Physicians, nurses must re-educate themselves about pain management

Patients in real pain are undermedicated and suffer needlessly

Diane Krasner’s deep interest in chronic wound pain was not spurred by intellectual curiosity or even by working as a nurse with patients who suffered chronic wound pain. It began when she experienced the pain herself and realized that many patients suffered pain needlessly because they thought it was unavoidable, while others appealed for pain relief but were ignored by a medical establishment mired in the Draconian "no pain, no gain" mentality.

After undergoing surgery several years ago, Krasner developed a serious surgical wound infection that required debridement several times. Each time, says Krasner, the pain was excruciating. In the midst of one of the debridement procedures, Krasner, in tears, piped up about the pain.

"You’re hurting me!" she told the doctor. She says he looked at her with a surprised expression, as if to say, "Oh, there’s a patient attached to this wound."

"You’ve been doing this to patients for 10 years," the doctor commented. "You’re right," Krasner said, "and I won’t do it anymore." With that, her wound care career started unexpectedly on a new track.

Soon thereafter, Krasner chose to focus on venous ulcer pain as the subject of her doctoral dissertation. She received her PhD and now is a postdoctoral fellow at the Johns Hopkins University School of Nursing in Baltimore. She also holds RN, CETN, and CWS credentials.

Who says venous ulcers aren’t painful?

Krasner searched the medical literature but found little information about wound pain. In the work she did find, she noticed a common underlying assumption throughout: Venous ulcers are not painful, but arterial ulcers are. This fallacy was even suggested as a distinguishing characteristic when trying to make a diagnosis. Other authors suggested that pain was an unavoidable consequence of chronic wounds.

If professionals believed this, it would follow that patients might hold the same beliefs, Krasner thought. Therefore, patients wouldn’t request pain medications even when they were greatly needed because patients believed pain was an unavoidable consequence of chronic wounds, and clinicians would not regularly assess for pain. The results are the same in both scenarios: Patients in real pain are undermedicated, and they suffer needlessly.

The apparent assumption that pressure ulcers aren’t painful because the nerve endings are gone is only partially true; there are still plenty of live sensory receptors around the wound edges and in underlying tissue. Krasner laments that even though the most current research clearly shows that pain and chronic wounds are usually partners, many clinicians still harbor misconceptions about wound pain and pain management.

Krasner noted that interest in and awareness of chronic wound pain seemed to increase in the late 1980s, primarily in the United Kingdom. Researchers there began to look at the effects of pain on quality of life. Krasner began seeing work challenging the notion that venous ulcers aren’t painful. Some research showed that 35% to 75% of venous ulcer patients had pain, and that for some patients, pain was the worst symptom. In another study, 59% of patients reported having wound pain of some type, while only 2% were given analgesics for the pain. "This was a real important message that we weren’t attending to this problem," Krasner says.

State of pain management is hurting

The overall state of pain management is bad, according to Margo McCaffery, RN, MS, a Los Angeles-based nursing consultant. Throughout the American medical establishment, pain is under-recognized and undertreated, she says. "Many people don’t consider that a patient’s pain is real. Patients give up and figure they just have to endure it," says McCaffery, who is author and editor of a clinical manual on pain management due out in December.1

What’s frustrating to enlightened wound care professionals is that pain caused by chronic wounds can be reduced with medication. However, there remains a barrier — the persistent myth that patients receiving opioids are liable to become addicted to the painkillers. This is a baseless fear, and there is no evidence that proper prescription of opioids will lead to addiction, says McCaffery. She adds that fewer than 1% of patients receiving opioids become addicted.

Low-level, ongoing wound pain may respond well to anti-inflammatory medications, but as the pain increases, opioids are often indicated. However, physicians are often afraid to prescribe them. Even patients whose pain is well-managed by OTC anti-inflammatories, such as ibuprofen or naproxen sodium, may need stronger medications in preparation for dressing changes and debridement, which often cause acute short-lived pain. Yet McCaffery can’t understand why many physicians won’t consider narcotic painkillers even for these discrete events.

"More people than before realize the problem of wound pain and treatment, but there’s still an incredible phobia around the management of pain," says Frank D. Ferris, MD, a palliative care physician at the Temmy Latner Centre for Palliative Care at Mount Sinai Hospital in Toronto. "Many people perceive barriers, not the least of which is that they think if you start opioids that the patient will get addicted. That really is a myth. There’s no data to support the contention. In fact it’s quite contrary. If you use opioids in a situation where you understand the pathology, the patient will do well and get off the opioids and there will be no problem."

Ferris notes that in some circumstances, unrelieved pain can actually create further physical damage and perpetuate the problem. The goal of pain management should be to treat and minimize pain early in treatment, he emphasizes.

Lia van Rijswijk, RN, ET, a nurse consultant in Newtown, PA, also underscores the point that wounds can cause severe pain, and that less-than-adequate pain control is common in patients with chronic wounds. She adds that many patients, particularly older or immobile people, cannot communicate their level of pain, so nurses must be vigilant for signs of pain, such as grimaces or moans when a patient is turned or during dressing changes. "The patient may not move in bed because that motion may cause pain, and that immobility can cause even more pressure sores," says van Rijswijk.

Van Rijswijk explains that all skin trauma and breakdown causes nociceptive pain (pain stimulated by injury). In a chapter to be published in McCaffery’s book, she writes, "Even when the dermis and its sensory receptors are absent, as may be the case in full-thickness wounds (such as deep pressure ulcers and third-degree burns), the wound edges as well as the underlying tissues will contain sensory receptors. Also, sensations such as pressure (e.g., from sitting or wound packing materials) and movement (e.g., wound manipulation) will be perceived by the proprioceptive receptors in the underlying fascia, muscles, tendons and ligaments."1 She adds that peripheral nerves will regenerate in healing wounds. The immature nerve tissues produced during this process are hypersensitive to wound care procedures and topical agents.

It is also the nurse’s responsibility to inform physicians when patients are in pain, McCaffery adds. "Nurses need to know that their job is to let the physician know when the patient needs pain medication," she says. Clinicians also should make regular use of pain assessment tools, such as the pain analog scale or the Wong Baker FACES pain rating scale, says Ferris.

Despite assertions to the contrary, wound pain is real and it often goes undertreated. However, it can easily be controlled if only clinicians would replace their misconceptions about pain control with facts.

Reference

1. McCaffery M, Pasero C. Pain: Clinical Manual. 2nd ed. St. Louis: Mosby; in press.