Kansas

Kansas State Board of Nursing 
Guideline for Pain Management
Adopted: July 11, 2001

The management of pain must be a major priority for nurses and all others who provide care to persons in pain. Pain is sometimes undertreated due to lack of knowledge or fear of sanctions by regulatory or enforcement agencies. This guideline is intended to:

1) promote the optimal level of nursing practice in pain management;

2) establish a standard of practice that leads to sound clinical judgement in managing acute and chronic, and end-of-life pain; and

3) reassure nurses that by following these guidelines, they will be supported and not disciplined by the Board for appropriate pain management.

The Kansas State Board of Nursing endorses the "Precepts of Pain Management" set forth by the Living Initiatives for End of Life Care (LIFE) Project and has drawn upon the precepts to formulate nursing principles of pain management. They are:

• All persons who are experiencing pain have the right to have their pain relieved to the greatest extent possible. The nurse’s goal is to reduce pain at least to a level specified by the recipient of care, while recognizing that all persons have the right to refuse treatment.
  
• A person’s perception of pain is the optimal standard upon which all pain management interventions are based.
  
• A comprehensive nursing assessment includes the subjective description of pain, objective data, and the identified need for psychosocial/spiritual support.
  
• Fear of addiction to opioids and other pain medications need not be a barrier to pain management. Nurses recognize and apply the following concepts:

• Tolerance and physical dependence are consequences of sustained use of opioid analgesics and are not synonymous with addiction
  
• "Pseudoaddiction" is a pattern of drug-seeking behavior of persons with pain who are receiving inadequate pain management and may be mistaken for addiction.

• Persons with a history of substance abuse have the right to adequate pain relief, even if opioids must be used. Such persons require specialized care and treatment.
  
• Continuity of care within and across health care settings is essential to effective pain management.
  
• An interdisciplinary approach to pain management is optimal.
  
• Nurses and other clinicians pursue the most effective modes of treatment to their maximal benefit. Research indicates that most persons experiencing pain can achieve optimal pain relief with simple, cost-effective modes of treatment.
  
• Pain management continues even if the person becomes unresponsive.
  
• Sedation is an acceptable means of controlling pain and discomfort when all other reasonable efforts have failed.
  
• Assisted suicide and euthanasia are illegal in the state of Kansas and are not acceptable alternatives to optimal pain management.
  

Nurses are responsible for maintaining the knowledge and skills necessary to coordinate optimal pain management.

The nursing functions of appropriate pain management include:

• Ensuring that the person or their legal representative actively participates in the treatment plan and understands the options available for pain relief and potential side effects.
  
• Educating persons and their families in a culturally competent manner regarding pain management.
  
• Educating staff members about pain assessment, treatment and the common barriers to adequate pain management.
  
• Using a standardized scale, to periodically assess and document a person’s pain in accordance with institutional policies and procedures.
  
• Developing and implementing a plan of care that prevents and alleviates pain as much as possible.
  
• Administering medications and treatments as prescribed, using knowledge to maintain both safety and pain relief.
  
• Initiating non-pharmacological nursing interventions as indicated.
  
• Serving as an advocate to assure effective pain management.
  
• Communicating side effects or any reports of unrelieved pain to the prescriber and to appropriate team members.
  
• Documenting pain assessment, intervention, evaluation and changes to the plan of care in a clear and concise manner.

 

Only the physician or other health professional with authority to prescribe may change the medical pain management plan. When pain is not controlled under the currently prescribed treatment plan, the nurse is responsible for reporting such findings to the prescriber and documenting the communication.

The nurse is often the health professional most involved in on-going pain assessment, implementing the prescribed pain management plan, evaluating the person’s response to such interventions and adjusting medication levels based on the person’s status. In order to achieve adequate pain management, the prescription must provide dosage ranges and frequency parameters with which the nurse may adjust (titrate) medication in order to achieve adequate pain control. Consistent with the licensee’s scope of practice, the RN or LPN is accountable for implementing the pain management plan utilizing his/her knowledge base and documented assessment of the person’s needs. The nurse has the authority to adjust medication levels within the dosage and frequency ranges stipulated by the prescriber and according to the agency’s established policies and procedures. Nurses should not fear disciplinary action from the Kansas State Board of Nursing for administering medication to control pain for a legitimate medical purpose and in the usual course of professional practice.

For the purposes of these guidelines, the following terms are defined:

"Acute pain" is the normal, predicted physiological response to an adverse chemical, thermal or mechanical stimulus and is associated with surgery, trauma and acute illness. It is generally time-limited and is responsive to opioid therapy, among other therapies.

"Addiction" is a neuro-behavioral syndrome with genetic and environmental influences that results in psychological dependence on the use of substances for their psychic effects and is characterized by compulsive use despite harm. Addiction may also be referred to "psychological dependence." Physical dependence and tolerance are normal physiological consequences of extended opioid therapy for pain and should not be considered addiction.

"Chronic pain" is a pain state which is persistent beyond the usual course of an acute disease or a reasonable time for an injury to heal, or that is associated with a chronic pathologic process that causes continuous pain or pain that recurs at intervals for months or years.

"Pain" is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

"Physical dependence" on a controlled substance is a physiologic state of neuro-adaptation which is characterized by the emergence of a withdrawal syndrome if drug use is stopped or decreased abruptly, or if an antagonist is administered. Physical dependence is an expected result of opioid use. Physical dependence, by itself, does not equate with addiction.

"Pseudoaddiction" is a pattern of drug-seeking behavior of persons with pain who are receiving inadequate pain management that can be mistaken for addiction.

"Substance abuse" is the use of any substance(s) for non-therapeutic purposes or use of medication for purposes other than those for which it is prescribed.

"Tolerance" is a physiologic state resulting from regular use of a drug in which an increased dosage is needed to produce the same effect, or a reduced effect is observed with a constant dose. Tolerance may or may not be evident during opioid treatment and does not equate with addiction.

A Position Statement of Pain Management, The American Society of PeriAnesthesia Nurses, April 18, 1999.

Bonica, J. J. (ed.), The Management of Pain, 2^nd ed., Lean & Febiger, Philadelphia, 1990.

Bringing Better Pain Management into "Ordinary Medical Practice", Last Acts, State Initiatives in End of Life Care.

California Board of Nursing. Pain Management Policy.

Guidelines for the Use of Controlled Substances for the Treatment of Pain, Kansas State Board of Healing Arts, October 17, 1998.

Kansas HB 2141, by Committee on Health and Human Services, Session of 2001: An Act concerning the healing arts relating to pain management.

North Carolina Board of Nursing and Board of Pharmacy, Joint Statement on Pain Management and End of Life Care, September 24, 1999.

Pain Management Resource Manual for Hospitals and Health systems published by the LIFE Project, 2001.

Pain Management Resource Manual for Long Term Care Facilities published by the LIFE Project, 2001.

Statement from the American College of Surgeons, (ST-28) Principles Guiding Care at the End of Life, Bulletin of the American College of Surgeons, Vol. 83, No. 04, April 1988.

United States Department of Health and Human Services - Agency for Healthcare Research and Quality.

World Health Organization