Pain is a subjective experience. Nurses have been taught that pain is what the patient says it is and exists when the patient says it does. We have also been taught lack of objective signs does not always mean lack of pain or lack of an obvious physiologic cause. Yet, one study demonstrated 25-34 percent of nurses do not base interventions on these premises.¹

While the patient's first concern about pain management is comfort, pain relief encompasses more than this concept. Improper pain relief prolongs the stress response, delays wound healing and causes immunosuppression.² Pain may increase oxygen demand, promote coagulation and decrease gastric and intestinal motility. Further, the vicious cycle of pain-muscle tension-anxiety and increased pain-decreased mobility, can result in DVT, PE, atelectasis, and pneumonia.

Acute pain differs from chronic pain in that the onset tends to be sudden and the pain may be attributed to a specific cause. It usually signifies underlying trauma or disease and may be easily localized. This type of pain may result from trauma such as fractures or burns, ischemia, inflammation or surgery. Acute pain is usually self-limiting, perhaps making it easier to cope with than chronic pain. Nonetheless, it must be addressed effectively.

Pain Assessment Tools
There are many assessment tools available such as the simple 1-10 numerical scale or visual analog scale (VAS). Typically, a horizontal line is drawn and the number 1 placed to show a very little pain. The number 10 is placed at the opposite end of the scale with the cue the worst pain possible. The patient is then asked to point to or to state the amount of pain he has that corresponds to the scale.

The Wong-Baker FACES scale, where children or non-verbal patients can point to a face representing their level of pain, contains faces. The face representing comfortable shows a smiling face. Each subsequent rating the faces appear more and more distressed until the face exhibiting "unbearable pain" is shown crying.

The McGill-Melzack questionnaire assesses not only location and quality of pain but psychosocial factors as well. Questions regarding how the pain feels, how the pain changes with time as well as a section to evaluate response to treatment are included in this full-page tool.

While instructions for assessment tools and pain management materials are appropriate, many narcotics lead to blurred vision as well as poor concentration or confusion impeding understanding. Because patients receiving narcotic analgesic may have sedation, explanations may need to be given several times. Patients should have their eyeglasses and hearing aids in place during assessments to maximize understanding of the questions.

Many nurses, patients and their families believe pain is a part of growing old. This misconception may lead to incomplete assessment and improper analgesia. An elderly patient may be anxious, temporarily disoriented from a new environment or have dementia or cognitive impairments that make pain assessment difficult. The nurse may need to rely on non-verbal or behavioral changes such as grimacing or guarding, restlessness or agitation, hostility or combativeness to assist with pain assessment. This does not mean elderly patients or patients with dementia should not be medicated for pain or receive narcotic analgesics. Rather, a rule of thumb of "start low-go slow" should be followed.

Step Approach to Pain Management
Anticipating and preventing pain is superior to attempting to relieve pain, particularly as severity increases. Pain management must be dynamic and medications titrated as necessary.

The World Health Organization's three-step approach to pain management suggests: for mild pain, a non-opioid such as a NSAID; for mild-to-moderate or increasing pain, a mild opioid with a non-opioid, such as acetaminophen with codeine or oxycodone with acetaminophen; for increasing or severe pain, an opioid with or without a non-opioid may be used, such as morphine.

Narcotics do not need to be injectable to be effective. Using an equianalgesic dose (see Table) of the drug selected and administering at appropriate intervals, before the drug has worn off, can make oral agents just as effective. Equianalgesic doses of analgesics refer to the comparison of the analgesic strength of a given medication to 10 mg of parenteral morphine. Adjuvant/adjunct therapies or secondary drugs such as antiemetics, antihistamines, skeletal muscle relaxants, corticosteroids and neuropathic agents may be added as indicated. These adjuncts will be more effective in combination with analgesics than if either is used alone.

Addiction vs. Tolerance
Education for patients and families related to pain management is always a nursing priority. Some patients fear addiction, although it is well documented that less than 1 percent of patients develop drug addiction. Patients may confuse the term tolerance with addiction. Tolerance refers to the phenomenon of developing gradual adaptation to the narcotic on the central nervous system. A patient may need a higher or more frequent dose to obtain the same analgesic effect. This may occur within several days or with prolonged exposure to narcotics. One technique to treat this is to decrease the dose by one-half and change to another opiod.

You may have heard nurses complaining on the second or third postoperative day that a patient "shouldn't" be asking for so much pain medication. If we don't believe pain is what the patient says it is and exists when the patient says it does, then we are judging our patients.

Dependence is a physiologic adaptation of the body to the drug and abrupt removal without tapering may lead to anxiety, irritability, inability to sleep, nausea, vomiting, abdominal cramps, diaphoresis, etc. While patients may relate these symptoms to "drug addicts" or "street users," tolerance and physical dependence are anticipated and expected. Nurses should teach patients that drugs are used judiciously to promote comfort and recovery and will be titrated downward slowly when appropriate.

Tapering narcotics by 25-50 percent every 48 hours when appropriate will prevent physiological withdrawal. Patients usually do this naturally on their own as pain decreases. If the patient increases his activity and/or tolerance develops, it is possible he may need an adjustment in the pain management regimen. When it is necessary to limit opioids, use of a NSAID such as ketorolac may be helpful.

In general, administration of pain medication should be done before pain becomes severe. Around-the-clock dosing should be used rather than prn dosing. It is important to have an adequate dose and the proper dosing interval. If this practice is followed, patients use smaller doses of narcotic with fewer side effects. They will also be better rested and able to carry out ADLs. Shorter hospital stays, fewer complications, decreased costs and improved patient satisfaction have been documented with proper postoperative pain management.

Anticipating Side Effects
The goal of pain management is to relieve pain while minimizing side effects and adverse effects. After administration of pain medication, the nurse should monitor and document the response using the original tool or scale. Nurses should also assess for side effects and adverse effects, and plan interventions to decrease these effects when possible. The most critical of these adverse effects are cardiorespiratory and CNS depression such as hypoventilation, apnea, decreased respiratory rate, hypotension and oversedation.

Generally, narcotics should be held for respiratory rates less than 10 breaths per minute, systolic blood pressure less than 90 mm Hg or confusion. If the respiratory rate is less than 8 or the patient is unable to be aroused, the narcotic antagonist naloxone may be used. The typical dose is 0.4-2 mg IV, IM or SC, with an onset within 2 minutes. Naloxone may be repeated every 2-3 minutes until effective. As most narcotics have a longer duration than naloxone, another dose may be needed within 30 minutes.

Opioids may be resumed at half the original dose when the patient is easily aroused and the respiratory rate is greater than 9 breaths/minute. When administered, pain will return and acute withdrawal in the opiate-sensitized patient is likely. Dizziness and drowsiness may occur.

Another side effect related to opioids is a depressed cough reflex. This is important to keep in mind with postoperative patients. Their plan of care should include coughing and deep breathing, incentive spirometry, frequent turning and early mobility. If necessary, the nurse should suctioning secretions to prevent atelectasis and airway obstruction. Care should be taken with patients with chronic lung disease, as hypoventilation can increase carbon dioxide levels, leading to somnolence and respiratory failure. Many health care providers are reluctant to medicate patients with lung disease for this reason as well as fears that symptoms of hypercarbia will be masked.

Gastrointestinal Effects
Several gastrointestinal side effects may occur with narcotic use. Vomiting and nausea results from stimulation of the chemoreceptor trigger zone in the brain stem and can be managed with antiemetics such as ondansetron (Zofran^®, GlaxoSmithKline), prochlorperazine (Compazine^®, GlaxoSmithKline) or trimethobenzamide (Tigan^®, King Pharmaceuticals). While antiemetics will not relieve pain, they may potentiate sedation. As with pain management, nausea is more easily resolved than actual vomiting.

Dry mouth is a major complaint of patients taking opioids. Frequent mouth care, ice chips, fluids where possible and lubrication of the lips may be helpful.

Constipation secondary to decreased peristalsis, general anesthesia and inattention to stimulation of defecation reflex may occur. When narcotics are used for more than 2-3 days, a stool softener or bulk agent may be added if the patient is tolerating oral medications. Warm or hot beverages, increasing dietary fiber and early ambulation may stimulate bowel activity. A stimulant cathartic or laxative may be needed.

Nervous system side effects will include drowsiness and pinpoint pupils. Drowsiness secondary to stimulation of opioid receptors will decrease with time; however, pupil size will remain small. Occasionally, euphoria, dysphoria or confusion may result. The drug may need to be changed and a co-analgesic used.

Safety is an issue at this time; side rails should be up and patients reminded not to get up alone. Frequent assessment of these patients is important as sedation and possible confusion may impede patients' ability to follow instructions. Pinpoint pupils may interfere with the ability to read printed materials and neurological assessment.

Orthostatic hypotension and hypotension result from vasodilation, decreased peripheral resistance and inhibition of baroreceptors. Patients should arise slowly, dangle before getting out of bed or wait until the peak hypotensive effect of the drug passes, usually within 1 hour.

Symptoms such as urinary retention may occur due to increased tone of smooth muscle and spasms in the urinary tract. Monitor for bladder distention and encourage voiding. Men may need to stand to void, or straight catheterization may be needed.

Other expected side effects may include itching or flushing secondary to histamine release. This is usually not an allergy. If problematic, diphenhydramine IV, IM or orally may be used. For epidural morphine, small doses of naloxone may be used.

Routes of Delivery
Severe pain is anticipated with trauma or surgery, and opioids (narcotic analgesics) are the drugs of choice. The drug and route depends on physician preference, other illnesses and the patient's ability to tolerate oral medications, such as immediately after general anesthesia or gastrointestinal surgery. The parenteral route is usually used for the first 24-48 hours, after which time oral analgesics are used.

The intramuscular route is not recommended for pain management due to pain, tissue or nerve damage and slow absorption. This is particularly important postoperatively where decreased blood volume, hypothermia and decreased muscle activity delay drug absorption, requiring additional doses. These additional doses may "flood" the bloodstream once circulation improves, leading to adverse effects. The risk of respiratory depression is five times higher with the IM route than with the IV route.³

The prototype for narcotic analgesia is morphine, which will be discussed in depth as all opioids have similar actions, side effects and adverse effects. All drugs will be related to the equianalgsic dose or analgesic equivalent of 10 mg of parenteral morphine. Morphine is a potent opioid agonist, stimulating morphine receptors in the brain, spinal cord and other tissues. It is a "non-ceiling" drug, meaning there is no upper limit to the dosage in patients who are tolerant. While it can is typically given by IV or IM, routes postoperatively or in the ED, patients with no IV access can benefit from SC morphine, which is better absorbed than intramuscular morphine.

Morphine can also be administered orally, as a rectal instillation, intrathecally or via the epidural route, making it versatile and easily titrated. Patients with cancer, end-stage COPD or heart failure can benefit from aerosolized morphine for severe dyspnea when inability to swallow exists. It is the drug of choice for pulmonary edema because it reduces preload and therefore cardiac workload. Sustained-release morphine tablets such as MS Contin^® (Purdue Frederick) are used for chronic pain and continuous acute pain that will return if untreated.

By the parenteral route, morphine's onset is rapid, with a half-life of 1.5 hours and a duration of approximately 3 hours. Morphine IV should be diluted with 5 cc of NSS or D5W and administered slowly over 4-5 minutes.

While some texts suggest a dosing interval for morphine of every 4 hours, others prescribe morphine in small doses every 1-3 hours because of the short half-life.

In pain associated with an MI, morphine may be given in increments of 1-2 mg q 15 minutes until the pain is relieved. Smaller, more frequent doses are more easily titrated and relieve pain better than less frequent, higher doses. Consider the order morphine 3-4 mg q6h prn, occasionally see for elderly patients vs. morphine 2 mg q3h prn. Even if a larger dose is administered, if the time interval is longer, the analgesic effects may have diminished. The patient often requires more medication to return him to a state of comfort. However, with a lower dose administered at more frequent intervals, there is a more continuous absorption.

When a dose range is ordered, i.e., morphine 2-4 mg IV q2h, it is appropriate to begin with the lower dose range and increase the dose by 50 percent if pain is not relieved. Therefore, if 2 mg of morphine does not provide relief, it would be appropriate to administer 3 mg.

Patient-Controlled Analgesia
Morphine is frequently used as patient-controlled analgesia (PCA). This intravenous pump is controlled by the patient, gives a preset dose of the narcotic, has a fixed time between doses (lockout) and a maximum dose limit. Education for patients and families is essential when PCA is in use. No one should ever press the button for the patient, as oversedation may result. No additional narcotics such as oxycodone or IM injections should be given. Medication should be available for breakthrough pain in an instant-release oral form or an intravenous bolus of the same medication.

Studies have shown patients using PCA use less narcotic and report more pain relief than patients who need to call the nurse when in pain. PCA may not be the best option for elderly or confused patients. Instead, a small continuous dose may be prescribed (basal dose) to maintain patient comfort; this may also be helpful during sleep or when a patient is unable to follow verbal or written instructions. A maintenance IV infusion is necessary while patients have PCA to dilute the drug and ensure it is delivered into the vein. A narcotic antagonist must be available.

Epidural Analgesia
Epidural analgesia, delivered via an epidural catheter, may be used to control postoperative or cancer pain. This route is beneficial for patients in whom other routes of analgesic have been inadequate or those with chronic lung disease or obesity. This route provides analgesia with little motor or CNS depression.

While rate and depth of respiration and degree of sedation is monitored with all narcotics, including those by the epidural route, the nurse must monitor lower extremity strength and for bladder distention. For added relief, the epidural infusion may be mixed with a local anesthetic such as ropivacaine (Naropin^®, AstraZeneca LP) or bupivacaine (Sensorcaine^®, AstraZeneca LP).

Catheter migration, resulting in incomplete pain relief or dislodgement, may be a problem. It's important to maintain an occlusive dressing and monitor for fever, which is indicative of infection. Getting patients out of bed with epidural catheters is based on physician orders as these catheters are usually taped and not sutured.

Other Opioids
Hydromorphone is a semi-synthetic narcotic that is stronger than morphine and causes less respiratory depression and physical dependence.⁴ A dose of 1.5 mg hydromorphone is equianalgesic to 10 mg morphine by the same route. Hydromorphone is may be given IV by intermittent injection or PCA, IM, orally, or transmucosally in lollipop form. It has a half-life of 2-4 hours. This drug is being used more frequently for PCA, as meperidine has been implicated in causing seizures. Hydromorphone may cause transient hyperglycemia, which does not occur with morphine.

Meperidine, a synthetic narcotic, has been decreasing in use, as doses well over 75-100 mg are needed for analgesia. It is irritating to tissues intramuscularly and is frequently used intravenously. While meperidine is available for oral use, it is only half as effective orally. Meperidine is metabolized to nor-meperidine, a CNS toxin, within hours. This metabolite can causes muscle twitching, confusion and seizures. Therefore, meperidine is avoided where multiple doses are needed unless the patient is allergic to morphine.

Meperidine may cause more hypotension than morphine. Hydantoins decrease the effectiveness of meperidine, perhaps secondary to increased hepatic metabolism of meperidine. To prevent accumulation, patients should have normal renal function when using this drug. Its use is contraindicated with MAOIs.

The narcotic agonist-antagonists such as pentazocine, butorphanol, dezocine and nalbuphine should be used with care. These drugs may precipitate acute withdrawal in patients who were previously taking narcotic agonists, i.e., morphine or heroin. Butorphanol and pentazocine may increase pulmonary artery pressure and systemic vascular resistance, leading to increased cardiac workload. They may also increase intracranial pressure. Pentazocine and butorphanol cause little respiratory depression due to the antagonist effect. Nalbuphine and dezocine possess reparatory depressant effects similar to morphine but not the cardiovascular effects of pentazocine and butorphanol.

Fentanyl is frequently thought of as a peri-anesthetic agent; however, it possesses analgesic properties similar to morphine. Its potency is greater than morphine, with 0.1 mg equianalgesic to 10 mg of morphine. A fentanyl lollipop is available for transmucosal and oral absoprtion. An off-label use is pain control for epidural PCA postoperatively.²

More commonly seen is transdermal fentanyl, used for chronic pain, applied every 72 hours. Patients may be switched from intermittent narcotics to this system for pain that becomes more long term. Note that when first applied, it may take up to 12-24 hours for full pain relief. For example a patient taking 2 mg morphine every 3 hours IV may complain of pain 4 hours after the patch is applied. Doses of a short-acting narcotic for breakthrough pain should be available. Conversely, when removed, effects may linger for 8-12 hours or longer.

Oral Opioids
Oral narcotics can provide excellent pain relief when equianalgesic dosing is used. Oxycodone, frequently combined with aspirin or acetaminophen, can be used for moderate-to-severe pain. The onset, half-life and duration should be considered. Acetaminophen has no effect on inflammation, while aspirin will. Care must be taken with aspirin-containing products in patients with bleeding tendencies, thrombocytopenia or on anticoagulants. When acetaminophen is ordered for fever or pain, care must be taken not to exceed the daily dose of acetaminophen (4,000 mg), which may lead to hepatotoxicity. Another antipyretic such as ibuprofen may be used.

Oxycodone-containing products may be given with food or after meals where appropriate if nausea or stomach upset occurs. Amylase and lipase levels may increase with these drugs. Rapid-release oxycodone (OxyIR^®, Purdue Pharma) is available. Sustained-release oxycodone (Oxycontin^®, Purdue Pharma) has been typically used for chronic pain; however, it is being used more frequently for acute pain. With an onset of 45 minutes and duration of 12 hours, it offers rapid and long-lasting relief.³ While instant-release capsules may be opened, controlled-release tablets or capsules should not be crushed or altered. This drug has been in the news for its controversial abuse potential.

For management of acute moderate-to-severe pain, ketorolac, a non-steroidal anti-inflammatory drug, may be used alone or in combination with narcotics. Ketorolac works best if the initial dose is parenteral. This drug can be given IV by rapid push, IM or orally. Doses are limited to 5 days or 20 doses.

The major side effect is GI upset secondary to inhibition of gastric prostaglandins; this effect will be enhanced with concurrent use of aspirin, alcohol or glucocorticoids. Ketorolac may also increase the risk of bleeding when taken with valproate and certain antineoplastics. Other side effects include drowsiness, headache, nausea, vomiting, diarrhea, dyspepsia and constipation. Anaphylaxis may occur and asthmatics may have increased risk of hypersensitivity. This drug may be taken orally with food or milk.

Codeine, a narcotic for mild-to-moderate pain, may be used by subcutaneous injection, or orally alone or in combination with acetaminophen or other nonsteroidal anti-inflammatory drug. Codeine 30 mg is commonly combined with acetaminophen 325 mg. Codeine causes nausea and vomiting on an empty stomach. Strong antitussive effects may make it undesirable in patients with asthma, COPD and/or pneumonia. Codeine may increase intracranial pressure.

Propoxyphene, a mild opiate, in doses 65-100 mg is equivalent to 32 mg of codeine or 650 mg of aspirin or acetaminophen. It is available for oral use with aspirin or acetaminophen. It is not a substitute for narcotics. Tolerance and dependence may occur.

Hydrocodone, similar to codeine, possesses analgesic and antitussive effects. It is only available with acetaminophen, aspirin or other non-steroidals. A 10 mg oral dose of hydrocodone is equivalent to 60-80 mg codeine.⁴ Tramadol (Ultracet^T, Ortho-McNeil Pharmaceutical), a synthetic centrally acting drug, may bind to pain receptors and inhibit reuptake of norepinephrine and serotonin in the brain. It causes less respiratory depression than morphine.

Methadone, a synthetic narcotic similar to morphine with a long duration of action, is an excellent and inexpensive narcotic analgesic when dosed properly for pain. It is also an effective alternative for those who cannot tolerate morphine. Analgesia occurs within 30-60 minutes after oral dosing. This drug may be used for acute and chronic pain as well as a "replacement"/maintenance narcotic for heroin addicts that does not produce the euphoria of heroin.

Special Situations
Special situations for pain relief include individuals already taking an opioid such as heroin or prescription narcotics such as oxycodone, or individuals with chronic pain following surgery or experiencing an exacerbation of the underlying condition. In this instance, starting at the basal rate and adding drug for the new situation is appropriate. Keep in mind that these individuals are opiate-tolerant and dosing may be higher than the typical patient. As always, keep naloxone on hand to reverse respiratory or central nervous system depression.

Substance abusers, particularly opiate users, represent problem patients when traumatic injury or other problem causes acute pain. Individuals with a history of abuse may be looked upon with skepticism and undermedicated based on biases regarding their lifestyles.¹ Nurses may feel they are reinforcing a drug habit if administering narcotics to control pain, yet the patient may find sources outside the health care facility if pain is not controlled. These individuals are often tolerant to opioids and require higher doses. A basal dose of opioid combined with a non-opioid, cutaneous stimulation including ice or massage, avoiding the use of agonist-antagonists like butorphanol, and clear limits about dosing schedules and choices of drugs are needed.

In such cases, contracts are recommended and consultation with a pain management team may be useful. These documents, developed with the patient and health care team, should include goals for analgesia without sedation or withdrawal symptoms. Expected outcomes and consequences of unacceptable patient behaviors should be included. These patients should be monitored to ensure drugs are not being stolen, hoarded or shared, and to be sure illegal substance are not being brought from outside the hospital. Contracts for outpatients should include dispensing the smallest amount of drug possible and drug screens to detect non-prescribed drugs. No further prescriptions would be given if non-prescription drugs are detected.

Pseudoaddiction
Clock-watchers pose another problem for nurses. They are not usually "addicts" or dependent. Rather, these individuals often have unrelieved pain or fears of unrelieved pain. Patients fear the nurse won't come, will be busy or that their pain is a symptom of a horrible disease. If patients are forced to wait until pain is severe, they may take more medication to provide relief as well as to satisfy psychological craving. While nurses are familiar with pain assessment, we must look deeper into the meaning of pain for the patient. Drug-seeking behavior such as this, termed pseudoaddiction, should be considered a failure of the pain management regimen and not the fault of the patient. Tolerance to opioids may exacerbate the problem.

Failure of many pain regimens is due to undermedication, especially at night. Keep the following points in mind. If a patient is in pain 1-1.5 hours after an injectable pain medication - the peak time - the patient is probably needs a higher dose of the drug. Maximum pain relief should occur at these times. For example, many drugs are prescribed every 4-6 hours when the duration is 3-4 hours. Smaller doses given more frequently will be more effective.

Patients who report inability to eat or sleep may need higher doses, more frequent intervals or adjuvant therapy. Sleeping does not indicate pain relief; the patient may be fatigued due to undermedication or sleeping to cope with pain. Normal sleep should not be confused with overmedication; if respirations are regular (over 10) and the patient is easily awakened, continue with the same dosing regimen and monitor the patient. Round-the-clock dosing will maintain a therapeutic level, even with PCA.

Adjuvant Therapies
Adjuvant therapies, adjunct to pain management can be very helpful. Hydroxyzine or promethazine may add to the analgesic effect of an opioid while promoting relaxation and decreasing the incidence of nausea and vomiting. This is not a substitute for narcotic analgesics when indicated. The muscle relaxation promoted by these drugs will help break the cycle of pain, anxiety and increased pain. According to the manufacturer, hydroxyzine cannot be given intravenously, only IM or orally. Deep IM or the Z-track method is recommended. When patients are using intravenous opiates, consider giving hydroxyzine orally when appropriate, instead of IM.

In cases where nerve pain exists, NSAIDs such as ibuprofen can be used. Carbamazepine, valproate or clonazepam may be effective. Newer anticonvulsants such as gabapentin (Neorontin^®, Parke Davis), topiramate (Topamax^®, Ortho-McNeil Pharmaceutical), lamotrigine (Lamictal^®, GlaxoSmithKline) and tizanidine (Zanaflex^®, Elan Pharmaceuticals) are used regularly for neuropathic pain. Antidepressants such as amitryptiline or imipramine may be used. As nerve pain may become chronic, these adjuncts may help decrease or eliminate the need for narcotic. Other adjuncts include caffeine, which enhances the effects of aspirin, acetaminophen or ibuprofen. An example is the use of aspirin with caffeine for headaches.

Lastly, although perhaps first in importance, no analgesic makes up for nursing care. Comfort measures such as repositioning, proper body alignment, eliminating bright lights and distractions, rhythmic breathing, descriptions of the pain, and emotional support are important. Massage, such as a simple backrub, establishes rapport, stimulates large fiber nerves and closes the pain gate, which induces muscle relaxation and sedation.

The gate control theory of pain suggests there are "gates" that can modify the entry of pain stimuli into the spinal cord and brain. When open, the pain impulses travel from peripheral nerves to lateral spinothalamic tracts and ascend to the brain, where pain is perceived. Sensory stimulation such as back rubs, heat, ice or TENS units make the patient more aware of one sensory stimulus than the pain, which "closes the gate" to the passage of pain impulses. Imagery and distraction with music may also close the gate.

Suggesting to the patient the medication is effective, works quickly or has helped others is known to enhance the drug's effect. Teaching patients and families what to expect decreases fear of the unknown, muscle tension and pain.

Compliance with JCAHO
JCAHO has mandated that health care institutions demonstrate assessment, reassessment, effective management and education for patients about pain management. Points to help your institution remain in compliance with JCAHO standards include: