11.2 Comfort Basic Concepts

Definitions of Pain

Pain has historically been defined as, “Whatever the patient says it is, experienced whenever they say they are experiencing it.”^[1] In 2020 the International Association for the Study of Pain (IASP) released a revised definition of pain as, “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage,” along with these additional notes:

• Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
• Individuals learn the concept of pain throughout all stages of their life.
• A person’s report of an experience as pain should be respected.
• Although pain usually serves an adaptive role, it can have adverse effects on function, socialization, and psychological well-being.
• Verbal description is only one of several behaviors that express pain. The inability to communicate does not negate the possibility that a person is experiencing pain.^[2]

Pain motivates the individual to withdraw from dangerous stimuli, to protect a damaged body part while it heals, and to avoid similar experiences in the future. Most pain resolves after the painful stimulus is removed and the body has healed, but sometimes pain persists despite removal of the stimulus and apparent healing of the body. Additionally, pain can occur in the absence of any detectable stimulus, damage, or disease.^[3]

Physiology of Pain

Let’s begin by reviewing the physiological processes of pain. A nociceptor is a type of sensory receptor that responds to potentially damaging stimuli by sending nerve signals to the spinal cord and brain in a process called nociception. There are several types and functions of nociceptors:

• Thermal nociceptors are activated by noxious heat or cold, such as a hot pan.
• Mechanical nociceptors are activated by excess pressure or mechanical deformation, such as a finger getting caught in a car door. They also respond to incisions that break the skin surface.
• Chemical nociceptors are activated by a wide variety of spices commonly used in cooking. For example, capsaicin is a compound in chili peppers that causes a burning sensation of the mucus membranes. It is also used in common over-the-counter creams for pain relief because when it is applied to the skin, it blocks the transmission of pain impulses.^[4]

Noxious stimuli are detected by nociceptors and transduced into electrical energy. An action potential is created and transmitted along nociceptor fibers. There are two types of nociceptor fibers, A-Delta and C. A-Delta fibers are fast-conducting fibers and associated with the initial sharp, stinging, or pricking pain sensation. C fibers are slower-conducting fibers and are associated with the secondary sensation of diffuse, dull, burning, and aching pain. The pain impulse is transmitted along these nociceptor fibers to the dorsal horn in the spinal cord and then from the spinal cord to the thalamus, where pain messages are relayed to the cerebral cortex. In the cerebral cortex, pain impulses are perceived, and the conscious awareness of pain occurs.^[5],[6] See Figure 11.1^[7] for an illustration of how the pain signal is transmitted from the nociceptors to the spinal cord and then to the brain.

Types of Pain

Pain can be divided into visceral, deep somatic, superficial, and neuropathic pain.

• Visceral structures are highly sensitive to stretch, ischemia, and inflammation. Visceral pain is diffuse, difficult to locate, and often referred to a distant, usually superficial, structure. It may be accompanied by nausea and vomiting and may be described as sickening, deep, squeezing, and dull.^[8]
• Deep somatic pain is initiated by stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fascia, and muscles and is a dull, aching, poorly localized pain. Examples include sprains and broken bones.^[9]
• Superficial pain is initiated by the activation of nociceptors in the skin or other superficial tissue and is sharp, well-defined, and clearly located. Examples of injuries that produce superficial somatic pain include minor wounds and minor (first-degree) burns.^[10]
• Neuropathic pain is defined by the International Association for the Study of Pain (IASP) as pain caused by a lesion or disease of the somatosensory nervous system. It is typically described by patients as “burning” or “like pins and needles.” Neuropathic pain can be caused by several disease processes, such as diabetes mellitus, strokes, and HIV, and is generally undertreated because it typically does not respond to analgesics. Medications such as tricyclic antidepressants and gabapentin are typically used to manage this type of pain.^[11]

Pain can radiate from one area to another. For example, back pain caused by a herniated disk can cause pain to radiate down an individual’s leg. Referred pain is different from radiating pain because it is perceived at a location other than the site of the painful stimulus. For example, pain from retained gas in the colon can cause pain to be perceived in the shoulder. See Figure 11.2^[12] for an illustration of common sites of referred pain.

Factors Affecting the Pain Experience

There are many biological, psychological, and social factors that affect the perception of pain, making it a unique, individual experience. See Table 11.2a for a list of these factors.^[13] Nurses must consider these factors while assessing and providing holistic nursing care for patients experiencing pain.

Table 11.2a Biological, Psychological, and Social Factors Affecting Pain

Acute vs. Chronic Pain

Pain is differentiated between acute pain and chronic pain. Acute pain has limited duration and is associated with a specific cause. It usually causes a physiological response resulting in increased pulse, respirations, and blood pressure. Diaphoresis (sweating, especially to an unusual degree) may also occur. Examples of acute pain include postoperative pain; burns; acute musculoskeletal conditions like strains, sprains, and fractures; labor and delivery; and traumatic injury.

Chronic pain is ongoing and persistent for longer than six months. It typically does not cause a change in vital signs or diaphoresis. It may be diffuse and not confined to a specific area of the body. Chronic pain often affects an individual’s psychological, social, and behavioral responses that can influence daily functioning. Chronic medical problems, such as osteoarthritis, spinal conditions, fibromyalgia, and peripheral neuropathy, are common causes of chronic pain. Chronic pain can continue even after the original injury or illness that caused it has healed or resolved. Some people suffer chronic pain even when there is no past injury or apparent body damage.

People who have chronic pain often have physical effects that are stressful on the body. These effects include tense muscles, limited ability to move around, lack of energy, and appetite changes. Emotional effects of chronic pain include depression, anger, anxiety, and fear of reinjury. These effects can limit a person’s ability to return to their regular work or leisure activities.^[14] It is estimated that chronic pain affects 50 million U.S. adults, and 19.6 million of those adults experience high-impact chronic pain that interferes with daily life or work activities.^[15] See Figure 11.3^[16] for an illustration of low back pain, an example of both acute and chronic pain that often affects daily functioning.

Life Span and Cultural Considerations

The pain experience varies across the life span. Newborns and infants can feel pain but are unable to verbalize it. Repetitive and prolonged pain may be associated with altered pain sensitivity and pain processing later in life. Toddlers and preschoolers often have difficulty describing, identifying, and locating pain. Instead, pain may be demonstrated behaviorally with crying, anger, physical resistance, or withdrawal. School-age children and adolescents may try to be “brave” and rationalize the pain; they are more responsive to explanations about pain.

Older adults are at increased risk for undertreatment of pain. It is estimated that up to 70% of older adults in the community and up to 85% living in long-term care centers have significant pain due to chronic conditions such as osteoarthritis and peripheral neuropathy. Pain is often underassessed in older adults because they are less likely to report it and also because it can present atypically with confusion and agitation.^[17]

Other special populations who are at increased risk for the undertreatment of pain include the following:

• Patients with a history of addictive disease
• Nonverbal, cognitively impaired, or unconscious patients
• Patients who endure pain without complaining due to cultural or religious beliefs
• Non-English-speaking patients where communicating is a barrier
• Uninsured or underinsured patients where cost of medications is a barrier^[18]

Nurses must be especially vigilant of nonverbal signs of pain in these at-risk groups and implement appropriate assessment tools and interventions. Read an example of a patient with untreated pain in the following box.

Standards of Care

Pain assessment and management standards were published in 2018 by The Joint Commission. The revised standards require hospitals to identify pain assessment and pain management, including safe opioid prescribing, as an organizational priority. Nurses are expected to implement these best practices. See Table 11.2b for a summary of associated requirements that must be incorporated into nursing care.^[19] If these components are not included when providing nursing care, the hospital may be cited by The Joint Commission and potentially lose Medicare funding.

Table 11.2b The Joint Commission’s Pain Assessment and Management Requirements^[20]

Pain Management and the Opioid Crisis

The American Nurses Association published a position statement in 2018 on the ethical responsibility of nurses to properly manage pain.^[21] In 2019 the U.S. Department of Health and Human Services published Pain Management Best Practices.^[22] Why is there continued emphasis on optimal pain management? Let’s review some trends related to pain management over the past few decades.

Trends Related to Pain Management

Pain assessment and pain management began to undergo significant changes in the 1990s when pain experts recognized that inadequate assessment and treatment of pain had become a public health issue. Recommendations for improving the quality of pain care were followed by initiatives that recognized patients’ reported pain as “the 5th vital sign.” Hospital administrators and regulators began to focus on pain scores, encouraging and incentivizing providers to aggressively treat pain to lower pain scores. These trends led to liberal prescribing of opioid pain medications for both acute and chronic pain.

Unfortunately, this increase in prescription of opioid pain medication led to a rise in misuse and overdose deaths related to opioid pain medications. Organizations began to urge caution about the use of opioids for pain, including guidelines published in 2016 by the Centers for Disease Control (CDC) on prescribing opioids for pain.^[23] The 2016 CDC guideline led to limited prescriptions of opioids and unintended consequences, such as forced tapering of medications for established patients requiring chronic pain control and the transition of some patients desperate for pain control to using illicit drugs, such as heroin.

In 2022 the CDC released new guidelines for the prescribing opioids for pain. The CDC recommends that people experiencing pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient’s circumstances. The guidelines are intended to improve communication with patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.^[24]

In this manner, pain management and the opioid crisis have influenced each another and continue to evolve. It is imperative for nurses to ensure that patients with painful conditions can work with their health care providers to develop pain treatment plans that balance pain control, optimize function, and enhance quality of life while also minimizing risks for opioid misuse and harm.^[25]

Associated Definitions

When discussing pain management and the opioid crisis in the United States, it is important to understand the following terms:

• Opioid intoxication refers to significant behavioral or psychological changes (e.g., apathy, dysphoria, psychomotor agitation or retardation, or impaired judgment) that occur during or shortly after opioid use. Symptoms of opioid intoxication include drowsiness or coma, slurred speech, or impairment in attention or memory.^[26]
• Overdose is the biological response of the human body when too much of a substance is ingested.
• Tolerance refers to a diminished effect with continued use of the same amount of an opioid, or a need for increased amounts of opioids to achieve the desired effect or intoxication.^[27]
• Misuse refers to taking prescription pain medications in a manner or dose other than prescribed; taking someone else’s prescription, even if for a medical complaint such as pain; or taking a medication to feel euphoria (i.e., to get high).^[28]
• Substance use disorder is an neurobiological illness caused by repeated misuse of substances (including opioids, which is specifically referred to as opioid use disorder). When taken in excess, these substances have a common effect of directly activating the brain reward system and producing such an intense activation of the reward system that normal life activities may be neglected. A person diagnosed with opioid use disorder has at least two of the symptoms listed below in a given year^[29]:
  • Opioids are taken in larger amounts or over a longer period of time than intended.
  • There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
  • A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
  • The person experiences craving, a strong desire or urge to use opioids.
  • Recurrent opioid use results in the person’s failure to fulfill major role obligations at work, school, or home.
  • Opioid use continues despite the person having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
  • Important social, occupational, or recreational activities are given up or reduced because of opioid use.
  • Opioids are recurrently used in situations in which it is physically hazardous.
  • Opioids are continued to be used despite the person having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
  • The person experiences symptoms of tolerance to opioids.
  • The person experiences withdrawal symptoms causing significant distress after stopping or reducing opioid use, with symptoms such as dysphoric mood, nausea, vomiting, muscle aches, rhinorrhea or lacrimation, pupillary dilation, piloerection, sweating, diarrhea, yawning, fever, or insomnia.
• Physical dependence refers to withdrawal symptoms that occur when an opioid is suddenly reduced or stopped because of physiological adaptations that occurwith chronic exposure to the medication.^[30] For example, if a patient who receives hydromorphone daily suddenly has their prescription stopped, they will likely experience symptoms of withdrawal, such as sweating, goose bumps, vomiting, anxiety, insomnia, and muscle pain.
• Addiction is a term used in many countries to describe severe problems related to compulsive and habitual use of substances. However, it is no longer a diagnosis by the American Psychiatric Association because of its potentially negative connotation.^[31]

Recognizing and Treating Opioid Overdose

Five basic steps are recommended for nurses, first responders, health professionals, and other bystanders to rapidly recognize and treat opioid overdose to prevent death.^[32]

1. Recognize Signs of Opioid Overdose:
   • Signs of opioid overdose include unconsciousness or the inability to awaken; pinpoint pupils; slow, shallow breathing; breathing difficulty manifested by choking sounds or a gurgling/snoring noise from a person who cannot be awakened; fingernails or lips turning blue or purple; or respiratory arrest
   • If an opioid overdose is suspected, try to stimulate the person by calling their name or vigorously grinding one’s knuckles into their sternum.
2. Obtain Emergency Assistance: If the person does not respond, call 911 or obtain emergency assistance.
3. Provide Rescue Breathing, Chest Compressions, and Oxygen As Needed:
   • Provide rescue breathing if the person is not breathing on their own. A barrier device is recommended to reduce the risk of disease transmission. Rescue breathing for adults involves the following steps:
     • Be sure the person’s airway is clear.
     • Place one hand on the person’s chin, tilt the head back, and pinch the nose closed.
     • Place your mouth over the person’s mouth to make a seal and give two slow breaths.
     • Watch for the person’s chest (but not the stomach) to rise.
     • Follow up with one breath every five seconds.
   • If the individual becomes pulseless, provide cardiopulmonary resuscitation (CPR).
   • Administer oxygen as needed.
4. Administer the First Dose of Naloxone:
   • Naloxone should be administered to anyone suspected of an opioid overdose.
   • Research has shown that women, older adults, and those without obvious signs of opioid use disorder are undertreated with naloxone and, as a result, have a higher death rate. Therefore, naloxone should be considered for women and the elderly who are found unresponsive.
   • Naloxone can be used in life-threatening opioid overdose circumstances in pregnant women.
   • Naloxone can be given intranasally, intramuscularly, subcutaneously, or intravenously. The nasal spray is a prefilled device that requires no assembly and delivers a single dose into one nostril. An auto-injector is injected into the outer thigh to deliver naloxone intramuscularly or subcutaneously.
   • All naloxone products are effective in reversing opioid overdose, including fentanyl-involved opioid overdoses, although overdoses involving potent or large quantities of opioids may require additional doses of naloxone.
   • Withdrawal triggered by naloxone can feel unpleasant; some people may awaken confused, agitated, or aggressive. Provide safety, reassurance, and explain what is happening.
5. Administer a Second Dose of Naloxone If the Person Does Not Respond:
   • If the person overdosing does not respond within 2 to 3 minutes after administering a dose of naloxone, administer a second dose of naloxone.
   • People who have taken long-acting or potent opioids (like fentanyl) may require additional intravenous bolus doses or an infusion of naloxone.
   • The duration of effect of naloxone depends on dose, route of administration, and overdose symptoms. It is shorter than the effects of some opioids, so a second dose may be required.
6. Monitor the Person’s Response:
   • Most people respond to naloxone by returning to spontaneous breathing within two to three minutes. Continue resuscitation while waiting for the naloxone to take effect.
   • The goal of naloxone therapy is to restore adequate spontaneous breathing but not necessarily achieve complete arousal.
   • The individual should be monitored for recurrence of signs and symptoms of opioid toxicity for at least four hours from the last dose of naloxone. People who have overdosed on long-acting opioids like fentanyl require prolonged monitoring.
   • Because naloxone has a relatively short duration of effect, overdose symptoms may return. Therefore, it is essential to get the person to an emergency department or other source of medical care as quickly as possible, even if the person revives after the initial dose of naloxone and seems to feel better.

Substance Use Disorder Among Nurses and Nursing Students

It is important to understand that substance use disorder is a neurobiological illness that can happen to anyone, including nurses and nursing students. The American Nursing Association released the following statements in 2016^[33]:

• Health care facilities should provide education to nurses and other employees regarding alcohol and other drug use and establish policies, procedures, and practices to promote safe, supportive, drug-free workplaces.
• Health care facilities and schools of nursing should adopt alternative-to-discipline approaches to treating nurses and nursing students with substance use disorders, with stated goals of retention, rehabilitation, and reentry into safe, professional practice.
• Nurses and nursing students should be aware of the risks associated with substance use, impaired practice, and drug diversion and have the responsibility and means to report suspected or actual concerns.