A Holistic Approach to Pain Management: Integrated, Multimodal, and Interdisciplinary Treatment Position Statement
Position
Holistic pain management incorporates multiple treatment modalities, engages the patient, and utilizes the skills, knowledge, and abilities of all members of the patient’s interdisciplinary team. Non-opioid analgesics should be used as the first line of treatment whenever possible. While many patients may benefit from access to opioid analgesics, there has been an alarming increase in prescription opioid diversion, opioid use disorder, and opioid-related mortality and morbidity.1-5 There is also a growing recognition of the impact of pain on the health, productivity, and well-being of individuals in the United States, as well as worldwide.4,6-8
Pain is a personal experience that, if left undertreated or mismanaged, can radically change an individual’s quality of life and impact important relationships. Acute and chronic pain is best treated and managed by an interdisciplinary team that actively engages the patient to diagnose and manage their pain for improved well-being, functionality, and quality of life. As members of the interdisciplinary team, Certified Registered Nurse Anesthetists (CRNAs) are well positioned to provide holistic, patient-centered, multimodal pain management and management across the continuum of pain and in all clinical settings (e.g., hospitals, ambulatory surgical centers, offices, and pain management clinics).9-14 CRNAs practice in accordance with their professional scope of practice, federal and state law, clinical guidelines, and facility policy to provide acute and chronic pain management services.
Partnering with the Patient
Compassionate patient-centered care is a hallmark of CRNA clinical practice. Patient-centric pain management offers the patient greater transparency, understanding, and engagement in their care. Pain assessment and pain care must be individualized to incorporate the patient’s preferences, age, culture, beliefs, social environment, healthcare history, and physical and psychological condition.4,15-19 It is important to note that certain racial, ethnic, gender identity, and socioeconomic groups are at particular risk of receiving suboptimal pain management.1517,19,20 The COVID-19 pandemic and the associated governmental and societal restrictions exacerbated these disparities in pain management.15,21,22 See The CRNA’s Role in Addressing Racial and Ethnic Disparities in Anesthesia Care Position Statement, Policy and Practice
Considerations for more information on how CRNAs and facilities can develop effective policies and practices that promote equitable care for all patients.
As new diagnostic techniques continue to emerge and are optimized, they can play a major role in personalized medicine and the development of patient-specific pain treatment and management plans. One example is the integration of pharmacogenomic testing to examine how inherited genetic differences affect an individual’s response to drugs. Other examples include ketamine clinics, virtual reality, and complementary therapies such as acupuncture, breath work, and massage.23-28
Using a shared decision-making model and a robust communication plan, CRNAs facilitate collaborative care through planning and discussion of risks and benefits of the pain management plan. Holistic patient care may include collaborating with experts from the field of pain psychology and physical therapy.29 This approach encourages the patient to express their preferences and values and to establish realistic goals for well-being and quality of life. It is
important to provide patients with the appropriate skills, education, and resources so that they can play an active role in their pain management.30,31
Psychology of Pain
The International Association for the Study of Pain defines pain as both a negative sensory and emotional experience.32 Acknowledgement of the patient’s pain psychology is an important aspect of chronic pain management as pain is often associated with psychological distress, lack of social functioning, and a reduced quality of life.33 One of the most noteworthy behavioral pain models is the Fear-Avoidance Model (FAM).34 Pain-related fear and avoidance of pain are often accompanied by other signs of emotional and psychological distress, and thus patients can be stuck in a vicious cycle of suffering.34,35 The patient’s avoidance behaviors can interfere with daily activities and lead to further physical and emotional distress.34 Interventions focus on identifying and challenging the patent’s fears and negative beliefs and addressing the cycle of pain, fear, and avoidance behaviors. The patient’s interdisciplinary team requires communication and coordination of treatment, which may involve a combination of cognitivebehavioral therapy, physical therapy, and other approaches aimed at helping the patient manage their symptoms and improve their quality of life.
Patient-centric pain management also includes acknowledgment of the patient’s current mental health status. Before the patient’s pain can be treated, any underlying mental health disorders (also referred to as negative health affects) must first be addressed.36,37 It is estimated that 51.8 – 59.1 percent of chronic pain patients suffer from depression.17 Anxiety, post-traumatic stress disorder (PTSD), and substance use disorder also frequently occur with the chronic pain patient.15,29,38,39 Pain and mental health disorders form a reinforcing feedback loop where prolonged pain leads to increased negative effects, which leads to increased pain and potentially unhealthy opioid use.
15,29,31,37
Multimodal Pain Management
Opioid prescribing peaked in 2012 with a dispensing rate of 81.3 prescriptions per 100 persons.40 Since that time, the overall national opioid dispensing rate declined to 43.3 prescriptions per 100 persons in 2020.40 According to the 2016 National Pain Strategy, multimodal pain management “addresses the full range of an individual patient’s biopsychosocial challenges, by providing a range of multiple and different types of therapies that may include medical, surgical, psychological, behavioral, and integrative approaches as needed.”30
CRNAs integrate multimodal pain management as an element of enhanced recovery after surgery (ERAS) protocols to manage pain.41 Management occurs from pre-procedure to post discharge using opioid sparing techniques such as regional anesthesia, peripheral nerve blocks, non-pharmacologic approaches, and non-opioid based pharmacologic measures.14,42-44 ERAS pathways use multimodal pain management to reduce the use of opioids and shorten overall hospital length of stay.37,45 Careful assessment and treatment of acute pain, which may include appropriate opioid prescribing, can decrease the risk of acute pain transitioning to chronic pain or the probability of the development of opioid dependency and abuse.28,37,46,47 Acute pain management of the chronic pain patient can pose perioperative challenges, but may also be addressed using a multimodal, interdisciplinary approach tailored to the patient’s needs.44
Preoperative / Preprocedure Period37,41,43,44,48
• Provide patient and caregiver education.
• Ensure patient history includes pain assessment and evaluation
• Development of patient-specific treatment plan & informed consent.
• Begin patient optimization:
o Oral fluids and carbohydrate loading two hours preoperatively
o Antibiotic prophylaxis
o No or minimal premedication
o Begin pain management plan
Intraoperative / Intraprocedure Period14,37,41,43-45
• Provide multimodal pain management
o Prioritizing non-opioid analgesics
o Administering regional and/or neuraxial blockade, where applicable
o Antiemetic(s)
• Maintain Normovolemia, avoid salt and water overload.
Postoperative / Postprocedure Period28,31,37,41,43-45
• Provide patient and caregiver education
• Take steps to prevent and manage postoperative nausea and vomiting (PONV)
• Offer early nutrition
• Administer systemic analgesics
• Assist with early mobilization.
• Define discharge criteria
• Identify symptoms and subsequent early rescue, if needed.
Home Recovery Period23,31,37,41,49,50
• Collaborate care coordination with interdisciplinary clinical team
• Ensure patient and/or caregiver have a clear understanding of instructions
• Provide postanesthesia follow-up.
• If indicated, prescribe only the necessary amount of opioids, reassess patient prior to new prescription for opioids.
• Encourage complementary pain management (e.g., mindfulness, breath work, physical exercise).
• Transition multimodal regimens into the rehabilitative phase at home
• Address and track patient-reported symptoms.
Chronic Pain Treatment and Management11,30,51,52
• Establish realistic treatment goals that focus on quality-of-life improvement
• Collaborate with the patient’s interdisciplinary team.
• Incorporate appropriate pain management modalities tailored to patient’s level of pain, functionality, and response
o Non-pharmacologic
o Pharmacologic
o Interventional
• Continue to reassess pain to tailor treatment plan.
• Provide education on safe opioid use (including signs and symptoms of an overdose), storage, and disposal.
o Access the Prescription Drug Monitoring Program when prescribing opioids
o Know how to access Naloxone
Cancer, Palliative, and/or Hospice Care
37,53-57
• Develop interdisciplinary pain management plan.
• Adjust pain medications according to patient response and level of pain.
• Provide patient and caregiver education and counseling
• Treat and manage acute, chronic, or breakthrough pain due to cancer or cancer treatments using non-pharmacologic and pharmacologic modalities when appropriate.
• Manage opioid side effects (e.g., constipation, nausea, drowsiness)
• Focus on functional goals and quality of life
• Implement and track multi-symptom patient-reported outcome measures
References
1. Centers for Disease Control and Prevention. Drug Overdose. Accessed March 27, 2023, https://www.cdc.gov/drugoverdose/index.html
2. Azadfard M, Huecker MR, Leaming JM. Opioid Addiction. StatPearls [Internet]. StatPearls Publishing; 2023.
3. National Institute on Drug Abuse. Drug Overdose Death Rates. Accessed March 29, 2023, https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates
4. Kraus M, Lintzeris N, Bhaskar A, et al. Consensus and Controversies Between Pain and Addiction Experts on the Prevention, Diagnosis, and Management of Prescription Opioid Use Disorder. J Addict Med. Jan/Feb 2020;14(1):1-11. doi:10.1097/ADM.0000000000000577
5. Darnall BD. Speaking of Psychology. Speaking of Psychology: Using psychology for pain relief and opioid reduction, with Beth Darnall, PhD. https://www.apa.org/news/podcasts/speaking-ofpsychology/pain-opioid-reduction
6. Degenhardt L, Grebely J, Stone J, et al. Global patterns of opioid use and dependence: harms to populations, interventions, and future action. Lancet. Oct 26 2019;394(10208):1560-1579. doi:10.1016/S0140-6736(19)32229-9
7. IOM (Institute of Medicine). 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press.
8. Gerra MC, Dallabona C, Arendt-Nielsen L. Epigenetic Alterations in Prescription Opioid Misuse: New Strategies for Precision Pain Management. Genes (Basel). Aug 10 2021;12(8)doi:10.3390/genes12081226
9. Scope of Nurse Anesthesia Practice. Rosemont, IL: American Association of Nurse Anesthesiology; 2020.
10. Standards for Nurse Anesthesia Practice. Rosemont, IL: American Association of Nurse Anesthesiology; 2019.
11. Chronic Pain Management Guidelines. Rosemont, IL: American Association of Nurse Anesthesiology; 2021.
12. Standards for Accreditation of Post-Graduate CRNA Fellowships. Rosemont, IL. Council on Accreditation of Nurse Anesthesia Educational Programs; 2018.
13. Nonsurgical Pain Management (NSPM) Examination Handbook. Chicago, IL: National Board of Certification and Recertification for Nurse Anesthetists; 2021.
14. Regional Anesthesia and Analgesia Techniques - An Element of Multimodal Pain Management. Rosemont, IL: American Association of Nurse Anesthesiology; 2018.
15. Hamilton TM, Reese JC, Air EL. Health Care Disparity in Pain. Neurosurg Clin N Am. Jul 2022;33(3):251-260. doi:10.1016/j.nec.2022.02.003
16. Ly DP. Racial and Ethnic Disparities in the Evaluation and Management of Pain in the Outpatient Setting, 2006-2015. Pain Med. Feb 1 2019;20(2):223-232. doi:10.1093/pm/pny074
17. Abd-Elsayed A, Heyer AM, Schatman ME. Disparities in the Treatment of the LGBTQ Population in Chronic Pain Management. J Pain Res. 2021;14:3623-3625. doi:10.2147/JPR.S348525
18. Knoebel RW, Starck JV, Miller P. Treatment Disparities Among the Black Population and Their Influence on the Equitable Management of Chronic Pain. Health Equity. 2021;5(1):596-605. doi:10.1089/heq.2020.0062
19. The CRNA’s Role in Addressing Racial and Ethnic Disparities in Anesthesia Care. Rosemont, IL. American Association of Nurse Anesthesiology; 2021.
20. Bateman BT, Carvalho B. Addressing Racial and Ethnic Disparities in Pain Management in the Midst of the Opioid Crisis. Obstet Gynecol. Dec 2019;134(6):1144-1146. doi:10.1097/AOG.0000000000003590
21. Mueller BR, Lawrence S, Benn E, et al. Disparities in telehealth utilization in patients with pain during COVID-19. Pain Rep. May-Jun 2022;7(3):e1001. doi:10.1097/PR9.0000000000001001
22. Lopez L, 3rd, Hart LH, 3rd, Katz MH. Racial and Ethnic Health Disparities Related to COVID-19. JAMA. Feb 23 2021;325(8):719-720. doi:10.1001/jama.2020.26443
23. U.S. Pain Foundation: Complementary Therapies. Accessed April 3, 2023, https://uspainfoundation.org/pain/complementary/
24. de Vries FS, van Dongen RTM, Bertens D. Pain education and pain management skills in virtual reality in the treatment of chronic low back pain: A multiple baseline single-case experimental design. Behav Res Ther. Mar 2023;162:104257. doi:10.1016/j.brat.2023.104257
25. Goudman L, Jansen J, Billot M, et al. Virtual Reality Applications in Chronic Pain Management: Systematic Review and Meta-analysis. JMIR Serious Games. May 10 2022;10(2):e34402. doi:10.2196/34402
26. Orhurhu V, Orhurhu MS, Bhatia A, Cohen SP. Ketamine Infusions for Chronic Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Anesth Analg. Jul 2019;129(1):241254. doi:10.1213/ANE.0000000000004185
27. Orhurhu VJ, Roberts JS, Ly N, Cohen SP. Ketamine In Acute and Chronic Pain Management. StatPearls. 2023.
28. Cheung CK, Adeola JO, Beutler SS, Urman RD. Postoperative Pain Management in Enhanced Recovery Pathways. J Pain Res. 2022;15:123-135. doi:10.2147/JPR.S231774
29. Gillman A, Zhang D, Jarquin S, Karp JF, Jeong JH, Wasan AD. Comparative Effectiveness of Embedded Mental Health Services in Pain Management Clinics vs Standard Care. Pain Med. May 1 2020;21(5):978-991. doi:10.1093/pm/pnz294
30. National Pain Strategy: A Comprehensive Population Health-Level Strategy for Pain. The Interagency Pain Research Coordinating Committee, National Institutes of Health, 2016.
31. Mackey S. Future Directions for Pain Management: Lessons from the Institute of Medicine Pain Report and the National Pain Strategy. Hand Clin. Feb 2016;32(1):91-8. doi:10.1016/j.hcl.2015.08.012
32. IASP Annouces Revised Definition of Pain. Accessed April 4, 2023, https://www.iasppain.org/publications/iasp-news/iasp-announces-revised-definition-of-pain/
33. Castelnuovo G, Schreurs KMG. Editorial: Pain Management in Clinical and Health Psychology. Front Psychol. 2019;10:1295. doi:10.3389/fpsyg.2019.01295
34. Flink IK, Reme S, Jacobsen HB, et al. Pain psychology in the 21st century: lessons learned and moving forward. Scand J Pain. Apr 28 2020;20(2):229-238. doi:10.1515/sjpain-2019-0180
35. Braunwalder C, Muller R, Glisic M, Fekete C. Are Positive Psychology Interventions Efficacious in Chronic Pain Treatment? A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Pain Med. Jan 3 2022;23(1):122-136. doi:10.1093/pm/pnab247
36. Budge C, Taylor M, Mar M, Hansen C, Fai F. Chronic pain: good management of practical pain control strategies is associated with being older, more health activated and having better mental health. J Prim Health Care. Sep 2020;12(3):225-234. doi:10.1071/HC19066
37. Echeverria-Villalobos M, Stoicea N, Todeschini AB, et al. Enhanced Recovery After Surgery (ERAS): A Perspective Review of Postoperative Pain Management Under ERAS Pathways and Its Role on Opioid Crisis in the United States. Clin J Pain. Mar 2020;36(3):219-226. doi:10.1097/AJP.0000000000000792
38. Harding K, Day MA, Ehde DM, Wood AE, McCall A, Williams R. Mental and Physical Health Correlates of Pain Treatment Utilization Among Veterans With Chronic Pain: A Cross-sectional Study. Mil Med. Mar 1 2019;184(3-4):e127-e134. doi:10.1093/milmed/usy235
39. Galli F. Understanding Nociplastic Pain: Building a Bridge between Clinical Psychology and Medicine. J Pers Med. Feb 10 2023;13(2)doi:10.3390/jpm13020310
40. Centers for Disease Control and Prevention. U.S. Opioid Dispensing Rate Maps. Accessed April 4, 2023, https://www.cdc.gov/drugoverdose/rxrate-maps/index.html
41. Enhanced Recovery after Surgery. Rosemont, IL. American Association of Nurse Anesthesiology; 2017.
42. American Association of Nurse Anesthesiology. Enhanced Recovery after Surgery. Accessed April 4, 2023, https://www.aana.com/practice/clinical-practice-resources/enhanced-recovery-aftersurgery
43. Lukyanova V, Reede L. Perioperative Care Pathways for Enhanced Recovery and Anesthesia. AANA NewsBulletin. May 2015;69(3):17-19.
44. Chen Q, Chen E, Qian X. A Narrative Review on Perioperative Pain Management Strategies in Enhanced Recovery Pathways-The Past, Present and Future. J Clin Med. Jun 10 2021;10(12)doi:10.3390/jcm10122568
45. Simpson JC, Bao X, Agarwala A. Pain Management in Enhanced Recovery after Surgery (ERAS) Protocols. Clin Colon Rectal Surg. Mar 2019;32(2):121-128. doi:10.1055/s-0038-1676477
46. Glare P, Overton S, Aubrey K. Transition from acute to chronic pain: where cells, systems and society meet. Pain Manag. Nov 2020;10(6):421-436. doi:10.2217/pmt-2019-0039
47. Fregoso G, Wang A, Tseng K, Wang J. Transition from Acute to Chronic Pain: Evaluating Risk for Chronic Postsurgical Pain. Pain Physician. Sep 2019;22(5):479-488.
48. ERAS Society. Patient Information. Accessed April 5, 2023, https://erassociety.org/patients/
49. Bernardo S. How are you managing post-op pain? Outpatient Surgery. Denver, CO: Association of periOperative Registered Nurses; 2022.
50. Liu JB, Pusic AL, Temple LK, Ko CY. Patient-reported outcomes in surgery: Listening to patients improves quality of care. Bulletin of the American College of Surgeons. Chicago, IL: American College of Surgeons; 2017.
51. Centers for Disease Control and Prevention: Save a Life from Prescription Opioid Overdose. https://www.cdc.gov/rxawareness/prevent/index.html
52. American Academy of Family Physicians. AAFP Chronic Pain Management Toolkit.
https://www.aafp.org/family-physician/patient-care/care-resources/pain-management/aafpchronic-pain-management-toolkit.html
53. American Cancer Society. Managing Cancer Pain at Home.
https://www.cancer.org/treatment/treatments-and-side-effects/physical-sideeffects/pain/pain.html
54. Scarborough BM, Smith CB. Optimal pain management for patients with cancer in the modern era. CA Cancer J Clin. May 2018;68(3):182-196. doi:10.3322/caac.21453
55. Bugada D, Drotar M, Finazzi S, Real G, Lorini LF, Forget P. Opioid-Free Anesthesia and Postoperative Outcomes in Cancer Surgery: A Systematic Review. Cancers (Basel). Dec 22 2022;15(1)doi:10.3390/cancers15010064
56. Lopes-Junior LC, Rosa GS, Pessanha RM, Schuab S, Nunes KZ, Amorim MHC. Efficacy of the complementary therapies in the management of cancer pain in palliative care: A systematic review. Rev Lat Am Enfermagem. 2020;28:e3377. doi:10.1590/1518-8345.4213.3377
57. Sinha A, Deshwal H, Vashisht R. End of Life Evaluation and Management of Pain. StatPearls [Internet]. StatPearls Publishing; 2023.
Adopted by AANA Board of Directors July 2016
Revised by the AANA Board of Directors Aug 2023
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