Myths & facts about pain

Myths & facts about pain
Rn, Feb 1998
Sonia R Strevy 

Abstract:
Several misconceptions about pain relief are examined. The goal of 
chronic pain management is to keep the patient as comfortable as 
possible, not to keep the dose as low as possible.

Full Text:

Debunking these misconceptions will allow you to provide more 
effective-more compassionate-pain relief. 

Surveys show that severe, chronic pain is such a frightening prospect to 
many patients that they would prefer dying to enduring it. One study of 
patients with metastatic cancer, for instance, found that seven out of 
10 would consider suicide if they couldn't obtain adequate pain relief.1 

It is that same dread that prompts some patients in severe pain to look 
to clinicians for help in ending their lives. Recent Supreme Court 
decisions-one upholding state bans on assisted suicide, the other 
permitting Oregon's assisted suicide law to stand-have forced the 
healthcare community to take a closer look at how to provide better 
endof-life care. Above all else, that means finding improved ways of 
relieving pain. 

And it's not just chronic pain that needs to be treated more 
effectively: About half of all postop patients suffer needlessly from 
acute pain because they're undermedicated.2 

A large part of the problem is the number of myths about pain that 
continue to circulate. Here we will expose some of the more common ones. 

MYTH: The goal of chronic pain management is to keep the dose of 
medication as low as possible. 

Wrong. Pain experts agree that the real goal should be to keep the 
patient as comfortable as possible and to promote a better quality of 
life. Usually the best way to accomplish this is to combine medication 
with other treatment options. These non-drug approaches often help 
reduce the need for medication and in the process may reduce the cost of 
care and drug reactions; but they are not substitutes for pain 
medication given at optimal doses. 

Among the non-drug options that can complement pain medication, consider 
the following: 

Massage, pressure, and vibration can help relax the patient and distract 
him so he has less time to concentrate on the pain. 

Transcutaneous electrical nerve stimulation (TENS) provides pain relief 
by blocking the pain impulses traveling to the patient's brain. 

Exercise will mobilize the patient's joints, strengthen weak muscles, 
and improve cardiovascular conditioning, all of which can help alleviate 
pain. 

Heat and cold applications can help ease pain, depending on the 
individual patient and his circumstances. Don't use heat on irradiated 
tissue or tumor sites, however. It's best to avoid cold over irradiated 
tissue, and in patients with peripheral vascular disease. 

The other non-drug approaches worth considering include progressive 
muscle relaxation, guided imagery, and therapeutic touch. 

MYTH: Because opioids can easily cause addiction, they should be given 
only to end-stage cancer patients. 

Many clinicians exaggerate the risk of addiction and needlessly deprive 
patients of opioids-or they give too low a dose. This reluctance is 
based in part on confusion surrounding the terms physical dependence and 
psychological dependence, or addiction. 

Physical dependence on opioids may occur after two to three weeks of 
therapy, depending in part on the dose that's being given. For patients 
on drugs like codeine or morphine, which have a short half-life, 
symptoms such as anxiety, chills, irritability, hot flashes, joint pain, 
sweating, and vomiting emerge six to 12 hours after the drug is abruptly 
discontinued. For drugs like levorphanol (Levo-Dromoran) and transdermal 
fentanyl (Duragesic), which have a long half-life, it takes 24 hours or 
more and symptoms are usually less severe. 

But psychological dependency is a very different phenomenon. In the 
words of one expert panel, it is the "compulsive use of a substance 
resulting in physical, psychological, or social harm to the user and 
continued use despite that harm."3 A number of studies have shown that 
cancer patients on long-term opioids very rarely fall into this trap! 

Of course, that doesn't mean patients should be given an opioid when a 
less potent drug will do the job. To avoid that tendency, the World 
Health Organization developed a three-step analgesic ladder that 
outlines a systematic approach to opioid therapy.5 The first line of 
defense, indicated for the least severe pain, includes oral analgesics 
such as acetaminophen and ibuprofen. These drugs should be used along 
with adjuvant medications like antidepressants, anticonvulsants, and 
antiemetics, when needed. 

Second-line treatment includes mild opioids like codeine, combined with 
the first-line treatments, as needed. Third-line therapy, for the most 
resistant pain, includes the use of a strong opioid like morphine or 
fentanyl (Duragesic, Sublimaze). 

To avoid a seesaw effect, a regular dosing schedule is best, but it 
needs to be individualized and then fine-tuned, not written in stone. 
Some patients will need pain medication q2h or even more often to gain 
adequate relief. Other patients, like those on long-acting meds, will 
need a less frequent dosing schedule. 

While a patient-reported pain scale is helpful in identifying the 
severity of pain, it's only one part of a complete pain assessment. To 
remember the other areas to cover, keep in mind the mnemonic P,Q,R,S,T: 

Precipitating/alleviating factors. What causes the pain? What aggravates 
or relieves it? For instance, does the leg hurt while walking but feel 
better with rest? Has any medication or treatment worked in the past? 

Quality of pain. Ask the patient to describe the pain, using words like 
sharp, dull, stabbing, stinging, and burning. Sharp, stinging pain often 
originates in the skin while an aching or burning pain suggests a deeper 
problem. 

Radiation. Determine if the pain exists in only one location or if it 
radiates to other areas. A patient who says his pain is localized in the 
hip area, for instance, may be suffering from arthritis. But someone who 
says it also radiates to the thigh, behind the knee, and into the ankle 
may be suffering from a sciatic condition.6 

Severity. Have the patient use a descriptive, numeric, or visual scale 
to relay how bad the pain is. (With the 0 -10 scale, for instance, 0 
indicates no pain and 10 means the worst pain imaginable.) 

Timing. Ask whether the pain is constant or intermittent, when it began, 
and whether it pulsates or has some rhythmic pattern to it. Each of 
these changes suggests different diagnoses and treatments. Quite the 
contrary. Many patients in pain don't ask for medication, and many of 
those who do don't ask early enough to obtain adequate pain control. 

There are several reasons for this: Some patients avoid drugs because 
they are afraid of the side effects, or because they're timid or passive 
and don't want to bother the nurse with a request. Others find it hard 
to ask for pain relief because it conflicts with their cultural norms 
and beliefs. Still other patients don't ask because they believe, 
mistakenly, that their pain is inevitable and untreatable. 

Let your patients know that most pain can be controlled. Explain the 
relative benefits and risks of the drugs you're administering to help 
allay fear of adverse effects. Also explain that giving medication in 
anticipation of pain, especially prior to painful procedures or before 
the patient's activity level is about to increase, can help "catch" pain 
before it becomes unmanageable. 

Finally, adopt an approachable demeanor and get patients more actively 
involved in all aspects of their care. This may give timid patients the 
courage to speak up when they need pain relief. 

MYTH: If the patient doesn't look like he's in pain, it's okay to 
withhold medication or decrease the dose. 

Pain is an extremely subjective phenomenon, perceived and expressed by 
each patient in his own unique way. Some may cope with their suffering 
by wailing or crying; others with the same degree of pain may present 
with a calm, quiet appearance. 

Since only the patient knows how much pain he's experiencing, you need 
to ask him about it-at regular intervals. Using a pain scale, as 
mentioned earlier, can help monitor changes in intensity as well. So can 
checking vital signs: An elevated blood pressure or heart rate suggests 
that he's in pain even if he doesn't look or act like it. 

MYTH: The side effects of pain are limited to discomfort and increases 
in heart rate and BP. 

These reactions are only the tip of the iceberg. Acute pain may 
contribute to wound dehiscence or cause guarding and decreased mobility. 
The latter may contribute to pneumonia and embolism. Chronic pain 
diminishes quality of life and may also bring on anxiety, depression, 
and a sense of helplessness. The stress of seeing a loved one suffer, 
along with financial burdens resulting from the illness, can take a 
heavy toll on family members, too. And nurses can easily become 
frustrated when pain is poorly controlled, resulting in feelings of 
inadequacy and helplessness. 

No matter how hard we try, we all fall prey to prevailing misconceptions 
and half-truths at times. Making a conscious effort to get all the facts 
about pain relief will make our patients a lot more comfortable. o 

Take the open-book multiple-choice CE test that follows this article and 
earn two contact hours from the RN/AUHS Home Study Program. You should 
be able to: 1. Describe the different 

classifications of pain. 2. Evaluate the effectiveness of pain 
management plans. 3. Recognize common myths related to pain. Other CE 
options are explained on page 41. 

REFERENCES 

1. Foley, K. M. (1995). Misconceptions and controversies regarding the 
use of opioids in cancer pain. Anticancer Drugs, 6(Suppl. 3), 4. 2. 
Agency for Health Care Policy and Research. (1992). Clinical practice 
guideline: Acute pain management: Operative or medical proCedures and 
trauma. Rockville, MD: U.S. Department of Health and Human Services. 3. 
Rinaldi, R. C., Steindler, E. M., et al. (1988). Clarification and 
standardization of substance abuse: Terminology. JAMA, 259(4), 555. 4. 
Portenoy, R. K., & Payne, R. (1992). Acute and chronic pain. In J. H. 
Lowinson, P. Ruiz, & R. B. Millman (Eds.), Substance abuse: A 
comprehensive textbook (2nd ed.), (pp. 691 - 721). Baltimore: Williams & 
Wilkins. 5. Drourr, N., Bajwa, Z., & Warfield, C. (1997). Cancer Pain. 
Seminars in Anesthesia , 16(2), 105. 

6. Burrell, L. 0. (1992). Adult nursing in hospital and community 
settings (pp. 186 187). Norwalk, CT: Appleton & Lange. 

SONIA STREW is the president of Health Education, Inc, a Wabash, 
Indiana-based company that develops on-site health and safety programs 
for a variety of corporations.
This page last updated on August 7, 1998.