Understanding pain, part 2:

pain management
Helen Godfrey

Abstract
This article is the second in a two-part series which explores pain
and its management from a physiological perspective. Nurses play
an important role in assessing and managing pain. Effective pain
management by nurses requires them to have an understanding
of the biological basis of the pain interventions which may be used
to control pain. This article emphasizes the importance of pain
assessment as a precursor for effective pain management and explores
the biological basis of pain interventions which contribute to pain
control. The role of non-pharmacological approaches in alleviating
pain and their actions which contribute to pain relief are explored.
The three main types of pharmaceutical agents used, non-opioids,
opioids and adjuvant drugs, are introduced and their mechanisms
of actions discussed.
Key words: Pain and pain management

Physiology

ain is a common experience for patients in hospitals

(Whelan et al, 2004) and in the community setting
(Smith et al, 2001). Despite a range of treatment
approaches, pain remains a significant problem
(Hader and Guy, 2004). Effective management of early pain is
important since this can influence the subsequent pain
experience (Carr and Goudas, 1999). Successful pain relief
can also reduce complications including depression, anxiety
and poor sleeping and can shorten recovery time and length
of hospital stay (Hader and Guy, 2004; Lellan, 2004). The
control of pain is inevitably intricate since pain is a
complicated active process. Additionally, pain is a
multidimensional experience shaped by a variety of
influences (Melzack, 1999). Although much is known about
pain and how to control it, there are still many patients who
suffer pain following surgery (Watt-Watson et al, 2001), and
many whose chronic pain is not effectively managed
(Stannard and Johnson, 2003).
Nurses play an important role in assessing and managing
pain (Lellan, 2004; Madjar, 2004). Effective pain management
is a major challenge (Barnason et al, 1998) and nurses lack of
knowledge about pain management is well documented
(Clarke et al, 1996; McCaffery and Ferrell, 1997; Twycross,
2002; Madjar, 2004).To effectively manage pain and to select
the appropriate approaches to alleviate pain, an understanding
Helen Godfrey is Principal Lecturer, Faculty of Health and Social Care,
University of the West of England, Bristol
Accepted for publication: July 2005

904

of the physiological basis of pain and pain interventions is

required together with an accurate assessment of the pain the
individual is experiencing. The first article in this two-part
series, Understanding pain, part 1: physiology of pain
(Godfrey, 2005), explores the key concepts in contemporary
pain physiology, while this article aims to enhance nurses
knowledge by exploring the biological basis of pain
interventions which contribute to pain management.

Pain assessment
Effective pain assessment is a prerequisite for choosing the
most appropriate pain interventions to alleviate pain. Pain
assessment is a complex issue which has physiological,
emotional, cognitive and social dimensions (Manias and
Bucknall, 2002). Pain is a subjective experience and, since
there are no precise objective measures, nurses should ask
about pain, and the patients self-report should be the primary
source of assessment (Lynch, 2001; Martelli et al, 2004).
The assessment should include a description of the pain:
its location, duration, frequency, intensity, aggravating and
relieving factors, and the patients cognitive response to pain.
In addition the assessment should inquire about pain-related
interference with activities and any pain-associated distress
(Martelli et al, 2004).Two components to pain assessment can
be considered: screening, which identifies the existence of
pain at an initial assessment, and intensive assessment, which
is the clinical evaluation of pain (Alcenius, 2004). Assessment
of pain should be carried out frequently to identify changes
in the intensity, quality and location of pain and to ascertain
the effectiveness and side effects of pain management
interventions (Lynch, 2001; Hader and Guy, 2004).
The use of a formal assessment tool can reduce the difficulty
of assessing pain (Briggs, 1995; Carr, 1997; Lynch, 2001).
However, selecting an appropriate tool from the range of pain
assessment tools is difficult. The criteria for choosing a pain
assessment tool include that it must be reliable and valid for the
particular patient (Bird, 2003). Pain assessment tools usually
incorporate numerical or verbal rating scales which record the
intensity of pain and consequences on a range of activities of
daily living and quality of life together with a range of other
pain characteristics, such as location, description, onset,
episodes and the effects of interventions (Lynch, 2001).
Since the effective assessment of pain is fundamental for
successful pain control, this, in addition to routine
monitoring of blood pressure, temperature, pulse and
respiratory rate is advocated, and pain is considered to be the
fifth vital sign (Lynch, 2001; Hader and Guy, 2004).Although
autonomic responses, such as changes in heart rate, blood

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PAIN MANAGEMENT
pressure and respiratory rate, may be associated with the pain
experience and should form part of the pain assessment
(Briggs, 1995; Carr and Mann, 2000), as already emphasized,
the patients report of pain is the most reliable indicator of
pain (McCaffery and Ferrell, 1997; Lynch, 2001).

Multimodal approach to managing pain

Pain management approaches develop from pain assessment
and are aimed at removing the cause of pain, where
possible, while achieving optimal comfort and function
with minimal side effects from the interventions used
(Lynch, 2001). The pain management system should use a
multimodal approach that includes pharmacological and
non-pharmacological interventions (Hader and Guy, 2004).
A multimodal approach targets interventions at different
points in the pain pathway, and knowledge of the neurones
and neurochemicals involved in pain, and the psychosocial
mechanisms which maintain pain, forms the basis of
effective pain control (Holdcroft and Power, 2003).

Non-pharmacological interventions
There are a variety of non-pharmacological approaches to
managing pain (Table 1), including physiotherapy, heat pads
or ice packs, massage, relaxation and distraction therapies,
hypnotherapy, transcutaneous electrical nerve stimulation
(TENS) and acupuncture (Carr and Mann, 2000; Lynch,
2001). Complementary therapies for pain may be used to
alleviate pain directly by inducing analgesia or by acting
indirectly to alleviate some of the comorbid symptoms such
as nausea, vomiting, anxiety or depressed mood and by
improving sleep (Chwistek, 2005).
In an American study of community dwelling older
adults (n = 77), 84% of respondents reported use of at least
one complementary therapy for pain, and most participants
reported that the therapies were helpful in relieving pain
(Kemp et al, 2004). There is evidence of increasing use of
complementary therapies in the UK. A Scottish study
comparing use of therapies between 1993 and 1999
suggests an increased use of complementary therapies for
relief of pain from headaches and musculo-skeletal
problems (Emslie et al, 2002). Although there is evidence
in the form of primary studies to suggest that nonpharmacological nursing interventions are effective in the
management of pain, a meta-analysis of 49 of these studies
failed to detect a difference between the treatment and
control groups, emphasizing the need for randomized
controlled trials (RCTs) to test these interventions
(Sindhu, 1996).
Acupuncture has been used in traditional Chinese
medicine for thousands of years for the alleviation of pain
(Lundeberg and Stener-Victorin, 2002; Goddard et al, 2005).
Although acupuncture is now an accepted pain-relieving
modality in most countries and is frequently used as a
complement to other treatments (Lundeberg and StenerVictorin, 2002), its efficacy in alleviating pain is controversial
(Ernst, 2004). It is proposed that acupuncture may relieve
pain in a number of ways, including the release of
endogenous opioids, such as endorphins, which bind to
opioid receptors (Lundeberg and Stener-Victorin, 2002).

British Journal of Nursing, 2005,Vol 14, No 17

However, the notion of acupuncture-mediated endogenous

opiate analgesia is contentious (Szmelskyj, 1998).
TENS is a non-invasive therapy used for pain relief in a
variety of pain syndromes but, despite its frequent use, the
evidence from RCTs for treatment of chronic pain remains
inconclusive (Carroll et al, 2000).The possible mechanisms by
which TENS produces pain relief are reviewed by Sluka and
Walsh (2003) and include stimulation of large diameter
afferents (A-beta fibres) which inhibits pain impulse
transmission in the dorsal horn as proposed by the gate control
theory introduced in part one of this series (Godfrey, 2005).
TENS is also thought to induce descending inhibition and to
elicit the release of endogenous opioids (Sluka and Walsh,
2003).The stimulation of A-beta fibres may also underlie the
pain relief afforded by massage (Lundeberg and StenerVictorin, 2002). Massage is thought to stimulate large diameter
A-beta fibres which will close the gate and inhibit pain
information conducted in A-delta and C fibres from reaching
the brain.A systematic review indicates that massage might be
beneficial for patients with chronic, non-specific low-back
pain, especially if combined with exercise and education
(Furlan et al, 2002).

Table 1. Non-pharmacological interventions

to managing pain

Physiotherapy for positioning and maintenance of function

Heat pads or ice packs to reduce muscle aches, stiffness and oedema
Massage for relaxation
Relaxation and distraction therapies
Hypnotherapy
Transcutaneous electrical nerve stimulation (TENS)
Acupuncture
Source: Carr and Mann (2000); Lynch (2001)

Heat therapy and cold therapy are other common forms of

cutaneous stimulation which have been used to alleviate pain
(Carr and Mann, 2000). In a study of 50 post-cardiac surgery
patients, ice therapy before, during and after chest tube
removal did not significantly reduce pain in the experimental
group (Sauls, 2002). Both heat and cold treatments are
commonly recommended in the treatment of low-back pain
(Car and Sheikh, 2003), although a systematic review has yet
to be published (French et al, 2004).
A number of interventions are based on the premise that
changes in brain activity can be used to influence the
experience of pain. Hypnosis and relaxation are commonly
used as therapies in the treatment of acute and chronic pain,
and there does seem to be some evidence for their
effectiveness based on a review of RCTs by Kessler et al
(2003). The neurophysiological mechanisms underlying
analgesia mediated by hypnosis have yet to be elucidated. In an
experimental study of 20 healthy subjects, hypnosis
significantly reduced subjective pain and the findings also
suggest that hypnosis modulated both the affective and
sensory-discriminative components of pain (Sandrini et al,
2000). The authors suggest that hypnosis uses the descending
inhibitory pathways for the control of pain. In a more recent
study (Faymonville et al, 2003) using positron emission
tomography (PET), the anti-nociceptive effects of hypnosis

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were linked to increased activity in the anterior cingulate

cortex and its functional connectivity to other regions in a
neural network of cortical and subcortical regions. The
anterior cingulate cortex is suggested to have a key role in
modulating the processing of noxious stimuli within this large
neural network in the hypnosis-related alteration of pain
perception (Faymonville et al, 2003). Another psychological
approach used to control pain is cognitive behavioural therapy
(CBT). CBT is often used as an adjunct treatment to help
patients with chronic illnesses to better manage their pain, and
there is some evidence that CBT is effective for certain
chronic conditions, such as rheumatoid arthritis, osteoarthritis,
chronic fatigue syndrome and irritable bowel syndrome
(Bradley et al, 2003). CBT addresses the psychological and
emotional components of pain and can help an individual
control their pain and anxiety (Garcia and Altman, 1997).

Pharmacological approaches
The use of drugs is an important component of pain
management. Pharmacological interventions include opioid and
non-opioid analgesia and adjuvant drugs (MacPherson, 2000;
Lynch, 2001; Briggs, 2003; Miller, 2004). Adjuvants are drugs
which are not usually analgesic themselves, but in combination
with analgesic drugs may enhance the analgesic effect.Although
opioids continue to be an integral component of pain
management strategies, prominence is also given to adjuvant
drugs and anti-inflammatory agents which can enhance pain
control and decrease the use of opioids (MacPherson, 2000).

The World Health Organization analgesic ladder

The World Health Organization (WHO) analgesic ladder was
introduced to improve pain control in patients with cancer pain
(WHO, 1986), although it also provides a framework for other
types of pain management as well (Garcia and Altman, 1997;
Lynch, 2001).The WHO ladder embraces the combination of
Freedom from pain
Step 3
Opioid for moderate to severe
pain + non-opioid +/- adjuvant

Pain persisting or increasing

Step 2
Opioid for mild to moderate
pain + non-opioid +/- adjuvant

Pain persisting or increasing

Step 1
Non-opioid +/- adjuvant

Figure 1.World Health Organization analgesic ladder (WHO, 1986).

906

opioid, non-opioid and adjuvant medications and emphasizes a

systematic approach which stresses the use of analgesics in a
sequential order according to the patients response. There are
three steps in the ladder, and they are only ascended when
pain persists (Figure 1).The first step is to use non-opioid drugs
like paracetamol (acetaminophen) or non-steroidal antiinflammatory drugs (NSAIDs), such as ibuprofen, with or
without adjuvants, for mild pain. If the pain persists the second
step is to introduce weak opioids like codeine with or without
adjuvants. The third step of the ladder is ascended when pain
continues and strong opioids such as morphine are introduced
with or without non-opioid and adjuvant analgesia (Garcia and
Altman, 1997; Briggs, 2003; Miller, 2004). For patients who are
still experiencing pain after this three step approach, a fourth
step may be necessary which involves administration of
intraspinal agents via epidural or intrathecal routes (Kedlaya et
al, 2003). As well as stepping up the ladder, stepping down the
ladder may be appropriate for some patients, for example, as
healing occurs (National Prescribing Centre, 2000).

Non-opioid agents
Non-opioid analgesia comprises paracetamol and NSAIDs,
which include salicylates, such as aspirin. Paracetamol is one
of the most commonly used over-the-counter drugs and
within its therapeutic range it has few side effects (Schug et
al, 2003). Paracetamol is mainly metabolized by the liver and
should be avoided in patients with liver dysfunction or those
at risk of liver toxicity, such as those with a high alcohol intake
(Schug et al, 2003; Miller, 2004). The mechanism for the
analgesic effects of paracetamol remains unclear; however, it is
thought to inhibit prostaglandin synthesis in the periphery
(MacPherson, 2000). Other mechanisms might also operate,
including the inhibition of prostaglandin synthesis in the
central nervous system (CNS) (Garcia and Altman, 1997).
The mechanism of action for NSAIDS is the inhibition of
cyclooxygenase (COX), an enzyme involved in prostaglandin
synthesis. Since prostaglandins are involved in the activation
and sensitization of nociceptors, a reduction in prostaglandin
synthesis will tend to alleviate pain (Garcia and Altman, 1997).
There is a limit or ceiling to their analgesic efficacy beyond
which increasing the dose will have no effect (Lynch, 2001).
Prostaglandins and thromboxanes are products of a pathway in
which membrane phospholipids are converted into arachidonic
acid (Gilron et al, 2003). COX exists in two forms, COX-1 and
COX-2.The COX-1 enzyme is important in the synthesis of
prostaglandins involved in gut and kidney function and platelet
activation.The COX-2 enzyme produces prostaglandins which
are involved in inflammation and pain (Jordan and White, 2001;
Gilron et al, 2003; Miller, 2004) (Figure 2).
Most NSAIDs are non-selective and have some effect on
both COX-1 and COX-2 (Gilron et al, 2003).The inhibition
of both forms of the COX enzyme accounts for the adverse
effects of NSAIDs, which include renal dysfunction,
gastrointestinal ulceration and bleeding and inhibition of
platelet aggregation (Garcia and Altman, 1997; Gilron et al,
2003; Miller, 2004). NSAIDs have been developed which
selectively inhibit COX-2; these COX-2 inhibitors have
analgesic efficacy with fewer side effects (MacPherson, 2000;
Gilron et al, 2003; Miller, 2004).

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PAIN MANAGEMENT
NSAIDs have been developed which selectively inhibit
COX-2, these COX-2 inhibitors have analgesic efficacy with
fewer side effects (MacPherson, 2000; Gilron et al, 2003;
Miller, 2004). However, there is evidence that COX-2
inhibitors are associated with increased risk of adverse
cardiovascular events (Jones, 2005) which has prompted
manufacturer action and updated advice on their use
(National Prescribing Centre, 2005).
Salicylates, such as aspirin, also exert their analgesia via
inhibition of cyclooxygenase-mediated prostaglandin synthesis.
Aspirin binds to both COX-1 and COX-2 interfering with
enzyme activity and thus inhibiting prostaglandin synthesis
(Vane and Botting, 2003). The adverse effects of salicylates
include gastrointestinal upset, ulceration and bleeding, platelet
dysfunction and allergic reactions (Garcia and Altman, 1997). In
addition, aspirin is related to Reyes syndrome in children
under 16 years of age (McGovern et al, 2001; Miller, 2004).

Opioids
Opioids are the main class of analgesics used in the
management of moderate to severe pain (Garcia and Altman,
1997). Opioids are widely used in the management of somatic
and visceral pain (Lynch, 2001) and cancer pain (Harrison,
2001). There are weak opioids, such as dihydrocodeine and
codeine, which are used in step 2 of the WHO ladder, and
strong opioids, such as morphine and pethidine, which are
used in step 3 (Lynch, 2001; Miller, 2004).
Opioids produce analgesia by binding to specific opioid
receptors inside and outside the CNS (Garcia and Altman,
1997) (Figure 3). Opioid drugs (exogenous opioids) mimic the
effects of naturally occurring opioids, the endorphins and
enkephalins. Opioid receptors are usually stimulated by
endogenous opioids. The first article in this series (Godfrey,
2005), describes how endogenous opioids are secreted by
inhibitory neurones in the dorsal horn of the spinal cord.
Endogenous opioids interact with opioid receptors suppressing
substance P mediated neurotransmission across the synapse.
This inhibits the flow of pain information up to the brain and
alleviates pain (Barasi, 1991; Clancy and McVicar, 1998).
Opioid receptors are found in low concentrations
throughout the CNS with the exception of the
hypothalamus (Garcia and Altman, 1997). Opioids modulate
pain via the gating mechanism in the spinal cord, although
there is evidence that opioids may also have peripheral effects
since opioid receptors are located on peripheral terminals of
sensory neurones (Stein et al, 1995).
There are several different types and sub-types of opioid
receptor.The three types of receptor associated with analgesia
are: mu (), kappa (k) and delta (), with analgesia being most
commonly related to mu receptors (Garcia and Altman, 1997;
Schug et al, 2003). Opioid analgesics can be divided into
agonists, such as morphine and fentanyl which express full
receptor activation to mu receptors, and partial agonists, such
as buprenorphine which, while possessing affinity for mu
receptors, only elicits a partial response with reduced effects
(Garcia and Altman, 1997; Schug et al, 2003; Johnson et al,
2005).There are also antagonists such as naloxone which bind
to opioid receptors but lack analgesic effects (Garcia and
Altman, 1997; Schug et al, 2003). The characteristics of the

British Journal of Nursing, 2005,Vol 14, No 17

different groups of opioid drugs dictate their suitability for

control of certain types of pain, but not others. For example,
because pure agonists have a broad range of clinically effective
doses they can be used by patients who require increasing
doses of opioids (Garcia and Altman, 1997).
Opioid doses are given incrementally until pain is
effectively controlled or unwanted side effects occur; this is
called titration and is the adjustment of medication to achieve
optimal analgesia. When these drugs are given at regular
intervals, large fluctuations in blood levels are avoided,
breakthrough pain is minimized and side effects are less likely
(Lynch, 2001).The most common side effects of opioid drugs
are nausea and vomiting, constipation and depressed
breathing. Most side effects can be minimized if there is
effective titration of the dose (Miller, 2004). Although
respiratory depression is associated with greatest morbidity,
nausea and constipation often distress the patient most
(MacPherson, 2000). When opioid medication needs to
change, perhaps because the side effects become unacceptable
or pain control is inadequate, one opioid regimen may be
changed for another, and in these circumstances equianalgesia
conversion charts may be used to determine the dose of the
substituted opioid (MacPherson, 2000; Lynch, 2001).
Opioids have the advantage of being available in a variety
of formulations and can be administered via traditional oral,
intravenous and intramuscular routes together with other
routes which continue to be investigated, including
transdermal, intranasal, inhalational, intrathecal and epidural
routes (MacPherson, 2000; Lynch, 2001). The oral route for
opioid administration is preferable because it is convenient,
non-invasive and cost-effective (Garcia and Altman, 1997).
Some patients experience breakthrough or episodic pain. A
number of mechanisms may lead to transient episodes of
uncontrolled pain, including end-of-dose failure during initial
titration or inadequate pain management; this pain can be
managed by various classes of drugs delivered via a number of
routes (Mercadante, 2002). The short-acting medication

Membrane phospholipids

Arachidonic acid

COX-1
Cyclooxygenase-1
Inhibited
by
NSAIDS

COX-2
Cyclooxygenase 2
Inhibited by
NSAIDS and COX-2
inhibitors

Prostaglandins

Prostaglandins

Involved
in homeostasis,
including gut and
kidney function
and platelet
activation

Involved
in inflammation
and pain

Figure 2.The role of cyclooxygenase in prostaglandin synthesis.

NSAIDS=non-steroidal anti-inflammatory drugs.

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Figure 3.The pain pathway showing key sites for particular pharmacological interventions.
 

 

 


 





 








 




  

 
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needed to manage breakthrough pain could include patientcontrolled analgesia (Davis et al, 2005). Self-regulation of
analgesic administration is an important method of pain
control. Patient-controlled analgesia (PCA), in which drugs are
administered via an electronically-controlled pump, is accepted
as an important method of providing pain relief and is a
developing field (Lehmann, 2005). Of two meta-analyses of
trials comparing opioid administration in post-operative
settings, one indicates that PCA improves analgesia and that
patients prefer PCA (Walder et al, 2001) and another suggests
that patients experience less pain with PCA compared with
intramuscular opioids, although epidural analgesia appeared to
be more effective than PCA (Dolin et al, 2002).
Tramadol is a centrally-acting analgesic which, although
chemically unrelated to opioids (Garcia and Altman, 1997), is
included here because it appears to have both opioid and nonopioid properties (Raffa, 1996; Miller, 2004).Tramadol seems
to exert its analgesic effects in two ways: by binding to mu
receptors and by inhibiting re-uptake of serotonin and
noradrenaline (Raffa, 1996; Garcia and Altman, 1997; Miller,
2004). Both these neurotransmitters are involved in
descending inhibitory pathways which modulate pain in the
spinal cord gating mechanism (Figure 3). The descending
neurones synapse with the inhibitory interneurones in the
dorsal horn and secrete serotonin and noradrenaline (Cross,
1994; McHugh and McHugh, 2000).These neurotransmitters
then excite the inhibitory neurone, thereby suppressing pain
transmission to the brain. By inhibiting reuptake of these
neurotransmitters, tramadol enables serotonin and
noradrenaline to remain in the synapse and stimulate the
inhibitory neurone thereby easing pain.

Adjuvant agents
Adjuvant analgesics are a variety of drugs with a primary
indication other than pain (Lussier et al, 2004).Adjuvant agents

908

include antidepressants, anticonvulsants, muscle relaxants,

corticosteroids and local anaesthetics (Garcia and Altman,
1997; Lussier et al, 2004). Adjuvant medications enhance pain
control and reduce opioid use (MacPherson, 2000).
Tricyclic antidepressants are considered to be useful in many
painful disorders, including low back pain, fibromyalgia, postherpetic neuralgia and neuropathic pain (Garcia and Altman,
1997).The analgesic effect of antidepressants is thought to be
independent of their antidepressive effect because lower doses
are effective and there is a more rapid onset of action (Garcia
and Altman, 1997; MacPherson, 2000). The mechanism of
action seems to involve inhibition of serotonin and
noradrenaline re-uptake. Re-uptake inhibition would enhance
pain modulation by the descending inhibitory pathways and
lead to analgesic effects by preventing the transmission of pain
impulses across the synapse between the first and second order
neurones in the dorsal horn (Figure 3) (Garcia and Altman,
1997; MacPherson, 2000).
Anticonvulsants are used widely in the treatment of
neuropathic pain (Lynch, 2001). Damaged nerves may
become more excitable and produce spontaneous bursts of
action potentials (Garcia and Altman, 1997) by blocking
sodium ion channels; this accounts for their analgesic effects
(MacPherson, 2000).
Systemic local anaesthetics such as lidocaine have also been
shown to be effective in neuropathic pain (Kalso et al, 1998;
Lussier et al, 2004).The mechanism of action remains unclear
but probably involves the blockage of sodium ion channels
and reduction of spontaneous neuronal activity (Garcia and
Altman, 1997; Kalso et al, 1998).
Several other drugs with different pharmacological profiles
are under investigation for their role in therapeutic pain
modulation, including cannabinoids (MacPherson, 2000).
Endogenous cannabinoid mechanisms exist which are
distinct from those involving the endogenous opioids.
Cannabinoid receptors are mainly found in the CNS
although peripheral neurones also possess them (Iversen and
Chapman, 2002). A key problem in the use of cannabinoids
is to alleviate pain without inducing psychoactive effects. A
novel cannabinoid with this characteristic, along with antiinflammatory and analgesic effects, is being investigated
(Burstein et al, 2004).

Conclusions
Individuals continue to suffer pain despite the wide range of
interventions available. Nurses can play a crucial role in pain
management by using a range of strategies and interventions.To
make an effective contribution to the alleviation of pain, nurses
need to be knowledgeable about pain mechanisms and
understand the physiological basis for the non-pharmacological
approaches used. They should also appreciate the different
points along the pain pathway which are potential targets for
pain modulation. In addition, nurses need to be familiar with
the means by which non-opioid and opioid analgesia exert
their effects and understand how adjuvant drugs intervene in
the pain pathway.This knowledge and understanding will allow
nurses to appreciate the significance of a multimodal approach
in the control of pain and enable them to play a more informed
BJN
role in pain management.

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PAIN MANAGEMENT
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KEY POINTS
 Nurses have a key role to play in assessing
and successfully managing pain.
 Effective management of pain is crucial as this can influence
the subsequent pain experience and reduce complications.
 An understanding of the physiological basis
of pharmacological and non-pharmacological
interventions contributes to effective management of pain.
 A multimodal approach targets interventions at different
points in the pain pathway providing optimal
management of pain.
 The WHO ladder emphasizes a systematic approach
in the use of analgesics and stresses their use in a
sequential order according to the patients response.

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