Porth's Essentials of Pathophysiology, 4e

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Somatosensory Function, Pain, and Headache

C h a p t e r 3 5

Pain Management When prescribing pharmacologic and nonpharmacologic methods of pain management for the older population, care must be taken to consider the cause of the pain, the person’s health status, concurrent therapies, and mental status. In the older population, where the risk of adverse reaction to drugs is higher, the nonpharmacologic options are usually less costly and cause fewer side effects. Common nonpharmacologic interventions include application of cold (which suppresses the release of products from tissue damage) and heat (which pro- motes the release of endogenous endorphins). 66 The role of mental focus and anxiety is important, and relaxation techniques, massage, and biofeedback may be useful. Physical therapy and occupational therapy bring a vari- ety of modalities, including the use of braces or splints, changes in biomechanics, and exercise, all of which have been shown to promote pain relief. 65 Although efficacy is important when considering the use of pharmacologic agents for pain relief in the elderly, safety must also be considered. The elderly may have physiologic changes that affect the pharmacoki- netics of medications prescribed for pain management. These changes include decreased blood flow to organs, delayed gastric motility, reduced kidney function, and decreased albumin related to poor nutrition. 66 Also, the elderly often have coexisting health problems requir- ing medications. On average, a 70-year-old takes seven different medications. 66 The addition of analgesics to a complex medication regimen may cause drug interac- tions and complicate compliance; however, these con- siderations should not preclude the appropriate use of analgesic drugs to achieve pain relief. Non-opioids are generally the first line of therapy for mild to moder- ate pain, and acetaminophen is usually the first choice because it is relatively safe for older adults. 66 Opioids are used for more severe pain and for palliative care. As with younger persons, adjuvant analgesics are effec- tively used for treatment of pain in older adults. The use of some assessment tool to evaluate the level of pain and effectiveness of treatment is essential. Monitoring for side effects is also critical. ■■ Children experience and remember pain, and even fairly young children are able to accurately and reliably report their pain. Recognition of this has changed the clinical practice of health professionals involved in the assessment of children’s pain. Pharmacologic (including opioids) and nonpharmacologic pain management interventions have been shown to be effective in children. Nonpharmacologic techniques must be based on the developmental level of the child and should be taught to both children and parents. SUMMARY CONCEPTS

R E V I EW E X E R C I S E S 1. A 25-year-old man is admitted to the emergency department with acute abdominal pain that began in the epigastric area and has now shifted to the lower right quadrant of the abdomen. There is localized tenderness and guarding or spasm of the muscle over the area. His heart rate and blood pressure are elevated, and his skin is moist and cool from perspiring. He is given a tentative diagnosis of appendicitis and referred for surgical consultation. A. Describe the origin of the pain stimuli and the neural pathways involved in the pain that this man is experiencing. B. Explain the neural mechanisms involved in the spasm of the overlying abdominal muscles. C. What is the significance of his cool, moist skin and increased heart rate and blood pressure? currently receiving a long-acting opioid analgesic supplemented with a short-acting combination opioid and nonnarcotic medication for breakthrough pain. A. Explain the difference between the mechanisms and treatment of acute and chronic pain. B. Describe the action of opioid drugs in the treatment of pain. C. Define the term tolerance as it refers to the use of opioids for treatment of pain. 3. A 42-year-old woman presents with sudden, stabbing-type facial pain that arises near the right side of her mouth and then shoots toward the right ear, eye, and nostril. She is holding her hand to protect her face because the pain is “triggered by touch, movement, and drafts.” Her initial diagnosis is trigeminal neuralgia. A. Explain the distribution and mechanisms of the pain, particularly the triggering of the pain by stimuli applied to the skin. B. What are possible treatment methods for this woman? ■■ Pain is a common symptom in the elderly. Assessment, diagnosis, and treatment of pain in the elderly can be complicated.The elderly may be reluctant or cognitively unable to report their pain. Diagnosis and treatment can be complicated by comorbidities and age- related changes in cognitive and physiologic function. 2. A 65-year-old woman with breast cancer is receiving hospice care in her home. She is