Tips for Managing Pain More Effectively

C L I N I C A L N O T E B O O K

Author: Polly Gerber Zimmermann, RN, MS, MBA, CEN,

Chicago, Ill

Section Editor: Gail Pisarcik Lenehan, RN, EdD, FAAN

Polly Gerber Zimmermann is Assistant Professor, Harry S. TrumanCollege, Chicago, Ill.

For reprints, write: Polly Gerber Zimmermann, RN, MS, MBA, CEN,4200 N Francisco, Chicago, IL 60618; E-mail: pollyzimmermann@msn.com.

J Emerg Nurs 2004;30:470-2.

0099-1767/$30.00

Copyright n 2004 by the Emergency Nurses Association.

doi: 10.1016/j.jen.2004.06.018

470

o nurse wants to see a patient suffer. Beyond

Nobtaining an analgesia order, what can aid in

providing more effective pain relief ? The an-

swer is increased awareness of current f indings and the

following practical tips.

Dispelling the myths

Lingering brulesQ can hinder the application of today’s

advancing knowledge.

MYTH 1: NO ANALGESIA CAN BE GIVEN UNTIL

THE DIAGNOSIS IS ESTABLISHED

Studies have revealed no differences in physical f indings

or diagnostic accuracy between patients who received

morphine and those who received a placebo.123 In addition,

3 major specialty organizations recommend changing the

practice of routinely withholding analgesia during a diag-

nostic workup.

A 2004 American Pain Society guideline states that

pain should be treated as the investigation proceeds and

that withholding all analgesia is rarely justif ied.4 The

American College of Emergency Physicians’ 1994 clinical

policy statement encourages early pain relief in stable

patients with nontraumatic acute abdominal pain.5 The

Canadian Association of Emergency Physicians 1994 con-

sensus statement indicates that there is bno justif ication

to not relieve the (abdominal) pain immediately. Judicious

IV opioid titration used to relieve most of the pain but not

leave the patient somnolent is not only humane but, in

fact, allows a better abdominal examination.Q 6

JOURNAL OF EMERGENCY NURSING 30:5 October 2004

C L I N I C A L N O T E B O O K / Z i m m e r m a n n

MYTH 2: THERE IS A HIGH RISK FOR RESPIRATORY

DEPRESSION AND ADDICTION WITH NARCOTIC

ADMINISTRATION

In a survey of registered nurses published in 2002,7 40%

mistakenly believed that there is a high risk for respiratory

depression and addiction with narcotic administration.

The reality is that clinically signif icant, opioid-induced

respiratory depression occurs less than 1% of the time.

The patients at most risk are the opioid naRve, that is,

those who have not recently received regular daily doses

of opioids (eg, a trauma victim, a young adult with a new

femur fracture). The key assessment is to monitor these

patients for sedation level, because signif icant sedation

precedes respiratory depression.7,8

In the same survey, 46% misperceived the rate of

addiction with the use of narcotics for medical reasons.7

In one study, an addiction disorder developed in only 4

patients of the 12,000 hospitalized patients who received

opioid analgesics, and only 1 of those cases was def ined

as major.7,8

MYTH 3: AN INJECTION OF DEMEROL AND

PHENERGAN IS HIGHLY EFFECTIVE FOR

SEVERE PAIN

Use of meperidine (Demerol) has fallen into disfavor,

especially for elderly patients or when ongoing needs are

anticipated. Its active metabolite, noremerpedine, accumu-

lates and results in neurotoxicity (observe for a f ine hand

tremor). Toxicity was not often noted in past practice

because meperidine traditionally was prescribed in sub-

therapeutic doses. For adequate pain relief, most adults

would require at least 75 to 100 mg (some adults would

require up to 150 to 200 mg) every 2 to 3 hours.7,9

Promethazine (Phenergan) also is no longer recom-

mended as a bpotentiatorQ for any narcotic.5,6 Actually, it

neither relieves pain nor potentiates opioid analgesia; one

study showed that it increased sensitivity to pain and the

amount of opioid needed.1,8

MYTH 4: BIAS HAS BEEN ELIMINATED IN

ANALGESIC ADMINISTRATION

Past studies revealed a discrepancy between analgesia

provided to persons of different races with the same

objective diagnosis. Surely health care has bf ixedQ this

subconscious bias.

A study published in 2003 of 64,487 patients seen

in US emergency departments over 3 years found no overall

October 2004 30:5

difference in the receipt of some analgesia by race. How-

ever, blacks and Hispanics were 28% less likely than were

whites to receive an opioid analgesic for the same severity of

pain. The discrepancy was particularly noted in conditions

where the severity was more dependent on a patient’s sub-

jective report, such as a migraine or back pain, compared

with an objective condition, such as a long-bone fracture.10

MYTH 5: REQUIRING LARGE DOSES OF

OPIOIDS FOR RELIEF IS INDICATIVE OF A

PHYSICAL DEPENDENCE

The amount of opioids required to provide relief varies

widely between patients. Pain Consultant Margo McCaff-

ery, MS, RN, FAAN, notes that someone who has taken

opioid analgesics regularly (someone who is bopioid

tolerantQ) may require 100 times more opioid than an

opioid-naRve patient (that is, someone who has not received

opioids regularly) (personal communication, June 24,

2004). Some conditions, such as sickle cell crisis, can

require more opioids than are normally given postopera-

tively for major surgery. There is no bceilingQ effect on

the analgesia with morphine and morphinelike opioids

(eg, Hydrocodone), unlike other classes of opioids, non-

opioids, and adjuvants. If a dose of morphine fails to

relieve pain, and there are no adverse reactions, the dose

should be increased by 25% to 50%.1,8

Tricks of the trade

Try these hints to enhance your patient’s pain management:

TURNING THE HORIZONTAL SCALE VERTICALLY

Some older children or adults have diff iculty using

horizontal, left-to-right classic pain scale presentations,

such as a numeric rating scale (0Q10) or Wong-Baker Faces

Pain Rating Scale.11 This phenomenon may be seen more

often in persons who speak a language that is read vertically

or from the right to left.

Turn the scale vertically instead.12 The scale should be

positioned so that the b10Q is at the top because sequences

that progress upward are more universally recognizable

than those that progress downward.

MANUAL PRESSURE PRIOR TO AN

INTRAMUSCULAR INJECTION

Applying manual pressure to the site of an intramuscular

injection for 10 seconds prior to administering the

JOURNAL OF EMERGENCY NURSING 471

C L I N I C A L N O T E B O O K / Z i m m e r m a n n

injection reduces patients’ sensation of pain.13 It is

hypothesized that this research-validated technique works

because the pressure stimulates multiple nerve endings so

the body does not sense the new needle prick. Anecdotally,

when I apply manual pressure before tetanus immunization

administration, the patients compliment me for giving a

bgood shotQ that did not hurt.

ORAL GLUCOSE FOR INFANT ANALGESIA

Oral glucose (1 mL of 30%) was compared with the use of

EMLA cream (lidocaine 2.5% and prilocaine 2.5%) during

venipuncture on infants. Only 20% of infants in the oral

glucose group were scored as having pain (using PIPP

[Premature Infant Pain Prof ile]), compared with more

than 40% of the infants in the EMLA group. The glucose

solution also had the advantage of taking effect almost

immediately.14 It is hypothesized that that the glucose

activates endorphins and includes a more central analgesic

effect than does the topical response.

From the available research, it also appears that both

EMLA and ELA-Max (an over-the-counter 4% lidocaine

cream) have similar eff icacy in both children and adults,

with or without occlusive dressings. EMLA must be

applied for a minimum of 60 minutes, but ELA-Max has

the advantage of being effective in 15 to 30 minutes.15217

Future trend: Increased administration of

prehospital analgesia?

Research on the topic of increased administration of

prehospital analgesia reveals that accurate pain assess-

ments can be done in the f ield but field analgesia is often

not provided, even with obvious etiologies. In cases where

analgesia was given, patients obtained signif icant pain

relief earlier (up to 2 hours earlier), and no serious

adverse effects were evident.18220 For example, one EMS

system allows paramedics to administer up to 0.1 mg/kg

morphine sulfate (except for standard contraindications,

such as a closed head injury) in addition to the tradi-

tional nonpharmacologic measures (ie, ice, elevation,

and immobilization).

Conclusion

Pain relief is a patient’s right. With current knowledge and

tricks of the trade, ED nurses can help ensure the best relief

possible is available for their patients.21

472 J

REFERENCES

1. Pasero C. Pain in the emergency department. Withholding painmedication is not justif ied. Am J Nurs 2003;103:73-4.

2. Thomas SH, William S, Cheema F, Reisner A, Aman S,Goldstein JN, et al. Effects of morphine analgesia on diagnosticaccuracy in emergency department patients with abdominalpain: a prospective, randomized trial. J Am Coll Surg 2003;196:18-31.

3. Vermeulen B, Morabia A, Unger PF, Goehring C, Grangier C,Skljarov I, et al. Acute appendicitis: inf luence of early pain reliefon the accuracy of clinical and US findings in the decision tooperate—a randomized trial. Radiology 1999;210:639-43.

4. American Pain Society. Principles of analgesic use in thetreatment of acute pain and cancer pain. 5th ed. Glenview (IL):American Pain Society; 2004.

5. American College of Emergency Physicians. Clinical policy forthe initial approach to patients presenting with a chief complaintof nontraumatic acute abdominal pain. Ann Emerg Med 1999;23:906-22.

6. Ducharme J. Emergency pain management: a Canadian Associ-ation of Emergency Physicians (CAEP) consensus document.J Emerg Med 1994;12:855-66.

7. McCaffery M, Robinson E. Your patient is in pain. Here’s howyou respond. Nursing 2002;32(10):36-47.

8. McCaffery M, Pasero C. Pain: clinical manual. 2nd ed. St. Louis:Mosby; 1999.

9. McDermot PA. Recognizing normeperidine toxicity. Nursing2003;33(3):24.

10. Tamayo-Saver JH, Hinze SW, Cydulka RK, Baker DW. Racialand ethnic disparities in emergency department analgesicprescription. Am J Public Health 2003;93:2067-73.

11. Wong DL, Hockenberry-Eaton M, Wilson D, Winkelstein ML,Ahmann E, Divito-Thomas PA. Whaley and Wong’s nursingcare of infants and children. 6th ed. St. Louis: Mosby; 1999.p. 1153.

12. McCaffery M. Using the 0-to-10 Pain Rating Scale. Am J Nurs2001;101:81-2.

13. Chung JWY, Ng WMY, Wong TKS. An experimental study onthe use of manual pressure to reduce pain in intramuscularinjections. J Clin Nurs 2002;4:457-61.

14. Gradin M, Eriksson M, Holmquist G, Holstein ASA, Schollin J.Pain reduction at venipuncture in newborns: oral glucosecompared with local anesthetic cream. Pediatrics 2002;110:1053-7.

15. Wong D. Topical local anesthetics. Am J Nurs 2003;103:42-5.16. Kleiber C, Sorenson M, Whiteside K, Gronstal BA, Tannous R.

Topical anesthetics for intravenous insertion in children: arandomized equivalency study. Pediatrics 2002;110:758-61.

17. Eichenf ield LF, Funk A, Fallow S, Lander F, Cunningham BB.A clinical study to evaluate the eff icacy of ELA-Max (4%liposomal lidocaine) as compared with eutectic mixture of localanesthetics cream for pain reduction of venipuncture in children.Pediatrics 2002;109:1093-9.

18. McEachin CC, McDermott JT, Swor R. Few emergency medicalservices patients with lower-extremity fractures receive prehospi-tal analgesia. Prehosp Emerg Care 2002;6:404-10.

19. DeVeelis P, Thomas SH, Wedel SK, Stein JP, Vinci RJ.Prehospital fentanyl analgesia in air-transported pediatric traumapatients. Pediatr Emerg Care 1998;14:321-3.

20. Chambers JA, Guly HR. Prehospital intravenous nalbuphineadministered by paramedics. Resuscitation 1994;24:153-8.

21. Zimmermann PG. Pain assessment and management. InZimmermann PG, Herr RD. Nursing triage secrets. St. Louis:Mosby (in press).

OURNAL OF EMERGENCY NURSING 30:5 October 2004