonanalgesic emotional effects. Opioids (narcotics) with an affinity for both m and s receptor sites produce euphoria and hallucinations. Thus, these drugs are the most frequently abused opioids. When people take opioids to relieve pain, tolerance and physical dependence may occur, but addiction will not necessarily follow. Psychological dependence is far more complex and involves emotional, social, and cultural issues. (Pain management in clients with addictive disease is discussed further later in this course.)
Pseudoaddiction is a term used to describe people who, because of severe, unrelieved pain, focus on finding relief. As a consequence, they seem preoccupied with obtaining opioids. This preoccupation is not truly "drug-seeking" but "relief-seeking." Their quest for opioids is directly related to inadequate pain relief caused by an inappropriate opioid or inadequate doses spaced too far apart.

Adjuvant Analgesics

Adjuvant analgesics (co-analgesics) are drugs that were developed for uses other than pain but have been found to enhance the effects of analgesics. Caregivers need to remember that these are "helper drugs," not substitutes for analgesics. Clients in pain still need analgesics. The following table describes some common adjuvant analgesics.

COMMON ADJUVANT (CO-ANALGESIC) DRUGS

Class of Adjuvant Drugs	Indications and Primary Effects
Antidepressants: Tricyclics and serotonin, reuptake inhibitors	Burning, neuropathic pain; improves sleep, enhances mood and analgesic effects
Anti-epileptic drugs	Neuralgic and neuropathic pain (sharp, prickling, shooting pain)
Antispasmodic	Reflex sympathetic dystrophy syndrome
Anxiolytic drugs: Benzodiazepines, buspirone, venlafaxine	Anxiety and sedation
Botulinum toxin	Migraine headache
Lidocaine	Neuralgic pain and diabetic neuropathic pain
Psychostimulants	Offsets sedating side effects and enhances analgesic effects of opioids
Steroids	Inflammatory and chronic pain of cancer, malignant spinal cord compression, headaches, and arthritis

Placebos

A placebo is a "sugar pill," an inactive substance prescribed as if it were an effective dose of a medication. Research has found that placebos produce hoped-for results in 30% to 50% of the people who take them (Thompson, 2000). This so-called "placebo effect" has been exploited for centuries by hucksters and charlatans who sell tonics, treatments, and gadgets to people in pain. Because their purpose is to deceive and strip clients of the right to make informed decisions, legitimate medical practice does not use placebos. Such acts violate the ethical principles of honesty and autonomy. The only exception to this prohibition is when subjects give prior consent for the possible use of placebos in research studies.

World Health Organization Pain Management Ladder

Because of widespread misconceptions about treatment of chronic pain and addiction, in 1990 the World Health Organization (WHO) recommended a three-step pain management ladder based on the intensity of pain.

1. Mild pain (intensity 1–3 on the 0–10 standard): Use nonsteroidal anti-inflammatory drugs and adjuvants. If pain persists, then
2. Mild to moderate pain (intensity 4–6): Use combination medications such as oxycodone and acetaminophen and adjuvants. If pain persists, then
3. Moderate to severe pain (intensity 7–10): Use potent opioids such as morphine, fentanylm methadone, and adjuvants.

To prevent undertreatment of malignant cancer pain, some authorities recommend a different approach. They begin the treatment of malignant cancer pain with strong opioids, providing immediate relief, then slowly reduce the type and dosage until pain relief is achieved at the lower level (Jackson & Stanford, 2003).

Routes of Administration

Analgesics can be administered by many routes. Each has advantages and disadvantages as well as indications and contraindications. The overriding considerations are effectiveness and safety. The table below lists some of the most common routes for the administration of analgesic drugs.

ANALGESIC DRUG ADMINISTRATION

Route	Indications	Contraindications
Oral (per os = PO)	Preferred route due to lower cost and convenience; may be prepared as powders, capsules, tablets, liquids, or lozenges	Gastrointestinal irritation; inability to swallow; need for more potent analgesic
Rectal (R)	Inability to take oral drugs; can be self-administered; longer duration than oral	Anal or rectal lesions, diarrhea, thrombocytopenia
Intramuscular (IM)	Acute, short-term pain relief	Need for prolonged pain relief; absorption may be poor; possible muscle or nerve damage; costly
Intravenous (IV) bolus	Offers most rapid pain relief (5–15 min) but lasts less than 60 min	Requires IV access; gives only brief pain relief when prolonged relief is needed
Continuous intravenous (IV) infusion	Gives constant opioid blood level when other methods are ineffective	Requires infusion pumps with alarms and close monitoring
Patient-controlled analgesia (PCA)	Allows predetermined IV bolus of analgesic when client desires pain relief	Requires IV access, client cooperation, close supervision; does not give continuous pain relief
Subcutaneous (SC) opioid infusion	Continuous, prolonged parenteral opioids when IV not possible; allows home use	Requires site change every 7 days of 27-gauge butterfly needle; potential site irritation
Intraspinal (neuraxial), intrathecal, epidural, subarachnoid, intraventricular	Labor contractions; also intractable pain when client cannot tolerate systemic opioids by other routes	Requires expert insertion of catheter into intended space; attached to infusion pump or implanted reservoir; high risk for infection or dislodgment
Regional nerve blocks	Continuous or single dose analgesic for acute and chronic pain; used for trauma, burns, and labor	Requires expert insertion of catheter to specific nerve root; attached to infusion pump or implanted reservoir; high risk for infection or dislodgment
Topical (cream-laden anesthetic)	Analgesic for needle sticks, venipuncture, dermatitis, and insect stings	Must be applied 30–60 min in advance of need
Transdermal skin patch	Continuous dose of opioid; allows home use	Costly; when body temperature is over 102°F, absorption is accelerated
Nasal sprays	Alternative to IV, IM, and oral opioid administration; rapid onset of action	Nasal exudates or mucosal swelling may prevent consistent absorption

Principles for the Use of Analgesics

To guide caregivers, the American Pain Society (2005) identifies thirteen principles regarding the use of analgesics to control pain:

1. Individualize the route, dosage, and schedule of analgesics medications.
2. Administer analgesics on a regular basis if pain is present most of the day.
3. Know the dose and time course of several opioid analgesic preparations:
   • Ask client about prior experience with certain drugs.
   • Give preference to long-acting, sustained-release opioids such as OxyContin, which provides up to 12 hours of analgesia; Kadian and Avinza, controlled-release morphine preparations which provide up to 24 hours of pain relief; and transdermal fentanyl, which provides up to 3 days of pain relief.
   • Avoid the adverse effects of emesis by giving anti-emetics.
   • Rotate opioids to compensate for tolerance.
   • Use rapid-onset opioids when necessary.
   • Use concentrated dosage forms when injection volume must be minimized.
4. Give infants and children adequate opioid doses.
5. Follow clients closely, particularly when beginning or changing analgesics.
6. When changing to a new opioid or a different route, first use equianalgesic doses to estimate the new dose. Then, modify the estimate, based on the clinical situation and the specific drug.
7. Recognize and treat side effects, such as sedation, constipation, nausea, itching, respiratory depression, by doing the following:
   • Change the dose or route of the same drug to maintain constant blood levels.
   • Try different opioids analgesics.
   • Consider multi-drug and multi-modal therapy.
   • Add another drug that counteracts the adverse effects, such as a stimulant for sedation.
   • Use an administration route that minimizes drug concentrations at the site producing the side effect, such as intraspinal instead of oral when appropriate.
8. Do not use meperidine (Demerol) because of neurotoxicity risk or mixed agonist-antagonists (Talwin) because of psychotomimetic effects.
9. Do not use placebos to assess the nature of pain.
10. Monitor for the development of tolerance and treat appropriately. Increased pain may be due to progressive disease, new pathology, skipped doses, or other causes.
11. Expect physical dependence and prevent withdrawal symptoms.
12. Do not diagnose patients as "opioid addicted" solely because of opioid dependence.
13. Be alert to the psychological state of the client.

NONPHARMACOLOGIC INTERVENTIONS

Although there are myriad drugs to relieve pain, all have some risk and cost. Fortunately, there are many nonpharmacologic interventions to reduce pain, especially when used in conjunction with pharmacologic measures. Described as physical and cognitive-behavioral interventions, many of these approaches are noninvasive, low-risk, inexpensive, easily performed and taught, and within the scope of nursing practice. Physical interventions give comfort, increase mobility, and alter physiologic responses. Cognitive-behavioral interventions alter the perception of pain, reduce fear, give a greater sense of control, and are considered holistic nursing practice.

Physical Interventions

Comfort measures such as clean and smooth sheets, soft and supportive pillows, warm blankets, and a soothing environment have been used by nurses throughout history to relieve pain and suffering. These measures may be difficult to provide in the noisy, mechanized healthcare facilities of today. Nonetheless, they are important to the mental and physical well-being of patients.
Position change and movement are well-known pain-relieving interventions. Moving the body, even a small amount, relieves muscle spasm and provides a degree of pain relief. So important is movement of the body to health, an entire profession has developed specializing in physical therapy. However, nurses need not wait for a specialist to offer these important pain-relieving interventions.
Massage relieves muscle spasm, improves circulation, and provides cutaneous stimulation. While there are many different massage techniques, they all involve rubbing the skin in various patterns and degrees of pressure. Once considered an expected part of basic nursing care, backrubs offer an important noninvasive way to relieve pain and provide comfort.
Applications of hot and cold are effective pain-relieving measures when used appropriately. Heat decreases muscle spasm and increases blood flow to an area. Cold decreases blood flow, edema, and inflammation and may decrease muscle spasm and pain. Many devices are available to provide hot and cold, including electric heating pads, patches, and ice packs. Soaks and baths relieve muscle spasm and are an important means of providing comfort.
Transcutaneous electrical nerve stimulation (TENS) provides a continuous, mild electric current via 2 to 4 electrodes placed on the skin near a painful site. The stimulator is a small, battery-operated devise worn by the client. Experienced as a tingling sensation, TENS works by stimulating large nerve fibers to close the "gate" in the spinal cord. It also may stimulate endorphin production. TENS may be used for acute postoperative pain or for chronic conditions such as low back pain, phantom limb pain, and neuralgia.
Surgical interventions may be recommended when severe pain persists despite medical treatment. If pain is due to a known condition, such as osteoarthritis of a joint, joint replacement surgery may be offered. When specific interventions are not available and conservative measures do not relieve pain, surgical interruption of pain pathways may be undertaken. Rhizotomy and cordotomy are two such procedures. In a rhizotomy the surgeon destroys dorsal posterior nerve roots as they enter the spinal cord, either by delivering neurolytic chemicals, heat, or extreme cold by way of a catheter or by performing a laminectomy, isolating the nerve roots, and directly destroying the nerve. A chordotomy is more extensive than a rhizotomy, involving resection of the spinothalamic tract. Both procedures cause permanent loss of pain and thermal sensations, however they may also cause paralysis due to motor nerve damage.

Cognitive-Behavioral Interventions

Relaxation exercises are useful ways to reduce anxiety, decrease muscle tension, and lower blood pressure and heart rate. They induce a state of altered consciousness and give individuals a sense of control and peace of mind. Meditation, yoga, and other such interventions may effectively relieve pain. One such exercise involves controlled breathing. A coach speaks in a calm, clear voice, suggesting the subject begin by breathing slowly and diaphragmatically, allowing the abdomen to rise slowly and the chest to expand fully. Then, the coach suggests the subject locate an area of muscle tension, contract the muscles in that area, and then relax them. As the subject relaxes, pain perception and anxiety diminish.
Guided imagery is similar to relaxation exercises in that a coach leads subjects in a calm, clear voice, often beginning with a relaxation exercise. The coach then suggests subjects imagine themselves in some peaceful place where they experience various sensory pleasures such as the warmth of the sun, the sound of ocean waves, and the smell of salt water. The purpose of the exercise is to provide an experience of relaxation and relief from stress and pain.
Distraction diverts the attention of individuals away from painful stimuli. When people focus on something that gives pleasure, they are less likely to feel acute pain. This phenomenon occurs because the reticular activating system briefly inhibits the awareness of pain. Distraction works best for short acute pain, such as a needle stick. Such things as listening to music, watching an intense scene on television, or describing something of special interest may temporarily distract a person from pain. Distraction, however, does not work for chronic, long-term pain.
Biofeedback is a method of treating chronic pain and other stress-related conditions. It uses an electric device to gather information about physical responses and report them back to clients. The information goes to the biofeedback machine by way of electrode sensors placed on the person's skin. It is displayed as visual signals on a monitor. As clients watch these signals, they learn to control their responses.

Complementary and Alternative Medicine (CAM)

To relieve their pain, an increasing number of people in the United States are also turning to theories and practices outside the realm of conventional Western medicine. In 1991, the federal government established the Office of Alternative Medicine. In 1998, the agency became the National Center for Complementary and Alternative Medicine (NCCAM), making the center one of 27 institutes and centers of the National Institutes of Health within the Department of Health and Human Services. NCCAM defines CAM as "a group of diverse medical and healthcare systems, practices, and products that are not currently part of conventional medicine" (NCCAM, 2009a).
The mission of NCCAM is to explore "complementary and alternative healing practices in the context of rigorous science…and [to] disseminate authoritative information to the public and professionals" (NCCAM, 2007). In this context, "complementary" describes practices used in conjunction with or to supplement conventional medical treatments, and "alternative" means those that are used independently or in place of conventional medicine. Practitioners of such techniques and practices often use the term holistic because they view health and illness as affecting the whole person—body, mind, and spirit.
The major categories of complementary and alternative medicine are:

• Biologic (herbal mixtures; macrobiotic diets; orthomolecular, such as megadoses of vitamins, magnesium, melatonin, etc.)
• Energy fields (acupuncture, therapeutic touch, pulse fields, Reiki, etc.)
• Manipulative and body-based (chiropractic, lymphatic drainage, reflexology, aromatherapy, deep-muscle massage, shiatsu, etc.)
• Mind-body (biofeedback, hypnosis, art therapy, prayer, etc.) (Diluzio  & Spillane 2002)

Biologic. Plants have been used to treat human ailments throughout history. Their therapeutic effects are due to the chemical compounds they contain. Such chemicals may be administered to patients by giving some part of a plant or by extracting or synthesizing the essential chemical. When prepared in a purified form, the dose is more precise than it can be from a plant. Some common active chemicals originally derived from plants are: digitaloid found in the foxglove plant (digitalis), saponins found in sarsaparilla (irritant laxatives), alkaloids found in nightshades (atropine), and alkaloids found in the opium poppy (morphine) (McGuigan & Krug, 1942).
Energy fields. Such healing measures are based on theories about unseen forces in the human body. Acupuncture, for instance, is based on an ancient Chinese theory that two opposing forces, yin and yang, move along meridians in the body. When these forces are out of balance, pain and illness result. There are at least 350 acupuncture points by which energy flows are accessible. The theory posits that by stimulating these points with very fine needles, the energy flow can be rebalanced and pain relieved (Mayo Clinic, 2009; NCCAM, 2009b).
Chiropractic is a healthcare approach that focuses on the relationship between the body's structure—mainly the spine—and its functioning. Although practitioners may use a variety of treatment approaches, they primarily perform adjustments to the spine or other parts of the body with the goal of correcting alignment problems and supporting the body's natural ability to heal itself. People seek chiropractic care primarily for pain conditions such as back pain, neck pain, and headache. Side effects and risks depend on the type of chiropractic treatment used. Ongoing research is looking at effects of chiropractic treatment approaches, how they might work, and diseases and conditions for which they may be most helpful. (NCCAM, 2009c.)
Osteopathy is a medical specialty that combines traditional and nontraditional medicine. Practitioners, called doctor of osteopathy (DO), practice traditional, science-based medicine, and are licensed to perform surgery and prescribe drugs. They "take a holistic view of the body as an integrated system and approach prevention, diagnosis, and treatment by way of the musculoskeletal system" (Asher, 2007).
Biofeedback is a method of treating chronic pain and some stress-related conditions. It uses an electric device to gather information about physical responses and report them back to clients. The information goes to the biofeedback machine by way of electrode sensors placed on the person's skin. The machine displays information as visual signals on a monitor. As clients watch the signals, they learn to control their responses.

Evaluating the Effectiveness of Interventions

Evaluation is one of the most critical phases of the nursing process. It tells us the degree to which an intervention achieved an expected outcome. If the expected outcome is pain reduction, evaluation tells us if the intervention did, in fact, reduce pain and if so, how much and at what cost in time, treasure, and long-term effects.
To find out, we gather data from the best source of information, the client, or the second-best source, the client's caregivers. To be of value, the information must address the aspects of pain that were noted before the intervention, including the location, intensity, quality, and duration of the pain. In addition, data is gathered about adverse effects of an intervention, such as an allergic reaction, hypotension, or respiratory depression.
Such feedback is essential if we are to revise the plan of care effectively. A positive evaluation means that an intervention was successful and probably should be continued. A negative evaluation means that an intervention was not satisfactory and should be changed. Hence the adage "negative feedback makes for change."

Communicating, Documenting, and Teaching

Communication about pain and the response of clients to interventions is facilitated by accurate and thorough documentation. This communication needs to be conveyed from nurse to nurse, shift to shift, and nurse to other responsible healthcare providers. Various tools have been devised to facilitate this communication, including pain flow sheets, running diaries, and bedside computer charting, called "point-of-care." When communicating information about pain, it is important to describe the time and exact nature of an intervention, including details such as an analgesic and dose administered, level of pain before and after the intervention, and any adverse effect that follows, such as respiratory depression. The more specific and timely a report, the more effective the evaluation.
Because pain is a potent motivator for change, people who suffer are vulnerable to all manner of fake gadgets and magical cures. It is the responsibility of healthcare professionals, especially nurses, to give patients accurate information about medications, devices, physical activities, and psychological strategies in clear, understandable ways. Such teaching empowers those who suffer and demonstrates genuine concern, accurate empathy, nonpossessive warmth, and respect.

PAIN MANAGEMENT IN CHILDREN

Unbelievable as it may seem, only recently has the medical profession taken seriously the pain and suffering of infants and children. Not long ago, newborn infants were circumcised without anesthesia or analgesia, and seriously injured children were given pain medication "as needed." Happily, such undertreatment of pain in children is changing as a result of research by caring nurses and other healthcare professionals. Better assessment tools, new pharmaceuticals, and innovative delivery systems are contributing to these advances.
Research has shown that neonates and infants do feel and remember pain. In fact, by 6 months of age, when children are taken to places where they had experienced pain, they demonstrate anticipatory fear (Pasero, 2004). One study measured the long-term effect of newborn circumcision without analgesia on behavioral response to immunizations. When pain was measured by observable indicators such as facial expression, length of crying, and body movement, 4- to 6-month-old infants circumcised without analgesia had higher pain scores than those circumcised with analgesia (Anand, 1997).
Other research found some children so traumatized by past injections that were intended to relieve pain that they were afraid to admit having present pain (Stevens, 1999). These and other studies have corrected many misconceptions about pain in infants and children, as described in the table below.

MISCONCEPTIONS ABOUT PAIN IN INFANTS AND CHILDREN

Misconceptions	Correct Information
Preterm infants are less sensitive to pain than term infants and older children due to an immature nervous system.	Preterm infants have the anatomical and functional ability to process pain and an even greater sensitivity to pain than term infants.
Infants and children have a diminished perception of pain and no memory of its occurrence.	Perception of pain is present with the first insult, requires no prior experience, and is remembered.
Infants are incapable of expressing pain.	Although infants cannot verbalize pain, they give physical signs and behavioral cues.
Pain in infants cannot be assessed accurately.	Behavioral cues and physiologic signs of pain can be reliably and validly assessed; facial expressions are the most valid indicators.
Anesthetics and analgesics cannot be given to neonates and infants because of an immature ability to eliminate drugs.	Infants older than 1 month metabolize drugs in the same way as older infants and children.
Opioids are too dangerous to give to infants and children because of the risk of addiction and other adverse effects.	Adverse effects of opioid and nonopioids can be minimized by careful monitoring, drug titration, and weaning.
Infants and children tolerate pain well and become accustomed to pain.	Pain is pain, whether it occurs in an infant, child, or adult.
Postoperatively, children should not receive the next analgesic dose until they show obvious signs of pain.	Opioids are most effective if administered as a continuous infusion rather than "as needed," thus avoiding the need of children to complain.
Infants and children cry or complain at the slightest discomfort even when they are not in pain.	Often children are afraid to complaint of pain because their fear of an injection is greater than their pain.

Communicating with Children and Adolescents

To manage pain effectively in children and adolescents, nurses and other healthcare professionals need to be able to communicate with them. Such communication must be appropriate to age and stage of development. The following table describes some approaches that can be used to refine a nurses's interactions with children and, at the same time, model effective communication skills for family members.

COMMUNICATING WITH CHILDREN AND ADOLESCENTS

Age and Stage	Approaches and Communication Modes
Source: Cohen, 1991.
Infants (birth to 12 months)	Communicate through touch. Speak in a soft tone. Maintain eye contact without staring or intruding. Avoid overstimulation. Comfort by holding, rocking, singing softly. By 8 months, infant may be fearful of strangers. Infant interacts by reaching out.
Toddlers (1 to 3 years)	Give child time to complete thoughts without interruption. Avoid discussion of frightening issues in child's presence. Set limits by using distraction and alternative choices. State specifically what you want the child to do. Speak with child at eye level. Use parallel play to teach behavior, with child imitating adult. Child shows rapid language development. Imagination is vivid, merges with the real world.
Preschoolers (4 to 5 years)	Use simple, direct language. To avoid imagined fears, speak with understood vocabulary. Use play to allow child to act out thoughts and feelings. Child thinks in concrete, egocentric ways, not conceptual. Plays actively, expressively. Child has relatively short attention span.
School-age children (6 to 12 years)	Avoid overly grim descriptions or predictions. Give children opportunity to speak for themselves. Child able to grasp seriousness of events in family. Heightened ability to use logic and understand events. Can grasp seriousness of events around them. Less egocentric and more empathetic. May assume inappropriate role reversal. May be reluctant to communicate their own needs. Responds to third-person conversation: "I knew a girl who was afraid to get an x-ray because the machine was so big."
Adolescents (13 to 18 years)	Show respect by listening and explaining clearly, not talking "down." Give adolescents opportunity for confidential communication. Thinks in extremes: all or nothing, good or bad, cool or clueless. A large issue for adolescents is trust of adults. Topics of conversation: Home, Education, Employment, Activities, Drugs, Sexuality, Suicide, Weight (HEADSSW)

Children's Responses to Pain

PHYSIOLOGIC

Because infants and children may not be able to tell us they are in pain, nurses and caregivers must use other means to gather information about their distress. Acute pain initiates a response known as the general adaptation syndrome (GAS). This begins with the sympathetic nervous system, causing initial physiologic signs such as tachycardia, rapid respirations, hypertension, pupil dilation, pallor, and increased perspiration—the alarm reaction.
As the stress response continues, the body adapts physiologically in the resistance stage, and vital signs return to near normal and perspiration decreases. For this reason, measurement of vital signs is not a reliable indication of pain in children. Other means must be used to gather this information. Eventually, when severe, prolonged pain goes unrelieved, the body enters the exhaustion stage, causing release of catecholamines, cortisol, aldosterone, and other corticosteroids and decreased insulin, which leads to hyperglycemia.

BEHAVIORAL

Long before pain pushes infants and children to the exhaustion stage, they show behavioral signs in developmental and age-appropriate behavioral responses. The table below summarizes some common responses of infants and children to pain.

BEHAVIORAL RESPONSES TO PAIN IN CHILDREN

Age	Behavioral Response	Verbal Response
Source: Adapted from Ball & Binder, 1999.
Infants (birth to 6 months)	Generalized body movement, facial grimacing, chin quivering, refusal to drink or eat	Crying
Infants (6 to 12 months)	Disturbed sleep, irritability, reflex withdrawal to stimulus	Crying
Toddlers (1 to 3 years)	Disturbed sleep, aggressive behavior, localized withdrawal	Crying, screaming, unable to describe intensity of pain
Preschoolers (3 to 6 years)	Low frustration level, active physical resistance, strikes out when hurt	Able to identify location, intensity, and characteristics of pain
School age (7 to 9 years)	Resists passively, holds body rigidly, emotional withdrawal, plea bargains for relief of pain	Able to identify location, intensity, and characteristics of pain
School age (10 to 12 years)	May regress with stress and anxiety, pretend not to hurt to project bravery, perform poorly in school	Able to describe location, intensity, and characteristics in detail, including psychic pain
Adolescents (13 to 18 years)	Controls behavior to be socially acceptable, may perform poorly in school, irritable, unable to concentrate	Detailed, able to give a more complete description of pain and its meaning

Assessing Pain in Children

The assessment of pain in children should include gathering all the same details as with adults, namely the location, intensity, quality, chronology, pattern, precipitating events, alleviating actions, and accompanying symptoms. Information about these factors is gained by means of a pain history, physical examination, observations, and various pain assessment scales.

PAIN HISTORY

In today's information age, healthcare providers have ready access to earlier medical and surgical events in the life of infants and children. However, details about their pain, effective pain-relieving measures, and the family's customary approach to pain may not be included in the record. This information may be gathered in a pain history, using tools such as the questionnaire shown below.

PAIN EXPERIENCE ASSESSMENT QUESTIONNAIRE

Child	Parent or Caregiver
Can you tell me what a pain or hurt is?	What word or words does your child use in regard to pain?
Have you ever had a pain (hurt, ow-y, ouch, etc.) before?	What painful experiences has your child had before?
When you have a hurt, whom do you tell?	Does your child tell you or others when in pain?
What do you want others to do for you when you hurt?	How do you know when your child is in pain?
What do you do for yourself when you are hurting?	How does your child usually react to pain?
What helps the most to take away your hurt?	What works best to decrease or take away your child's pain?
Is there something special you want me to know about you when you hurt? If so, what is it?	Is there something special you want me to know about your child and pain? If so, what is it?

PHYSICAL EXAMINATION AND OBSERVATION

Complaints and signs of pain in children need to be taken seriously and investigated appropriately. The physical examination should include inspection, palpation, percussion, and auscultation:

• Inspection should be general, observing the child from front to back, and systemic, inspecting each body region from head to toe.
• Palpation involves using your hands to gain information about skin temperature, bodily pulsations, internal masses, and tenderness or rigidity of organs and structures.
• Percussion involves tapping or striking the child's skin surface with fingers or hands to elicit sounds, evaluate reflexes, uncover abnormal masses, and detect pain or tenderness.
• Auscultation involves listening to sounds produced by internal body structures such as the heart, lungs, blood vessels, and bowels. Usually, one uses a stethoscope to ausculate.

Although procedural and postoperative pain is anticipated, unexpected intense pain should be assessed immediately, particularly if it is accompanied by altered vital signs. Such pain may signal serious complications, such as internal bleeding, hematoma, constricting bandages, allergic reaction, infection, or even wound dehiscence.
Because infants and children are dependent on the adults in their lives and in many ways molded by them, observation of interactions between children and family members informs nurses and therapists about how they respond to pain. Children who have been punished or shamed for crying may not report pain and may suffer in silence. Others who had been neglected or ignored may have found the only way to get attention was to cry; thus, they may need affection more than pain medicine.

PAIN ASSESSMENT SCALES

Children are in a state of constant change physically, mentally, and emotionally. For this reason, pain assessment strategies are more effective it they are adapted to chronological age, developmental level, functional status, cognitive ability, and emotional status. Although a complete pain assessment includes many variables, the most common one in hospitalized children is intensity. Thus, most assessment scales focus on that issue. The table below lists some well-known assessment scales according to the age and developmental level of children.

PAIN ASSESSMENT SCALES FOR INFANTS AND CHILDREN

Age Group	Name of Scale	Description of Scale
Preterm: 28 to 36 weeks' gestation	Premature Infant Pain Profile (PIPP)	Assessor observes for 5 to 30 seconds on various pain indicators, including physiologic signs; gestational age affects scoring (Pasero, 2002).
Preterm to 6 weeks	Neonatal Infant Pain Scale (NIPS)	Assessor scores infant on 7 criteria: cry, facial expression, breathing pattern, arm movement, leg movement, state of arousal (Lawrence et al., 1993).
Preterm to 6 weeks	Neonatal facial responses	Illustration of a neonate in pain.
Birth to 6 weeks	CRIES Neonatal Post-Op Pain Scale	Assessor scores infant's crying, requiring oxygen, increased vital signs, expression, sleeplessness as 0 to 10; severe pain = 10 (Pasero, 2002).
Birth to 3 years	Netherlands Comfort Scale	Assessor scores 0 to 5: child's alertness, agitation, respirations, crying, physical movement, muscle tone, facial tension; severe pain = 35 (van Dijk, 2005).
Two months to 7 years	FLACC Behavioral Pain Assessment Scale	Assessor observes child for 1 to 5 minutes, then scores face, legs, activity, cry, consolability as 0 to 10; severe pain = 10 (Pasero, 2002).
3 to 6 years	Finger Span Scale	Assessor uses span of index finger and thumb to indicate degree of pain. Asks, "How big is your pain?" (Merkel S, 2002).
3 to 7 years	Oucher Scale (photographs)	Photos of 3 children of different skin colors in 6 levels of pain, from no pain to severe pain (Ball & Binder, 1999).
3 to 7 years	Poker chips	Assessor uses piles of poker chip, from 1 to 5; asks "How much is your pain?" (Ball & Binder, 1999).
4 to 16 years	FACES Pain Scale	Illustration of 6 round faces, smiling to crying.
4 to 16 years	FACES Pain Scale–Revised (FPS-R)	Illustration of 6 egg-shaped faces, "no pain" to "very much pain."
9 to 18 years	Number Scale	Assessor asks child "On a scale of 0 to 10, with 10 the most, how much is your pain?

Diagnosing Pain in Children

The North American Nursing Diagnosis Association (NANDA) has identified two primary diagnoses for pain: acute and chronic. Acute pain is sudden and of short duration (less than 6 months). It includes the pain caused by surgical and medical procedures and by trauma and burns. The diagnosis of pain in a child with burns might be "acute pain related to tissue damage manifested by continuous, searing pain." Chronic pain lasts for 6 months or longer and is generally associated with a prolonged disease process. The diagnosis of pain in a child with juvenile rheumatoid arthritis might be "chronic pain related to inflammation of right knee, manifested by aching pain."

Planning and Implementing Interventions

During the planning stage, healthcare professionals synthesize the information they have gained from the pain history, physical examination, and assessment and plan appropriate interventions. The goals of interventions are to relieve pain both physically and emotionally, reduce complications, and facilitate a return of function. Of course, there may be many other diagnoses, such as anxiety and a risk of infection, each of which includes specific interventions and expected outcomes.

PHARMACOLOGIC INTERVENTIONS

As with adults, there are both pharmacologic and nonpharmacologic interventions for pain in children. Pharmacologic interventions include nonopioids, opioids, and adjuvant drugs. Nonpharmacologic interventions include physical and cognitive-behavioral measures. While all drugs used to alleviate pain in adults may be prescribed for infants and children, they must be in preparations appropriate to the development of the child, such as a liquid rather than a tablet, and they must be in safe and effective dosages relative to the body weight of the child. As new analgesics gain FDA approval, manufacturers publish suggested dosages according to body weights. Often equianalgesic doses are calculated for children and adults who weigh more than 50 kilograms (110 pounds) and those who weigh less than 50 kilograms (110 pounds). As a cautionary measure, many physicians prescribe potent drugs in smaller-than-recommended initial doses.
Pain relief for children should be continuous, not sporadic or "as needed." The preferred routes of administration are intravenous for acute pain and oral as the child recovers. Continuous infusion analgesia eliminates the highs and lows of pain control and is recommended to maintain constant drug levels, particularly in children with severe, persistent pain. If oral preparations are prescribed, they should be scheduled to reduce the likelihood of breakthrough pain and the expectation of its return. When analgesics are given "as needed," greater amounts of drugs are needed to restore control of the pain.
Patient-controlled analgesia (PCA) is not for adults only. It is an effective method to administer intravenous analgesics such as morphine to children 5 years of age or older. The nurse programs a computerized pump to deliver a fixed dose of analgesic at certain intervals, controlled by the child. After initial pain control has been achieved, the child presses a button to receive a smaller analgesic dose for episodic pain relief. In addition, the PCA monitor can be set up with a continuous infusion to prevent pain while sleeping. As the child's pain lessens, the PCA is discontinued and oral analgesics are prescribed.
Regional nerve blocks and continuous epidural infusions of analgesics via the lumbar or caudal space are being used with increasing frequency in children. In these procedures only small doses are required to achieve pain relief because a high concentration is delivered to opioid receptor sites. Though these methods of pain control require specialized knowledge, they are increasingly popular because they avoid many adverse effects of opioids on other body systems.

NONPHARMACOLOGIC INTERVENTIONS

Because pain is a subjective experience, influenced by the emotions, stress, sleep, activity, and even nutrition, it can be controlled by a variety of interventions. Fortunately, children respond well to nonpharmacologic pain reduction measures, especially when they are used in conjunction with appropriate pharmacologic interventions. Some of these interventions are: comforting, distraction, relaxation, hypnosis, imagery, applications of hot and cold, massage, and transcutaneous electrical nerve stimulation (TENS).
Comforting is one of the most important nondrug measures to relieve pain. The enfolding arms of a parent or caregiver around a frightened, hurting child provide far more than physical warmth. They give the child basic needs important to survival, such as safety, security, acceptance, and recognition. In fact, studies show that infants who do not receive adequate amounts of touch fail to thrive, even when they are fed and otherwise cared for (Polan, 1999). As a consequence, nurses encourage parents to participate in the care of children in pain. If parents are not available, surrogates may be found to provide this valuable intervention.
Distraction is a useful way to divert a child's attention away from a painful event, such as a needle stick. Focusing on something of pleasure, such as listening to music, watching an intense scene on television, or listening to a gripping story may temporarily distract a child from pain or reduce the amount of analgesic required to eliminate pain. Distraction works best for short acute pain, not for severe or chronic pain.
Relaxation, hypnosis, and imagery, when used in conjunction with analgesics, are especially effective pain relieving measures for children. Because children have an active imagination, unhampered by learned responses, they are able to disassociate from present reality to imaginary scenes and situations. These measures are especially useful when children must undergo repeated procedures that cause fear and pain.
Applications of hot and cold have been used for centuries to dull the pain of an acute injury and treat painful muscle spasms. Young athletes are well-acquainted with the use of cold to contract blood vessels, reduce inflammation, and numb peripheral nerves, and with heat to decrease muscle spasms and increases blood flow. People of every age find warm baths and soaks comforting and pain relieving.
Massage and touch stimulate the skin and comfort individuals of every age, even tiny pre-term infants. These measures give both children and adults the nonpossessive warmth and unconditional positive regard so needed when people are suffering and frightened.
Transcutaneous electrical nerve stimulation (TENS) delivers small amounts of electrical stimulation to the skin by electrodes. This stimulation may interfere with the transmission of pain from the peripheral nerves to the spinal cord. TENS is used for both acute and chronic pain in children of school age and older.

Evaluating, Communicating, and Documenting

As with adults, pain relieving interventions for children are judged by their effectiveness and the severity of adverse effects. Such evaluation must be continuous, hour by hour, day by day. To effect change, evaluation must be documented and communicated to those who provide ongoing care. If pain is not relieved adequately or if adverse effects occur, caregivers need to take corrective action without delay. Children of any age should not have to suffer pain.

PAIN MANAGEMENT FOR SPECIAL POPULATIONS OF ADULTS

All people deserve pain management of the highest quality, including those who sustain injuries, undergo invasive procedures, give birth, or suffer from painful diseases. Some folks, however, are especially vulnerable because they have conditions that complicate pain management. These include disorders of aging, cognitive and mental condition, addictive disorders, headaches, and neuropathic syndromes.

Aged Adults

By all standards, the relief of pain is inadequate in older adults. Nonetheless, this sorry picture of pain management in older adults can be changed. With educational programs for older adults, their caregivers, and especially healthcare professionals, needless suffering can be reduced. 

BARRIERS TO EFFECTIVE PAIN MANAGEMENT

Unrelieved pain is so common among older adults that it is accepted as inevitable and cynically described as "better than the alternative" (i.e., death). Research has shown that:

• 70% of people over 65 years of age experience noncancerous chronic pain, primarily caused by osteoarthritis and neuralgia (Davis, Hiemenz, & White, 2002).
• Of the nearly 500,000 older adults who die from cancer each year, most experience inadequate treatment for malignant pain before they died (Jost, 2000).
• Of 709 patients admitted to a Midwestern hospital with hip fractures, only 22.3% received continuous analgesia during the first 24 hours after admission, the time when patients were more likely to experience acute pain (Ferri & Sofer, 2004).

Financial constraints add to the problems of pain in the aged. Even when some of the newer sustained-release nonopioid and adjuvant drugs are prescribed, older adults may not be able to afford them. According to a survey of AARP members in Washington state, 25% skip doses of prescribed drugs to "make them go further" (AARP Bulletin, 2005). In addition, pharmacies often limit the number of doses of opioid they will dispense per prescription, a policy that increases the cost to sufferers. In many states, Medicaid, the managed healthcare program for the poor, will not pay for more effective, but more costly, analgesics.
Fear of addiction and the side effects of analgesics, especially opioids, keep many older adults from taking medications sufficient to relieve their pain. As a result, they take smaller doses than are prescribed or wait until pain is unbearable before they "give in" and take an analgesic.
Age-related pharmacokinetics—the absorption, excretion, and action of drugs—differs significantly from one individual to the next, particularly in an ever-enlarging population of people over 85 years of age, the so-called "old-old." Though their physical stamina varies widely, many of these folks are frail, cared for in long-term care facilities, and at risk for both under- and over-treatment with drugs. For this reason, pain management requires particular attention at every step of the nursing process.

COMMUNICATING WITH OLDER ADULTS

Older adults often have difficulty hearing, speaking, and seeing. These sensory and cognitive deficits may be due to the normal aging process or common disorders such as cataracts, cerebrovascular accident, and dementia. Because of these deficits, seniors need time to gather their thoughts and express their needs. Caregivers should listen carefully and speak slowly, distinctly, and loudly enough to be heard and understood. They may want to ask family members or personal caregivers about the body language of a particular individual who is suffering pain. The following table lists some typical nonverbal indicators of pain and comfort.

THE NONVERBAL LANGUAGE OF PAIN IN ADULTS

Body Language	Indications of Pain	Indications of Comfort
Source: Adapted from Perkins, 2002.
Behavior	Rocking, fidgeting, squirming, agitation, decreased socialization	Enjoys and participates in activities, positive responses to interaction and touch
Breathing	Labored, irregular, noisy	Effortless, even, quiet
Extremities	Resistant to repositioning, knees pulled up, stiffened joints, clenched fists, wringing hands	Cuddled up or stretched out in restful position, joints relaxed, hands open
Face	Scowling, clenched jaw, stern or frightened look	Placid expression, smile, relaxed jaw
Mood	Cranky, sad, irritable, combative, confused	Cheerful, pleasant, serene
Sleep	May increase due to exhaustion or decrease due to frequent wakening	Restful and untroubled through the night
Verbalizations	Moaning, groaning, monotone, muttering, screaming, screeching	Agreeable responses, singing to self, humming, quiet

ASSESSING PAIN IN OLDER ADULTS

Pain assessment in older adults and persons with cognitive-mental disorders includes all the same factors as in adults and children, but with special considerations.

Location

Because older adults suffer many chronic conditions, they may experience pain in more than one area of the body at the same time. To gather accurate data, nurses and therapists need to inquire about the specific location of pain, asking the client to touch the place or places that hurt. Some facilities provide line drawing forms of the body, front and back, for marking the areas where clients indicate they have pain.

Intensity

A variety of scales are used to assess pain intensity in older adults, including numerical (0 to 10), descriptive (none-mild-moderate-severe-very severe), FACES (smiling to scowling), and vertically oriented (4-inch vertical line drawn on paper with "severe pain" at the top and "no pain" at the bottom) (D'Arcy, 2009). Regardless of the scale that is used, individuals need to understand their meaning. When a nurse or therapist breezes into a client's room and demands, "What is your pain number?" the older adult may not understand what is being asked. Instead, ask for a specific description of the pain they are experiencing; for example, "On a scale of 0 to 10, with 0 being no pain and 10 severe pain, what number would you give the pain in your right hip now?" Remember, older adults often feel pain in many places at once; therefore, it is important to identify the exact site in question.

Quality and Pattern

Older adults often have their own terms to describe the quality of their pain. They may call throbbing pain "jumping" or sharp pain as "stabbing or poking." It may be helpful to ask the person to liken their pain to a familiar experience, such as the vibration of an electric motor or the pricking of a needle.
Most adults remember what they were doing when they first felt acute pain, such as "I was walking down the front steps." However, chronic pain creeps up on people, and they may not remember when or how it began. To alleviate pain, people often try home remedies first, such as a shot of whiskey, an herbal preparation recommended by a neighbor, or an over-the-counter (OTC) medication. Finally, they may seek medical advice. For this reason it is useful to ask what remedies they have tried and which ones were most helpful.

Associated Symptoms

It is important to learn what other-than-pain symptoms older adults are experiencing, such as dizziness, blurred vision, urinary incontinence, retention, diarrhea, and constipation. These symptoms may be due to prescription drugs, home remedies, drug interactions, or other disorders. All such symptoms should be documented, reported, and investigated.

INTERVENTIONS WITH OLDER ADULTS

All of the adult nonpharmacologic and pharmacologic interventions discussed in this course can be used for older adults. However, adverse effects of analgesic drugs are of special concern because of age-related changes in the body's systems. In older adults, these adverse effects may occur with markedly different dosages than they do in younger people. Particular attention should be paid to adverse effects on renal and hepatic function, metabolism, and clearance of analgesics, as follows:

• Propoxyphene (Darvocet) and meperidine (Demerol) should be avoided in older adults because the metabolites of these drugs are toxic, causing CNS excitability and seizures.
• Methadone (Dolophine) has a 24-hour half-life and may accumulate in the body, causing respiratory depression.
• Acetaminophen (Tylenol) can cause kidney and liver damage if a daily intake exceeds 4 grams. If the person drinks as little as 2.5 glasses of wine, 2.5 beers or 2.5 ounces of distilled spirits per day, the safe dose of acetaminophen is reduced to 2.5 grams per day.

EVALUATING AND DOCUMENTING PAIN IN OLDER ADULTS

In older adults, evaluation and documention are of special concern, both for beneficial and adverse effects of an intervention. Beneficial effects have to do with the relief of pain and the lessening of anxiety. Adverse effects have to do with undesirable reactions to interventions such as respiratory depression, mental confusion, and constipation. Adverse effects should be anticipated and steps taken to prevent them. Respiratory rates, mental status, gastrointestinal function, and renal function are of particular concern; they must be monitored closely and corrective action taken immediately when necessary.

JOINT COMMISSION RECOMMENDATIONS

In 2000, effective January 1, 2001, the Joint Commission on Accreditation of Healthcare Organizations published specific recommendations for healthcare providers to manage pain in older adults. In essence, they suggested the following actions:

• Assess all older adults for chronic pain at their initial visit.
• Recognize the impact of persistent or recurrent pain on function and quality of life.
• Use a variety of synonymous terms to describe pain, such as burning, discomfort, aching, soreness, heaviness, tightness.
• Recognize nonverbal behaviors in older adults with cognitive or language impairment that suggest pain, such as changes in gait, withdrawal, agitated behavior, moaning, groaning, or crying.
• Seek information about older adults with cognitive or language impairment from other caregivers.
• Identify and treat underlying disease or refer older adults to specialists for psychiatric, substance abuse, or life-altering intractable pain care.
• Provide comprehensive assessment, including medical history, physical examination, review of laboratory and diagnostic tests, and a definitive diagnosis, plan, and likely prognosis; pain assessment, including intensity, character, pattern, location, duration, and precipitating and relieving factors; analgesic drug history, including all medications and their side effects; physical examination, focusing on the neuromuscular system and musculoskeletal system.
• Evaluate physical function, focusing on pain-associated disabilities and psychosocial function, including mood and social networks; evaluate quantitative assessment of pain directly from client using various scales; avoid reports by others if possible.
• Instruct older adults to create a pain log or diary, recording pain intensity, all medications taken (including over-the-counter), response to treatment, and associated activities.
• Regularly monitor chronic pain for improvement, deterioration, or complications caused by treatment using the same assessment scales as in the initial assessment, including analgesic medications and their effects and nonpharmacologic treatments. (JCAHO, 2000)

Adults with Cognitive and Mental Conditions

Cognitive and mental conditions may be apparent at birth or develop at any age thereafter. The causes of these conditions may be metabolic, toxic, structural, or infectious (Merck, 2006). Regardless of their age or the cause of their condition, everyone with such conditions experiences real physical pain and deserves adequate and appropriate relief.
Respect and communication are vital. Nowadays, persons who have been cognitively impaired since childhood are often better equipped to tell healthcare professionals about their pain than people who have become impaired later in life. For instance, hearing-disabled children are taught signing (sign language) as part of their basic education. Adults with cognitive conditions seldom receive such instruction. Even so, nurses and therapists can learn from family members and caregivers how best to communicate with individual patients. Many strategies for communicating with children are effective with cognitive and mentally impaired adults. See the above tables, "Communicating with Children and Adolescents," "Behavioral Responses to Pain in Children," and "Pain Experience Assessment Questionnaire."

Adults with Addictive Disorders

Pain management of people who have addictive disorders is a serious concern because the drugs that relieve pain may be the very ones they abuse. Research has shown that people who suffer high levels of pain from traumatic injuries and chronic diseases such as pancreatitis and head and neck cancers are more likely to develop higher drug tolerance and physical dependency (Nichols, 2003). Furthermore, there is a strong association between drug craving and emotional and physical stress. In fact, the stress of unrelieved pain may contribute to substance abuse by people who have a history of abuse and are abstinent (in recovery) (Kreek & Koob, 1998).
Although the cause of substance abuse is not fully understood, society no longer attributes the disorder to moral depravity. In a consensus definition of the disorder, the American Academy of Pain Management, American Pain Society, and American Society of Addiction Medicine agreed on the following definition:

Addiction is a primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations, characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving (AAPM, 2001).

In 2002 the American Society of Pain Management Nurses (ASPMN) published a position paper entitled "Pain Management in Clients with Addictive Disease." In it they affirmed the right of clients with addictive disease and pain to be "treated with dignity, respect, and the same quality of pain assessment and management as all other clients…maintaining a balance between provision of pain relief and protection against inappropriate use of prescribed medications" (ASPMN, 2002).
The position paper makes 38 recommendations for pain management, addressing: (1) all clients with addictive disease, (2) active users of drugs and alcohol, (3) clients in recovery, and (4) clients on methadone maintenance treatment. The paper also identifies tools for assessing withdrawal, protocols for treatment of withdrawal, risk of unrelieved pain, treatment options for addictive disease, and therapeutic plans in case of relapse (Nichols, 2003).

Adults Who Suffer Headaches

Headaches are a special kind of pain that interferes with thought, creative endeavor, activity, and joyful living. There are many types and causes of headaches, including migraine, cluster, tension, rebound, and those caused by increased intracranial pressure.
Migraine headache produces intense throbbing pain, often beginning in and around the eye and then spreading to one or both sides of the head. More common in women, it is accompanied by anorexia, nausea, vomiting, photophobia, and phonophobia. There is no evidence of underlying disease, and the exact cause is unknown. It is believed to stem from the activation of the trigeminal-vascular system (Santoni-Reddy, 2004).
When a variety of triggers (eg., allergens, chocolate, perfume, bright light, menses) activate the trigeminal-vascular system, trigeminal neurons release inflammatory and vasodilatory neuropeptides, including substance P neurokinin A and calcitonin gene-related peptide. These neuropeptides increase trigeminal nerve activity, intensify the pain, and sensitize sensory neurons in the caudal brainstem and upper cervical spinal tract. As a result, normally nonpainful stimuli, such as light, noise, and touch, cause severe, disabling pain (Frazel, 2004).
The International Headache Society (IHS) defined two types of migraines, those with an aura of altered visual perceptions (15%) and those without an aura (85%). The IHS identified the following characteristics as diagnostic of a migraine headache:

• Unilateral (one side of the head)
• Pulsating or throbbing
• Moderate to severe intensity
• Aggravated by activities of daily living
• Sensitivity to light or noise
• Nausea and vomiting
• Lasting 4 to 72 hours

Cluster headaches, like migraines, are vascular disturbances that involve intracranial nerves, blood vessels, and neuropeptides. Though uncommon, the symptoms are similar to migraine in that severe pain is located on one side of the head. The pain may involve the eye, face, and neck, with edema below the eye, tenderness of the carotid arteries, rhinorrhea, and tearing. Cluster headaches afflict men more than women and may last from an hour to days, weeks, or months. Treatment is similar to migraine headaches.
Tension headaches, sometimes called muscle tension headaches, are associated with stress and anxiety and are characterized by a tightening quality of pain but no nausea or vomiting. They may be episodic or chronic and are treated with nonopioid medications such as aspirin and acetaminophen and stress reduction measures such as relaxation and physical exercise.
Rebound headaches are relatively common, diffuse, and generalized. They are believed due to overuse of medications or beverages containing caffeine or other vasoconstrictors to which the body has become tolerant. When the effects of caffeine wear off, the blood vessels dilate, intracranial pressure increases, and a dull, generalized headache results. By gradually reducing caffeine or the offending drug, the body gradually adapts and the headaches disappear.
Brain tumors, hemorrhages, infections, and traumatic injuries within the inflexible bones of the adult skull increase intracranial pressure and cause pain. A client's history, location, onset, pattern, and quality of pain are vital to a prompt and accurate diagnosis and treatment.

Neuropathic Syndromes

After direct injury to the central nervous system (CNS) or peripheral nervous system, pain may continue to recur and become chronic. The cause of this pain is not fully understood, but is believed to involve reorganization of central pain pathways in the brain related to the perception of pain. This group of pain syndromes includes reflex sympathetic dystrophy, phantom pain, root avulsions, and polyneuropathy due to spinal surgery, mastectomy, and amputation. Sufferers complain of tingling, burning, and stinging sensations severe enough to interfere with thought and action.
Medical diagnosis and treatment involve:

• Distinguishing peripheral nerve damage from other forms of neuropathic pain (some pain can be ameliorated by regional nerve blocks or surgery).
• Rehabilitative therapy to improve muscle strength and tone, particularly in peripheral nerve lesions in order to prevent disuse atrophy and joint ankylosis.
• Psychotherapy to prevent social isolation, depression, and anxiety.
• Analgesic nonopioid analgesics and anti-epileptic drugs may give some relief.
• Learning relaxation exercises and self-hypnosis techniques.

Pain management for these clients involves all the steps of the nursing process, especially assessing their psychological status. This is important because people with chronic pain often feel helpless, hopeless, and worthless—feelings associated with depression and suicide. It is essential for nurses to encourage creative endeavor, instill hope, and affirm the person's worth.

CANCER PAIN

To many people, the word cancer means pain and death. Sadly, there is much to support their point of view. One study found that 30% of clients experience pain at the time of diagnosis, 30% to 50% experience pain while undergoing therapy, and 70% to 90% experience pain as cancer advances and overcomes their defenses (Portenoy & Lesage, 1999). Since then, even more pain-relieving treatments have been developed. To achieve the goal of providing adequate pain relief for people with cancer, healthcare providers need to understand the causes and types of cancer pain, the impact of pain, and effective strategies to manage pain.

Causes and Types of Cancer Pain

Cancer pain is complex, interactive, and ever-changing. It comes from two general sources: the cancer itself and its various treatments. As cancer cells invade healthy tissue, visceral and somatic nociceptors sense tissue damage and send impulses to the brain, where the individual perceives pain. Such pain may be localized at the cancer site or referred to a remote area. Not only do sensory impulses inform the person of tissue injury, they initiate the release of neuromodulators that produce localized inflammation, generating more pain. As nervous tissue is infiltrated by tumor growth or damaged by its treatment, neuropathic pain results, often persisting long after the initial insult.
In addition to physical pain, people with cancer and their families experience the emotional pain of anticipatory grief and the stress and fear of cancer and its treatment. Thus, cancer causes many kinds of pain: nociceptor, neuropathic, psychogenic, and secondary:

• Nociceptor pain is pain that is transmitted over intact visceral and somatic nerve fibers from damaged tissue caused by cancerous invasion of bodily tissue, radiation therapy, and chemotherapy. Nociceptor pain may be sharp and stabbing, throbbing and aching, constant or dull.
• Neuropathic pain is pain that is transmitted over damaged nerve fibers due to the abnormal processing of sensory information and is caused by infiltration of nervous tissue by cancer cells, radiation, and chemotherapy. Neuropathic pain is burning, searing, tingling, and migratory.
• Psychogenic pain is caused by the negative emotions that result from pain, including anger, grief, fear, and revulsion or a combination thereof, such as blame, shame, and guilt. Such pain is stress-producing and may cause depression.
• Secondary pain is caused by space-consuming tumors, as when brain tumors increase intracranial pressure or tumors compress the spinal cord.

PAIN DUE TO THE CANCER ITSELF

Pain caused by cancer depends on the site and extent of growth. Often, tumors produce clusters of symptoms, or syndromes. The table below lists some common cancer pain syndromes and a description of the typical pain they create.

CANCER PAIN SYNDROMES

Syndrome		Typical Pain
Peripheral nerve syndromes		Constant, burning pain with dysesthesia in area of sensory loss; radiating, often unilateral
Cranial neuropathies		Severe head pain with cranial nerve dysfunction; metastasis to skull base and leptomeningeal area
Vertebra of spine		Constant dull, aching pain; may be relieved by standing or exacerbated by recumbency
Bone: metastatic or primary		Aching, deep, intense pain, usually worse at night; pain may be referred; associated muscle spasm and stabbing pain with nerve involvement
Viscera		Pain in related area: pancreatic pain is relentless, boring, mid-epigastric, radiating through to the mid-back
Plexopathies	Cervical plexus	Aching and diffuse in shoulder girdle and radiating
	Brachial plexus (Pancoast's) syndrome	Heaviness and tightness in upper arm, radiating
	Lumbosacral plexus	Aching, pressure-like, may be referred to abdomen, buttocks, lower back, or legs

PAIN DUE TO THE TREATMENT OF CANCER

Modern medicine treats cancer with potent chemicals, radiation, and surgery, each of which can cause pain; these treatments destroy healthy cells as well as cancer cells, and their side effects also cause pain. Some side effects include incisional pain from surgery, emesis from chemotherapy, and stomatitis from radiation. Sweeder (2002) estimated that 20% to 25% of cancer clients' pain is directly related to its treatment. The following table lists some common syndromes that result from treatment modalities and the associated pain and complications.

PAIN SYNDROMES CAUSED BY CANCER THERAPY

Syndromes	Typical Pain and Complications
Postoperative Pain Syndromes	Incision pain; sharp and burning
Mastectomy	Tight, constricting, burning in back of arm, axilla, over chest; worse on movement; tingling in distribution of peripheral nerves; loss of sensation
Axillary lymphectomy	Numbness and aching due to edema
Thoracotomy	Referred pain to arm and chest, sensory loss around scar; reflex sympathetic dystrophy may develop
Amputation	Phantom pain in place of missing limb or body part
Radical neck dissection	Tight burning sensationand numbness or prickly sensation in the neck; dysesthesia in area of sensory loss
Oophorectomy	Surgical menopause, hot flashes
Postradiation Pain Syndromes	Aching pain, similar to postoperative and tumor pain; radiation may cause new neurogenic tumors and soft-tissue fibrosis
Myelopathy	Aching or shooting pain in certain muscles
Necrosis of bone	Aching, prickling; may be localized or referred
Mucositis and stomatitis	Ulcers of the mucus membrane; raw, burning sensation; eating and drinking made painful
Postchemotherapy Pain Syndromes	Some drugs (vesicants) seriously damage tissue if they leak outside blood vessels (extravasation); most cause nausea and vomiting
Mucositis and stomatitis	Painful ulcers of the mucous membrane most common, especially from methotrexate, doxorubicin, daunorubicin, bleomycin, etoposide, fluorouracil, and dactinomycin; appears about 10 days after beginning of treatment; pain on eating or drinking
Aseptic necrosis of the bone	Jaw pain; intermittent calf pain and/or prickling in hands or feet
Painful polyneuropathy	May feel pain in several places at once
Steroid pseudorheumatism	Aching pain in joints
Chemical menopause for estrogen-positive breast cancer	Hot flashes from tamoxifen, an anti-estrogen
Pain due to tests and devices	Sharp, piercing pain from needle sticks; abdominal distention from cleansing enemas and colonoscopies; discomfort from exposure; squeezing from machines; burning from extravasation of IV drugs

Caring for Cancer Clients and Their Families

Cancer pain is more than a physical symptom. It is a reminder of one's mortality and a harbinger of death. It may interfere with normal routines, degrade the quality of life, and rob one of rest, creativity, joy, and peace. Cancer pain adds anxiety and stress to its sufferers and their friends and family. For this reason, professional caregivers:

• Take pain seriously, recognizing that only the person in pain knows how it feels.
• Provide information and resources for pain control.
• Communicate with genuineness, accurate empathy, and nonpossessive warmth.
• Encourage sufferers to share their feelings and network with other survivors.
• Respect cultural norms and wishes of sufferers, maximizing their control of pain.
• Encourage release of energy through joy-producing activities.
• Monitor pain medications, effectiveness, and adverse effects.
• Suggest clients keep a pain-relief record, including date, time, pain rating, medication amount, side effects, and comments (Haylock & Curtiss, 1997).

Assessing and Treating Cancer Pain

The management of cancer-related pain is complicated when sufferers have pre-existing chronic pain, a history of substance abuse, or are failing and near death. For this reason accurate assessment is essential, especially of "new pain." Caregivers may find the acronym OLDCART a useful tool as they gather information about the person's pain:

• O = Onset
• L = Location (possibly multiple sites)
• D = Duration (how long it lasts and whether it is constant or intermittent)
• C = Character (sharp, shooting, dull, aching, cramping, squeezing)
• A = Aggravating factors (moving, walking, sitting, turning, chewing, breathing,
   urinating, defecating, swallowing)
• R = Relieving factors (activities or drugs that make pain better or worse)
• T = Treatment (drug or nondrug interventions) (Bednash & Ferrell, 2002)

Cancer is treated with both traditional and nontraditional healing measures. Traditional measures include pharmacologic and nonpharmacologic therapies. Pharmacologic remedies include nonopioid analgesics, opioid analgesics, and co-analgesics/adjuvants. Unlike postoperative or post trauma pain, cancer pain may go on for months and years, adding to existing chronic pain. As the patient undergoes treatment or the cancer invades other tissue, the pain may become more intense.

PAIN MANAGEMENT AT THE END OF LIFE

The focus of pain management at the end of life is to provide support and comfort, rather than cure, for the dying and those they leave behind. To do this, nurses need to understand the concepts, guidelines, ethical concerns, and legal issues associated with the end of life.

Palliative Care and Hospice

Palliative care is the active, total care of clients with a goal of providing comfort rather than cure (WHO, 2000). It addresses pain control, symptom management, and social, emotional, spiritual, and financial concerns of people at the end of life.
In 1968 Cicely Saunders—nurse, social worker, and physician—opened St. Christopher's Hospice in England to care for people who were dying alone and in pain. She developed the concept of enhancing the quality of life through palliative care rather than curative treatment. In 1970 the philosophy of providing palliative care for dying patients was brought to the United States, and since that time it has spread throughout the nation, addressing the needs of people whose life is ending.
Suffering is a highly personal experience that depends on the meaning of an event, such as an illness or loss. One can suffer without physical pain, and one can have physical pain and not necessarily suffer. The founder of the modern hospice movement described suffering as "total pain," an experience of fear of physical distress and dying, concerns about relationships, changing self-perception, and memory of another person's suffering (Panke, 2002).
The word quality refers to a measure or a grade of services or products. Quality of life refers to the state or condition of one's being. If people are physically comfortable and emotionally satisfied, we say their quality of life is good. If they are in pain, under stress, alone, sad, or distressed, as many people are, we say their quality of life is poor. The goal of hospice and palliative care is to enhance the quality of life of dying clients.

Pain Control Guidelines

To help provide better care to individuals in pain and at the end of life, Paice and Fine (2001) suggest the following guidelines:

1. Perform a basic assessment of the client's pain and evaluate its effects on the client's quality of life. Titrate analgesics according to goals of care, pain, severity, need for supplemental analgesics, severity of adverse side effects, measurements of functional abilities (such as interaction with others, mobility, and sleep), emotional state, and effects of pain on quality of life.
2. Use sustained-release formulations and around-the-clock dosing for continuous pain relief.
3. Treat breakthrough pain with immediate-release formulations.
4. Monitor the client's status frequently, especially during dose titration.
5. Anticipate adverse effects and prevent or treat them as necessary.
6. Be aware of possible drug-drug and drug-disease interactions.
7. Reassess pain regularly. Determine what level of pain is acceptable to the client. If pain is not relieved adequately, don't give up. Consult resources outside your institution, including nursing colleagues and experts in related disciplines.
8. Differentiate pain from other symptoms such as delirium or multi-system failure.
9. Use sedation selectively to relieve intractable pain when other pain-relieving measures have failed and there is a do-not-resuscitate (DNR) prescription.
10. If the client is unable to communicate verbally, consult with caregivers and use nonverbal behaviors to evaluate pain.

Ethical and Legal Issues at the End of Life

Ethical principles guide nurses at every stage of life, including its end. Ethical and legal issues and end of life care are often intertwined (Scanlon, 2003). This is especially true because pain frequently accompanies terminal illnesses. Therefore, it is vital for all healthcare facilities to anticipate potential conflicts and see that advance directives are in place. When they are not, healthcare professionals may believe they are legally required to continue medically provided nutrition and hydration even when a client no longer benefits.
To resolve this conflict, all fifty states and the District of Columbia have enacted statutes to comply with the Client Self Determination Act (Omnibus Budget Reconciliation Act of 1990). The federal law requires that all healthcare institutions receiving Medicare and Medicaid funding must inform clients in writing about their right to accept or refuse medical or surgical treatment before they become incapacitated. Legal forms called advance directives facilitate this law.  (Instructions and forms for each state are available without charge at http://www.caringinfo.org/stateaddownload/.)
There are two basic types of advance directives:

• Living will (treatment directive): written document that directs treatment in accord with the client's wishes.
• Durable power of attorney for healthcare (appointment directive): also called a medical power of attorney for healthcare or healthcare proxy; a written document that designates a spokesperson (agent, proxy, surrogate) to represent the person in decision making. (Partnership for Caring, 2009)

Despite legislation, Last Acts found that only 15% to 20% of the general population had an advance directive. They also found that decision making was skewed by circumstances at the moment, and that nurses play a vital role in helping families come to terms with the impending death of a loved one because nurses are the first to recognize signs of approaching death (2002).
Communication strategies to help terminally ill clients and their families make decisions about end-of-life care were suggested by Norton and Talerico (2001):

• Use clear, unambiguous words, such as dying and death.
• Do not use words like hope because of the many meanings such words can convey.
• Collaborate with other providers to enforce evidence of failing health and the need to have an advance healthcare directive.

ETHICS AND PAIN MANAGEMENT

Ethics: A Branch of Philosophy

Many people roll their eyes and change the subject when they hear the word ethics, viewing it as too controversial or too complex to discuss freely. Nonetheless, ethics is a significant concern of thinking, caring persons, especially nurses who manage the care of people in pain.
Ethics is the branch of philosophy concerned with the rightness or wrongness of human behavior and the goodness or badness of its effects. Ethics assumes that people have the ability to make choices about their behavior. For that reason it has been the subject of philosophical discussion for centuries and has generated an enormous body of literature. Students of ethics have divided these writings into three general categories: descriptive (characterizing), analytical (metaethics), and prescriptive (normative).
Descriptive ethics reports and describes the moral choices people make.
Analytical ethics scrutinize the language people use to discuss issues of right and wrong.
Prescriptive ethics offers advice about how people should decide what is good or bad behavior. It does this from two very different perspectives: teleological and deontological.

• A teleological (consequential, utilitarian, situational) perspective affirms that the rightness or wrongness of an act is determined by the end result of an action. The term comes from the Greek teleos, meaning "end." If the end result harms others, the act is considered wrong or bad. If the end result benefits others, the act is considered good or right. The central issue of this perspective is the principle of the "greatest good." The utilitarian teachings of John Stuart Mill and the situation ethics teachings of Joseph Fletcher maintained that end results and circumstances are essential factors in considering the rightness or wrongness of human behavior (Hamilton, 1996).
  
  Teleological theories foster morality by developing the capacity of humans to make choices. These theories reject fixed rules of conduct such as the biblical command "Thou shalt not kill" (Exodus 20:13). For example, a man is suffering with intractable pain caused by an incurable condition. He begs the physician to give him a drug that will relieve his suffering but may hasten his death. According to teleological perspective, the physician should prescribe the medication because the end result (relieving pain) is a greater good than keeping the man alive with intractable pain.
   
• The deontological (nonconsequentialist) perspective fosters morality by teaching humans to accept and obey fixed laws. The term comes from the Greek deontos, meaning "duty to obey." Immanuel Kant is the theorist most often identified with deontological ethics. He maintained that certain acts are inherently right or wrong, regardless of the situation or the end results. In deontological ethics, there are no exceptions or mitigating circumstances. According to this perspective, preserving the life of the man with intractable pain is a greater good than relieving his pain and hastening his death. The physician's duty is to obey the commandment "Thou shalt not kill" regardless of the situation or end results. Thus, the deontological perspective simplifies ethical decision-making by removing the issue of mitigating circumstances.

Bioethics and Related Concepts

Bioethics is the application of ethics to matters of human life. As scientific knowledge expands and healthcare providers have greater control over pain and pain relief, life and death, it is vital that nurses address issues of right and wrong behavior.
Although some authors use the term morals to refer to human behavior and ethics to refer to formalized codes of conduct, both words mean the same thing. Ethics comes from the Greek word ethos and morals from the Latin word mores. In recent years, some politicians have substituted the word values for morality; however the word values has a much broader meaning.
Values are treasured ideals or attributes, such as creativity, achievement, adventure, power, friendship, and belief systems. Understanding one's values brings purpose and clarity to life. The desirability of such clarity was recognized by Socrates, who is credited with saying, "An unexamined life is not worth living." To help people examine their lives and clarify their values, Louis Raths (1979) suggested a seven-step process that he called "values clarification" (see box).
Belief systems are organized patterns of thought regarding the origin, purpose, and place of humans in the universe. These systems seek to explain the mysteries of life and death, good and evil, health and illness. Typically, belief systems include an ethical code of conduct about how people should relate to the world and its inhabitants.
Religions are patterns of thought and action that typically include belief systems, devotional rituals, organizational structures, and faith in a mystical power. Often, however, people develop their own belief systems, independent of organized religions.

Ethical Principles

Ethical principles are fundamental concepts by which people judge behavior. These principles help individuals make decisions and serve as criteria against which they measure behavior. Laws, on the other hand, are rules made by an authority with the power to enforce them. Although laws flow from ethical principles, they are limited to specific situations. Ethical principles are guiding ideals of conduct that speak to the spirit of a law, not necessarily to its letter. Over the years, five ethical principles have emerged as especially applicable to healthcare providers. They include: respect for human life and dignity, beneficence, autonomy, honesty, and justice. As we consider the management of pain, these principles take on special significance.

RESPECT FOR HUMAN LIFE AND DIGNITY

Respect for human life and dignity is one of the most basic of ethical principles. It requires that "individuals be treated as unique and equal to every other individual and that special justification is required for interference with an individual's own purposes, privacy, and behavior" (Rawls, 1971). This ethical principle elevates respect for the life, freedom, and privacy of all humans. Thiroux says this principle is necessary for any moral system because "there can be no human being, moral or immoral, if there is no human life" (1990). When applied to pain management, respect for human life and dignity means nurses:

• Attend to every report of pain by clients or their families.
• Regard the personal privacy of clients as they deal with pain.
• Respect the lifestyle, personhood, and belief systems of clients.
• Strive to sustain human life and dignity while relieving pain and suffering.

BENEFICENCE

Beneficence means doing good to benefit others. Although some writers separate beneficence (doing good) from nonmalfeasance (not doing harm), Frankena (1973) suggested the ethical principle of beneficence represents a continuum from not harming to doing good, specifically: 1) not inflicting harm, 2) preventing harm, 3) removing harm, and 4) promoting and doing good.
For nurses, beneficence means more than providing technically competent client care. It means acting in ways that demonstrate genuine and accurate empathy, providing nonpossessive warmth, listening, empathizing, supporting, and nurturing. In fact, the central task of nursing—its very essence—is doing good for others. When applied to pain management, beneficence means nurses:

• Believe clients when they report pain.
• Carefully assess their level of pain.
• Provide timely, appropriate interventions to relieve pain.
• Accurately evaluate the effectiveness of an intervention.
• Communicate the effectiveness of interventions to other healthcare members.
• Give clients nonpossessive warmth, accurate empathy, and unconditional positive regard.

AUTONOMY

Autonomy is the right of self-determination, independence, and freedom. It is the personal right of individuals to absorb information, comprehend it, make a choice, and carry out their choice. Nurses demonstrate the principle of autonomy when they provide accurate information to clients, help them comprehend it, and respect the decisions they make as a result of their understanding. When applied to pain management, autonomy means nurses:

• Inform clients about available options for pain management.
• Make sure clients fully understand the actions and risks of pain-relieving options.
• Allow clients enough time to consider pain-relieving alternatives.
• Accept decisions clients make regarding management of their pain.
• Implement and evaluate pain-relieving interventions chosen by clients.

HONESTY (TRUTHFULNESS)

Honesty means communicating the truth in word and deed. Even when nurses must convey unwelcome information to clients about an illness, injury, or treatment option, they must do so truthfully. Withholding information from clients is appropriate only when they are minor children or adults who require a legal guardian. When applied to pain management, the ethical principle of honesty means nurses:

• Provide factual information about treatment options, including benefits and risks.
• Use language that is clear and appropriate to the age and capacity of the client.
• Encourage client participation in pain-management decisions.
• Convey genuine concern when giving unwelcome information.
• Report and record critical data accurately, regardless of personal consequences.

JUSTICE

Justice implies fairness and equality. It requires impartial treatment of clients. Like other ethical principles, justice is based on respect for human life and dignity. The traditional image of justice is a blindfolded woman with a scale, weighing an issue on the basis of objective evidence and judicial precepts. Justice means that scarce resources are distributed equally, using the same criteria for everyone. When applied to pain management, the ethical principle of justice means nurses:

• Attend to complaints of pain by clients, no matter how difficult they may be.
• Assess pain and intervene to relieve pain with equal diligence for all clients.
• Evaluate and communicate information about pain with fairness and lack of bias.

Ethical Dilemmas

A dilemma is a perplexing problem that requires a choice between conflicting alternatives. An ethical dilemma is a moral problem that requires a choice between two or more opposite actions, each of which is based on an ethical principle. For example, a nurse weighs whether to fully disclose the risks of a proposed treatment for pain, honoring the ethical principle of autonomy, or whether to withhold such information to reduce the client's anxiety, honoring the ethical principle of beneficence. Healthcare professionals are faced with many such dilemmas.
Resolution of ethical dilemmas requires careful evaluation of all the facts of the case, consultation with all concerned parties, and appraisal of the decision-makers' ethical stance (whether it is teleological, considering end results, or deontological, obeying fixed laws of behavior).
Nowadays, ethical dilemmas in healthcare facilities arise more frequently because modern medicine can keep hearts and lungs functioning much longer than thinking brains. To help resolve these perplexing issues, many institutions appoint ethics committees made up of healthcare professionals, ethicists, lawyers, and clergy. The task of ethics committees is to help decision-makers resolve ethical dilemmas using an ethical decision-making process such as the following:

1. Gather relevant facts about the client's age, diagnosis, and circumstances and the ethical stance of the decision-maker (deontological or teleological)
2. Identify and clearly state the problem
3. List alternative actions, together with ethical principles that support each action
4. Determine who can make the decision and assist that person to make it
5. Provide emotional support to all involved parties

In support of the ethical principle of autonomy and to reduce ethical dilemmas, the Joint Commission on Accreditation of Healthcare Organizations recommends that all adults discuss their wishes regarding artificial life-support and sign a legal document called an Advance Healthcare Directive appointing someone to make healthcare decisions in their stead if they should become incapacitated (JCAHO, 2009).

Codes of Ethics

Codes of ethics are formal statements that set standards of ethical behavior for groups of people. In fact, one of the hallmarks of a profession is a code of ethics to which its members subscribe. For instance, the American Nurses Association's (ANA) Code of Ethics for Nurses with Interpretive Statements (see box) and the International Council of Nurses' (ICN) Code of Ethics for Nurses (see box) make explicit the goals and values of the profession and provide guidance for carrying out nursing responsibilities.

Federal Pharmaceutical Legislation

Although there are many modalities in the pain management arsenal, drugs constitute one of its most effective and often-used weapons. Until the beginning of the twentieth century, no federal rules or regulations protected consumers from ineffective or harmful drugs. After several drug-induced tragedies, the U.S. Congress passed the Pure Food and Drug Act of 1906. This act recognized the United States Pharmacopeia, a publication that lists drugs that met certain standards for dosage, therapeutic use, client safety, quality, purity strength, and packaging. These drugs were called "official" and were permitted to print "USP" after the name of the drug. The act also empowered the federal government to take legal action against manufacturers of drugs that did not comply with standards. Since then, many laws have been passed to further ensure the safety and effectiveness of drugs. The following table lists some of the most important pieces of federal legislation.

FEDERAL PHARMACEUTICAL LEGISLATION

Year	Title of Law	Major Provisions
Source: FDA, 2009.
1906	Pure Food and Drug Act	Designated official standards for drugs and their labeling in the USP and National Formulary
1912	Sherley Amendment	Prohibited manufacturers from making fraudulent claims about drug efficacy and therapeutic effects
1914	Harrison Narcotic Act	Legally classified habit-forming drugs as narcotics: regulated the importation, manufacture, sale, and use of narcotic substances
1938	Federal Food, Drug, and Cosmetic Act	Added the Homeopathic Pharmacopeia as a third drug standard; required that drugs be approved as safe by the FDA before marketing; further outlined criteria for drug labeling
1945	Amendment to the Food and Drug Act	Provided for certification of biological products used as drugs (antibiotics, insulin, etc.) on batch basis; allowed for direct supervision and inspection of drug manufacture
1952	Durham-Humphrey Amendment	Distinguished between prescription and nonprescription drugs
1962	Kefauver-Harris Amendment	Authorized FDA to supervise drug manufacture to ensure safety and efficacy and to establish official drug names; specified greater controls on experimental drugs
1971	Comprehensive Drug Abuse, Prevention, and Control Act, also known as the Controlled Substance Act	Set strict controls on manufacture and distribution of controlled substances (possession unlawful without a prescription); established government programs to promote prevention and treatment of dependence
1997	Food and Drug Administration Modernization Act	Tightened regulation of food, drug, devices, and biological products
1998	Drug Regulation Reform Act	Shortened drug investigation process to hasten release of drugs to the public
2007	Food and Drug Administration Amendment Act	Allowed the FDA to collect fees from biotechnology and pharmaceutical companies; skeptics raise concerns that FDA is now partially funded by the industries it regulates

In 1971, in response to the growing misuse and abuse of drugs in the 1960s, Congress passed the Comprehensive Drug Abuse, Prevention, and Control Act. Known as the Controlled Substance Act, the legislation is of particular concern to healthcare professionals concerned with the management of pain. The act created a schedule of controlled substances, ranking them according to their potential for abuse. Specifically, it identified five categories or schedules of drugs, from those with the highest abuse potential (C-I) to those with the lowest abuse potential (C-V) as shown in the table below.

CONTROLLED SUBSTANCES AND DISPENSING RESTRICTIONS

Category/ Schedule	Abuse Potential	Dispensing Restrictions	Examples
C-I	High, possible severe physical and psychological dependency, no approved medical use	Only with approved protocol	Heroin, marijuana, LSD, mescaline, peyote, psilocybin, methaqualone
C-II	High, possible severe physical or psychological dependency	Written prescription only (if phoned in, written prescription required within 24 hours), no prescription refills, container warning label required	Codeine, cocaine, hydromorphone, morphine meperidine, methadone, oxycodone, secobarbital, pentobarbital, amphetamine, methylphenidate
C-III	Less than C-II drugs, moderate to low physical or high psychological dependency	Written or oral prescription that expires in 6 months, no more than 5 refills in 6 months, container warning label required	Combination drugs containing hydrocodone, codeine, dihydrocodeine, oxycodone, paregoric, morphine; non-narcotic compounds of pentazocine, propoxyphene
C-IV	Less than C-III, limited physical or psychological dependency	Written or oral prescription that expires in 6 months, no more than 5 refills in 6 months, container warning label required	Barbital, phenobarbital, chloral hydrate, meprobamate, fenfluramine, benzodiazepines, pentazocine etc.
C-V	Less than C-IV, limited physical or psychological dependency	Written prescription or over-the-counter, varies with state law	Medications used for relief of coughs or diarrhea containing limited amounts of opioids

State Legislation

Legislative bodies of the states and territories also pass laws regulating the manufacture and distribution of food, drugs, and medical devices. This authority is derived from the Tenth Amendment to the United States Constitution, which says, "The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people."
Of special concern to healthcare providers are laws that affect the management of pain, in particular, the laws that authorize the medicinal use of marijuana. Because of vigorous enforcement of the Controlled Substance Act by the federal Drug Enforcement Administration (DEA) and harsh penalties imposed on individuals who use marijuana, an increasing number of states have passed laws regulating marijuana within their borders. These legislative acts permit some use, possession, and cultivation of marijuana for medicinal purposes and though they differ, most require a physician's diagnosis and prescription, registration of the user, and limitation of the amount of marijuana a person may grow or possess (Norml, 2009).

CONCLUSION

Pain is a universal human experience, the strongest motivator for an individual to seek medical care, and one of the body's most important protective mechanisms. Pain alters the quality of life more than any other health-related problem, interfering with sleep, mobility, thought, emotional well-being, sexual activity, and creativity. Yet, pain is one of the least understood, most under-treated, and often discounted problems faced by healthcare providers. For these reasons, it behooves all caregivers to manage pain more consistently and effectively and to support research to improve pain management for everyone.