Pain is a component of many chronic conditions, making chronic pain a health concern on its own. In fact, as many as 50 million Americans suffer from chronic pain, including myself. In 1991, I fell in my driveway and broke everything in my left leg from the knee down. During my recovery process, I experienced exceptionally poor pain management, which led me to seek my own answers on how to effectively manage pain. It was then, during my own experience with pain that transformed into living a life with chronic pain, that I realized I knew little to nothing about pain and pain management despite my background in healthcare.
Since my accident, I have made it my personal responsibility to act as a patient advocate when it comes to dealing with pain. Additionally, with nurse practitioners increasingly on the frontlines of patient care and pain management in skilled nursing facilities and long-term care settings, I’ve made it a priority to educate fellow NPs about how to properly manage their patients’ pain, leveraging my unique dual insight as both a patient and provider.
Side effects of pain treatment
Pain management is a complex and somewhat all-encompassing issue. This is because managing pain is often about more than just a patient’s pain and can include treating side effects and comorbid conditions that may result from a number of different things, including treatment options for pain. In fact, long-term opioid therapy, the most common treatment option for those suffering from chronic pain, can often result in various side effects such as constipation, dizziness, etc., all of which may increase patient discomfort. Up to 80% of patients taking opioids to manage chronic non-cancer pain are impacted by opioid-induced constipation (OIC), making it the most common adverse side-effect of opioid therapy. In my opinion, pain management and bowel care go hand-in-hand; if a patient taking long-term opioid therapy for the management of chronic pain is not beingasked about their bowel movements (BMs), that is a huge oversight.
The most important thing NPs can do is listen to their patients and create a comfortable, nonjudgmental environment that allows for open dialogue. This means not only listening to patients’ concerns, but also asking the right questions and opening conversations on topics that patients don’t always want to talk about, such as OIC. To do this, NPs need to create a trusting environment and ask direct questions like, “When did you have your last bowel movement?” “What kind of bowel movement was it?” Not surprisingly, I’ve found that if you just listen to patients and tell them you are interested in getting this kind of information because you want to help them, they’ll respond positively.
Additionally, it’s important that NPs strictly monitor and record patient BMs — especially when treating patients taking opioids who are older or who have cognitive impairments, as they might not be able to provide accurate self-reports. This is especially important in LTC settings, where the average patient age is 84 years old and nearly one-third of residents are on some type of opioid therapy for the management of one or more conditions. Unfortunately, documentation of BMs is often considered a less important part of care plans. But there are adverse consequences, such as impaction, or for patients on long-term opioid therapy, OIC, that can occur from lack of BMs, which is why monitoring and documentation is vital. With documentation it’s easier to notice abnormalities in patient regularity.
What’s concerning, however, is that when these conversations don’t take place and BMs are not properly monitored and recorded, many patients just let OIC symptoms linger for extended periods of time because they think there aren’t any options for them. Sometimes, patients try using over-the-counter medications, such as laxatives, to treat their OIC. In fact, nearly 55% of patients in LTC facilities use opioids and laxatives at the same time. However, these patients are unable to find the relief they are seeking because of the way opioids react in the gut. Constipation that is opioid-induced mechanistically differs from other forms of constipation, which can result from a variety of factors such as diet or as a side effect of aging. Because of this, OIC is not something that can be treated with a regular laxative. It is a condition that needs medical treatment like any other condition.
Relief from OIC
Ultimately, patients experiencing OIC need quick, effective relief. I’ve found that the most effective treatment option for OIC is Relistor. Given its long track-record, with more than 10 years of clinical experience, and as the first product specifically designed to treat OIC, it is a reliable and trusted treatment option. Personally, in my practice, I use the subcutaneous injection, which provides patients with a quick evacuation and, therefore, relief. It’s really just such a simple way to deliver relief to these patients who desperately need it.
At large, NPs have a responsibility to treat chronic pain as the comprehensive condition that it is. This includes treating OIC. Patients need to know that there are treatment options for this condition, and they don’t need to suffer. There are some simple solutions, like Relistor, that can help them find relief. With this in mind, NPs need to harness skills, such as listening and empathy, to help create a relaxed environment for patients to have open conversations about this topic. Additionally, increased education on the importance of regular bowel regimens is needed in SNFs and LTC settings to help shed the notion that BM documentation is a lesser part of patient care. NPs must know how to successfully monitor and record patient BMs, including approaches to notify physicians of patient irregularity. To develop an appropriate treatment plan for OIC as part of a larger pain management routine, and increase overall patient satisfaction and comfort in LTC settings, we must first take steps toward increased dialogue and education.
Yvonne D’Arcy, MS, CRNP, CNS, is a pain management and palliative care nurse practitioner with more than 20 years of pain management experience. She has held positions as pain and palliative care nurse practitioner for Johns Hopkins-Suburban Hospital and Mayo Clinic Jacksonville. She is the author of 10 books on pain management and presents frequently on a variety of pain topics.