NUR3500 Chap.8 Total Pain and Opioid Management
Total Pain and Opioid Management
What pain is, and what control aims at
Pain is an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage. It is always subjective and its meaning is learned through a lifetime of experience, so two people with identical imaging can report entirely different pain.
The goal of management is not a score of zero; it is relief and control at the lowest effective dose, with reversible contributors treated and function and quality of life improved.
Saying that honestly is itself therapeutic, because promising no pain at all sets up a failure that will be read as the drug not working.
A structured history, then three further questions
The history covers site, onset, character, radiation, associated symptoms, time course, exacerbating and relieving factors, and severity, and most patients in advanced illness have more than one pain, so each is mapped separately.
To that are added sleep and function, mood, and meaning. The last question, what the person thinks is causing the pain, matters most, because someone who believes the pain means the disease is spreading experiences it as worse.
Scales follow the patient: a numeric rating where they can self report, and an observational tool matched to the population where they cannot.
Mechanism decides the drug
Nociceptive pain arises from tissue injury and is somatic, described as aching, sharp and well localised, or visceral, described as cramping, dull and poorly localised.
Neuropathic pain arises from nerve injury and is described as burning, shooting, tingling or painful to light touch. Identifying the mechanism is the step that decides whether an opioid alone can work, and failure to do it is the most common reason a dose increase fails.
Total pain
Suffering in advanced illness is never confined to the body.
The psychological dimension carries anxiety, fear of worsening pain and the equation of pain with dying. The social dimension carries lost role, restricted activity and family strain. The spiritual dimension carries lost purpose and a life narrative changed without consent.
The prediction is specific: when a physical pain does not respond to rational escalation, look for an unaddressed dimension before assuming tolerance.
The ladder, the principles and the arithmetic
The analgesic ladder selects a class by severity: a non-opioid for mild pain, a weak opioid for moderate pain, a strong opioid for severe pain, and a fourth interventional step for refractory pain, with adjuvants at every step and movement in both directions.
Prescribing follows five principles: by the mouth, by the clock, by the ladder, individualised, and with attention to detail. The examinable arithmetic is short. The oral breakthrough dose is one sixth of the total daily regular dose.
Where pain is uncontrolled and breakthrough doses are being used repeatedly, the regular dose is increased by between a quarter and a half of the current daily total, and there is no ceiling dose for a strong opioid in palliative care.
Consequences, fears and what you do without drugs
Side effects are predictable and therefore preventable: constipation is effectively universal and always needs a laxative, nausea usually settles within a week or two, deepening sedation is the warning that comes before respiratory depression, which is uncommon at properly titrated doses, and a dry mouth needs mouth care.
Addiction does not develop when opioids are used for pain or breathlessness in serious illness with the dose titrated to response, and carefully titrated opioids do not shorten life. Adjuvants are co-first-line for neuropathic pain, and nursing interventions from positioning to therapeutic presence are part of treatment rather than optional extras.
What this chapter covers
- 01
Definition and the goal of pain control
- 02
Structured history plus sleep, mood and meaning
- 03
Nociceptive and neuropathic mechanisms
- 04
The four dimensions of total pain
- 05
The ladder, prescribing principles and titration
Titrating and calculating the breakthrough dose
- 3Calculate the total daily dose and the current breakthrough dose.
- 2Justify increasing the regular dose rather than continuing to top up.
- 3Calculate the new regular and breakthrough doses and state the review interval.
Key terms
- Total pain
- Suffering understood as physical, psychological, social and spiritual at once, converging on the single experience the patient reports.
- Nociceptive pain
- Pain arising from tissue injury, somatic when well localised and aching, visceral when cramping and poorly localised.
- Neuropathic pain
- Pain arising from nerve injury or dysfunction, described as burning, shooting or tingling, and often painful to light touch.
- Analgesic ladder
- A stepwise framework selecting analgesia by severity, with adjuvants at every step and movement in both directions.
- Breakthrough dose
- A rescue dose for pain occurring between regular doses, calculated orally as one sixth of the total daily regular dose.
- Adjuvant analgesic
- A drug whose primary purpose is not analgesia but which relieves particular pain types, especially neuropathic pain.
- Opioid titration
- Adjusting the regular dose against the response, with no ceiling for strong opioids in palliative care.
Total Pain and Opioid Management FAQ
How is a breakthrough dose calculated?
Orally it is one sixth of the total daily regular dose, given no more often than the prescription allows. A patient should never be without one, and frequent use is the signal to review the regular dose rather than to keep giving rescue doses.
Will strong opioids shorten my patient's life or cause addiction?
Neither, when they are titrated against response for pain or breathlessness in serious life limiting illness. A need for more is almost always progressive disease or a new pain rather than craving, and relieving severe symptoms can improve quality of life rather than hasten death.
Why did increasing the opioid not help this pain?
Most often because the mechanism is neuropathic, where opioids have limited effect and an adjuvant is co-first-line. The other common reason is an unaddressed psychological, social or spiritual dimension amplifying the physical sensation.
Exam move
Rehearse the arithmetic until it is automatic: daily total, divide by six, increase by a quarter to a half, recalculate. Then write the five prescribing principles with what each forbids, and list the side effects with the action that prevents rather than treats each.
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