Page 118 Complete Your CE Test Online - Click Here Postoperatively, multimodal analgesia that includes NSAIDS has been demonstrated to have the following benefits (Mugabure Bujedo et al., 2015): ● ● Reduced activity and sensitivity of peripheral nociceptors. ● ● Reduction of the inflammatory response. ● ● Better pain reduction in particular types of pain than opioids (bone pain, pain during coughing and moving). ● ● Reduction of opioid doses by 20% to 50%. ● ● A preventive analgesia administered preoperatively to reduce postoperative pain. A multimodal therapeutic approach can include medication as well as complementary alternative pain therapies. However, as health care costs increase, alternative therapies may be unrealistic for all patients because of lack of insurance coverage or rising copays for such therapies. Complementary alternative therapies to reduce pain Pain management can be complex and often requires complementary therapies to achieve the best outcome for the individual patient. Even though one therapy may be effective for a particular patient, the same therapy may have little to no effect on another patient. Finding the best treatment combination can be trial and error and typically starts with the least invasive type of therapy with the lowest potential for side effects. Complementary therapies are especially effective to help manage chronic pain. Complementary therapies include acupuncture, chiropractic manipulation, yoga, physical therapy, music therapy, massage, biofeedback, distraction, and guided imagery. Biofeedback is a conditioned response to pain that is thought to increase blood flow to specific areas as a result of relaxation, thereby decreasing the concentration of pain-inducing chemicals and possibly increasing the number of endorphins released (Copstead & Banasik, 2013). Distraction is thought to provide pain relief by providing additional input to the brain. The brain can process only a finite amount of stimulus; therefore, pain is reduced. Guided imagery is thought to alter the perception of painful stimuli in higher levels of the brain and produce relaxation and analgesic effects (Copstead & Banasik, 2013). Patient education Patients should be educated early in the course and methods of pain treatment, and the details should be included in the plan of care for pain management. Patients should be given a variety of appropriate pain relief options that are not simply limited to pharmacologic treatments. Patients should be advised on how and when to use nonpharmacologic treatments (ice, rest, elevation, physical therapy, guided imagery, meditation) and pharmacologic treatments. Education on pharmacologic options should include the side effects and benefits of medication and treatment as well as how and when to take the medication. Harm from opioids, including accidental overdose, can occur during the initial phase of opioid treatment. Therefore, the patient should be counseled on exactly how to take the medication in the outpatient setting. Patient education regarding the use of opioids should include the following information (Joint Commission, 2012): ● ● What is being prescribed, including generic and brand names and route of administration to avoid duplicate medication consumption. ● ● Side effects and risks of opioids, including constipation, nausea and vomiting, fall precautions, respiratory depression, and slower cognitive and motor function. ● ● The potential risk for dependency, tolerance, and withdrawal. ● ● The potential risk for serious complications, including death, when mixing alcohol or other central nervous system depressants with opioid medication. ● ● Proper storage and disposal of medication. ● ● How to discontinue pain medication. Discontinuing pain medication Pain medication taken for several days at regular intervals may cause a physical dependence. It is important that the patient be advised how and when to stop taking pain medications. The ACPA (2016) recommended medical supervision when the following medications are to be discontinued: ● ● Opioids that have been taken in regular daily doses for several days or longer. ● ● Benzodiazepines, muscle relaxants, antidepressants, and anticonvulsant medications that 
have been taken in regular daily doses for several days or longer. ● ● Barbiturates (butalbital) taken frequently for headache. Medications that may be prescribed to help lessen withdrawal symptoms from opioids include the following (ACPA, 2016): ● ● Alpha-2 agonists (such as clonidine). ● ● Muscle relaxants (such as methocarbamol). ● ● Stomach relaxants (such as dicyclomine). ● ● Anti-inflammatory pain medication (such as ibuprofen and naproxen). ● ● Sleep aids (such as trazodone and amitriptyline). ● ● Antianxiety agents (such as phenobarbital, hydroxyzine, and diazepam used cautiously because of addictive potential). ● ● Alternative opioids (such as methadone or buprenorphine that should be used only temporarily because of addictive potential). Self-assessment question 8 Which of the following medications should be used cautiously when trying to lessen withdrawal symptoms from opioids because of addiction potential? a. Naproxen. b. Dicyclomine. c. Tricyclic antidepressants. d. Diazepam. EBP alert! A study involving strategies for pain management showed that effective pain management included patient involvement in decision making, an evaluation of the medication administered or alternative strategies adopted, and an agreed-on plan of what would be done for the patient’s current pain situation (Manias, Bucknell, & Botti, 2005). It is important for the nurse to empower the patient through education and mutual decision making for optimal pain management. Special considerations for specific populations experiencing pain Geriatric population The older population (aged 65 years and older) is projected to increase by greater than 80% by 2030 in the United States (Atkinson, Fudin, Pandula, & Mirza, 2013). Because of this, it is important to understand the challenges associated with pain management in this rapidly expanding population. Chronic pain occurs in 45% to 85% of the older