Overcome Your Pain

Overcome Your Pain

by
Holly Verenski

“Pain is real, suffering is optional” is the motto
of the newly formed Pain Committee at Lake
Forest Hospital in Lake Forest, Illinois.
Although pain is the most common reason for
health care visits today, up to 50% of patients
report inadequate relief from their pain
(Journal of Intravenous Nursing, March/April
2001). Pain is described as the “Fifth Vital
Sign” and treatment of pain is finally receiving
deserved attention. Pain affects all areas of
life: physical, psychological, social and
spiritual well-being. Therefore a holistic
approach is being adopted by many health
care facilities.

Why should you suffer needlessly? In the past
Health care workers have either failed to
accurately assess pain or were not
knowledgeable about available alternatives.
Doctors have been reluctant to prescribe
more than minimal doses of pain
medications, fearing that they might
overmedicate patients or that patients would
become addicted to pain medications.
Recent media coverage of misuses of
Oxycontin has refueled this fear in doctors and
families of persons suffering from pain. We
are also at fault for not reporting our pain to
our doctors. “Pain is not a badge of courage
to be worn,” says Kim Gallagher, RN, who
works in home care, “Many people are afraid
to report pain because they think it is a sign of
weakness.” Others are afraid of the
underlying causes (fear of cancer or other
diseases).

THE NATURE OF PAIN

All pain is not created equal. Locations,
intensities, and causes vary. Different types of
pain require different treatments.

Previously pain was classified as either
chronic (pain that has been present for a long
period of time) or acute (pain of recent or
sudden onset and short duration). The new
classifications are: Nociceptive, Neuropathic
and Mixed pain. There are two types of
nociceptive pain: somatic and visceral.

Nociceptive pain occurs when trauma or
inflammation stimulates our somatic or
visceral pain receptors. A paper cut on your
hand stimulates the pain receptors on the
skin– this is known as Nociceptive Somatic
pain. Damage to or inflammation of our
organs stimulates their pain receptors
causing Nociceptive Visceral pain.
Nociceptive somatic pain is often described
as localized, aching or throbbing and may be
constant or intermittent. Nociceptive visceral
pain is described as diffuse, aching, sharp,
gnawing, cramping or as a feeling of pressure
and it may be referred to a part of the body
remote from the organ that is causing the pain
(feeling heart attack pain in your jaw for
instance). Neuropathic pain arises from
lesions or other damage to the nervous
system. This damage interferes with how we
process sensation. The pain associated with
Carpal Tunnel Syndrome is this type.
Neuropathic pain can also occur “… when
nociceptive pain has been inadequately
treated and goes awry”, says Diane
Goodman, RN, Co-Chair of the Lake Forest
Hospital Pain Committee. Phantom limb pain
can be of this type, caused by inadequate
management of nociceptive pain following an
amputation. Neuropathic pain is usually
described as tingling, burning, shooting, or
shock-like. The skin in the area may be numb
or hypersensitive to touch.

Mixed pain includes both neuropathic and
nociceptive pain. Following carpal tunnel
surgery you may have nociceptive pain from
the incision in your hand and neuropathic pain
from nerve inflammation. Back pain is often of
the mixed variety – nociceptive pain from
muscle inflammation, neuropathic pain from
”pinched” nerves.

ASSESSMENT: THE FIRST STEP TOWARD
RELIEF

If you have pain and don’t know why, the first
step is to see your doctor to determine the
underlying cause. If it is possible to treat the
underlying cause this should be done first.
Assessment of your pain should be ongoing
throughout the treatment.

When should you seek a pain assessment?
“If your pain interferes with your everyday
activities or movements,” says Penny Hiniker,
RN, Pain Management Team Leader for Lake
Forest Home Health Care. Pain has many
factors that can make assessment difficult. A
thorough assessment must take into account
all factors. Your doctor should consider what
pain means to you. The meaning attached to
pain varies from person to person and from
culture to culture. The effect that pain is
having on your emotional, psychological, and
spiritual well-being is just as important as its
physical effects.

To assist your doctor in assessing your pain
you should make a list that includes:
location(s), what alleviates the pain, what
increases the pain, and what you are currently
doing to treat your pain. It may be helpful to
rate your pain on a scale of one to ten for each
location when it is at its strongest and when it
is at its weakest. Keeping a pain journal for a
week is a useful tool and fairly simple to do. It
helps you to keep track of when your pain
occurs, how long it takes medicines or other
treatments to take effect and how long their
effects last. Present these to your doctor at
your initial assessment (or your regular
check-up) and follow up visits to help
determine whether your current regimen could
be made more effective or if a new approach
should be taken.

CHOOSING THE TREATMENT THAT’S RIGHT
FOR YOU

New studies have shown that uncontrolled
pain may impair our immune systems
(Journal of Intravenous Nursing, March/April
2001). “Not only does relieving pain make you
feel better, it may also help you heal faster,”
says Diane Goodman, RN.

It is essential that you and your doctor work
closely together to achieve the optimal
treatment for your pain. The World Health
Organization (WHO) has devised a guide to
treat pain in a holistic manner. It is known as
the WHO ladder and it has three levels for
treating pain and its effects on our overall
well-being. Initial treatment should always
begin at level one.

Level one is usually effective in relieving mild
to moderate pain. Your doctor may
recommend the use of non-opioids and
adjuvant medications at this level. Non-
opioids include acetaminophen and NSAIDS
(Non-Steroidal Anti-Inflammatories). NSAIDS
include ibuprofen and naproxen. There is a
new class of NSAIDS called Cox-2 inhibitors
that have fewer side-effects. These include
Celebrex and Vioxx. Adjuvant medications are
medications that are not used primarily as
pain relievers and include tricyclic
antidepressants, steroids, antispasmodics,
anticonvulsants and sleep aids.

Moderate to severe may persist beyond
treatment level one. At level two your doctor
may add low dose opioids to your current non-
opioid and adjuvant medications. Medicines
containing a combination of non-opioid and
opioid are commonly used at this stage.
Tylenol #3 (acetaminophen and codeine),
Percodan (aspirin and oxycodone), and
Darvocet (propoxyphene and acetaminophen)
are typically used for this purpose. Darvocet,
however, should be avoided in the elderly due
to its serious side-effects. Its analgesic
effects are equal to aspirin or acetaminophen.
The usefulness of drugs containing
acetaminophen is limited by the maximal daily
dose of acetaminophen (4mg). It may also be
more effective to use a short-acting opioid
separately for pain flare-ups, while continuing
to take scheduled doses of non-opioids.

When your pain persists in spite of the above
treatments level three recommends that your
doctor prescribe a long acting opioid as a
“background” drug. Your doctor may also
increase the dose of your short acting opioids
while you continue the use of non-opioids and
adjuvant medications. Adding a longer-acting
opioid on a scheduled basis and using short
acting opioids when pain flares up is often
most effective.

Working through these levels with your doctor
it should be possible to achieve adequate
relief of your pain. This doesn’t mean that
your pain will be completely absent –
especially if your pain has been severe for a
long period of time – but your pain should be
reduced to a level that you consider tolerable.
A level at which it does not affect your
enjoyment of life’s daily activities.

THE FEAR OF ADDICTION

“Less than one percent of people using pain
medications for true pain become addicted,”
reports Diane Goodman, RN, Co-Chair of the
Lake Forest Hospital Pain Committee. This is
the message that she wants to spread to
doctors, patients and their families. Fear of
addiction is one of the biggest barriers to
relieving pain through proper use of
medications. There have been numerous
reports of celebrities becoming addicted to
pain medications such as morphine.
Recently, misuse of the pain-relieving drug
Oxycontin has been in the spotlight. We often
have the misguided belief that if we take pain
medications, especially in a high dosage, that
we run the risk of becoming addicted. Our
friends and family frequently reinforce this
misguided belief, and worse, our physicians
may hold this belief. There is also widespread
misunderstanding of what constitutes
addiction.

Two terms that are often equated with
addiction are tolerance and physical
dependence. Tolerance means that you
adapt to the effects and side-effects of a
medication over a period of time and may
need to increase the dose to achieve the
needed effect. Tolerance to side-effects can
be beneficial if the side-effects interfere with
taking an effective dose of the medication.
Tolerance to the beneficial effects of pain
medications in persons with true pain is rare.
Physical dependence occurs when your body
adapts to the presence of opioid medications
in your system. It is made evident by
withdrawal symptoms if you suddenly stop
taking the medication or quickly reduce the
dose (by more than 50%). It is an expected
effect of long- term opioid use. To avoid
withdrawal symptoms you must work with
your doctor to decrease the medication
dosages gradually before stopping their use.
Physical dependence is NOT a sign you are
becoming addicted to a medication. The term
substance dependence is used to denote
addiction in psychiatric terms.

Is it addiction or pseudo addiction? Do you
know the difference? There is a fine line
between the two and many of us don’t
recognize the difference. Addiction and
pseudo-addiction to pain medications share
common observable characteristics:
preoccupation with the use of the medication,
hoarding medication, taking more than the
prescribed dose, frequently requesting pain
medications, and “clock watching” for the next
dose. If your family observes these behaviors
they may jump to the conclusion that you are
becoming addicted. When these behaviors
are the result of seeking adequate pain relief
they are referred to as pseudo addiction. In
addiction, these behaviors often become
deviant and destructive and are directed at
obtaining medications for their psychological
effects – not their pain relieving effects. The
destructive behaviors continue despite
negative social and economic consequences.

Emergency rooms are often faced with the
task of determining if a person is seeking
pain medications due to an addiction or for
relief of true pain. A major hospital in Illinois
set up a program that allowed patients three
months of treatment with pain medications,
increasing the levels at the patient’s request
(within medically safe ranges). Since pain
measurement is subjective, patients were
given the benefit of the doubt. Patients with
pseudo-addiction returned to work and to
normal functioning again when pain was
relieved. Patients who sought pain
medications because of addiction did not.
They withdrew from society instead.

ALTERNATIVES

There are alternative methods for treating
pain that may be used instead of medications
or with them to increase the effectiveness of
your pain management plan. Brett Sisler,
MSW, counsels people suffering from chronic
pain and finds that “even simple relaxation
techniques, that anyone can learn and use,
are helpful in reducing the severity of pain”.
Laura Sykes, P.T. (physical therapist),
recommends the use of ice and/or heat to
decrease pain - especially in sore muscles.
To find out what is best for you, first you need
to recognize that pain is interfering in your life
and seek a thorough assessment from a
doctor who is current on pain treatment
methods. And remember that pain is indeed
real, but suffering is optional.