By Sherree Geyer

Managing patients’ pain isn’t just for doctors; it takes a whole care team. However, much of the current literature isn’t from a nurse’s perspective.

To fill this void, the Association of Critical Care Nurses released a symposium of articles in its journal Advanced Critical Care, addressing the challenges and knowledge gaps in pain treatment in acute and critically ill patients.

“Pain management remains a daily challenge to care teams because high levels of pain are often reported by patients, and a significant proportion of acute and critically ill patients cannot communicate,” wrote the journal’s editor Céline Gélinas, PhD, RN, an associate professor in the Ingram School of Nursing at McGill University, in Montreal, in her introduction. “Adequate treatment of acute pain, based on a multimodal analgesic approach, is essential to provide appropriate pain relief to patients, optimize recovery and prevent chronic pain development.”

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Providers need to zero in on pain from the start of whatever critical treatment a patient receives, according to the research presented in the symposium’s first article (AACN Adv Crit Care 2019;30[4]:335-342), especially in patients suffering from chronic pain. Those patients may have hypersensitive neurons, study author Barbara St. Marie, PhD, AGPCNP, an assistant professor at the University of Iowa’s College of Nursing, in Iowa City.

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“They may be hypersensitive to pain,” Dr. St. Marie said. “When patients don’t have their acute pain well managed, there may be a persistence [in pain] that lasts longer and requires more opioids.”

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Nonverbal Assessment of Pain

As many providers know, it can be difficult to assess patients’ pain overall, but especially so with those who have trouble communicating or are not able to communicate their pain verbally. “Many ICU patients may not be able to self-report due to their critical care condition and related treatments, which may alter their consciousness and ability to interact,” Dr. Gélinas said.

Behavioral scales and observational techniques can fill the gap, according to the authors of another article in the symposium (AACN Adv Crit Care 2019;30[4]:365-387). The researchers reviewed a total of 106 articles, analyzing 13 behavioral pain assessment tools for various noncommunicative populations. After investigating the tools’ characteristics, such as reliability and feasibility, the researchers endorsed the Behavioral Pain Scale, the Behavioral Pain Scale Nonintubated and the Critical-Care Pain Observation Tool. “They have shown robust psychometric properties in discriminating between painful and nonpainful procedures and correctly classify patients,” Dr. Gélinas said. “They can guide appropriate decisions for pain treatment and evaluation of analgesia effectiveness.”

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Withdrawal and Opioid Use Disorder

The power of observation can also aid in avoiding iatrogenic withdrawal syndrome resulting from discontinuing opioids and/or benzodiazepines after prolonged patient use, according to another study in the symposium (AACN Adv Crit Care 2019;30[4]:353-364). The investigators note that “research to date is scant” on the subject, but providers must recognize the warning signs.

“[Iatrogenic withdrawal syndrome] is preventable with appropriate monitoring. Nurses must be aware of the signs and symptoms of withdrawal, which may affect the central nervous, gastrointestinal and sympathetic nervous systems,” Dr. Gélinas said.

Some patients at risk include those with opioid use disorder (OUD). These patients can be especially challenging in a critical care setting, but managing symptoms well, sometimes with medication-assisted treatments such as buprenorphine, can be achieved (AACN Adv Crit Care 2019;30[4]:335-342).

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“To provide the best care, nurses must recognize withdrawal and craving and discuss concerns of these symptoms with the multidisciplinary team, including those in addiction medicine,” Dr. St. Marie said. “Nurses play a vital role in assessments, especially identifying those at risk for psychological health care needs.”

However, there is a lack of guidelines on treating OUD patients in critical care, Dr. St. Marie explained. “Many of the gaps in clinical practice guidelines cover managing patients with an active disease of addiction with acute or chronic pain, or helping patients protect the work they’ve done in recovery,” she said.

“Another gap is helping those in recovery with medications for OUD when they have acute or chronic pain. Establishing expert panels to search literature for evidence and write guidelines is going to be important to our patients,” Dr. St. Marie added.

Nonpharmacologic Treatments

As the opioid crisis has forced more judicious uses of various pain medicines, more research is supporting nonpharmacologic methods for pain relief (AACN Adv Crit Care 2019;30[4]:388-397). Analyzing the current literature, the researchers found music and massage therapies are being used most often in critical care settings, as well as an increase in combining several therapies at the same time. Bundled interventions—such as massage, music, relaxation and cold therapy—have been proven to reduce pain in some patients, Dr. Gélinas said.

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“Some nonpharmacologic interventions reduce pain by 1 or 2 points on a 0-10 numeric rating scale in ICU patients,” she explained. “They can be administered by nurses following appropriate training. The selection of interventions should take into account the patient’s preferences and clinical condition.”

One source of nonpharmacologic support for patients can be including family members in the treatment process (AACN Adv Crit Care 2019;30[4]: 398-410). Although again, the literature was lacking, an assessment of 11 articles found that family members can be beneficial in helping to express a patient’s pain experience and choosing nondrug interventions—if they feel comfortable doing so.

“An important gap that deserves attention is the role of family members in assessing and managing pain. Family members should be encouraged to participate in the delivery of nonpharmacologic interventions if they feel comfortable,” Dr. Gélinas said. “It is suggested that family members get involved in the identification of pain behaviors in loved ones, [especially those] unable to self-report.”