The Future of Pain
How do clinicians mitigate the opioid crisis while still providing relief? Penn Nursing is leading the way with answers.
The patient presented a decade ago at three in the morning with a splinter in his left eye and a mild corneal abrasion. Accompanied by his sleepy teenaged son, who had been roused to drive his dad to the rural hospital ER, the man admitted he had failed to use proper eye protection while felling a tree with a chainsaw. It was a calm weeknight, and the medical staff on duty were able to treat him immediately. The physician administered topical tetracaine before expertly removing the splinter, and a resident followed up with a drop of cyclopentolate and a stern lecture on chainsaw safety.
Before the patient left, the discharge nurse gave him a full vial of Darvon (propoxyphene hydrochloride) with instructions to take no more than six 65mg capsules per day. The drug, no longer generally available under that label, is a CNS depressant, an opiate related to OxyContin, Norpramin, and Vicodin. When the patient got home he swallowed one capsule, slept soundly, and then flushed the remaining contents of the vial down the toilet.
It wasn’t that the drug was ineffective. In fact the opposite was true. He loved it so much it scared him. His family had a history of alcoholism and depression. Besides, he prided himself on being the strong, stoic type, seeing pain as a kind of useful health monitor. The abrasion quickly healed, his wife came home from a business trip and gave him a second lecture on drug disposal, and the patient bought a new pair of safety goggles.
While the incident hardly counts as a red letter day in the World Health Organization’s official Decade of Pain, the patient’s experience serves as a microcosm behind some of the problems with standard pain protocols. The team performed admirably to assess and treat the injury. Treating pain as the fifth vital sign, they administered the proper analgesics indicated for the type and severity of discomfort. Everything went perfectly… except for the prescription of Darvon. No one had asked the patient about his family’s history or whether he personally had experienced addiction or depression. Before the nurse gave him the Darvon, the physicians properly told him to take no more than six capsules a day and to avoid driving; they did not note that he didn’t have to finish the vial and they did not suggest other, non-opiate analgesics. Nor did they tell him how to dispose of the remaining capsules, a factor in the national opiate addiction and overdose crisis.
As of 2015, the most recent year that statistics were gathered, 640 morphine milligram equivalents were prescribed per capita in the United States—enough to keep every American medicated for three weeks, according to the Centers for Disease Control and Prevention.
But those gaps in treatment show hopeful signs of closing, thanks in part to work being done at the University of Pennsylvania’s School of Nursing. One of nine academic institutions designated by the National Institute of Health as a Center of Excellence in pain education, Penn Nursing is a leader in researching treatments for acute pain in ways that reduce the risk of chronic pain. Working with civilian and military organizations, the University’s Nursing faculty are developing innovative instruments of pain measurement, focusing on veterans and children. And they are coming to a new understanding of the nature of pain itself. Their findings—and their clinical implications—offer a glimpse at the future of pain, and nurses’ increasingly critical role.
To understand that future, though, we have to spend a bit of time in the past.
Pathology and Sympathy
Every nurse knows that pain is a neutral value, neither good nor bad in and of itself. We evolved pain as an autonomic defensive response, an efficient signal to avoid injury and to nurse wounds. The Stoics in ancient Greece developed an entire philosophy around pain. The avoidance of pain lies behind every human emotion, they believed. And so does emotion: The Greek word pathos forms the root of “pathology,” as well as “sympathy” and “empathy.” A true Stoic philosopher would cultivate his rational thinking by maintaining a studied indifference to pain. He was not alone; cultures throughout time have admired the ability to suffer. And yet throughout that same history, healers developed a sophisticated pharmacology of analgesics ranging from salicylic acid to cocaine to opioids. Alternatives to drugs developed in parallel throughout the millennia in various cultures, including capsaicin, massage, acupuncture, meditation, and distraction. As recently as the nineteenth century, European surgeons employed drummers during tooth extractions. The tooth would get yanked when the drumming reached a crescendo.
Until the last few decades, most analgesics were designed to treat acute pain. But as chemo, antibiotics, and other tools entered the picture, increasing numbers of patients survived once-mortal traumas and illnesses, leaving them with chronic pain. Pharmacological researchers sought analgesics that could relieve that pain without triggering addiction in susceptible patients.
Along came modern opioids, which began to see widespread use in the 1990s. Originally, they were mostly reserved for patients with chronic malignant pain— cancer—as well as acute pain. But in the early nineties, concern grew among the health and medical communities that patients were not getting sufficiently aggressive treatment for non-malignant chronic pain. “There was a real shift in the philosophy about opioids,” says Peggy Compton, PhD, RN, FAAN, Penn Nursing’s van Ameringen Chair in Psychiatric and Mental Health Nursing. “It came from a well-intended place.”
The blockbuster drug OxyContin followed in the mid-1990s. The opioids seemed like a godsend for chronic noncancer pain: effective, free of the side effects of NSAIDs such as gastric bleeding, and not perceived as leading to addiction when prescribed for pain. OxyContin in particular was formulated by its manufacturer, Purdue Pharma, for slow release, which theoretically made it less immediately pleasurable and therefore—again, theoretically— less addictive. Those claims proved to be untrue. In 2007, Purdue Pharma’s holding company paid a $600 million fine for misbranding OxyContin, and three of the company’s executives pled guilty to misdemeanor misbranding. But that was after more than a decade of intense marketing. The pharma industry spent millions sponsoring educational programs, with prominent pain researchers advocating opioids.
Among them was Rosemary Polomano, PhD, RN, FAAN, Professor of Pain Practice at Penn Nursing and Professor of Anesthesiology and Critical Care (Secondary) at the Perelman School of Medicine. A pain expert who in the 1990s educated health care professionals about the compassionate use of opioids to improve quality of life with chronic pain, she herself took part in pharma-sponsored education programs advocating for chronic opioid therapy. “’We operated on faulty data, believing that we were reducing pain and suffering,” she says, noting that a widely distributed 1980 retrospective chart review concluded that hospitalized patients receiving opioids would not become addicted. “We had no evidence to the contrary to ever predict the current opioid crisis.”
Professor Polomano is now one of the leading researchers exploring ways to solve the opioid problem. One solution: limit the use of opioids for acute pain and maximize the effects of other analgesics and interventions. Her research focuses on the use of multimodal analgesia, using non-opioid analgesics and regional analgesia, along with ketamine, for both acute and chronic pain. She also worked with experts from the American Academy of Pain Medicine to draft guidelines for routine urine detection monitoring for those with chronic noncancer pain receiving chronic opioid therapy to help identify misuse and abuse of opioids.
But as opioid addictions and overdoses grew during the 2000s—more than 33,000 died of opiate overdoses in 2015, over half of those deaths due to prescription opioids—providers began to emphasize restriction of opioids over alternatives. Clinicians began backing off from opioids, and heroin—cheaper, more readily available—became a national problem. “Heroin use increased when prescribed opioids became less available,” Peggy Compton says. “Now we’re even more disadvantaged. We’ve backed off from an effective therapy.”
Some providers even advocated eliminating routine pain assessment as the fifth vital sign. The rationale for the change? If clinicians don’t assess the pain as presented, then they would feel less compelled to prescribe medications for managing pain. The change, proposed at the 2016 meeting of the American Medical Association, will not mitigate the opioid problem, according to Martha Curley, PhD, RN, FAAN, Penn Nursing’s Ellen and Robert Kapito Professor in Nursing Science. Sure, the current approach to pain assessment needs rethinking. But instead of eliminating routine assessments, Curley says, practitioners should explore alternatives to opioids and employ a treatment model that emphasizes matching the patient’s level of pain with the appropriate pain reliever. Society’s expectations of pain and pain treatment must be reframed. “We need a clear and consistent message regarding opioid use and systemic change based on science,” Curley wrote in an editorial in the American Journal of Nursing, co-authored with Jean C. Solodiuk PhD RN, manager of the pain treatment service at Boston Children’s Hospital.
Science is where Penn is helping lead the way.
“Traditionally, our lab has not focused on opioids,” says Heath Schmidt, PhD, an assistant professor of biobehaviorial science at Penn Nursing and Penn’s Perelman School of Medicine. But in light of the opioid crisis, “we are expanding our research program to include studies investigating the intersections of pain, gender, and addiction- like behaviors.” Another goal: to develop new drugs for treating opioid addiction, using animal models—rats in particular.
To learn how pain gets processed in brains dependent on—or withdrawing from—opioids, Schmidt and his colleagues have rats self-administer oxycodone voluntarily, then study withdrawal by withholding the drug during weekends. The model helps the researchers identify neural substrates that regulate the analgesic effects of opioids and behaviors during self-administration and withdrawal. Future studies will investigate how pain alters the reward circuits in the brain, to see how chronic pain may make a patient more susceptible to addiction. “These studies will expand our understanding of the molecular mechanisms regulating pain and behavior,” he says. The studies can help provide a foundation for new thinking about prevention and treatment of addiction in pain patients.
Schmidt’s lab is also exploring adjunct medications to use alongside buprenorphine, in hopes of reducing the amount of the opioid administered. “The goal here is to reduce opioid exposure when treating chronic pain,” he says. Adjunct drugs “may also prevent the development of opioid-induced hyperalgesia,” he adds.
Peggy Compton is researching hyperalgesia itself, in which opioid-addicted patients on opioids like methadone become more sensitive to pain. Or do they? Are some people genetically predisposed to hyperalgesia? “I’m starting to ask whether some of those individuals come out of the womb already hyperalgesic,” she says. “The same patients may find opioids highly rewarding, and they may also have a hard time going through withdrawal.”
Compton also plans to examine patients with chronic pain. She says some patients with chronic pain report less pain when they are taken off opioids. Meanwhile, she uses existing evidence to debunk several myths.
A patient recovering from addiction should never be given opioids. “Not true,” Compton says. “If they’re in a good recovery program, going to meetings, seeing their therapist, they should be able to take opioids without relapsing.”
The single best way to treat chronic pain is with opioids. “Also not true.” Compton argues that exercise, physical therapy, weight loss, mindfulness meditation, and other alternatives may be equally, if not more, effective in treating chronic pain.
Chronic pain is purely a neurological phenomenon. “The neurological process may be only a small part of a patient’s condition,” Compton asserts. “Pain is a highly modulated sensory experience. There are so many ways that you can alter that sensory experience,” including methods that only indirectly affect the nervous system.
Patients who take opioids every day are addicts. “To be an addict, you have to meet the diagnostic criteria in the DSM,” Compton points out. “It’s not the chronic pain patients who are creating the addiction problem. But, to the lay public, and even some misinformed clinicians, the two are the same.” The real source of the addiction problem arises from the “large reservoir of pain medications available to addicts and susceptible people.” Too many clinicians, she says, are sending patients home with a large supply of opioids for acute pain.
“Three days out, they likely don’t need it any more. Yet with too many cases I get consulted on, the patient calls for refills.” Emerging data show that most surgical pain patients do not need opioids after three days. “If you’re still in pain a week out, there may be an infection or something else occurring.” Yet in Compton’s experience, some compliant patients finish the whole bottle thinking they’re supposed to, much the way a bottle of antibiotics must be taken in its entirety.
CDC guidelines call on clinicians to assess patients’ susceptibility to addiction. Yet until recently she says, “there’s been very little medical or nursing education devoted to addiction assessment.” For drug-seeking patients disguising their addiction, prescription drug monitoring programs (PDMPs) have been established in 49 states. “Right now, though, it’s all a patchwork,” Compton says.
Still, with the addiction problem being so widespread, should advanced practice nurses be pushing so hard to expand scope of practice in states that restrict them from prescribing opioids? “Opioids should be part of their toolbox,” Compton says. “We’re uniquely prepared not to rely on medication. We provide comfort in a variety of ways. We know when opioids are necessary.” Advanced practice nurses in many states can prescribe buprenorphine as an alternative to methadone, allowing addicted patients more access to a powerful treatment.
Besides, nurses are often in the position to use trend data to determine the type and dosage of pain meds, says Rosemary Polomano. “Nurses are with patients all the time. So they actually trend patient data around pain.” Physicians, on the other hand, “only see patients periodically.” Nonetheless, Polomano says, both professions should measure pain in the same way.
At Penn, the measurements have gotten interesting.
The Faces of Pain
In 2013, Polomano worked with colleagues from the military and Veterans Health Administration to develop and test a new pain measurement scale for armed services members and veterans. The Defense and Veterans Pain Rating Scale uses a rating scale from zero to ten, with each level grounded in what she calls “word anchors.” “No pain” rates a zero. “As bad as it could be, nothing else matters” rates a 10. The scale is enhanced with color coding and facial illustrations of pain, designed and tested with military and veteran populations. In addition, the scale includes four questions to assess how much the patient’s pain interferes with normal activities and sleep, as well as pain’s effect on mood and stress. Version 2.0 published last year. “The scale helps with the overarching goal of improving pain measurement science,” says one of Dr. Polomano’s PhD students, Nicholas Giordano, BSN, RN, a Penn Nursing Hillman Scholar in Nursing Innovation. “How do we integrate patient-reported pain measures into clinical practice in meaningful ways?” Imagine the patient reports a pain level of 5 on a scale of 0 to 10, but it prevents him from sleeping at night. The pain rating scale should help clinicians focus in on the best multimodal strategies for treating several aspects of the pain experience.
Martha Curley has been working to develop a different pain rating scale, also using pictures, for pre-verbal or non-verbal children undergoing major surgical procedures. The profession has come a long way from the days when some clinicians believed that infants didn’t feel pain at all. Curley’s individualized numerical rating scale (INRS) lets parents take a key role in assessment. “Has your child ever experienced a great deal of pain?” the clinician asks. “If yes, tell me about that.” The clinician continues, showing a card with a 0 to 10 scale. Nurse and parent work together to find adjectives describing the child’s individual symptoms at each pain level. Curley says she loves that scale, “and parents love it too. One of the parents’ greatest fears is that their child’s pain will not be interpreted by nurses. Just interviewing the parents up front helps relieve their stress.”
Why an individualized assessment? Samuel Matula, RN, a second year traditional PhD student at Penn Nursing, has been working with chronically ill children in lower and middle income countries—particularly his home country of Botswana. Matula notes that verbal children tend to respond to pain like adults, using words to articulate their pain and exhibiting changing breathing patterns. Non-verbal children, on the other hand, “exhibit an acute behavior change to attract attention to their pain,” he says. “The pain responses are individualized, and there is no specific pattern that indicates how these children respond to pain.” Hence Curley’s INRS.
But what about chronic pain? Can assessment of patients in acute pain, along with multimodal analgesia, actually help mitigate chronic pain after surgery?
Working under Polomano’s guidance, Hillman Scholar Nicholas Giordano recently joined a team of Penn and Department of Defense researchers to analyze findings from a Defense funded study. They investigated early regional anesthesia—entailing the use of catheters to deliver a local anesthetic to a region of the body—to treat major combat injury to extremities. The Regional Anesthesia Military Battlefield Pain Outcomes Study (RAMBPOS for short) involved the collection of numerous patient-reported pain and behavioral health outcomes over a two-year period from combat injured service members who sustained polytrauma, primarily from improvised explosive devices. The study was conducted from 2007 to 2013 during the Afghanistan and Iraq wars. The RAMBPOS will demonstrate the effectiveness of early and aggressive multimodal analgesic techniques and localized, directed pain management in improving long-term outcomes such as pain, physical function, post-traumatic stress disorder, and depression. The RAMBPOS team hopes to support pain practices aimed at preventing and reducing acute pain to mitigate chronic pain over the long term.
The theory is that having a more alert, present patient can prevent a more widespread pain response. “Opioids work on central regions of pain response, in the brain stem,” Giordano observes. “This causes a body-wide response to regional pain.” A more targeted approach to pain management 24 to 48 hours and up to a week after the injury may help limit the duration of pain. Based on data collected in 2015, “We’ve seen better-managed chronic pain and better-managed PTSD,” Giordano says.
Whether the approach will end up in general clinical practice remains to be seen. When RAMBPOS began at the outset of the Afghan and Iraq conflict, fewer than ten percent of military providers had been trained in regional anesthesia. While the number has increased somewhat, “we have to move the culture,” Giordano says. “That’s the exciting part: the RAMBPOS model is nurse-led management.” Nurse anesthesiologists and NPs can be trained to supplement relatively scarce physician anesthesiologists. Giordano’s own dissertation work looks at the approach’s cost effectiveness. “By investing in the training and education of APRNs in military and trauma settings, we can have huge benefits in savings with wounded warriors,” he says. What’s more, he believes the model may have implications for civilian mass shootings with high-velocity weapons.
Even the most advanced treatments for acute pain are unlikely to reduce the incidence of chronic pain in the future, however. Pain is a close companion to aging, and our population gets older every year. Combine these trends with a nation with a 36 percent obesity rate in adults, along with increased survival after traumatic injuries, and pain researchers say clinicians must be prepared to deal with even more chronic- pain patients.
Which makes the role of nurses more important than ever before.
The good news is, the science of pain continues to expand rapidly, as has the clinical culture. “Pain has really evolved to become understood as a subjective experience known only by the client, originating not only from physical etiologies, but also mental, emotional, spiritual, and existential sources,” says Billy Rosa, BSN, MSN, RN, a Penn Nursing PhD candidate, former palliative care nurse practitioner fellow at Memorial Sloan Kettering Cancer Center, and author of the book A New Era in Global Health. Rosa says that nurses and their holistic approach to patients have been integral to this trend: “The understanding of pain as a holistic phenomenon beyond the physiological level has altered how nurses engage with it.” Managing pain cannot be a simple matter of taking a blood pressure and a pain score, Rosa says. “Understanding a client’s pain is not a simple clinical task. It is a journey toward knowing who this person is and how they see themselves.”
His advice to nurses: “Be patient. Be kind. Be open. Ask for help from colleagues in other disciplines. Spend an extra moment to provide comfort. Listen deeply. Remain present. And simply ask, ‘What can we be doing better to help manage this pain?’
“To you, as a nurse, pain assessment may be one more required checklist item on the electronic medical record. It may be the ultimate vital sign,” he says. “But for the client, it may be defining their world. And because of that, how you respond to them will, quite literally, change their life.”
Help Patients Dispose of Opioids
No wonder patients are confused. Medicine take-back programs vary from city to city. Some drug labels contain disposal instructions; most don’t. Some law enforcement agencies, hospitals, and clinics offer drop boxes. Some let patients mail drugs in. Authorized collectors exist in many communities, but not all.
So what should you tell your patients about leftover opioids? We gleaned some tips from the Food and Drug Administration.
Tell patients to take only what they need. Some patients treat pain meds the way they do antibiotics, feeling they have to finish the bottle, observes Peggy Compton PhD RN FAAN, Penn’s van Ameringen Chair in Psychiatric and Mental Health Nursing.
Check the label for any disposal instructions. Those instructions should be the default choice—if you or the patient can find them on the label.
Check with local police. It helps if you can tell your patient whether local law enforcement has a take-back policy. Some communities collect medications only certain times of year.
Find the authorized collectors in your area. Google “Controlled substance public disposal locations” for the Drug Enforcement Administration’s search utility. Enter your zip code, and you’ll probably see a few pharmacies pop up. Have the addresses ready for patients.
Tell patients to deface the label. To protect their privacy, they should scratch out any personal information.
- Have them mix the medications with coffee grounds or kitty litter. If the other methods aren’t practicable, advise patients to empty the drugs from their containers. Mixing them with bad-tasting grounds or kitty litter will discourage children and pets. Pour the mixture into a baggie, seal tight, and put it in a garbage bag.
Jay Heinrichs is an editorial consultant for this magazine. His daughter, Dorothy Heinrichs, a rapid response nurse at the Medstar Washington Hospital Center, helped him navigate the terminology and issues in this story.