Pain in end stage renal disease

Pain in end stage renal disease

Marsha N. Rehm

Pain is considered a major health care problem in the nation today. More that 50 million people suffer daily due to poorly controlled pain. Poorly controlled pain leads to additional health care concerns as well as emotional and psychological dysfunction. In January 2000, the Joint Commission for Accreditation of Heathcare Organizations (JCAHO) determined that pain would become a national priority using its survey process to determine how well health care systems were managing pain in their patient populations. Pain was determined to be the “fifth” vital sign and, as such, deserved at least the same consideration from health care professionals as traditional measurements. Despite the national trend to “pay attention” to pain, many people with chronic illnesses continue to suffer needlessly.

End stage renal disease (ESRD) is often a result of chronic hypertension and diabetes. The result of the end stage of renal failure is that the person then needs dialysis therapy or transplantation to survive. Since the prevalence is higher in older individuals (> 65 years of age), many have additional chronic problems that can cause pain and suffering, including cardiovascular disease, bone disease, and peripheral vascular disease, just to name a few. Pain control in this population of the chronically ill elderly is a challenge to the health care provider. Patients with ESRD are a special challenge due to the relationship between medication clearance and renal function. This leads to undertreatment of pain or oversedation and untoward side effects/complications when using certain types of medications.

The World Health Organization (WHO) determined a well-known, systematic, and predictable approach to the use of medications for pain, known as the analgesic ladder. Beginning with the nonopioid analgesics for mild to moderate pain, the analgesic “ladder” approach is to start low and go slow, increasing doses and changing the types of medication used based on the patients response. Acetaminophen and nonsteroidal anti-inflammatory medications (NSAIDS), such as ibuprofen, may be helpful for certain types of pain including any pain with an inflammatory etiology. Since NSAIDs can cause renal damage, they may only be used in patients currently undergoing hemodialysis. Caution must be taken since many ESRD patients already have coagulopathies and may experience gastrointestinal bleeding as a result of NSAID use. The newer types of selective NSAIDs may be considered, but risks versus benefits must still be explored. If pain persists or worsens, then adding an opioid analgesic is acceptable with or without a nonopioid.

Most opioids can be safely used in the ESRD patient with a few precautions. First, the majority of opioids are metabolized in the liver and excreted in the kidneys. Therefore, consideration must be given to dose, frequency, the pharmacokinetics of the selected opioid, previous exposure to opioid medications, and level of pain. Second, assessment of the pain must be completed. A starting point for prescribing can be reached based on the type of pain syndrome described. If pain is acute and short-term in nature, then a short-acting medication, such as oxycodone immediate release or morphine immediate release, given on an “as needed” basis may be sufficient. However, if pain is chronic and is not expected to resolve within 1-3 months, then a long-acting medication such as morphine continuous release or oxycodone continuous release may be more appropriate. These long-acting preparations will provide a more constant therapeutic dose of medication and provide around-the-clock pain relief. Start with the lowest dose of medication, assessing the patient for any side effects that may occur including nausea, itching, drowsiness, and constipation. Each of these side effects can be managed with adjuvant medication such as antiemetics, antihistamines, and laxatives. After several days, most side effects will go away. However, constipation must be treated aggressively for the duration of time the patient takes the opioid. If pain persists then an increase in the opioid may be indicated. Increasing in small incremental doses is essential, since ESRD patients will not clear the medication well. This can lead to possible accumulation, causing mental status changes and somnolence. If not recognized and addressed by decreasing the medication, respiratory depression can occur. Fear of these outcomes should never be an excuse not to treat the patient’s pain aggressively, since many patients tolerate opioid medications without any problems whatsoever.

Depending on the type of description the patient gives regarding the pain, nonopioid and opioid medication may not be enough. Neuropathic pain syndromes related to diabetes or other vascular diseases are common in ESRD patients. If a patient describes the pain as burning, sharp, shooting, or pins and needles, this may indicate nerve damage or malfunction. In this instance, an anticonvulsant such as gabapentin or a triclyclic antidepressant such as amyltriptyline may be used. One or both of these medications can be used in the ESRD patient. However, gabapentin must not be given until the dialysis treatment is completed, since it is excreted completely by the kidneys and will continue to circulate and provide relief until dialyzed off. Trial and error using small doses and titrating is the most important concept and will provide the most comprehensive approach to medication management for pain in the ESRD patient. In addition to medications, pain may also be addressed using a nonmedication approach.

Nonmedication approaches must also be used to address the psychological and emotional components of pain, which are most certainly present if the patient has had pain for greater than 3 months. The definition of pain from the International Association of the Study of Pain states that pain is both “sensory and emotional.’ Relaxation training, biofeedback, massage, guided imagery, distraction, and many other therapies may be employed to treat the emotional side of pain. Patients with chronic, poorly-controlled pain often need assistance with coping skills and stress management. Cognitive and psychological therapies are essential to providing a comprehensive approach.

Pain management in the ESRD patient is most certainly challenging, but not impossible. With a systematic approach to medication selection, appropriate ongoing assessment, prompt management of side effects, and the addition of nonmedication therapies, patients can have a high quality of life and maintain function. Utilizing the nephrology team and consulting with a pain management specialist when required can make a difference. As Albert Schweitzer once said, “We all must die, but if I can save him days of torture that is what I feel is my great and ever new privilege, pain is a more terrible lord of mankind that even death himself.”

Marsha N. Rehm, MSN, RN, AOCN, FAAPM, is Clinical Nurse Specialist Pain Management/Oncology, University Health Systems of Eastern Carolina, Greenville, NC.

COPYRIGHT 2003 Jannetti Publications, Inc.

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