Assessment and Multimodal Management of Pain an Integrative Approach

Front Cover
Mini Title
Assessment and Multimodal Management of Pain: An Integrative Approach
Copyright
Dedication
Reviewers
Contributors
Foreword
Acknowledgments
Contents
Half Title
Chapter 1 The Evolution of Pain Assessment and Multimodal Analgesia as an Integrative Pain Management Approach
	Incidence and Prevalence of Pain
	Historical Perspective of Multimodal Pain Management
		Growth in Pain Research
		Early National Efforts to Address Pain
	Pain Assessment as the Foundation of Multimodal Analgesia
	Evolution of an Integrative Multimodal Approach for Pain Management (Multimodal Analgesia) (Multimodal Treatment)
		Early Support for Multimodal Analgesia
		The Increase in Opioid Prescribing
		Rise in Opioid-Related Complications
		Resurgence of Support for Integrative, Multimodal, Opioid-Sparing Approaches
	Drivers for Integrative, Multimodal, Opioid-Sparing Approaches
		Professional Organizations
		Centers for Disease Control and Prevention Guidelines
		The Joint Commission
		Enhanced Recovery After Surgery Society Guidelines
		Institute of Medicine Report
		National Pain Strategy
	Future Challenges and Opportunities for Multimodal Analgesia Within an Integrative Approach
	References
Chapter 2 Importance of Multimodal Pain Management
	Physiologic Complications of Unrelieved Pain
	Psychosocial Implications of Unrelieved Pain
		Anxiety
		Depression
		Agitation
	Role of Multimodal Analgesia in the Perioperative Setting
	Role of Multimodal Analgesia in the Management of Chronic Pain
	Ethical Considerations
		Ethical Principles
		Autonomy
		Beneficence
		Nonmaleficence
		Doctrine of Double Effect
		Justice
		Veracity
		Fidelity
	Clinical Application
	Key Points
	Case Scenario
	References
Chapter 3 Physiology of Pain
	Theories of Pain
		Gate Control Theory of Pain
		The Neuromatrix Theory of Pain
		Gain Control Theory
	Other Models
		Biopsychosocial Model
		Fear Avoidance Model
	Classifications of Pain
		Classification Based on Duration
		Classification Based on Mechanism
			Nociceptive Pain
			Neuropathic Pain
			Mixed Pain States
			Pain Physiology and Pathophysiology
		Physiologic Processing of Pain
			Transduction
			Transmission
			Perception
			Modulation
		Abnormal Processing of Pain: Neuropathic Pain and Hypersensitization
			Peripheral Mechanisms and Neuropathic Pain
			Central Mechanisms and Neuropathic Pain
		Neuroinflammation and Immune System
	Special Conditions
		Central Pain
		Chronic Regional Pain Syndrome
	Key Points
	Case Scenario
	References
Chapter 4 Barriers to Effective Pain Management
	Patient Barriers
		Misconceptions
		The Meaning of Pain
		Culture and Beliefs
	Clinical Application
		Past Experiences With Pain
		Patient Expectations of Pain and Pain Control
	Fear
	Fear of Side Effects
		Fear of Substance Abuse or Misuse
			Fear of Appearing To Be Drug Seeking
	Health Care Literacy
	Family
	Access Issues
		Finances
		Transportation
		Residential Area
	Provider Barriers
		Culture
		Perception
		Education
		Clinician Experience
		Golden Rule Versus Platinum Rule
	System Barriers to Effective Pain Management
		Culture of the Organization
		Continuing Education of Clinicians
		Time
		Insurance Coverage
	Opportunities
	Key Points
	Case Scenario
	References
Chapter 5 Introduction to Pain Assessment
	Importance of Pain Assessment
	Classification of Pain
		Differentiation of Acute From Chronic Pain
		Assessment of Pain Mechanisms
	Roles of the Health Team in Pain Assessment
	Timing and Frequency of Pain Assessment
		Discrepancies in Pain Assessment
		Hierarchy of Pain Assessment: Assessing Pain in Patients Who Cannot Self-Report
	Key Points
	Case Scenario
	References
Chapter 6 Pain Assessment in Cognitively Intact Adults
	Accurate Pain Assessment
	Pain Assessment
		Mnemonics for use in Pain Assessment
	Components of a Comprehensive Pain Assessment
		Physiologic and Sensory Aspects of Pain Assessment
			Location
			Intensity
			Onset and Duration (Temporal Aspects)
			Quality
			Aggravating and Alleviating Factors
			Effects of Pain
		Pain Affect
		Psychosocial
		Cognition
			Mental Status
		Sociocultural Factors
			Health Literacy
		Environmental Factors
		Context of Care
		Pertinent History
			Medical History
			Mental Health History
			Substance Use Disorder Risk and History
		Patient Goal
	Conducting the Pain Assessment
		Assessment of Acute Pain
		Assessment of Chronic Pain
	Tools for Assessing Pain
		Clinically Important Changes
		Unidimensional Pain Assessment Tools
			Numeric Rating Scale
			Visual Analogue Scale
			Verbal Descriptor Scales
			Wong-Baker FACES Pain Rating Scale
			FACES Pain Scale (Revised)
			Iowa Pain Thermometer
			Colored Analogue Scale
		Multidimensional Pain Assessment Tools
			Clinically Aligned Pain Assessment Tool
			The Defense and Veterans Pain Rating Scale 2.0
			McGill Pain Questionnaire
			Brief Pain Inventory
			PEG Scale
			Functional Pain Scale
			Chronic Pain Grade Scale
			Short-Form 36 Bodily Pain Scale
		Neuropathic Pain Assessment
			Leeds Assessment of Neuropathic Symptoms and Signs
			Neuropathic Pain Questionnaire
		Breakthrough Pain Assessment
			Alberta Breakthrough Pain Assessment Tool for Cancer Patients
			Breakthrough Pain Assessment Tool
			Italian Questionnaire for Breakthrough Pain
	Key Points
	Case Scenario
	References
	Appendix 6-1
		Translations of the Numeric Rating Scale
	Appendix 6-2
		Translations of Wong-Baker FACES Pain Rating Scale
Chapter 7 Pain Assessment of Patients Who Cannot Self-Report Pain
	Pain Assessment of Patients Who Cannot Self-Report Pain
	Pain Assessment in Critically Ill Adults Who Cannot Self-Report Pain
		Pain Assessment and Intervention Notation Algorithm
		Nonverbal Pain Assessment Tool
		Adult Nonverbal Pain Score
		Behavioral Pain Scale
		The Critical Care Pain Observation Tool
	Patients With Delirium Who Cannot Self-Report Pain
	Patients With Dementia Who Cannot Self-Report Pain
		Pain Assessment Checklist for Seniors With Limited Ability to Communicate
		Pain Assessment in Advanced Dementia
	The Checklist of Nonverbal Pain Indicators (CNPI)
	Patients With Intellectual Disabilities Who Cannot Self-Report Pain
		The Revised Faces, Legs, Activity, Cries, Consolability Scale
		The Individualized Numeric Rating Scale
		The Non-Communicating Adult Pain Checklist
	Patients at the End of Life Who Cannot Self-Report Pain
		The Multidimensional Objective Pain Assessment Tool
		The Pain Assessment in Advanced Dementia Tool
	Newer Trends in Pain Assessment for Patients Who Cannot Self-Report Pain
		Bispectral Index
		Pupillary Reflex as a Physiologic Measure
		The Nociception Level Index
	Cautions
	Key Points
	Case Scenario
	References
Chapter 8 Assessment of Factors Affecting Pain and Affected by Pain
	Sleep
		Insomnia Disorder
		Assessment of Sleep Quality
		Treatment of Sleep Disorders
		Obstructive Sleep Apnea
			Assessment of Sleep Apnea
	Anxiety and Depression
		Anxiety
			Anxiety Sensitivity
			Discomfort Intolerance
			Pain Anxiety
			Pain Catastrophizing
			Assessment of Anxiety
		Depression
			Assessment of Depression
			Suicide Ideation
	Family Assessment
	Financial Assessment
	Key Points
	Case Scenario
	References
Chapter 9 Basic Concepts Involved with Administration of Analgesic Medications
	Patient Considerations
		Age
		Genetics
	Route Selection
		Oral Route
		Transmucosal Route
			Sublingual, Buccal, and Intranasal
			Rectal Route
			Gastrointestinal Stomal Route
			Vaginal Route
		Intravenous Route
		Subcutaneous Route
		Intramuscular Route
		Topical
			Intraarticular and Periarticular Injections
		Transdermal
		Neuraxial and Peripheral Nerve Routes
	Analgesic Dosing Considerations
		Equianalgesic Dosing
		Around-the-Clock Dosing
		Awakening Patients for Analgesic Administration
		Dosing to Pain Intensity Using Numbers or Word Descriptors
		Range Orders
		Therapeutic Duplication
	Key Points
	Case Scenario
	References
Chapter 10 Nonopioid Analgesic Medications
	Aspirin and Nonsteroidal Antiinflammatory Drugs
		History
		Pharmacologic Effects
			Aspirin
			NSAIDs
		Indications for Use
			Aspirin
			NSAIDs
		Adverse Effects
			Bleeding and Gastrointestinal Adverse Effects
			Cardiovascular Adverse Effects
			Renal Adverse Effects
			Blood Pressure Adverse Effects
			Cognitive Adverse Effects
			Hepatic Adverse Effects
			FDA Warnings
			Safety Summary
		Nanopharmacology
		Dosing and Formulations
			Oral
			Parenteral
			Topical Salicylates and NSAIDs
			Other NSAID Routes
				Ophthalmic Route
				Intranasal Route
			Monitoring Patients Receiving NSAID Therapy
		Use in Special Populations
			Older Adults
			Patients With End-Stage Renal Disease
			Surgical Patients
			Patients Who Have Undergone Bariatric Surgery
			Orthopedic Patients
		Acetaminophen
			History
			Pharmacologic Effects
			Indications for Use
			Routes, Formulations, and Dosing
			Adverse Effects
			Hepatotoxicity
				Treatment of Hepatotoxicity
			FDA Warnings
			Monitoring of Patients
			Use in Special Populations
				Older Adults
				Patients With Liver Disease
				Patients With Impaired Renal Function
	Multimodal Use of Nonopioid Analgesics
	Key Points
	Case Scenario
	References
Chapter 11 Opioid Analgesics
	Section 1
		Opioid Pharmacology
		Background
	Opioid Receptors
		Discovery
		Nomenclature
		Opioid Receptor Signaling
	Factors Affecting Drug Response
		Pharmacodynamics
		Pharmacokinetics
			Absorption
			Distribution
			Metabolism
				Drug-Drug Interactions: Phase I Metabolism
				Drug-Drug Interactions: Phase II Metabolism
				Clearance
				Renal Excretion
		Pharmacogenomics
	Opioid Classes
		Phenanthrenes
		Phenylpiperadines
		Diphenylheptane
			Methadone
		Phenylpropylamines
			TraMADol
			Tapentadol
		Benzomorphans
	Key Points
	Section 2
		Opioid Selection
		Indications and Use of Opioids
			Formulations
			Opioid-Related Labeling and Safety Practices
			Adverse Effects
			Assessment and Monitoring of Patients on Opioid Therapy
		Morphine
			Indications and Uses
			Routes and Formulations
			Pharmacologic Considerations
		Codeine
			Indications and Uses
			Routes and Formulations
			Pharmacologic Considerations
			Adverse Effects
		FentaNYL
			Parenteral FentaNYL
				Indications and Uses
				Pharmacologic Considerations
				Other Considerations
			Transmucosal FentaNYL
				Indications and Uses
				Pharmacologic Considerations
				Other Considerations
			Transdermal FentaNYL
				Indications and Uses
				Pharmacologic Considerations
				Other Considerations
		HYDROcodone
			Indications and Uses
			Routes and Formulations
			Pharmacologic Considerations
			Other Considerations
				Benzhydrocodone
		HYDROmorphone
			Indications and Uses
			Routes and Formulations
			Pharmacologic Considerations
		Meperidine
			Indications and Uses
			Adverse Effects
		Methadone
			Indications and Uses
			Routes and Formulations
			Pharmacologic Considerations
			Other Considerations
			Drug-Drug Interactions
		Levorphanol
			Indications and Uses
			Routes and Formulations
			Pharmacologic Considerations
		OxyCODONE
			Indications and Uses
			Routes and Formulations
			Pharmacologic Considerations
			Other Considerations
		OxyMORphone
			Indications and Uses
			Routes and Formulations
			Pharmacologic Considerations
			Other Considerations
		Other Mu Opioid Analgesics
			Alfentanil
				Indications and Uses
				Routes and Formulations
				Pharmacologic Considerations
				Other Considerations
			Remifentanil
				Indications and Uses
				Routes and Formulations
				Pharmacologic Considerations
				Other Considerations
			SUFentanil
				Indications and Uses
				Routes and Formulations
				Pharmacologic Considerations
				Other Considerations
		Dual-Mechanism Analgesics
			TraMADol
				Indications and Uses
				Pharmacologic Considerations
				Other Considerations
			Tapentadol
				Indications and Uses
				Routes and Formulations
				Pharmacologic Considerations
				Other Considerations
		Partial Mu Agonist
			Buprenorphine
				Indications and Uses
				Routes and Formulations
				Pharmacologic Considerations
				Other Considerations
		Mixed Agonist-Antagonist Opioids
		Opioid Antagonists
			Indications and Uses
			Routes and Formulations
			Pharmacologic Considerations
			Other Considerations
			Naloxone
				Indications and Uses
				Routes and Formulations
				Pharmacologic Considerations
				Other Considerations
	Key Points
	Section 3
		Opioid Dosing Practices
		Initiation of Opioid Therapy
		Titration of Short-Acting Opioid Dose
			Titration of Short-Acting Opioids in Patients With Severe Acute Pain
		Use of Modified-Release Opioids
		Titration of Modified-Release Opioid
		Continuous Intravenous Opioid Infusions
		Opioid Rotation or Switch
		Rotating From Other Opioids to Methadone
		Buprenorphine
	Tapering and Discontinuing Opioid Therapy
		Opioid Safety in the Community
	Key Points
	Case Scenario
	References
Chapter 12 Common Unintended Effects of Opioids
	Constipation
		Assessment of Opioid-Induced Constipation
		Prevention and Management of Opioid-Induced Constipation
		Pharmacologic Management
		Nonpharmacologic Management
	Xerostomia (Dry Mouth)
		Assessment
		Prevention and Management
	Opioid-Induced Nausea and Vomiting
		Assessment
		Prevention and Management
			Pharmacologic Management
			Nonpharmacologic Management
	Pruritus
		Assessment
		Prevention and Management of Opioid-Induced Pruritus
			Other Prevention and Management Considerations
	Urinary Retention
		Assessment for Urinary Retention
		Prevention and Management of Opioid-Related Urinary Retention
	Hypogonadism
		Assessment
		Prevention and Management of Opioid-Induced Hypogonadism
	Sedation
		Assessment
		Prevention and Management
	Myoclonus
		Assessment
		Prevention and Management
	Opioid-Induced Hyperalgesia
		Prevention
	Physical Dependence on Opioids
		Assessment
		Prevention and Management
	Opioid Tolerance
	Immune Suppressing Effect of Opioids
	Key Points
	Case Scenario
	References
Chapter 13 Preventing Opioid-Induced Advancing Sedation and Respiratory Depression
	Opioids and Respiratory Function
		Normal Respiratory Physiology and the Effect of Opioids
	Advancing Sedation and Opioid-Induced Respiratory Depression
		Incidence
		Overview of Current Recommendations
	Identification of the Risk Factors
		Nonmodifiable Risk Factors
			Obstructive Sleep Apnea
				Screening for Obstructive Sleep Apnea
			Screening for Obesity Hypoventilation Syndrome
		Risk Factors Associated With Naloxone Administration
		Modifiable Risk Factors
		Timing of Care and Assessments
		Communication Within the Health Care Team
		Health Care Team and Institutional Policies and Procedures
	Associated Pharmacologic Factors
		Formulations of Opioid Medications and Risks
		Mechanisms of Delivery of Opioid Medications and Risks
			Clinician Boluses
			Continuous Intravenous Infusion
			Intravenous Patient-Controlled Analgesia
			Neuraxial Analgesia
			Epidural Analgesia
			Peripheral Regional Analgesia
			Wound Infiltration Analgesia
			Periarticular Injections
		Delivery Systems
		Combining Classes of Medications and Their Synergistic Effects
	Strategizing to Improve Safety for Patients at Risk
	Assessing the Patient for Risk
		Subjective Assessment of Risk
		Objective Assessment of Risk
		Detection Using Electronic Monitoring Devices
		Monitoring the Patient
	Procedures for Intermittent Nursing Assessment for All Patients on Opioids: Level of Sedation
		Pasero Opioid Sedation Scale
		Michigan Opioid Safety Score
		Richmond Sedation Scale
	Procedures for Intermittent Nursing Assessment for All Patients on Opioids: Respiratory Status
		Continuous Electronic Monitoring
		Pulse Oximetry
		Respiratory Rate
		Capnography
		Minute Ventilation
		Interventions After Assessment
	Summary
	Key Points
	Case Scenario
	Acknowledgments
	References
Chapter 14 Opioid Use Disorder
	Substance Use Disorder and Opioid Use Disorder
		Pathophysiology of Substance Use Disorder
		Terminology Related to Substance Use Disorder
		Ethical Challenges to the Treatment of Pain in Patients With Comorbid Opioid Use Disorder
	Caring for Patients With Pain and Opioid Use Disorder
		Clinical Challenges of Treating Pain With Comorbid Opioid Use Disorder
		Risk Factors for Development of Opioid Use Disorder
	Treatment of Opioid Use Disorder
		Methadone
		Buprenorphine
		Naltrexone
	Pain and Opioid Use Disorder: Acute Care Setting
		Screening for Opioid Use Disorder in the Acute Care Setting
		Acute Pain Management of the Patient With Active Opioid Use Disorder Who Is Not in Active Treatment
		Acute Pain Management for Patients on Medication-Assisted Treatment
			Acute Pain Management for Patients on Methadone Maintenance Therapy
			Acute Pain Management for Patients on Buprenorphine Therapy
			Acute Pain Management for Patients on Naltrexone
		Acute Pain Management for Patients With Opioid Use Disorder in Recovery Without Medication-Assisted Treatment
		Acute Pain Management: Special Considerations
		Discharge Planning for Patients With Opioid Use Disorder
		Chronic Pain Management in Patients With Opioid Use Disorder
		Chronic Pain Management for Patients With Opioid Use Disorder on Medication-Assisted Treatment: Special Considerations
			Methadone Maintenance Therapy
			Buprenorphine Therapy
			Naltrexone Therapy
		Chronic Pain Management for Patients in Recovery Without the Use of Medication-Assisted Treatment
		Chronic Pain Management for Patients With Active Opioid Use Disorder Who Are Not in Recovery
	Strategies to Reduce Risk
		Universal Precautions
		Opioid Selection
		Designing a Safe Treatment Plan
		Overdose Prevention
		Additional Considerations
	Key Points
	Case Scenario
	References
Chapter 15 Coanalgesic Medications
	Medication Selection
	Gabapentinoids
		Mechanism of Action
		Indications and Uses
			Gabapentinoids and Neuropathic Pain
			Gabapentinoids and Perioperative Pain
			Gabapentinoids and Prevention of Chronic Postsurgical Neuropathic Pain
		Pharmacokinetics
		Dosing and Routes
		Adverse Effects
		Monitoring of Patients
	Antidepressants
		Tricyclic Antidepressants
			Mechanism of Action
			Indications and Uses
			Pharmacokinetics
			Dosing Selection
			Adverse Effects
			Monitoring of Patients
		Serotonin Norepinephrine Reuptake Inhibitors
			Mechanism of Action
			Indications and Uses
				DULoxetine
				Venlafaxine
				Milnacipran
				SNRIs and Pain-Related Research
			Pharmacokinetics
			Dosing and Routes
			Adverse Effects
			Monitoring of Patients
	Alpha-Adrenergic Receptor Agonists
		Mechanism of Action
		Indications and Uses
			CloNIDine
			TiZANidine
			Dexmedetomidine
		Pharmacokinetics
		Dosing and Routes
			CloNIDine
			TiZANidine
			Dexmedetomidine
		Adverse Effects
			CloNIDine
			TiZANidine
			Dexmedetomidine
		Monitoring of Patients
	Corticosteroids
		Mechanism of Action
		Indications and Uses
		Dosing and Routes
		Adverse Effects
		Monitoring of Patients
	N-Methyl-d-Aspartate Receptor Antagonists
		Dextromethorphan
			Mechanism of Action
			Indications and Uses
			Pharmacokinetics
			Dosing and Routes
			Adverse Effects
			Monitoring of Patients
		Ketamine
			Mechanism of Action
			Indications and Uses
			Acute Pain
			Chronic Pain
			Pharmacokinetics
			Dosing and Routes
			Adverse Effects
			Monitoring of Patients
		Magnesium
			Mechanism of Action
			Indications and Uses
			Dosing and Routes
			Adverse Effects
			Monitoring of Patients
	Sodium Channel Blockers: Lidocaine and Mexiletine
		Lidocaine
			Mechanism of Action
			Indications and Uses
			Dosing and Routes
			Adverse Effects
			Monitoring of Patients
		Mexiletine
			Indications and Uses
			Dosing and Routes
			Adverse Effects
			Monitoring of Patients
	Muscle Relaxants
		Baclofen for Spasticity From Upper Motor Neuron Syndromes
			Mechanism of Action
			Indications and Uses
			Dosing and Routes
			Adverse Effects
			Monitoring of Patients
		Skeletal Muscle Relaxants for Muscular Pain and Spasms From Musculoskeletal Conditions
			Mechanism of Action
			Indications and Uses for Skeletal Muscle Relaxants for Peripheral Conditions
			Dosing and Routes
			Adverse Effects
			Monitoring of Patients
	Dronabinol, Nabilone, and Cannabidiol
		Mechanism of Action
		Indications and Uses
		Dosing and Routes
		Adverse Effects
		Monitoring of Patients
	Other Coanalgesic Medications
	Key Points
	Case Scenario
	References
Chapter 16 Topical Analgesics for the Management of Acute and Chronic Pain
	Benefits of Topical Analgesics
	Types of Topical Analgesics
		Counter-irritants
			Capsaicin
				Capsaicin Application, Dosing, and Monitoring
			Salicylates
			Menthol
		Local Anesthetics
			Lidocaine
				Lidocaine Application, Dosing, and Monitoring
		Nonsteroidal Antiinflammatory Drugs
			Diclofenac
				Diclofenac Application, Dosing, and Monitoring
	Compound Analgesics
		Ketamine
		Amitriptyline
		Ketamine and Amitriptyline Combination
		CloNIDine
		Gabapentin
		Baclofen
		Opioids
	Key Points
	Case Scenario
	References
Chapter 17 Patient-Controlled Analgesia
	General Concepts
		Advantages of Use
		Indications for Use
	Optimize Safety Within the Patient-Controlled Analgesia Process
		Clinician Education
			General Concepts
			Equipment-Related Education
			PCA by Proxy
		Patient and Family Education
		Appropriate Prescription
		Patient Selection
			Cognitive Factors to Consider
			Psychological Factors to Consider
			Physiologic Factors to Consider
	Prescription Components
		Modes of Administration
		Medications Administered
			Medications Frequently Administered by PCA
				Mu Agonist Opioids
				Local Anesthetics
			Medications Not Frequently Administered by PCA
				CloNIDine
				Neostigmine
				Ketamine
				Dexmedetomidine
		Technical Components of Prescription
			Medication Concentration
			Clinician Rescue Dose and Loading Dose
			Bolus Dose or Demand Dose
			Lockout Interval
			Hourly Maximum
			Basal or Continuous Infusion Rate
	Routes of Administration
		Intravenous Route
		Epidural Route
		Regional Route
		Subcutaneous Route
		Transdermal Route
		Oral or Enteral Route
		Intranasal Route
		Sublingual Route
		Inhalation Route
	Patient Assessment and Monitoring to Optimize Safety
		Respiratory Assessment
		Sedation Assessment
		Monitoring With Equipment
			Pulse Oximetry
			Capnography
	Evaluating Equipment to Optimize Patient Safety
		Infusion Tubing
	Authorized Agent–Controlled Analgesia
		Family-Controlled or Caregiver-Controlled Analgesia
		Nurse-Controlled Analgesia
	Key Points
	Case Scenario
	References
Chapter 18 Regional Analgesia, Local Infiltration, and Pain Management
	Neuraxial Analgesia
		Principles of Neuraxial Analgesia
		Neuraxial Anatomy
			Vertebral Column
			Spinal Nerves
		Neuraxial Analgesic Interventions
			Neuraxial Analgesia
		Beneficial Effects of Neuraxial Analgesia
		Contraindications to Neuraxial Analgesia
		Neuraxial Analgesia Techniques
			Spinal (Subarachnoid or Intrathecal) Analgesia
			Epidural Analgesia
				Thoracic Epidural Analgesia
				Lumbar Epidural Analgesia
				Combined Spinal-Epidural
				Caudal Anesthesia
		Medications Used In Neuraxial Analgesia
			Basic Pharmacology of Neuraxial Opioid Analgesics
				Bioavailability
				Solubility
				Equianalgesic Dose Conversions
			Distribution
			Selected Opioid Analgesics
				Morphine
					Extended-Release Epidural Morphine
				HYDROmorphone
				FentaNYL
				SUFentanil
			Local Anesthetics
				Mechanism of Action
				Effects of Local Anesthetics
					Effects on Sensation and Motor Activity
					Vasodilatation
					Basic Chemical Structure
					Physiologic and Chemical Activity
					Absorption and Distribution
					Metabolism and Excretion of Local Anesthetics
				Local Anesthetic Choices
		Multimodal Analgesia Using Neuraxial Opioids and Local Anesthetics
		Coanalgesic Medications Used in Neuraxial Analgesia
			Epinephrine
			Alpha 2 -Adrenergic Agonists (CloNIDine and Dexmedetomidine)
		Administration of Neuraxial Medications
			Continuous Infusion
			Clinician-Administered Intermittent Bolus
			Patient-Controlled Epidural Analgesia
			Programmed Intermittent Epidural Bolus
		Unintended Effects of Neuraxial Analgesics
			Neuraxial Opioid Adverse Effects
		Unintended Effects of Neuraxial Local Anesthetics
			Allergic Reaction
			Local Anesthetic Neurotoxicity
			Local Anesthetic Systemic Toxicity
				Risk Factors for LAST
				Signs and Symptoms of LAST
				Strategies to Reduce Risks for LAST
				Treatment of LAST
			Cardiovascular Unintended Effects
				Hypotension
				Bradycardia
				Urinary Retention
				Motor Block
		Other Potential Complications Related to Neuraxial Analgesia
			Procedure-Related Complications
				Ineffective, Partial, or Incomplete Neuraxial Analgesia
				Dural Puncture and Postdural Puncture Headache
					Signs and Symptoms of PDPH
					Treatment of PDPH
				Direct Needle Trauma
			Epidural Catheter–Related Complications
				Epidural Catheter Migration
				Signs and Symptoms of Epidural Catheter Migration
		Neurologic Complications Associated With Neuraxial Analgesia
			Injection or Infusion of Neurotoxic Agents
			Infection
				Risk Factors for Neuraxial Infection
				Strategies to Reduce Risk for Neuraxial Infection
				Signs and Symptoms of Neuraxial Infection
				Treatment of Neuraxial Infection
			Epidural Hematoma
				Risk Factors for Epidural Hematoma
				Signs and Symptoms of Epidural Hematoma
				Diagnosis of Epidural Hematoma
				Treatment of Epidural Hematoma
	Regional Analgesia
		Overview of Truncal and Peripheral Regional Analgesia
		Peripheral Nerve Block Interventions
		Beneficial Effects of Peripheral Nerve Blocks
		Contraindications and Risks Associated With Peripheral Nerve Blocks
		Medications for Peripheral Nerve Blocks
		Administration of Peripheral Nerve Block Medications
		Management of Peripheral Nerve Block Catheters and Infusions
		Peripheral Nerve Blocks: Truncal Approaches
			Paravertebral Block
				Anatomy
				Indications
				Technique
				Considerations
			Erector Spinae Plane
				Indications
				Technique
				Considerations
			Pectoralis
				Indications
				Technique
				Considerations
			Transversus Abdominis Plane
				Indications
				Technique
				Considerations
			Quadratus Lumborum
				Indications
				Technique
				Considerations
		Peripheral Nerve Blocks: Extremity Approaches
			Interscalene Nerve Block
				Indications
				Interscalene Anatomy
				Technique
				Considerations
				Complications
			Supraclavicular
				Indications
				Technique
				Considerations
			Infraclavicular
				Indications
				Technique
				Considerations
			Axillary
				Indications
				Technique
				Considerations
			Femoral
				Indications
				Technique
				Considerations
			Fascia Iliaca
				Indications
				Technique
				Considerations
		Adductor Canal
			Indications
			Technique
			Considerations
			Sciatic Nerve Block
				Indications
				Technique
				Considerations
			Ankle Block
				Indications
				Technique
				Considerations
	Regional Analgesia Infusion Systems
		Tapering and Discontinuing Regional Analgesia Catheters
		Catheter Removal
		Preventing and Managing Regional Analgesia Infusion System Complications
		Minimizing Errors in Administration of Regional Anesthesia
	Local Infiltration Analgesia
	Additional Analgesic Procedures Involving Use of Local Anesthetics
	Key Points
	Case Scenario
	References
Chapter 19 Interventional Approaches
	Anatomy of the Central Nervous System
	Spinal Pain
	Diagnostic Imaging
	Spinal Injections
		Epidural Corticosteroid Injections
			Indications
			Contraindications
			Research
		Facet Injections
			Medial Branch Blocks
			Neurotomy
			Contraindications
			Complications
			Facet Injections
			Complications of Radiofrequency Ablation
			Postprocedure Care
			Research
		Vertebral Body Augmentation
			Contraindications
			Complications
			Postprocedure Care
			Research
	Implantable Therapies
		Spinal Cord Stimulators
			Devices
			Patient Selection
			SCS Trial
			SCS Device Implantation
			Contraindications
			Precautions
			Complications
			Postimplantation Care
			Research
		Intrathecal Drug Delivery System
			Indications
			Patient Selection
			Devices
			Intrathecal Medications
			IDDS Trial
			Permanent Implantation
			Contraindications
			Complications
			Postprocedure Care
			Research
	Key Points
	Case Scenario
	Acknowledgement
	References
Chapter 20 Exercise and Movement
	Fear of Pain With Movement
		Fear of Pain
		Fear-Avoidance Model
		Assessment of Fear of Pain With Movement
		Treatment of Fear of Pain With Movement
	Exercise-Induced Hypoalgesia
	Movement
		Movement When Recovering With Acute Pain
		Paleo Movement
		Movement With Chronic Pain
		The Feldenkrais Method
	Dance Movement Therapy
		Connection Dance
		Biodanza
	Exercise
		Isometric Exercise
		Pilates Exercise
		Land Aerobic Exercise
		Aquatic Exercise
		Strengthening Exercises
		Goldfish Exercise
	Tai Chi
	Yoga
	Physical Therapy
		Therapeutic Exercise
		Mechanical Modalities
		Passive Therapies
		Electrotherapeutic Modalities
	Patient Education for All Exercise and Movement
	Key Points
	Case Scenario
	References
Chapter 21 Distraction and Relaxation
	Distraction
		Types of Distraction
			Evidence and Indications for Pain Management
		Humor
			Evidence and Indications for Pain Management
			Cautions
		Art, Coloring, Drawing, and Doodling
			Evidence and Indications for Pain Management
		Electronic Games
			Evidence and Indications for Pain Management
			Cautions
	Virtual Reality and Immersion or Immersive Virtual Reality
		Evidence and Indications for Pain Management
	Relaxation
		Breathing Activities
		Types of Relaxation Breathing
			Diaphragmatic Breathing
			Abdominal Breathing
			Yogic Breathing or Pranayama
			Alternate Nostril Breathing
			Square Breathing
			Lamaze Breathing
		Evidence and Indications for Pain Management
		Cautions
	Progressive Muscle Relaxation
		Evidence and Indications for Pain Management
		Cautions
	Music Therapy
		Music Therapy as a Profession
		Music Therapy and Multimodal Pain Management
		Indications Using Music for Pain Control
		Evidence and Indications for Pain Management
		Concerns, Cautions, and Contraindications
	Animal-Assisted Therapy
		Definitions
			Animal-Assisted Therapy
			Animal-Assisted Activity
		Indications for Animal-Assisted Therapy and Animal-Assisted Activity
		Evidence and Indications for Pain Management
		Cautions
	Guided Imagery
		Evidence and Indications for Pain Management
		Cautions and Contraindications
	Autogenic Training
		Evidence and Indications for Pain Management
		Contraindications
	Key Points
	Case Scenario
	References
Chapter 22 Cognitive-Behavioral and Psychotherapeutic Interventions as Components of Multimodal Analgesic Pain Management
	Integrative, Interdisciplinary, and Multimodal Pain Treatment
	Interdisciplinary Pain Rehabilitation or Functional Restoration Programs
	Cognitive-Behavioral Therapy
		Goal Setting
		Identifying Maladaptive Thinking
		Cognitive Restructuring
		Problem-Solving
		Behavioral Activation (Graded Behavioral Activation)
		Exposure Therapy (Graded Exposure Therapy)
		Coping Skill Development
		Coping With Trigger Factors
		Relapse Prevention and Maintenance of Skills
	Evidence Supporting Cognitive-Behavioral Therapy for Pain Management
		Cautions and Contraindications
	The Activating Event Belief Consequence Model
		Evidence for Pain Management
	Acceptance and Commitment Therapy
		Evidence for Pain Management
	Biofeedback (Applied Psychophysiology)
		Evidence for Pain Management
	Mindfulness-Based Stress Management and Mindfulness-Based Cognitive Therapy
		Evidence for Pain Management
	Psychoeducation
		Evidence for Pain Management
	Key Points
	Case Scenario
	References
Chapter 23 Energy Healing Therapies or Biofield Therapies as Components of Multimodal Analgesic Pain Management
	Reiki
		Indications
		Evidence for Pain Management
		Cautions
	Therapeutic Touch
		Evidence for Pain Management
		Cautions
	Healing Touch
		Evidence for Pain Management
		Cautions
	Acupuncture
		Evidence for Pain Management
		Caution
	Auricular Acupuncture
		Evidence for Pain Management
		Caution
	Acupressure
		Evidence for Pain Management
		Caution
	Key Points
	Case Scenario
	References
Chapter 24 Manual Therapies for Pain Management
	Manual Therapy
	Osteopathy, Osteopathy Manual Medicine, or Osteopathic Manipulative Therapy
		Evidence for Pain Management
		Research
	Craniosacral Therapy
		Evidence for Pain Management
		Cautions
	Massage Therapy
		Evidence for Pain Management
		Cautions
	Reflexology
		Evidence for Pain Management
		Cautions
	Chiropractic Practice
		Evidence for Pain Management
	Cautions
	Myofascial Trigger Point Therapy
		Evidence for Pain Management
		Cautions
	Muscle Energy Technique
		Evidence for Pain Management
		Cautions
	Fascial Distortion Model
		Evidence for Pain Management
		Cautions
	Key Points
	Case Scenario
	Acknowledgments
	References
Chapter 25 Spirituality as a Component of Multimodal Pain Management
	Spirituality
	Prayer
		Evidence for Pain Management
		Cautions
	Meditation
		Centering Prayer (Spiritual Meditation)
			Evidence for Pain Management
		Kabbalah (Qabalah)
			Evidence for Pain Management
		Loving Kindness Meditation
			Evidence for Pain Management
		Mindfulness Meditation
		Reflective Walking, Labyrinth Walking, and Movement Meditation
			Evidence for Pain Management
		Ridhwan School Diamond Approach
			Evidence for Pain Management
		Self-Realization Fellowship
			Evidence for Pain Management
		Tibetan Buddhist Meditation
			Evidence for Pain Management
		Transcendental Meditation
			Evidence for Pain Management
		Zen Buddhism/Ch’an
			Evidence for Pain Management
	General Cautions and Precautions Regarding Meditation
	Key Points
	Case Scenario
	References
Chapter 26 Natural Products: Supplements, Botanicals, Vitamins, and Minerals as a Component of Multimodal Pain Management
	Dietary Supplements
	Botanicals and Herbs
		Cannabis (Cannabis sativa, Cannabis indica, and Cannabis indica)
			Evidence for Pain Management
			Cautions and Contraindications
			Contraindications
			Potential Interactions With Medications
		Cat’s Claw (Uncaria tomentosa)
			Evidence for Pain Management
			Cautions
			Contraindications
			Potential Interactions With Medications
		Cayenne (Capsicum frutescens)
		Devil’s Claw (Harpagophytum procumbens, Harpagophytum zeyheri)
			Evidence for Pain Management
			Cautions
			Contraindications
			Potential Interactions With Medications
		Feverfew (Tanacetum parthenium L.)
			Evidence for Pain Management
			Cautions
			Contraindications
			Potential Interactions With Medications
		Frankincense or Olibanum (Boswellia serrata)
			Evidence for Pain Management
			Cautions
			Contraindications
			Potential Interactions With Medications
		Ginger (Zingiber officinale Roscoe)
			Evidence for Pain Management
			Cautions
			Contraindications
			Potential Interactions With Medications
		Turmeric (Curcuma longa or Curcuma domestica)
			Evidence for Pain Management
			Cautions
			Contraindications
			Potential Interactions With Medications
		Willow Bark (Salicis cortex) and White Willow Bark (Salix alba)
			Evidence for Pain Management
			Cautions
			Contraindications
			Potential Interactions With Medications
		Other Herbs and Botanicals Used for Pain Management
			Brazilian arnica (Solidago chilensis)
			Butterbur (Petasites hybridus)
			Comfrey (Symphytum officinale L.)
			Ginseng (Panax ginseng)
			Myrrh (Commiphora molmol)
			St. John’s Wort (Hypericum perforatum)
	Pharmaconutrients: Nutritional Modulators of Pain
		Avocado and Soybean Unsaponifiables (Persea gratissma and Glycine max) (Piascledine)
			Evidence for Pain Management
			Cautions
			Contraindications
			Potential Interactions With Medications
		Bromelain (Ananas comosus) (Pineapple Plant)
			Evidence for Pain Management
			Cautions
			Contraindications
			Potential Interactions With Medications
		Flavocoxid
			Evidence for Pain Management
			Cautions
			Contraindications
			Potential Interactions With Medications
		Green Tea (Camellia sinensis)
			Evidence for Pain Management
			Cautions
			Contraindications
			Potential Interactions With Medications
		Honey
			Evidence for Pain Management
			Cautions
			Contraindications
			Potential Interactions With Medications
	Supplements
		Acetyl-l-Carnitine
			Evidence for Pain Management
			Cautions
			Contraindications
			Potential Interactions With Medications
		Coenzyme Q10 (Ubiquinone-10)
			Evidence for Pain Management
			Cautions
			Contraindications
			Potential Interactions with Medications
		Glucosamine Hydrochloride or Sulfate and Chondroitin Sulfate
			Evidence for Pain Management
			Cautions
			Contraindications
			Potential Interactions With Medications
		Hyaluronic Acid
			Evidence for Pain Management
			Cautions
			Contraindications
			Potential Interactions With Medications
		Lactic Acid–Producing Bacteria (Lactobacillus acidophilus, casei, fermentum, gasseri, johnsonii, paracasei, plantarum, reu ...
			Evidence for Pain Management
			Cautions
			Contraindications
			Potential Interactions With Medications
		Magnesium
			Evidence for Pain Management
			Cautions
			Contraindications
			Potential Interactions With Medications
		Methylsulfonylmethane
			Evidence for Pain Management
			Cautions
			Contraindications
			Potential Interactions With Medications
		Omega-3 Polyunsaturated Fatty Acids (Eicosapentaenoic Acid and Docosahexaenoic Acid)
			Evidence for Pain Management
			Cautions
			Contraindications
			Potential Interactions With Medications
	Vitamins
		B Vitamins
			Vitamin B1 (Thiamine)
				Evidence for Pain Management
				Cautions
				Contraindications
				Potential Interactions With Medications
			Vitamin B2 (Riboflavin)
				Evidence for Pain Management
				Cautions
				Contraindications
				Potential Interactions With Medications
			Vitamin B6 (Pyridoxine, Pyridoxal, and Pyridoxamine)
				Evidence for Pain Management
				Cautions
				Contraindications
				Potential Interactions With Medications
			Vitamin B9 (Folate or Folic Acid)
				Evidence for Pain Management
				Cautions
				Contraindications
				Potential Interactions With Medications
			B12 (Cyanocobalamin or Cobalamin)
				Evidence for Pain Management
				Cautions
				Contraindications
				Potential Interactions With Medications
			Vitamin B Complex and Combinations
				Evidence for Pain Management
				Cautions
				Contraindications
				Potential Interactions With Medications
		Vitamin D
			Evidence for Pain Management
			Cautions
			Contraindications
				Potential Interactions With Medications
		Vitamin E
			Evidence for Pain Management
			Cautions
			Contraindications
			Potential Interactions With Medications
	Key Points
	Case Scenario
	References
Chapter 27 Additional Nonpharmacologic Interventions as Components of Multimodal Pain Management
	Aromatherapy
		Evidence for Pain Management
		Cautions
	Caring, Empathy, and Compassion by Caregivers
		Evidence for Pain Management
		Cautions
	Crossing Hands and/or Arms Over the Midline
		Evidence for Pain Management
		Cautions
	Dietary Choices
		Antiinflammatory Diet
			Evidence for Pain Management
			Cautions
		Ketogenic Diet
			Evidence for Pain Management
			Cautions
	Environmental Modifications
		Lighting
		Sound
		Temperature
		Position
		Evidence for Pain Management
		Caution
	Hypnosis
		Evidence for Pain Management
		Caution
	Mirror Therapy or Mirror Visual Feedback Therapy
		Evidence for Pain Management
		Mirror Visual Feedback Therapy and Other Chronic Pain Conditions
		Virtual Reality Mirror Visual Feedback Therapy
		Mirror Visual Feedback Therapy in Home Settings
		Mirror Visual Feedback Therapy and Referred Sensations
		Cautions for Using Mirror Visual Feedback Therapy
	Obesity and Weight Management
		Evidence for Pain Management
		Cautions
	Static Magnet Therapy
		Evidence for Pain Management
		Cautions
	Temperature Modalities
		Therapeutic Superficial Heat
			Evidence for Pain Management
			Cautions
			Contraindications
		Therapeutic Cold, Ice, Cryotherapy
			Evidence for Pain Management
			Cautions
			Contraindications
	Alternating or Contrasting Temperature Therapy
		Evidence for Pain Management
		Cautions
	Valsalva Maneuver
		Evidence for Pain Management
		Cautions
		Contraindications
	Key Points
	Case Scenario
	References
Chapter 28 Improving Institutional Commitment for Effective Multimodal Pain Management
	Organizational Commitment to Quality and Pain Management
		Customer Satisfaction
		Patient Safety
		Clinical Care
	Organizational Initiatives to Support Quality of Safe and Effective Multimodal Pain Management
		Interdisciplinary Pain Oversight Committee
		Medication Safety Committee
		Opioid Risk Initiatives and Safety Interventions
			Naloxone Availability
	Quality Improvement
		Plan-Do-Study-Act
		Lean Methodology
		A3 Methodology
			A3: Pitfalls
		Clinical Research Programs
	Clinical Nursing Efforts to Support Organizational Initiatives
		Nursing Shared Governance
		Pain Resource Nurse Program
	Education of Clinicians
	Future Opportunities for Improvement
		Innovation
		Resources for Guiding Improvements in Institutional Commitment to Safe and Effective Pain Management
	Key Points
	Case Scenario
	References
Appendix: Terminology
Index