#23 Acute Pain Management

From post-operative to acute illness, managing pain in the hospital is both an art and a science. As the lead advanced practitioner on an Acute Pain Team, Jason Low, RN, NP discusses important clinical concepts such as the multi modal approach, acute on chronic pain, as well as some cultural considerations when discussing pain management with our patients.

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Acute Pain Service

A multidisciplinary team comprised of nurses, pharmacists, anesthetists, and surgeons. A recent addition to healthcare systems.

Per Jason, the majority of patients seen by his acute pains service are post-operative, although they are consulted for medical patients as well.

Multimodal Pain Management

Using medications from different drug classes to produce a synergistic in combination. The aim of this approach is to reduce the amount of narcotics needed for effective pain relief.

Examples of medications used in the multimodal approach: Acetaminophen, NSAIDS, Gabapentin, Lidocaine patches, SSRIs, and regional anesthetics (i.e. nerve blocks and epidurals).

Long acting opioids

Methadone is an opioid agonist. It produces less euphoria, but does maintain some analgesic properties. Methadone requires close monitoring and dosing can be tricky.

Buprenorphine is a partial opioid agonist, which only partially stimulates the opioid receptors when it binds to it. This provides a mild analgesic effect with little euphoria or respiratory depression.

https://www.youtube.com/watch?v=kA4y2iyV6lI

Acute on Chronic Pain

Patients who take opioids at home who are then experiencing acute pain in the hospital present a unique challenge: How can we adequately manage their pain while preventing respiratory depression?

Jason explained that there is a “golden window” of opioid dosing that is high enough to produce adequate analgesia while a low enough to avoid respiratory depression. Patients who have a high tolerance to opioids have a very small or even no window of safe analgesia. It is not uncommon to see these patients either sleeping or awake and yelling in pain. In this situation, it is important to prioritize safety and communicate with the provider.

The Physiology and Maintenance of Respiration: A Narrative Review

Tips for communicating with patients who are hesitant about taking pain medication

  1. Explain the risks of being in severe pain
    • You will not be as mobile and will not be able to fully participate with physical therapy
    • You will have a higher risk of developing a blood clot
    • You will breathe more deeply and decrease your risk of pneumonia
  2. “No pain no gain” does not translate well for acute pain situations. In fact, not taking analgesics could increase your length of hospital stay
  3. Understand that there may be cultural differences between you and your patients. For example, Jason told the story of his mom refusing pain medication because she thought she was absolving past “sins”.