Practical Treatment of Wound Pain and Trauma: A Patient-Centered Approach. An Overview

Author(s): 
Madhuri Reddy, MD, FRCPC(Geriatric Med); Rosemary Kohr, RN, MScN, ACNP; Douglas Queen, BSc, PhD, MBA; David Keast, MD, FCFP; and R. Gary Sibbald, MD, FRCPC(Med)(Derm)

However, consensus statements from major professional pain organizations (eg, the Canadian Pain Society, the American Academy of Pain Management, and the American Pain Society) endorse their use in appropriate situations, and the practice is becoming more acceptable.4 Although healthcare providers have been reluctant to prescribe these drugs because of political and social pressures, the incidence of addictive behavior among patients taking opioid drugs for medical reasons is low.32-35
Consultation with a specialist in pain medicine may be needed, but unfortunately these consultants are not always available on a timely basis to primary care physicians. Therefore, a consultation with a specialist in pain management should not be a prerequisite to the use of opioid therapy.36
Opioid peak concentrations occur 60 to 90 minutes after oral ingestion. When given as breakthrough doses for dressing changes, these drugs should be given in the appropriate time frame to be effective (see Table 3).
Long-term opioid therapy should be started at low doses and carefully titrated until an adequate level of analgesia is obtained or until unmanageable side effects occur. Use of combination products (eg, oxycocet [Oxycet, Technilab, Quebec, Canada, or Percocet, Dupont Pharma, Ontario, Canada]) may be limited because of ceiling doses of acetaminophen or acetylsalicylic acid (ASA) which are combined with the opioid. In addition, these combination medications often contain caffeine as a co-analgesic and may be undesirable in some patients. Use of an opioid with a long duration of action has many advantages for treating chronic pain: It can facilitate patient adherence and provide a more consistent blood level (hence, fewer side effects).37 Breakthrough opioid doses should be provided and may be used, for example, before dressing changes. The goal of optimal opioid titration is to decrease the frequency of breakthrough doses to a minimum.36
Methadone is a potent µ-opioid-receptor agonist. It can be an effective medication for treatment of chronic pain and may slow the development of opioid tolerance. However, it is difficult to titrate because of its long and variable half-life.38 Clinicians prescribing methadone must be experienced with its use in closely monitored settings.39 In some jurisdictions, methadone prescription is limited to specifically authorized physicians who prescribe it primarily for the treatment of drug habituation (see Table 4).
Monitoring side effects of opioid therapy should focus on neurologic, gastrointestinal, and cognitive-behavioral effects. Common side effects should be anticipated and prevented before they become severe problems. A prophylactic bowel regimen should be initiated with the commencement of persistent opioid therapy.
Adjuvant drugs. A number of drugs developed for purposes other than analgesic may alter or modulate pain perception. Selective serotonin-reuptake inhibitors (SSRI) have improved the treatment of depression, but have not been effective against pain. Amitriptyline, nortriptyline, desipramine (all antidepressants) and gabapentin (an anti-epileptic) may be considered alternatives but should be used with caution in the elderly as they may cause unacceptable side effects.
Drugs to avoid. Meperidine should be avoided in treating chronic pain, particularly in the elderly patient, because of the increased risk for seizures. It is best used in the short term for acute pain. Other drugs that are also not recommended include pentazocine.16

Patient-Centered Concerns in Wound Care
Pain in the context of wound care often has been described as the patient's subjective experience. However, more often than not, it is the caregiver who interprets patient pain according to his/her own cultural/environmental perspective.

References: 

1. Wulf H, Baron R. The theory of pain. In: European Wound Management Association. Pain at Wound Dressing Changes: A Position Document. 2002.
2. Dougherty PM, Palecek J, Paleckova V, Willis WD. Infusion of substance P or neurokinin A by microdialysis alters responses of primate spinothalamic tract neurons to cutaneous stimuli and to iontophoretically released excitatory amino acids. Pain. 1995;61:411-425.
3. Dickenson AH, Chapman V, Green GM. The pharmacology of excitatory and inhibitory amino acid-mediated events in the transmission and modulation of pain in the spinal cord. Gen Pharmacol. 1997;28:633-638.
4. AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. American Geriatrics Society. J Am Geriatr Soc. 2002;50:S205-S224.
5. Krasner D. Caring for the person experiencing chronic wound pain. In: Krasner D, Rodeheaver GT, Sibbald RG, eds. Chronic Wound Care, 3rd ed. Wayne, Pa.: HMP Publications;2001.
6. Ferrel BA. Pain. In: Osterweil D, Brummel-Smith K, Beck JC, eds. Comprehensive Geriatric Assessment. New York, NY: McGraw Hill; 2000:381-397.
7. Herr KA, Mobily PR, Kohout FJ, et al. Evaluation of the faces pain scale for use with the elderly. Clin J Pain. 1998;14:29-38.
8. Gagliese L, Melzack R. Age differences in the quality of chronic pain: a preliminary study. Pain Research and Management. 1997;2:157-162.
9. Bergh I, Sjostrom B, Oden A, Steen B. Assessing pain and pain relief in geriatric patients with non-pathological fractures with different rating scales. Aging (Milano). 2001;13(5):355-361.
10. Choiniere M, Melzack R, Rondeau J, Girard N, Paquin MJ. The pain of burns: characteristics and correlates. J Trauma. 1989;29(11):1531-1539.
11. Gallacher G, Rae CP, Kinsella J. Treatment of pain in severe burns. Am J Dermatol. 2000;1(6):329-335.
12. Bieri D, Reeve RA, Champion GD, Addicoat L, Ziegler JB. The faces pain scale for the assessment of the severity of pain experienced by children: development, initial validation, and preliminary investigation for ratio scale properties. Pain. 1990;41(2):139-150.
13. Hicks CL, von Baeyer CL, Spafford PA, van Korlaar I, Goodenough B. The faces pain scale revised: toward a common metric in pediatric pain measurement. Pain. 2001;93(2):173-183.
14. Ferrell BA, Ferrell BR, Osterweil D. Pain in the nursing home. J Am Geriatr Soc. 1990;38:409-414.
15. Grossberg GT, Sherman LK, Fine PG. Pain and behavioral disturbances in the cognitively impaired older adult: assessment and treatment issues. Annals of Long Term Care. 2000;8:22-24.
16. Cobbs E, et al. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, 4th ed. Dubuque, Ia.: Kendall/Hunt Publishing;1999.
17. Ian Anderson Continuing Education Program in End-of-Life Care. Available at http://www.cme.utoronto.ca/endoflife/PPT%20Pain.pdf. Accessed December 1, 2002.
18. American Medical Association. Pain Management: Resources for the Young Physician. Adapted from a report of the American Medical Association Young Physicians Section Governing Council, "Guidelines for Patients in Pain." Chicago, Ill.: AMA Department of Young Physician Services;2002.
19. Sibbald RG, Williamson D, Orsted HL, Campbell K, Keast D, Krasner D, Sibbald D. Preparing the wound bed - debridement, bacterial balance and moisture balance. Ostomy/Wound Management. 2000;46(11):14-35.
20. Jacox A, Carr DB, Payne R, et al. Clinical Practice Guideline Number 9: Management of Cancer Pain. Rockville, Md. Agency for Health Care Policy and Research, US Department of Health and Human Services, Public Health Service.Agency for Health Care Policy and Research; 1994: AHCPR Publication No. 94-0592.
21. Ferrell BR. Patient education and non-drug interventions. In: Ferrell BR, Ferrell BA, eds. Pain in the Elderly. Seattle, Wash: IASP Press; 1996:35-44.
22. Rochon PA, Fortin PR, Dear KB, et al. Reporting of age data in clinical trials of arthritis. Deficiencies and solutions. Arch Intern Med. 1993;153:243-248.
23. Ventsfridda V, Saita L, Ripamonti C, De Conno F. WHO guidelines for the use of analgesics in cancer pain. Int J Tissue React. 1985;7(1):93-96.
24. Dalton JA, Youngblood R. Clinical application of the World Health Organization analgesic ladder. Journal of Intravenous Nursing. 2000;23(2):118-124.
25. Sindrup SH, Jensen TS. Efficacy of pharmacological treatments of neuropathic pain: an update and effect related to mechanism of drug action. Pain. 1999;83(3):389-400.
26. Boulton AJ. Treatment of symptomatic diabetic neuropathy. Diabetes Metab Res Rev. 2003;19(Suppl 1):S16-S21.
27. American College of Rheumatology Subcommittee on osteoarthritis guidelines. Recommendations for the Medical Management of Osteoarthritis of the Hip and Knee. Arthritis & Rheumatism. 2000;43(9):1905-1915.
28. MacLean CH. Quality indicators for the management of osteoarthritis in vulnerable elders. Ann Intern Med. 2001;135:711-721.
29. Graham DY, White RH, Moreland LW, et al. Duodenal and gastric ulcer prevention with misoprostol in arthritis patients taking NSAIDs. Misoprostol Study Group. Ann Intern Med. 1993;119:257-262.
30. Geba GP, Weaver AL, Polis AB, et al. Efficacy of rofecoxib, celecoxib, and acetaminophen in osteoarthritis of the knee: a randomized trial. The VACT Group (Vioxx, Acetaminophen, Celecoxib Trial). JAMA. 2002;287:64-71.
31. AGS Panel on Chronic Pain in Older Persons. The management of chronic pain in older persons. American Geriatrics Society. J Am Geriatr Soc. 1998;46:635-651.
32. Melzack R. The tragedy of needless pain. Sci Am. 1990;262:27-33.
33. Fine PG. Pain and aging: overcoming barriers to treatment and role of transdermal opioid therapy. Clin Geriatr Med. 2000;8:28-36.
34. Portenoy RK. Chronic opioid therapy for persistent non-cancer pain: can we get past the bias? American Pain Society Bulletin. 1991;1-5.
35. Harden RN. Chronic opioid therapy: another reappraisal. American Pain Society Bulletin. 2002;12:1-12.
36. Canadian Pain Society task force. Use of opioid analgesics for the treatment of chronic non-cancer pain - a consensus statement and guidelines from the Canadian Pain Society. Pain Research and Management. 1998;3(4).
37. Persoli-Gudelj M. Treatment of pain with opiod analgesics and the role of TTS-fentanyl. Reumatizam. 2001; 48(2):29-37.
38. Fainsinger R, Schoeller T, Bruera E. Methadone in the management of cancer pain: a review. Pain. 1993;52:137-147.
39. Hanks G, Cherny N. Opioid analgesic therapy. In: Doyle D, Hanks GW, MacDonald N, eds. Oxford Textbook of Palliative Medicine, 2nd ed. Oxford, UK: Oxford University Press;1998:331-355.
40. Hollinworth H, Collier M. Nurses' views about pain and trauma at dressing changes: results of a national survey. Journal of Wound Care. 2000;9(8):369-373.
41. Moffatt CJ, Franks PJ, Hollinworth H. Understanding wound pain and trauma: an international perspective. In: European Wound Management Association. Pain at Wound Dressing Changes: A Position Document. 2002:2-7.
42. Krasner, D. Managing pain from pressure ulcers. Am J Nurs. 1995;95(6):22, 24.
43. Ferrell BR, Ferrell BA, Ahn C, et al. Pain management for elderly patients with cancer at home. Cancer. 1994;74:2139-3432.
44. Ferrell BR, Rhiner M, Ferrell BA. Development and implementation of a pain education program. Cancer. 1993;72:3426-3432.
45. LeFort SM, Gray-Donald K, Rowat KM, et al. Randomized controlled trial of a community-based psychoeducation program for the self-management of chronic pain. Pain. 1998;74:297-306.
46. Ferrell BA, Josephson KR, Pollan AM, et al. A randomized trial of walking versus physical methods for chronic pain management. Aging (Milano). 1997;9:99-105.
47. Melzack R. From the gate to the neuromatrix. Pain. 1999;Suppl 6:S121-S126.
48. Ferrell BR, Ferrell BA, eds. International Association for the study of Pain Task Force on Pain the Elderly. Pain in the Elderly. Seattle, Wash.: IASP Press;1966.
49. Gardner SE, Frantz RA, Troia C, Eastman S, MacDonal M, Buresh K, Healy D. A tool to assess clinical sign and symptoms of localized infection in chronic wounds: development and reliability. Ostomy/Wound Management. 2001;47(1):40-47.
50. Krasner D, Sibbald RG. Local aspects of diabetic foot ulcer care: assessment, dressings and topical agents. In: Levin ME, O'Neal DN, Bowker JH, eds. The Diabetic Foot, 6th ed. St. Louis, Mo.: Mosby-Yearbook;1999.
51. Bowler PG. Wound pathophysiology, infection and therapeutic options. Ann Med. 2002;34(6):419-427.
52. Bowler PG. Bacterial growth guideline: reassessing its clinical relevance in wound healing. Ostomy/Wound Management. 2003;49(1):44-53.
53. Wright JB, Lam K, Buret AG, Olson ME, Burrell RE. Early healing events in a porcine model of contaminated wounds: effects of nanocrystalline silver on matrix metalloprotineases, cell apoptosis and healing. Wound Repair Regen. 2002;10(3):141-151.
54. Winter GD. Formation of the scab and the rate of epithelialization of superficial wounds in the skin of the young domestic pig. 1962. Journal of Wound Care. 1995;4(8):366-367.
55. Kannon GA, Garrett AB. Moist wound healing with occlusive dressings. A clinical review. Dermatol Surg. 1995;21(7):583-590.
56. Rovee DT. Evolution of wound dressings and their effects on the healing process. Clinica Materials. 1991;8(3-4):183-188.
57. Meuleneire F. Using a soft silicone-coated net dressing to manage skin tears. Journal of Wound Care. 2002;11(10):365-369.
58. Barnes HR. Wound care: fact and fiction about hydrocolloid dressings. J Gerontol Nurs. 1993;19(6):23-26.
59. Baxter H. A comparison of two hydrocolloid sheet dressings. Br J Community Nurs. 2000;5(11):572-577.
60. Eaglestein WH. Occlusive dressings. J Dermatol Surg Oncol. 1993;19(8):716-720.
61. Siegel DM. Contact sensitivity and recalcitrant wounds. Ostomy/Wound Management. 2000;46(1A Suppl):65S-74S.
62. Benbow M. Mixing and matching dressing products. Nursing Standard. 2000;23-29; 14(49):56-58,60,62.
63. Fletcher J. Exudate theory and the clinical management of exuding wounds. Professional Nurse. 2002;17(8):475-478.
64. Anderson I. Practical issues in the management of highly exuding wounds. Professional Nurse. 2002;18(3):145-148.
65. Cutting KF, White RJ. Avoidance and management of peri-wound maceration of the skin. Professional Nurse. 2002;18(1):33-36.
66. O'Brien M. Exploring methods of wound debridement. Br J Community Nurs. 2002;Dec:10-18.
67. Collier M, Hollingworth H. Pain and tissue trauma during dressing change. Nurs Stand. 2000;July;21-27;14(40):71-73.
68. Terrill PJ, Varughese G. A comparison of three primary non-adherent dressings applied to hand surgery wounds. Journal of Wound Care. 2000; 9(8):359-363.
69. Knauth A, Gordin M, McNelis W, Baumgrat S. semi-permeable polyurethane membrane as an artificial skin for the premature neonate. Pediatrics. 1989;83(6):945-950.
70. Ameen H, Moore K, Lawrence JC, Harding KG. Investigating the bacterial barrier properties of four contemporary wound dressings. Journal of Wound Care. 2000; 9(8):385-388.
71. Sprung P, Hou Z, Ladin DA. Hydrogels and hydrocolloids: an objective product comparison. Ostomy/Wound Management. 1998;44(1):36-46.
72. O'Dovovan DA, Mehdi SY, Eadie PA. The role of Mepitel silicone net dressings in the management of fingertip injuries in children. J Hand Surg (Br). 1999;24(6):727-730.
73. Limova M, Troyer-Caudle J. Controlled, randomized clinical trial of two hydrocolloid dressings in the management of venous insufficiency ulcers. Journal of Vascular Nursing. 2002;20(1):22-32.
74. Mertz PM, Marshall DA, Eaglstein WH. Occlusive wound dressings to prevent bacterial invasion and wound infection. J Am Acad Dermatol. 1985;12(4):662-668.
75. Fowler E, Papen JC. Evaluation of an alginate dressing for pressure ulcers. Decubitus. 1991;4(3):47-52.
76. Young T. Reaping the benefits of foam dressings. Community Nurse. 1998;4(5):47-48.
77. Campton-Johnston S, Wilson J. Infected wound management: advanced technologies, moisture-retentive dressings, and die-hard methods. Critical Care Nursing Quarterly. 2001;24(2):64-77.



Post new comment

  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
  • Use to create page breaks.

More information about formatting options

Image CAPTCHA
Enter the characters shown in the image.